ChanBeDu/relevant_section_length · Datasets at Hugging Face

48,826

119,492

49503

Discharge summary

report

Admission Date: [**2100-11-11**] Discharge Date: [**2100-12-5**] Date of Birth: [**2019-7-19**] Sex: M Service: MEDICINE Allergies: Tetanus&Diphtheria Toxoid / Amoxicillin / Vicodin / Levaquin Attending:[**First Name3 (LF) 2712**] Chief Complaint: Weakness Dysarthria Hypotension Major Surgical or Invasive Procedure: Intubation Right IJ Central Venous Line [**11-11**] PICC line placement [**11-20**] CT guided drainage of right sided perianastomotic fluid collection Midline placement Tracheostomy History of Present Illness: This is an 81 yoM with history ESRD s/p renal transplant s/p hemicolectomy for stage 1 colon CA who presents for altered mental status. Per rehab reports, patient appeared more fatigued while at rehab and was not willing participate with activities. Also per documentation, patient was noted to be dysarthric. In ED, intitial VS were 97.9 76 93/50 16 97%. Initially hypotensive received 1.5L. RIJ was placed and levophed was started. Zosyn was initially given however after confirming allergies, pt was switched to vanco/cefepime. Also received digoxin 0.25mg for afib with RVR. CT showed now acute intraabdominal abscess however with new abdominal wall fluid collection. CT head was negative. There was also an RUL infiltrate. In the MICU, patient was conversing complaining of some shortness of breath however did not have any other concerns. 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: PMH: Hypertension Hyperlipidemia Coronary Artery Disease Hiatal hernia per wife gout h/o DVT, PE (on coumadin) Hemorrhoids PSH: renal transplant [**2077**] h/o diverticulitis s/p sigmoid colectomy [**2087**] CABG [**2086**] ([**Doctor Last Name 14714**]) EVAR [**3-/2092**] ([**Doctor Last Name **]) Revision of aortic stent graft [**1-/2096**] ([**Doctor Last Name **]) Open right colectomy [**2100-9-6**] Incision and drainage of left wrist [**2100-9-15**] Social History: Nonsmoker. Occassional drinker. He used to be employed by the utility company but is currently retired. Mr. [**Known lastname 103570**] lives with his wife- no home services. Family History: Noncontributory. Physical [**Known lastname **]: Physical [**Known lastname **] on Admission to MICU General: Alert, oriented, in mild resporta HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission labs: [**2100-11-11**] 04:20PM BLOOD WBC-11.3* RBC-4.06* Hgb-12.0* Hct-34.9* MCV-86 MCH-29.6 MCHC-34.5 RDW-21.4* Plt Ct-338 [**2100-11-11**] 04:20PM BLOOD Neuts-70 Bands-1 Lymphs-22 Monos-5 Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2100-11-11**] 04:20PM BLOOD PT-56.6* PTT-47.4* INR(PT)-6.1* [**2100-11-11**] 04:20PM BLOOD Glucose-92 UreaN-12 Creat-0.8 Na-118* K-4.3 Cl-93* HCO3-16* AnGap-13 [**2100-11-11**] 04:20PM BLOOD ALT-13 AST-33 LD(LDH)-338* CK(CPK)-98 AlkPhos-103 TotBili-0.6 [**2100-11-11**] 04:20PM BLOOD Albumin-2.5* Calcium-7.7* Phos-4.0 Mg-1.1* [**2100-11-11**] 08:52PM BLOOD pO2-38* pCO2-30* pH-7.35 calTCO2-17* Base XS--7 [**2100-11-11**] 08:52PM BLOOD freeCa-0.97* [**2100-11-11**] 04:20PM BLOOD cTropnT-0.02* [**2100-11-11**] 06:30PM URINE Color-DkAmb Appear-Clear Sp [**Last Name (un) **]-1.014 [**2100-11-11**] 06:30PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR [**2100-11-11**] 06:30PM URINE RBC-<1 WBC-2 Bacteri-FEW Yeast-NONE Epi-0 [**2100-11-11**] 11:26PM URINE Hours-RANDOM Creat-124 Na-51 K-39 Cl-60 [**2100-11-11**] 11:26PM URINE Osmolal-395 [**2100-11-12**] 04:42AM BLOOD CK-MB-4 cTropnT-0.02* [**2100-11-12**] 12:22PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN- 0.1 [**2100-11-12**] 12:22PM BLOOD B-GLUCAN- > 500 pg/mL [**2100-11-12**] 09:50PM BLOOD PTH-66* [**2100-11-12**] 09:50PM BLOOD VITAMIN D 25 HYDROXY- 9 ng/mL [**2100-11-12**] 09:50PM BLOOD ALDOSTERONE- 2 ng/dL (upright 8-10AM, < or 28 ng/dL; upright 4-6PM, < or = 21 ng/dL; supine 8-10M [**4-14**] ng/dLv) [**2100-11-15**] 05:23PM BLOOD ACTH - FROZEN- 9 pg/mL (normal [**7-/2039**] pg/mL) [**2100-11-15**] 05:23PM BLOOD Cortsol-4.6 [**2100-11-15**] 06:05PM BLOOD Cortsol-8.6 [**2100-11-18**] 04:17AM BLOOD GGT-973* [**2100-11-21**] 03:59AM BLOOD ALT-56* AST-120* CK(CPK)-22* AlkPhos-1305* TotBili-2.3* [**2100-11-22**] 01:28AM BLOOD WBC-21.5* RBC-3.48* Hgb-10.7* Hct-33.3* MCV-96 MCH-30.8 MCHC-32.2 RDW-25.0* Plt Ct-238 [**2100-11-22**] 01:28AM BLOOD Neuts-92* Bands-0 Lymphs-5* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 = = = = = = = = = = ================================================================ MICROBIOLOGY [**2100-11-12**] 10:47 am SWAB Source: abdominal abscess. **FINAL REPORT [**2100-11-17**]** GRAM STAIN (Final [**2100-11-12**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. WOUND CULTURE (Final [**2100-11-17**]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. Further workup requested by DR. [**Last Name (STitle) 2323**] [**Name (STitle) 2324**]. STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH. COAG NEG STAPH does NOT require contact precautions, regardless of resistance 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. STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH. SECOND MORPHOLOGY. COAG NEG STAPH does NOT require contact precautions, regardless of resistance 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. STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. COAG NEG STAPH does NOT require contact precautions, regardless of resistance 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 _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | STAPHYLOCOCCUS, COAGULASE NEGATIVE | | STAPHYLOCOCCUS, COAGULASE N | | | CLINDAMYCIN-----------<=0.25 S <=0.25 S <=0.25 S ERYTHROMYCIN---------- =>8 R =>8 R =>8 R GENTAMICIN------------ <=0.5 S <=0.5 S <=0.5 S LEVOFLOXACIN---------- =>8 R =>8 R =>8 R OXACILLIN------------- =>4 R =>4 R =>4 R RIFAMPIN-------------- <=0.5 S <=0.5 S <=0.5 S TETRACYCLINE---------- <=1 S <=1 S <=1 S VANCOMYCIN------------ 2 S 2 S 2 S ANAEROBIC CULTURE (Final [**2100-11-16**]): NO ANAEROBES ISOLATED. [**2100-11-12**] 3:21 pm BRONCHOALVEOLAR LAVAGE BAL #1. **FINAL REPORT [**2100-11-26**]** GRAM STAIN (Final [**2100-11-12**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): COLUMNAR EPITHELIAL CELLS. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2100-11-14**]): NO GROWTH, <1000 CFU/ml. LEGIONELLA CULTURE (Final [**2100-11-19**]): NO LEGIONELLA ISOLATED. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2100-11-14**]): NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Final [**2100-11-26**]): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2100-11-15**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Final [**2100-11-23**]): NO MYCOBACTERIA ISOLATED. VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Final [**2100-11-24**]): CYTOMEGALOVIRUS . PRESUMPTIVE IDENTIFICATION. [**2100-11-12**] 3:21 pm Rapid Respiratory Viral Screen & Culture BAL #1. **FINAL REPORT [**2100-11-17**]** Respiratory Viral Culture (Final [**2100-11-17**]): No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at [**Telephone/Fax (1) 6182**] within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final [**2100-11-15**]): Less than 60 columnar epithelial cells;. Specimen inadequate for detecting respiratory viral infection by DFA testing. Interpret all negative results from this specimen with caution. Negative results should not be used to discontinue precautions. Refer to respiratory viral culture results. Recommend new sample be submitted for confirmation. [**2100-11-13**] 5:37 pm URINE Source: Catheter. **FINAL REPORT [**2100-11-14**]** Legionella Urinary Antigen (Final [**2100-11-14**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). [**2100-11-23**] 12:15 pm FLUID,OTHER PERIANASTAMOTIC. GRAM STAIN (Final [**2100-11-23**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. FLUID CULTURE (Final [**2100-11-26**]): ENTEROCOCCUS SP.. HEAVY GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S PENICILLIN G---------- =>64 R VANCOMYCIN------------ =>32 R ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. [**2100-11-23**] 01:33AM STOOL CLOSTRIDIUM DIFFICILE TOXIN, PCR- Negative = = = = = = = = = ================================================================ CYTOLOGY: [**2100-11-12**] - BAL: Bronchial cells, pulmonary macrophages, neutrophils, and lymphocytes. Negative for malignant cells = = = = = = = = = ================================================================ RADIOLOGY [**2100-11-11**] - CT Head Without Contrast IMPRESSION: 1. No acute intracranial process. 2. Redemonstration of left subinsular hypoattenuation. If clinically indicated, this could be correlated with MRI [**Year (4 digits) **] if not contraindicated. 3. Stable age-related involution, small vessel ischemic disease, and bifrontal probable hygromas. - CXR AP Portable IMPRESSION: Right lung consolidation persists, but decreased as compared to the prior study. Possible small bilateral pleural effusions. Low lung volumes. Left perihilar opacity is again seen. - CT Chest without contrast; CT Abdomen/Pelvis with contrast IMPRESSION: 1. Worsening multilobar pneumonia centered within the right upper lobe. 2. Stable small bilateral pleural effusions, right greater than left. 3. No intra-abdominal or intra-pelvic abscess. 4. Stable periduodenal fluid and lower anterior abdominal wall fluid pocket along the prior surgical incision site. 5. Stable hypodense right thyroid lesion, which could be further characterized by ultrasound if not already performed. [**2100-11-14**] - MRI head without contrast IMPRESSION: 1. No evidence of acute infarct or intracranial hemorrhage. 2. Unchanged bilateral frontal subdural hygromas. 3. Generalized cerebral atrophy with changes of chronic small vessel ischemic [**2100-11-19**] - RUQ U/S IMPRESSION: 1. Gallstones and a small amount of sludge within the gallbladder. There are no signs of cholecystitis. 2. No biliary dilatation. 3. Bilateral pleural effusion. disease. [**2100-11-22**] - Abdomen X-ray FINDINGS: A frontal view of the abdomen was obtained. There is no free air. There is air seen in the small bowel and colon without evidence of dilatation. There is an NG tube seen with its tip either in the stomach antrum or first portion of the duodenum. There is an aorto/common iliac endovascular stent placed. Sternotomy wire is seen. There are sutures seen in the right lower quadrant and pelvis. There are hyperdensities in the lower pelvis that represent bladder stones. IMPRESSION: No evidence of megacolon, no evidence of obstruction. - HIDA Gallbladder scan IMPRESSION: Cholestasis with poor excretion of radiotracer into the biliary tree. Reimaging in 12 hours can be considered in an attempt to visualize the gallbladder if the patient condition improves. [**2100-11-23**] - CT abdomen/pelvis with contrast IMPRESSION: 1. Interval development of free intraabdominal air with a small fluid collection adjacent to the right lower quadrant enteric anastomosis. High attenuation material within the fluid collection is highly concerning for an enteric anastamotic leak. 2. Bilateral pleural effusions with worsening left basal consolidation. 3. Satisfactory appearance of the right lower quadrant renal transplant graft. Other solid viscera are within normal limits within limits of a noncontrast examination. - MRI C-spine without contrast Impression: 1. Multilevel degenerative changes of the cervical spine worse at C4-5. 2. There is fullness of the left vallecula and piriform sinus. Fluid is noted in the trachea and larynx. Correlation with direct visualization is recommended. 3. 3.3 cc x 2.4 trv x 2.6 ap CM lesion in the right thyroid gland which was described on CT [**2100-11-11**], but new since [**9-4**]. US is suggested if clinically warranted. - CT guided drainage of right-sided perianastomotic fluid collection Impression: 1. Peri-anastomotic fluid collection containing oral contrast in keeping with persistent anastomotic leak. 2. Successful placement of an 8-French [**Last Name (un) 2823**] pigtail catheter within the fluid collection. 3. Free intra-abdominal gas as noted previously; however, interval development of gas within the right renal transplant collecting system, likely refluxing from the bladder however clinical correlation is advised. [**2100-11-29**] GB scan: Markedly abnormal hepatobiliary scan. Persistent cholestasis with no biliary excretion into either the gallbladder or the small bowel after an hour. Interval worsening of tracer uptake compared with [**2100-11-22**], evident by persistent tracer activity in the heart after 60 minutes. Activity within bowel at 24 hours suggests a primary hepatocellular disorder with delayed excretion into bowel, however, intermittent common bile duct obstruction is not excluded given the delayed biliary excretion into bowel. Brief Hospital Course: 81 yo M with history of ESRD s/p renal transplant, recent hemicolectomy for stage 1 colon cancer presented with altered mental status. Course complicated by septic shock, respiratory failure requiring intubation and subsequently trach, and bowel perforation. Family meeting was held on [**2100-12-3**] - decision was made to make the patient CMO at that time. Ventilation was discontinued, and patient was started on morphine gtt. Details of his hospitalization are listed below: # Septic shock. Requiring IVF boluses and pressor prior to arrival to the MICU. Initial source was thought to be pneumonia based on clinical findings and imaging. He was started on broad spectrum antibiotics, vancomycin, cefepime, and flagyl initially to cover HCAP and aspiration pneumonia and fluconazole for possible infected fluid collection in the abdomen, as it was previously found to have yeast. Azithromycin was also added to cover possible atypical pneumonia. Colorectal surgery evaluated patient for possible infection of the fluid collection and sent a swab that was done around the fluid collection, and it was unable to be probed through. The swab essentially had coag negative staph, likely result of colonization of skin flora. The bronchoscopy and BAL was unrevealing except for possible CMV, but it was thought to be non-specific given his transplant status. With multiple antimicrobials, otherwise negative microbiology data, and improving clinical status off pressors, infectious disease recommended narrowing antimicrobials to fluconazole only after completion of a week course of antibiotics for pneumonia. Fluconazole was changed to micafungin for concern of rising alkaline phosphatase. He was peri-septic again in the setting of bowel perforation (see below), requiring IVF boluses. Antibiotics were again broadened to daptomycin, metronidazole, zosyn, and continued micafungin. Discontinued antibiotics when patient was made comfort measures only. He passed with family at the bedside on [**12-5**]. # Bowel perforation/Peri-anastomotic leak. This was discovered as part of the work up for his worsening leukocytosis after a period of improvement, abdominal tenderness, and worsening hemodynamics (AF with RVR, new borderline hypotension) requiring fluid boluses. His antimicrotics were broadened. Given his multiple comorbidities, he was not a surgical candidate. Therefore, a drain by IR was placed. # Hypoxemic respiratory failure. Patient was intubated given concern for tiring out and inability to maintain airway. He was treated for presumed pneumonia although no identifiable infectious source was identified via bronchoscopy. He was aggressively diuresed as his clinical picture improved initially off pressors. However, he was unable to be weaned off of the ventilator due to tachypnea/respiratory alkalosis and also ICU myopathy. It is likely that the respiratory alkalosis is [**3-3**] pain/discomfort, for which fentanyl was given. s/p trach placement. # Altered mental status/Delirium. [**3-3**] presumed pneumonia complicated by respiratory failure and later bowel perforation and pain. Required prolonged period of sedation holiday. Hence, had further MRI imaging of the head to rule out intracranial process and neurology consult. His mental status did not recover, patient made CMO. # Atrial fibrillation with rapid ventricular rate. Patient was on Digoxin and Metoprolol - discontinued when heart rates dropped to the 30s. # Anticoagulation/Supratherapeutic INR. Patient received vitamin K during his initial stay. Warfarin was held. He was switched to heparin gtt for anticoagulation given underlying AF, history of DVT, and the frequent possibility of requiring procedures. However, it was transitioned to heparin subcutaneously after discovery of the perianastomotic leak, requiring the possibility of surgical intervention. Anticoagulation was never restarted. # ICU myopathy. Suggested by his inability to be weaned off ventilator and persistent weakness. Evaluated by neurology. MRI C-spine without findings of cord compression. Medications on Admission: - ASpirin 81mg - Azathioprine 25mg daily - Calcium 1000mg daily - Cyclosporine 100mg daily - Flovent 50mcg diskus 2 puffs daily - Folic acid 1mg daily - Lasix 20mg daily - Metoprolol tartrate 50mg daily - MVI - Ramipril 2.5mg daily - Ranitidine 150mg [**Hospital1 **] - Remeron 15mg QHS - Triamcinolone 0.1% cream apply to b/l LE [**Hospital1 **] - Warfarin 2.5mg daily Discharge Medications: None. Discharge Disposition: Expired Discharge Diagnosis: primary: bowel perferation secondary: colon cancer sepsis s/p trach afib with RVR AMS Discharge Condition: deceased Discharge Instructions: none Followup Instructions: none

[ "428.20", "255.41", "998.13", "518.84", "V66.7", "153.9", "E849.8", "486", "427.1", "789.59", "V58.61", "038.9", "995.92", "707.03", "790.92", "293.0", "997.49", "428.0", "276.1", "569.83", "349.82", "E928.8", "785.52", "707.21", "427.31", "276.2", "359.9", "V42.0", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "86.04", "96.04", "31.1", "99.15", "96.6", "33.23", "96.72", "33.24", "54.91" ]

icd9pcs

[ [ [] ] ]

20810, 20819

16261, 20360

354, 537

20948, 20958

3159, 3159

21011, 21018

2573, 3140

20780, 20787

20840, 20927

20386, 20757

20982, 20988

1432, 1879

283, 316

565, 1413

3175, 11422

11458, 16238

1901, 2362

2378, 2557

32,216

158,834

4402

Discharge summary

report

Admission Date: [**2198-7-13**] Discharge Date: [**2198-9-3**] Date of Birth: [**2136-6-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3705**] Chief Complaint: transfer to MICU for management of persistent mental status changes Major Surgical or Invasive Procedure: s/p intubation s/p HD catheter placement History of Present Illness: 62 yo M h/o HTN, ETOH abuse, CLBP initially admitted for back pain/mulitple spinal surgeries, followed by SICU service, transferred to MICU for chronic post-op mental status changes. History obtained from daughter, [**Name (NI) 18933**], and chart, as pt presently not communicative. Pt was in USOH until around [**2198-5-28**] when pt fell while carrying refrigerator. Pt seen in ED [**6-26**] c/o back pain. L spine with ? OM. MRI recommended, but pt refused and was discharged form the ED. Pt again returned to [**Location **] [**7-13**] (this admission) c/o [**7-31**] back pain. MRI performed, demonstrating epidural abscess L4, L2-3 and L3-4 discitis, L3 compression fx. Started on ctx, vanc and flagyl and admitted to neurosurgery. On [**7-14**], pt started on 7 day course of vanc, flagyl, ctx. Pt taken to OR and had partial vertebrectomy of L2 and L3 and anterior fusion of L2-L4. Pt subsequently followed in SICU until [**7-17**] when he completed surgery with a total laminectomy of L4, multiple lumbar laminotomies L1-L5, and fusion L1-S1. Since that time pt has been minimally interactive per the primary surgical team. He was extubated [**2198-7-26**] and has remained minimally responsive with difficulty following commands. Of note pt had a abd U/S on [**7-23**] which revealed reversal of flow in the main portal vein and small ascites. MRI head on [**7-27**] without evidence of acute infarct or abnormal enhancement. Labs significant for persistently elevated AST, T bili, INR. CT head today negative. LP attempted on floor by surgical team was unsuccessful. Given persistent mental status changes the pt is being transferred to the MICU for further management. Past Medical History: hypertension Alcohol abuse chronic low back pain liver disease likely due to alcohol Social History: lives with daughter reports drinking >1 pint/day denies tobacco, denies drugs, denies IVDU Family History: non-contributory Physical Exam: Temp 100.1, Tm 101.8 last night 2200) BP 162/70 Pulse 88 Resp 11 O2 sat 100% ra I/O for today 2100/4600 Gen - somnolent, minimally rousable, intermittently follows simple commands HEENT - PER sluggishly RL, +icterus b/l, mucous membranes slightly dry Neck - no JVD Chest - Clear to auscultation bilaterally CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops Abd - Soft, nontender to deep palp, nondistended, with normoactive bowel sounds Extr - 1+ pitting edemain LE b/l. 2+ DP pulses bilaterally Neuro - as above Skin - No rash Pertinent Results: [**2198-7-13**] 05:36PM HIV [**Name (NI) 18934**] PT-16.7* PTT-35.2* INR(PT)-1.5* LACTATE-2.8* GLUCOSE-125* UREA N-6 CREAT-1.1 SODIUM-136 POTASSIUM-3.0* CHLORIDE-100 TOTAL CO2-26 ANION GAP-13 ALT(SGPT)-27 AST(SGOT)-89* ALK PHOS-315* TOT BILI-3.3* MAGNESIUM-1.2* HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc Ab-NEGATIVE HCV Ab-NEGATIVE WBC-4.9 RBC-4.35* HGB-15.4 HCT-45.5 MCV-105* MCH-35.3* MCHC-33.8 RDW-15.4 NEUTS-37.3* LYMPHS-50.0* MONOS-7.0 EOS-4.1* BASOS-1.6 PLT COUNT-140* SED RATE-60* . [**2198-7-31**] CEREBROSPINAL FLUID (CSF) WBC-170 RBC-[**Numeric Identifier 18935**]* Polys-77 Lymphs-6 Monos-3 Macroph-14 CEREBROSPINAL FLUID (CSF) TotProt-936* Glucose-79 CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS PCR- NEG CEREBROSPINAL FLUID (CSF) TB - PCR- NEG . [**2198-8-1**] PEP-UNUSUAL PA IgG-2206* IgA-754* IgM-53 . [**2198-8-17**] URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG . [**2198-8-17**] 12:58 pm STOOL CONSISTENCY: SOFT **FINAL REPORT [**2198-8-18**]** CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2198-8-18**]): REPORTED BY PHONE TO R. PFEIFFER, R.N. ON [**2198-8-18**] AT 0505. CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. . [**2198-8-23**] 07:20AM ALT-26 AST-56* LD(LDH)-243 AlkPhos-180* TotBili-4.4* [**2198-8-23**] 07:20AM WBC-9.9 RBC-3.22* Hgb-11.0* Hct-32.8* MCV-102* MCH-34.2* MCHC-33.6 RDW-17.8* Plt Ct-187 [**2198-8-23**] 07:20AM PT-22.7* PTT-43.5* INR(PT)-2.2* [**2198-8-23**] 07:20AM Glucose-99 UreaN-10 Creat-0.9 Na-135 K-3.8 Cl-100 HCO3-27 [**2198-8-23**] 07:20AM Albumin-3.3* Calcium-9.7 Phos-2.9 Mg-1.4* . . MR CERVICAL SPINE -- IMPRESSION: Limited evaluation of the cervical spine due to lack of axial images, but degenerative changes which are likely causing moderate canal stenosis at C3/4 and C6/7. -- Superior extent of the dorsal epidural phlegmon is the T12 level. Multilevel areas of ligamentum flavum thickening without high-grade canal stenosis. . . PATHOLOGY L3 DIAGNOSIS: 1. L3 bone (A-E): Focal osteonecrosis with granulation tissue and fibrosis. Features of acute osteomyelitis are not seen. Bone remodelling and marrow with fibrosis with chronic inflammation. Fibro- and hyaline-cartilage with reactive changes. 2. L3 vertebral body (F-I): Bony remodelling and degenerated fibrocartilage. Granulation tissue, fibrosis, fat necrosis in associated soft tissues. 3. L3-L4 disc (J): Granulation tissue and bone with remodelling. . CT SPINE ([**2198-7-19**]) IMPRESSION: 1. Status post posterior lumbar fusion; hardware intact and well positioned. Destruction of L3 and L4 consistent with the given history of osteomyelitis. 2. Asymmetrically enlarged left psoas muscle, a new finding from the MRI of [**2198-7-13**], concerning for an evolving abscess or postsurgical hematoma. This could be further evaluated by a dedicated abdominal CT. 3. No evidence of focal osteolysis to suggest advanced osteomyelitis within the thoracic spine, though see prior MRI for more sensitive assessment. 4. CT provides suboptimal intrathecal detail and cannot exclude an intrathecal hematoma or epidural abscess. See prior MRI. 5. Bilateral pleural effusions with associated atelectasis/consolidation. 6. Thoracic spondylosis as described above. . CT HEAD ([**2198-7-19**]) Comparison with the prior study of [**2197-7-22**] as well as a preceding examination from [**2195-7-10**] reveals no new intracranial hemorrhage, mass effect, or shift of normally midline structures. Once again, a small left frontal lobe hypodense region is seen, consistent with a chronic lacunar infarct. Considering patient age, there is mild peripheral cerebral atrophy detected. The surrounding osseous and soft tissue regions disclose moderate mucosal thickening within the sphenoid sinus, and to a minor extent within the posterior ethmoid sinuses. An air-fluid level is seen within the right maxillary sinus. These findings may relate to the intubated status of the patient, as would the noted mild opacification of both mastoid sinus complexes. CONCLUSION: No intracranial hemorrhage. See above report . LIVER US ([**2198-7-21**]) 1. No evidence of acute cholecystitis. Unchanged appearance of single large gallstone within the gallbladder. 2. Reversal of portal flow likely reflective of underlying cirrhotic pathology. Clinical correlation is recommended. Findings were discussed with Dr. [**Last Name (STitle) **]. [**Doctor Last Name 18936**] at approximately 10:20 p.m. on [**2198-7-21**] . SPINE MRI ([**2198-7-21**]) - Limited study secondary to both patient motion and metallic susceptibility artifact. - Probable large right paracentral disc protrusion/herniation at C3-C4 with probable severe stenosis along the right C3-C4 neural foramen. - Fluid within and tracking away from the left iliac bone graft harvest site demonstrates hematocrit effect and likely represents hematoma. The finding is unchanged in size when compared to [**2198-7-19**]. - Persistent left-sided pleural effusion. - Cervical, thoracic, and lumbar spondylosis without evidence of spondylolisthesis. - Osseous destruction of the C3 and C4 vertebral bodies, seen on recent CT examination, not well assessed secondary to magnetic susceptibility artifact. The findings are again concordant with patient's history of osteomyelitis. . ABDOMINAL US ([**2198-7-23**]) 1. Hematoma in left flank corresponding to area of clinical concern. 2. As seen [**2198-7-21**], ultrasound, a small amount of ascites, reversal of flow in the main portal vein, and gallstones. . HEAD MRI ([**2198-7-27**]) 1. No evidence of acute infarct or abnormal enhancement. 2. Mild brain atrophy and small vessel disease. 3. Extensive soft tissue changes in the sphenoid sinus and mastoid air cells. 4. Prominent CSF around the optic nerves bilaterally could be an incidental finding, but clinical correlation recommended to exclude papilledema. . Brief Hospital Course: SURGICAL COURSE: Patient was taken to operating room on [**2198-7-14**] for L3 fracture and spondylosis. PROCEDURE: 1. Partial vertebrectomy of L2 and L3. 2. Anterior fusion L2-L4. 3. Anterior debridement. 4. Autograft, allograft, bone morphogenic protein. No immediate post-op complications encountered. Patient was again taken to operating room on [**2198-7-18**] where the following procedures were performed: 1. Total laminectomy of L4. 2. Multiple lumbar laminotomies L1-L5. 3. Fusion L1-S1. 4. Segmental instrumentation L1-S1. 5. Autograft. Tissue was sent to pathology for evaluation. Patient had no immediate perioperative complications. Patient stayed in the surgical intensive care unit and had complicated extubation course secondary to delirium. Patient was transferred to the medical intensive care unit for workup of altered mental status. MICU course: Altered Mental status: hepatic encephalopathy vs. viral meningitis vs. seizure. Neuro recommended Fluoro-guided cervical tap and EEG. Pt started on lactulose and low-protein tube feeds, ammonia levels were followed. Pt was intubated to undergo these procedures, not for respiratory distress, so extubated following completion of procedures. CSF findings complicated by apparent traumatic tap but also showed large protein and significant WBCs. ID recommended starting Vanco, Ceftaz, Ampicillin, as well as Acyclovir b/c of concern for HSV. CSF sent for HSV PCR and Tb PCR, Brucellosis antibodies also sent. Ampicillin was d/c'd early, but Flagyl added, and other Abx continued pending cultures. EEG non-diagnostic. Pt was extubated on [**8-4**] with no change in mental status post-extubation. . Fever: Presentation concerning for pneumonia given CXR findings vs. viral meningitis vs. evolution of left psoas fluid collection. Pt was pan-cultured, one bottle Blood Cx growing gram positive cocci in clusters. CT abdomen/pelvis to assess left psoas collection. IR obtained sample from left psoas and flank/abdominal wall collections under CT-guidance, Gram stain showed PMNs but cultures had no growth. Infectious diseases was actively involved and guided team through prolonged workup. Only Klebsiella oxytoca was isolated from Sputum culture and was believed to be ventilator associated. Final workup did not reveal any pathogens including for negative tissue pathology from presumed epidural abscess. . Elevated Liver Enzymes: Found during prolonged hospitalization and concerning for history of long standing alcohol abuse. US findings suggested mild cirrhosis with portal hypertension and reversal of flow. Liver function was followed and continued to improve. . Coagulopathy: Most likely secondary to liver disease. Patient was given Vitamin K with no response. His INR was adjusted with FFP as needed for procedures with significant bleeding risk. . Hypertension: We manage blood pressure with beta-blocker and episodic hydralazine. . Fluids, electrolytes and nutrition: While intubated, patient received tube feeds, but was able to resume a regular diet without difficulty. Prophylaxis: Heparin SC, PPI, thiamine, folate, MVI were given throughout admission. Access: Multiple central and arterial lines were used while in surgical service and intensive care unit. Patient was only maintained with peripheral IV access in floor. Communication: daughter/HCP [**Name (NI) 18937**] [**Telephone/Fax (1) 18938**] (c) [**Telephone/Fax (1) 18939**] Course on Medicine Floor On the medicine floor all medications that could be contributing to change in mental status were discontinued including scopolamine and oxycodone. Hepatic encephalopathy was treated with rifaximin and lactulose. Antibiotics were discontinued because the only positive culture was sparse growth of klebsiella on sputum culture. Pt began to recover with decreasing need for supplemental O2, decreasing respiratory secretions, and improved mental status. Mental status improved to alert and oriented times 2. Pt started pulling out NG tube, so put on TPN for 2 days, then passed speech and swallow and TPN was discontinued. Also while on the floor the pt developed diarrhea, and c. dif toxin was positive. He was started on flagyl and treated for c. dif colitis. His lactulose was held given his diarrhea, but he was continued on Rifaximin. He is incontinent of stool so it is difficult to assess his bowel movements but his WBC count was normal as of [**2198-8-23**]. His mental status has remained slowly improved. The current assessment of his AMS is a likely combination of a mild hepatic encephalopathy with strong degree of delirium, most likely secondary to prolonged hospitalization. 1. Gammopathy: As part of workup for fracture, serum and urine electrophoresis were performed. Though urine protein electrophoresis only revealed albumin, serum study showed a polyclonal gammopathy with increases in IgG and IgA but not IgM. Findings discussed with clinical pathology who felt these were consistent with critical illness and may represent monoclonal gammopathy of unknown significance (MGUS). This condition can create a reactive polyclonal antibody pattern that can be elucidated with kappa to lambda ratio. In this case however, suspicion for malignancy is very low and we will defer any further investigation at this point. -- Patient will need to have follow-up SPEP in 6 months. 2. Hypomagnesemia: Patient has required replacement every [**4-26**] days, possibly secondary to increased stooling from Lactulose. Prescribed replacement orally every 4 days, he will need primary care physician to monitor as an outpatient when decision to continue or stop lactulose will be made. . Medications on Admission: meds on transfer: tylenol prn ablbuterol famotidine folate thiamine hep sc hydral 10 mg iv q6h ISS spironolactone 25 mg daily metoprolol 50 mg tid . meds at home: Aldactazide, asa, metoprolol, valium prn, vicodin prn, viagra prn Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: primary: epidural abscess and discitis . Secondary Altered Mental status alcoholic liver disease Discharge Condition: improved

[ "324.1", "303.90", "571.2", "008.45", "722.93", "572.2", "731.3", "E927", "401.9", "730.18", "263.0", "286.7", "518.0", "721.3", "275.2", "733.00", "572.3", "805.4", "273.9", "293.0", "291.81", "305.1", "998.12" ]

icd9cm

[ [ [] ] ]

[ "99.05", "81.08", "96.6", "83.95", "03.53", "81.62", "99.04", "77.79", "99.07", "03.31", "99.15", "84.52", "96.72", "81.63", "81.06", "80.51" ]

icd9pcs

[ [ [] ] ]

14873, 14931

8923, 9809

382, 424

15071, 15082

2954, 8900

2369, 2387

14952, 15050

14619, 14619

2402, 2935

275, 344

452, 2135

9824, 14593

2157, 2244

2260, 2353

14637, 14850

22,727

137,728

27966

Discharge summary

report

Admission Date: [**2183-5-15**] Discharge Date: [**2183-5-26**] Date of Birth: [**2104-3-5**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: 3VD, transferred from [**Hospital3 **] for CABG Major Surgical or Invasive Procedure: CABGx3 (LIMA-LAD, SVG-OM, SVG-PDA)[**5-21**] History of Present Illness: 79 YO f w/ breast cancer, h/o stable angina, with new +ETT s/p cath showing 3VD. Pt with recent dx breat cancer, had ETT for medical clearance for surgery. ETT/myocardial perfusion test positive for reversible anteroapical ischmia, LVEF 55%, apical hypokinesis. Sent for cath at [**Hospital6 5016**] showed 3VD (LAD proximal, LCX multiple occlusions , RCA-distal), AR 2+, mild inferior hypokinesis. She was then transferred to [**Hospital1 18**] for eval for CABG. Pt has been CP free since [**2178**]. Denies SOB/ orthopnea/PND/leg swelling, F/C/N/V. Reports 20# weight gain x2yrs. Able to amulate 20 blocks and 3 flights of stairs before SOB. Very active, able to ambulate. Past Medical History: R Breast cancer, surgery scheduled. Dr. [**Last Name (STitle) 38807**] also seen by Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10656**] @ [**Hospital1 18**] [**Telephone/Fax (1) 17070**] HTN, ^chol, arthritis, s/p T&A Social History: Lives in [**Location 7661**], MA with her 2 sons. widowed Retired from electronics Denies tobacco use or etoh or illicit drug use. Family History: mom-deceased-liver ca 52YO dad-deceased-dm 2 sisters alive and well-HTN son-dm Physical Exam: Admission T 98.4 BP 152/72 P63 R18 O2 94%RA GEN: awake and alert, NAD HEENT: normocephalic, atraumatic, no LAD Cardio: RRR, nl s1, s2, no murmurs. no carotid bruits. JVP wnl Lungs: Rales at bases B Breast: R nipple inverted. biopsy scar well healed. no lumps noted. no axillary lymphadenopathy bilaterally. L breast unremarkable Abd: SNTND +BS, no hepatosplenomegaly Ext: R femoral area clean and dry, no bruit, no hematoma. extremities-trace edema. DP/PT 2+ Discharge: VS- T98.4 BP 130/58 HR 81 RR 20 O2 93%/3LNP Gen: NAD Neuro: Alert, oriented, nonfocal exam Pulm: CTA-bilat CV RRR, sternum stable, incision CDI Abdm: soft, NT/ND +BS Ext: warm well perfused trace edema, Left LE w/steris from EVH Pertinent Results: [**2183-5-24**] 04:45AM BLOOD WBC-9.0 RBC-3.67* Hgb-10.9* Hct-31.0* MCV-84 MCH-29.8 MCHC-35.3* RDW-14.5 Plt Ct-133* [**2183-5-24**] 04:45AM BLOOD Glucose-95 UreaN-13 Creat-1.1 Na-137 K-4.2 Cl-104 HCO3-25 AnGap-12 [**2183-5-16**] 05:45AM BLOOD Glucose-90 UreaN-14 Creat-1.0 Na-146* K-3.8 Cl-111* HCO3-25 AnGap-14 [**2183-5-16**] 05:45AM BLOOD WBC-5.6 RBC-4.43 Hgb-12.7 Hct-36.9 MCV-83 MCH-28.7 MCHC-34.4 RDW-13.6 Plt Ct-181 Brief Hospital Course: 79yo woman transferred from [**Hospital6 5016**] for CABG after cardiac catherterization revealed 3VD. Pt was seen by cardiology thoracic surgery and the breast surgery service then brought to the operating room on [**5-21**]. She had coronary artery bypass grafting x3 with LIMA-LAD, SVG-OM, SVG-PDA. Please see OR report for full details. Patient tolerated the procedure well and was transferred from the OR to Cardiac surgery ICU on Neosynepherine and Propofol drips. Pt did well in immediate post-op period, anesthesia was reversed the patient was weaned from ventilator and successfully extubated. She remained hemodynamically stable however required neosynephrine infusion to maintain adequate BP control. This was weaned off on POD2, then she was transferred to the step down unit for continued postop care and cardiac rehabilitation. Once on the floor the patient had an uneventful postoperative course. Her activity level was advanced w/assistance of nursing and PT medicines were adjusted and on POD 5 it was decided she was stable and ready to be discharged home with visiting nurses. Medications on Admission: aspirin 81 mg po daily norvasc 5mg po daily atenolol 20mg po daily Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:*10 Tablet(s)* Refills:*0* 2. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day for 10 days. Disp:*20 Capsule, Sustained Release(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. 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. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed. Disp:*40 Tablet(s)* Refills:*0* 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 **] Home Healthcare Discharge Diagnosis: s/p CABGx3(LIMA-LAD, SVG-OM, SVG-PDA)[**5-21**]. PMH: Rt breast CA, HTN, ^chol, arthritis, s/p T&A Discharge Condition: good Discharge Instructions: Keep wounds clean and dry. OK to shower, no bathing or swimming. Take all medications as prescribed. Call for any fever, redness, or drainage from wounds. Followup Instructions: [**Hospital 409**] clinic in 2 weeks Dr [**Last Name (STitle) **] in 4 weeks Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**12-20**] weeks [**Last Name (NamePattern1) 68096**] in [**1-18**] weeks Breast Surgeon in [**1-18**] weeks(Dr [**Last Name (STitle) 38807**] @ [**Hospital3 **] or Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10656**] @ [**Hospital1 18**] [**Telephone/Fax (1) 17070**] Completed by:[**2183-5-26**]

[ "041.4", "599.0", "564.00", "793.1", "174.9", "411.1", "414.01", "272.0", "716.90", "401.9" ]

icd9cm

[ [ [] ] ]

[ "99.04", "88.72", "36.12", "39.61", "36.15" ]

icd9pcs

[ [ [] ] ]

4937, 5000

2821, 3918

368, 415

5143, 5150

2374, 2798

5353, 5825

1552, 1632

4036, 4914

5021, 5122

3944, 4013

5174, 5330

1647, 2355

281, 330

443, 1123

1145, 1387

1403, 1536

31,929

195,133

51858

Discharge summary

report

Admission Date: [**2178-11-17**] Discharge Date: [**2178-11-21**] Date of Birth: [**2103-4-18**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1234**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 107394**] is a 75 year old male with history of COPD, CAD s/p CABGx3, CHF, and Afib who is transferred from outside hospital with increasing shortness of breath. The patient is followed by Dr. [**Last Name (STitle) 1728**], Dr. [**Last Name (STitle) **], and Dr. [**Last Name (STitle) 575**] for his multiple medical conditions. He was placed on portable oxygen at home for nightly use for the last two weeks. He recently took a trip to Scottsdale, AZ. On the flight the patient experienced an episode of shortness of breath. He describes a "choking" feeling, unable to catch his breath. The patient was placed on oxygen for the remainder of the flight. The next day the patient experience another episode on dyspnea with excessive, productive cough while in the car with family members. The patient describes the sputum as a white "gluey" material. He is currently denying fever/chills. . OSH Course The patient went to the ED for assessment of his dyspnea. He was given narcotics for a secondary complaint of torticullis which resulted in altered mental status. The patient was admitted for five days. He received a work-up for pneumonia, CHF exacerbation, and COPD exacerbation. On admission the patient had an elevated BNP of 2813, a CK MB 0.5, and troponin-I of 0.06. OSH CXR showed right-sided infiltrate. An EKG showed incomplete RBBB, nonspecific ST changes, and no evidence of acute ischemic change. LENIs negative for DVT. ECHO showed EF of 45-50%, aortic valve thickening and calcification, with elevated RV pressures. All of these findings were consistent with findings on previous Echo at [**Hospital1 18**]. The patient was started on ceftriaxone for suspected pneumonia. The patient was given 20mg torsemide daily. Past Medical History: COPD FEV1/FVC 82% [**2178-11-6**] CAD s/p CABG ([**2161**]) LIMA to LAD, SVG to PDA, SG to OM [**2178-8-19**]: Cath - 1. Coronary angiography in this right dominant system revealed three vessel disease conduit vessels from prior CABG. The LMCA, LAD and LCx were occluded. The RCA had a 60% mid-vessel stenosis and an occluded pDA. 2. Arterial conduit arteriography revealed the LIMA to be widely patent. The SVG-OM was widely patent. SVG to the PDA the patent with 60-70% proximal diffuse disease and distal 50% disease. 3. Resting hemodynamics revealed elevated right and left sided filling pressure with RVEDP of 18 mmHg and pulmonary capillary wedge pressure of 28 mmHg. The cardiac index was preserved at 3.1 l/min/m2. Liver dysfunction, NOS HTN . PSHx CABGx3 Hypercholesterolemia Atrial flutter s/p ablation Osteoarthritis Fatty Liver EtOH abuse Anemia AV Wenckebach Mild Aortic Stenosis Barrett's Esophagus Carotid Artery Disease Chronic Kidney Disease SMA Stenosis MEDICATIONS ON TRANSFER Advair 500/50 [**Hospital1 **] Albuterol 2 puffs every 4 hours Aspirin 81mg daily Lescol 80 mg daily Plavix 75mg Zetia 10 mg daily [**Doctor First Name **] 180 mg daily Prilosec 20 mg daily Torsemide 80 mg daily Fluconazole [**12-30**] sprays daily Spiriva 1 capsule daily Multivitamin Calcium Vitamin C Potassium 60 mg daily Social History: Social history is significant for the absence of current tobacco use. There is past history of EtOH abuse, pt reports he currently drinks 2-3 glasses of wine nightly. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS: Temp 96.5, BP 130/70, HR 72, RR 24, O2Sat 96/2L Gen: Patient appears fatigued, in mild respiratory distress. Skin: Skin warm and moist. Nails without clubbing or cyanosis. No suspicious nevi. No rash, petechiae, or ecchymoses. HEENT: Head NC/AT. Sclerae anicteric, conjunctiva pink. PERRLA, EOMs intact. Oropharynx clear and nonerythematous. Mucous membranes moist. Trachea midline. Neck supple. Tenderness and muscle tension on posterior right neck. Thyroid not enlarged and without nodules. No LAD. Cardiac: JVP 12 cm above the sternal angle. Carotid pulses 2+ bilat.; upstrokes brisk; without bruits. PMI slightly deviated laterally. S1 & S2 normal. No murmurs, rubs, or gallops. Pulmonary: Left basilar crackles, markedly decreased breath sounds at right base halfway up. Anterior wheezes. Abdomen: Firm, nontender, moderately distended. BS present in all 4 quadrants. Fluid wave present. positive for shifting dullness. sacral pitting edema. GU:Not performed Extremities: DP pulses 1+ bilat. Good capillary refill bilat. 3+ pitting edema in lower extremities bilaterally. Edema extends up to the thigh and abdomen bilaterally. Anterior left calf is erythematous but nontender. MSK: Neck tenderness with limited ROM. Limited ROM in lower extremities MMSE: AOx3. Rest of MMSE deferred. CNs: II-XII intact to direct testing. Motor: Tone normal. Strength 4/5 throughout. DTRs: patellar 2+ bilaterally. Coordination: Rapid alternating movements intact. No asterisix. Pertinent Results: ADMISSION [**2178-11-17**] 07:30PM GLUCOSE-110* UREA N-22* CREAT-0.9 SODIUM-137 POTASSIUM-4.9 CHLORIDE-99 TOTAL CO2-30 ANION GAP-13 [**2178-11-17**] 07:30PM CALCIUM-9.8 PHOSPHATE-2.3* MAGNESIUM-2.0 [**2178-11-17**] 07:30PM WBC-6.9 RBC-3.15* HGB-9.6* HCT-29.6* MCV-94 MCH-30.4 MCHC-32.3 RDW-14.7 [**2178-11-17**] 07:30PM proBNP-6022* CXR: Right sided pleural effusion halfway up, left sided blunting, overall c/w overload [**11-19**] CT ABDOMEN AND PELVIS: There is a large acute left retroperitoneal hematoma extending along the left psoas muscle, which is expanded. The hematoma is acute in appearance with dependent high-attenuation material consistent with layering phenomenon. There is also focal increased attenuation at the posterior aspect of the hematoma on the enhanced CT suggesting active extravasation. The hematoma measures 10 x 9 x 16 cm in dimensions. [**2178-11-19**] 02:53PM BLOOD Hct-17.8*# [**2178-11-20**] 08:29PM BLOOD WBC-33.48*# RBC-3.08* Hgb-9.6* Hct-25.8* MCV-83.9 MCH-31.0 MCHC-37.0* RDW-15.5 Plt Ct-157# [**2178-11-21**] 03:19AM BLOOD WBC-32.1* RBC-3.53* Hgb-11.0* Hct-29.0* MCV-82 MCH-31.1 MCHC-37.9* RDW-15.4 Plt Ct-176 [**2178-11-21**] 12:04AM BLOOD PT-18.3* PTT-36.5* INR(PT)-1.7* [**2178-11-20**] 09:12AM BLOOD Glucose-153* UreaN-30* Creat-1.5* Na-140 K-4.4 Cl-100 HCO3-28 AnGap-16 [**2178-11-21**] 03:19AM BLOOD Glucose-166* UreaN-41* Creat-2.1* Na-137 K-4.3 Cl-96 HCO3-27 AnGap-18 [**2178-11-20**] 08:29PM BLOOD ALT-40 AST-74* AlkPhos-89 TotBili-3.2* [**2178-11-19**] 04:25PM BLOOD CK-MB-5 cTropnT-0.05* [**2178-11-20**] 04:45AM BLOOD CK-MB-24* MB Indx-4.9 cTropnT-0.72* [**2178-11-20**] 09:12AM BLOOD CK-MB-25* MB Indx-4.8 cTropnT-0.90* [**2178-11-20**] 02:07PM BLOOD Lactate-3.0* Brief Hospital Course: CONGESTIVE HEART FAILURE, ACUTE ON CHRONIC SYSTOLIC The patient was admitted with anasarca and a 2L oxygen requirement. He was started on IV diuretics, responding to 60mg IV torsemide. FALL The patient sustained a fall from a chair on [**2178-11-18**], landing on his buttocks without head trauma or LOC. Hip films were obtained to consider skeletal damage or fracture, which were negative. RETROPERITONEAL BLEED On the morning of [**2178-11-19**], the patient awoke with sharp left lower quadrant pain that he felt was radiating up from his left leg. His abdomen was more distended, and a CT was obtained that showed an acute retroperitoneal hematoma. The patient was initially very hemodynamically stable, but later became tachycardic and hypotensive, and was transferred to the medical intensive care unit. He was transfused units, including one irradiated unit that was given via emergency release when the patient began to decompensate. PNEUMONIA The patient was admitted in a hospital in Scottsdale, AZ with shortness of breath and fever. He was treated with ceftriazone, starting on [**2178-11-11**]. ANEMIA The patient was found to have iron deficiency anemia, with blood loss anemia on top of that after developing the RP bleed. He was transfused X #units. MSK PAIN The patient has had pain in his thighs bilaterally for [**3-1**] weeks. He describes the pain as sometimes achy and sometimes sharp. - CK wnl - Tylenol PRN; no more than 2g total daily . #ASCITES/CIRRHOSIS Previous U/S in [**Month (only) 116**] showed portal vein is patent with normal centripetal flow. Could be right heart related, but need to consider other factors. No h/o repeated blood transfusions. - Hep serologies pending When patient decompensated, urgent vascular surgical consult was obtained. Patient was seen immediately, and asked to have the patient be transfarred to an ICU as well as transfuse 3-4U of blood. Attending surgeon was notified and reviwed the scans - this was not an operative situation. As the patient was not doing well, possible intubation was discussed with the fmaily. The patient's abdomen gradually became more distended and firm with elevated bladder pressures. The patient was also becoming more obtunded. He was intubated, and general surgery was also consulted by the medical team since vascular did not feel that this patient should go to the OR. General surgery agreed. The patient was eventually transfered to the surgical service and underwent agressive fluid/blood product resusitation and optimizatrion of his ventilatory settings. He stopped making urine, required paralysis and sedation due to his compartment syndrome in order to ventilate him. Discussions were failry continuous with the family who stated/decided that the patient would never want to live like this, so he was made CMO in discuassion with all of his family and the attending physician. [**Name10 (NameIs) **] was withdrawn after the paralytics wore off and the patient expired soon thereafter Medications on Admission: Advair 500/50 [**Hospital1 **] Albuterol 2 puffs every 4 hours Aspirin 81mg daily Lescol 80 mg daily Plavix 75mg Zetia 10 mg daily [**Doctor First Name **] 180 mg daily Prilosec 20 mg daily Torsemide 80 mg daily Fluconazole [**12-30**] sprays daily Spiriva 1 capsule daily Multivitamin Calcium Vitamin C Potassium 60 mg daily Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: retroperitoneal bleed abdominal compartment syndrome ventilatory failure renal failure Discharge Condition: expired Discharge Instructions: none Followup Instructions: none Completed by:[**2178-12-27**]

[ "E884.2", "493.20", "571.5", "427.31", "428.0", "518.81", "868.04", "486", "585.9", "530.85", "428.23", "E849.7", "V45.81", "958.4", "424.1", "789.59", "285.29", "427.32", "958.93", "584.9" ]

icd9cm

[ [ [] ] ]

[ "96.71", "99.07", "38.93", "96.04", "99.04", "99.05" ]

icd9pcs

[ [ [] ] ]

10420, 10429

7019, 10014

336, 342

10559, 10568

5265, 6996

10621, 10657

3674, 3756

10391, 10397

10450, 10538

10040, 10368

10592, 10598

3771, 5246

277, 298

371, 2125

2147, 3473

3489, 3658

14,999

132,503

28013

Discharge summary

report

Admission Date: [**2155-8-15**] Discharge Date: [**2155-8-20**] Date of Birth: [**2083-5-7**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: Myocardial infarction Major Surgical or Invasive Procedure: 1. Placement of extracorporeal membrane oxygenation circuit and cannulae in the catheterization laboratory. 2. Emergent coronary artery bypass grafting x3 with the saphenous vein grafts to the marginal artery, left anterior descending artery and right coronary artery. 3. Placement of Abiomed BVS 5000 left ventricular assist device. 4. Bilateral groin exploration with repair of arterial and venous puncture sites. 5. Exploration, evacuation of hematoma 6. Exploratory laparotomy, left colectomy History of Present Illness: This is a 72-year-old male who had a h/o coronary artery disease and underwent a left anterior descending artery stent about a month ago. He persisted in having chest pains and he was brought back to the catheterization lab in an attempt to angioplasty his left anterior descending artery as well as his right coronary artery. During his catheterization, he developed a clot in his left main and left anterior descending artery. He went into ventricular tachycardia and arrested. Chest compressions were initiated. CT surgery was called down to the catheterization lab where we set up an ECMO circuit and reinserted a 15-French cannula in the right femoral artery percutaneously followed by a 24-French venous cannula up to the right femoral vein percutaneously. The ECMO was initiated and we stopped chest compressions. We then brought him to the operating room emergently for a coronary artery bypass grafting and a possible left ventricular assist device placement. We had discussed the risks and benefits with his daughter, who agreed with us to proceed. Past Medical History: Hypercholesterolemia, HTN, CAD s/p LAD stenting [**7-1**], severe COPD, pituitary disorder, carotid a. dz s/p L CEA [**2152**], ?h/o TIA, BPH, herpes PSH: L CEA, orchiectomy age 16 after trauma, R arm injury, b/l cataract surgery Social History: Patient is married with three adult children. He previously was a truck driver. Family History: No h/o CAD Physical Exam: expired Pertinent Results: [**2155-8-20**] 07:20AM BLOOD WBC-16.4* RBC-3.85* Hgb-12.2* Hct-33.3* MCV-86 MCH-31.7 MCHC-36.7* RDW-15.5 Plt Ct-108* [**2155-8-20**] 07:20AM BLOOD PT-26.1* PTT-63.1* INR(PT)-2.7* [**2155-8-20**] 07:20AM BLOOD UreaN-36* Creat-4.0* Na-139 Cl-92* HCO3-18* [**2155-8-20**] 07:20AM BLOOD ALT-819* AST-4319* AlkPhos-161* TotBili-8.6* [**2155-8-20**] 10:52AM BLOOD Type-ART pO2-74* pCO2-43 pH-7.22* calTCO2-19* Base XS--9 [**2155-8-20**] 10:52AM BLOOD Glucose-88 Lactate-19.8* K-5.6* Brief Hospital Course: On [**2155-8-15**], Mr. [**Known lastname **] was admitted to the cardiac surgery service under the care of Dr. [**Last Name (STitle) 914**] following an emergent CABG. For details of the operation please see Dr.[**Name (NI) 9379**] operative report. Post-operatively Mr. [**Known lastname **] had a very complicated course. He was in critical condition from the start. He was cared for in the CSRU with a left ventricular assist device. He underwent an exploratory laparotomy on [**8-18**] with resection of his left colon secondary to ischemic colitis. Mr. [**Known lastname 68200**] cardiovascular status never recovered from the initial infarct, and required defibrillation multiple times throughout the course of his ICU stay. On [**2155-8-20**], after long discussion with family members, it was decided to make him comfort measures only. He expired at 2:35 pm. Medications on Admission: ASA 325, Zocor 20, Quinine sulfate 260, Plavix 75, Minitran 0.2mg patch 2 patches qAM, Combivent INH prn, Spiriva INH qd, Lisinopril-HCTZ 20-12.5mg qAM, Lopid 600", HCTZ 25 q M/W/F, Lasix 40prn for leg swelling, Norvasc 7.5", Folic acid 1mg', KCL 20meq', Bromocriptine 2.5", Doxazosin 2 qhs, Imdur 30, Acyclovir 400 prn herpes outbreaks, Centrum silver Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Myocardial infarction Discharge Condition: Expired Followup Instructions: N/A

[ "998.11", "401.9", "785.51", "496", "557.0", "V66.7", "349.1", "584.5", "427.1", "276.7", "272.4", "427.5", "410.11", "414.01", "997.1" ]

icd9cm

[ [ [] ] ]

[ "39.32", "36.13", "88.72", "86.09", "37.61", "99.05", "99.62", "96.71", "34.91", "37.22", "39.61", "54.21", "39.31", "37.66", "96.04", "39.65", "37.78", "45.76", "54.63", "99.07", "38.93", "45.75", "99.04", "34.03", "39.95" ]

icd9pcs

[ [ [] ] ]

4152, 4161

2852, 3721

341, 840

4227, 4237

2350, 2829

4260, 4267

2295, 2307

4124, 4129

4182, 4206

3747, 4101

2322, 2331

280, 303

868, 1928

1950, 2182

2198, 2279

61,825

181,643

43257

Discharge summary

report

Admission Date: [**2132-8-3**] Discharge Date: [**2132-8-7**] Date of Birth: [**2065-10-3**] Sex: M Service: MEDICINE Allergies: Atenolol / Ms Contin Attending:[**First Name3 (LF) 1253**] Chief Complaint: COPD exacerbation Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 13621**] is a 66-year-old smoker with a history of COPD, recent DVT now off coumadin, AAA, and multiple admissions for pneumonia who presented with dyspnea and is transferred to the [**Hospital Unit Name 153**] for management of COPD exacerbation requiring bipap. He has been hospitalized multiple times for COPD exacerbation and pneumonia requiring ICU admission and intubation on a single occasion in [**2131-9-23**], and most recently was discharged in [**Month (only) **] [**2131**] to rehab and has been home for a few weeks. At baseline he is unable to walk a few steps without getting short of breath and he is not on supplemental O2 at home. He was in his usual state of health when he developed worsening of his chronic, productive cough of white sputum, worsening dyspnea, and tachypnea last night. His symptoms progressed and he activated EMS. Per report, O2 sat on room air upon their arrival was 81%. Of note, he was diagnosed with a right segmental PE and LLE DVT in [**2131-12-24**] and was on warfarin until [**2132-5-22**] when it was discontinued because of concerns of medication adherence. In the ED initial vital signs were 97.5 116 158/94 28 95%O2. His exam was notable for minimal air sounds and mild wheezes, and he was intermittently tachypneic to the high 30s, with tachycardia to the 130s. A CXR demonstrated left sided infiltrate, which was confirmed on a chest CTA that was negative for PE but demonstrated multifocal pneumonia. He was placed on cpap and given nebs, solumedrol 125 mg iv x1, ceftriaxone, and levofloxacin. Review of Systems: (+) Per HPI (-) Denies fever, chest pain, nausea, vomiting, diarrhea, and rash. Past Medical History: - Right segmental PE and LLE DVT in [**12/2131**], on Coumadin - COPD, admission to [**Hospital1 2177**] with COPD exacerbation last winter, not on home O2. - AAA - HTN - Hyperlipidemia - Gout - Osteoporosis, history of L1 burst fracture on chronic opioids for pain relief, l3 compresion fracture Social History: Home: lives alone, son very involved, visits daily. EtOH: 4 beers per day. Drugs: Denies. Tobacco: currently smoking 4 cigarrettes daily, trying to cut back and has >80 PPY history Family History: No history of CAD. No history of clotting disorder. Physical Exam: GEN: NAD, cachectic, anxious VS: 113 118/68 26 100% cpap 10/5 off HEENT: MMM, no OP lesions, JVP not distended CV: RR, NL S1S2 no S3S4 MRG PULM: decreased BS b/l ABD: BS+, soft, NTND, no masses or HSM LIMBS: No LE edema, no tremors or asterixis, no clubbing SKIN: No rashes or skin breakdown NEURO: CNII-XII nonfocal, strength 5/5 of the upper and lower extremities On Discharge: Tm: 97.7 T:97.7 BP:123/85 P:89 R:18 O2:96%RA (95-97 RA) General: Alert, oriented, no acute distress. Cachectic appearing. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Minimal air entry. Inspiratory wheezes bilaterally. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. LEs are wasted. Pertinent Results: Leukocytosis on admission eventually trended down: (On admission) [**2132-8-3**] 03:10AM WBC-30.6*# RBC-5.22 HGB-15.4 HCT-47.6# MCV-91 MCH-29.6 MCHC-32.4 RDW-14.2 NEUTS-89* BANDS-2 LYMPHS-3* MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 (-)UA on admission BCx had NGTD upon discharge. [**2132-8-3**] CXR IMPRESSION: Interval development of left mid lung hazy opacity , concerning for pneumonia. [**2132-8-4**] Chest X ray IMPRESSION: Unchanged left mid lung field opacity concerning for pneumonia. [**2132-8-3**] CTA CT CHEST WITH AND WITHOUT CONTRAST: There is no pulmonary embolism. The pulmonary arterial vasculature is patent to the segmental level. The aorta demonstrates no acute pathology. The remaining great mediastinal vessels are unremarkable. The heart is normal in size without pericardial effusions. Moderate coronary calcifications are again noted. Small mediastinal lymph nodes are not pathologically enlarged, compatible with the underlying pneumonia. There is no definitive hilar or axillary lymphadenopathy. Again noted are severe emphysematous changes of the lung parenchyma, with upper lobe predominance and also parasagittal bulla in the anterior lungs. There is interval increase of honeycombing opacity in the left upper lobe, with persistent left lower lobe consolidation, compatible with worsening infectious process in the left lung. The right lung base opacification from prior pneumonia appears to decrease in size. There is no pneumothorax or pleural effusion. The central tracheobronchial tree remains patent. The study is not designed for subdiaphragmatic diagnosis. An abdominal aortic aneurysm is not adequately assessed in the current study, measuring up to 30 mm in diameter (image 3:127). BONE WINDOW: Multilevel degenerative changes are mild to moderate. Left-lateral spinal fusion rod is unchanged in position. Mild-to-moderate loss of vertebral heights are again noted. There are no suspicious lytic or sclerotic lesions. IMPRESSION: 1. Interval worsening of left-sided multifocal pneumonia. Near-resolution of right lower lobe pneumonia. 2. No PE or acute aortic dissection. Incidental note of an abdominal aortic aneurysm. 3. Unchanged severe centrilobular emphysema. Lower extremity ultrasound [**2132-8-6**]: FINDINGS: There is normal compressibility, color Doppler and pulse-wave Doppler waveforms of the left common femoral vein, popliteal vein, posterior tibial and peroneal veins. There is non-occlusive thrombus in the superficial femoral vein on the left. Overall, this represents partial resorption of clot seen on the prior exam [**2131-12-30**]. There is normal compressibility, color Doppler and pulse-wave Doppler of the right common femoral, superficial femoral, popliteal veins. There is thrombus seen within the duplicated posterior tibial veins. The right peroneal vein was not seen. IMPRESSION: 1. Partially resorbed clot in the left popliteal vein with persistent thrombus in the left superficial femoral vein. 2. New thrombus in the right posterior tibial veins. Brief Hospital Course: 66 yo male with hx of severe COPD, recent DVT now off coumadin, AAA, and multiple admissions for COPD exacerbations and PNA, p/w COPD exacerbation and found to have multifocal PNA on CT. Patient was admitted with shortness of breath, treated with nebs in the ER, and ultimately required bipap. Patient was transferred to the ICU, where he was weaned off Bipap and eventually tolerating O2 via NC. He was started on Solumedrol and Levaquin/Ceftriaxone. Patient was transferred to the floor on O2 via NC and converted to PO Prednisone. We also stopped the ceftriaxone and continued the levaquin. Patient eventually was tolerating RA and was discharged home with VNA services. Problem [**Name (NI) **]: 1. COPD Exacerbation: Patient started on ceftriaxone, levaquin, and IV solumedrol on admission and required bipap. He was quickly weaned off bipap and continued on abx and steroids. He rapidly improved clinically and was saturating well on RA upon discharge. He was discharged and instructed to take 50 mg Prednisone daily x 3 days, and taper by 10 every three days thereafter. 2. Multifocal PNA: Patient had leukocytosis on admission and found to have evidence of multifocal PNA on CT. He was started on Levaquin and Ceftriaxone. Blood cultures were negative as was legionella antigen. The leukocytosis quickly resolved over the hospitalization and the ceftriaxone was discharged once patient was transferred to general medicine floor. Patient was discharged after completing a 5 day course of his levaquin. 3. Cavitary Lung Lesion: Seemed to have decreased based on CT done on admission. Patient was intructed to follow up with pulmonologist and PCP. [**Name10 (NameIs) **] was read as negative. 4. DVT: Patient received duplex ultrasound that demonstrated resolving clot in Left superficial femoral. New thrombus found in posteriar tibial. Patient was kept on prophylaxsis heparin dosing. 5. Hyperglycemia: Patient was on insulin sliding scale secondary to steroid use. Patient was also started on basal NPH when he received his dose of steroids. He was instructed to use the NPH at home, starting with 12 units, when he takes his steroid dose every morning. He was instructed to check his glucose via glucometer to make sure sugars were stable. He was instructed to contact PCP with results so that he can taper his daily insulin shot to prevent hypoglycemia. 6. Hyperlipidemia: Stable on atorvastatin. 7. Hypertension: Stable. No medications were required. 8. Osteoporosis: Patient continued on Vitamin D. Patient remained DNR, but not DNI during this hospitalization. Patient was also advised to stop smoking. He was given scripts for nicotine patches and gum. Medications on Admission: ALBUTEROL SULFATE - 0.63 mg/3 mL Solution for Nebulization - [**11-24**] Solution(s) inhaled every 4-6 hours as needed for shortness of breath or wheezing ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs inh 4 times a day prn ALLOPURINOL - 300 mg Tablet - 0.5 (One half) Tablet(s) by mouth once a day ATORVASTATIN [LIPITOR] - 10 mg Tablet - 1 Tablet(s) by mouth daily CODEINE-GUAIFENESIN - 100 mg-10 mg/5 mL Liquid - [**3-31**] mL by mouth every six (6) hours as needed for cough FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose Disk with Device - 1 puff(s) inhaled twice a day rinse after use OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - 1 to 2 Tablet(s) by mouth four times a day as needed for pain RANITIDINE HCL - 150 mg Tablet - 1 Tablet(s) by mouth twice a day RISEDRONATE [ACTONEL] - 35 mg Tablet - 1 Tablet(s) by mouth weekly with full glass of water TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule, w/Inhalation Device - contents of one capsule by inhaler once daily TRAZODONE - 50 mg Tablet - 0.5 (One half) Tablet(s) by mouth qhs DOCUSATE SODIUM - 100 mg Capsule - 2 Capsule(s) by mouth once a day ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 400 unit Capsule - 2 (Two) Capsule(s) by mouth once a day (total of 800 units) FERROUS SULFATE - 325 mg (65 mg Iron) Tablet - 1 Tablet(s) by mouth once a day FOOD SUPPLEMENT, LACTOSE-FREE [ENSURE] - Liquid - 1 can by mouth tid with each meal NICOTINE - 21 mg/24 hour Patch 24 hr - apply to skin daily SENNA - 8.6 mg Capsule - 1 Capsule(s) by mouth at bedtime as needed Discharge Medications: 1. NPH Insulin Human Recomb 100 unit/mL (3 mL) Insulin Pen Sig: One (1) 12 Units Subcutaneous QAM. Disp:*1 Pens* Refills:*0* 2. Lancets Misc Sig: One (1) lancet Miscellaneous four times a day for 2 weeks. Disp:*1 Box of Lancets* Refills:*0* 3. Blood Glucose Monitor Kit Kit Sig: One (1) Miscellaneous four times a day: Please dispense glucometer and testing strips. Disp:*1 Kit* Refills:*0* 4. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization Sig: [**11-24**] solutions Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation four times a day as needed for shortness of breath or wheezing. 6. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Codeine-Guaifenesin 10-100 mg/5 mL Liquid Sig: [**3-31**] ml PO every six (6) hours as needed for cough. 9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day. 12. Risedronate 35 mg Tablet Sig: One (1) Tablet PO once a week. 13. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) capsule Inhalation once a day. 14. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 15. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO once a day. 16. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Ensure Liquid Sig: One (1) can PO three times a day. 18. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) patch Transdermal once a day: Please take off before going to bed. Disp:*30 patch* Refills:*0* 19. Senna 8.6 mg Capsule Sig: One (1) Tablet PO at bedtime as needed for Constipation. 20. Nicotine (Polacrilex) 2 mg Gum Sig: One (1) piece of gum Buccal Q1-2 Hours. Disp:*48 Gum Pieces* Refills:*0* 21. Prednisone 10 mg Tablet Sig: Five (5) Tablet PO once a day: Please take 5 tabs each day for 3 days ([**8-8**] - [**8-10**]) then take 4 tabs each day for 3 days ([**Date range (1) **]) then take 3 tabs each day for 3 days ([**Date range (1) 4215**]) then take 2 tabs each day for 3 days ([**Date range (1) 17341**]) then take 1 tab each day for 3 days ([**Date range (1) 17342**]). Disp:*45 Tablet(s)* Refills:*0* 22. Ergocalciferol (Vitamin D2) 400 unit Tablet Sig: Two (2) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary Diagnosis: 1. COPD Exacerbation 2. Multifocal Pneumonia Secondary Diagnoses: - Lower extremity deep vein thrombosis - Abdominal aortic aneurysm - Hypertension - Hyperlipidemia - Gout - Osteoporosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came to the hospital because you were very short of breath. You were found to have pneumonia and a COPD flare. You were admitted to the intensive care unit and given IV steroids and antibiotics as well as started on a breathing machine called Bipap. Your breathing improved and you were discharged home in good condition. Medications Added This Admission: 1. Prednisone 50 mg. Please take 50 mg for 3 more days, then take 40 mg for 3 more days, then take 30 mg for 3 days, then 20 mg for 3 days, then 10 mg for 3 days. 2. NPH Insulin - 12 units Please take 12 units of insulin when you take your prednisone and check your glucose in the morning, before meals, and before going to bed. If sugars are below 100 or you feel lightheaded/dizzy/palpitations/sweating please notify your primary care physician immediately and do not take anymore insulin. You will need to talk to your primary care doctor to decide when to stop this medication 3. Nicotine patch and Nicotine gum Please stop smoking. Smoking will only worsen your other chronic medical issues. You have been provided with a prescription for smoking cessation aids and we strongly encourage you to use them. Followup Instructions: You have the following scheduled appointments: Primary care Nurse Practitioner: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**] Tuesday, [**2132-8-12**]:00 am [**Location (un) **] [**Hospital Ward Name 23**] building, North Suite Pulmonologist: Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] Tuesday, [**8-26**] at 10 am (please arrive at 9:40 for your breathing tests) [**Hospital Ward Name 23**] building [**Location (un) 436**]

[ "249.00", "453.42", "274.9", "V58.69", "401.9", "724.5", "491.21", "V58.61", "272.4", "V15.82", "441.4", "733.13", "518.89", "V58.65", "E932.0", "486", "733.00", "453.51" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

13467, 13524

6634, 9312

297, 303

13775, 13775

3574, 6611

15124, 15663

2551, 2605

10921, 13444

13545, 13545

9338, 10898

13926, 15101

2620, 2988

13631, 13754

3002, 3555

1934, 2015

240, 259

331, 1915

13564, 13610

13790, 13902

2037, 2337

2353, 2535

1,324

140,065

8453

Discharge summary

report

Admission Date: [**2133-4-8**] Discharge Date: [**2133-4-14**] Date of Birth: [**2092-1-21**] Sex: M Service: General Surgery CHIEF COMPLAINT: Recurrent pancreatic pseudocyst. HISTORY OF PRESENT ILLNESS: The patient is a 41-year-old male who presented to Dr. [**Last Name (STitle) 29797**] with recurrent abdominal pain radiating to the back. He had a previous history of acute pancreatitis in 12/99 complicated by pancreatic pseudocyst for which he had a gastrostomy in 3/00. A month prior to admission he complained of abdominal pain and an abdominal CT revealed recurrent pancreatic pseudocyst. He then had an ERCP which showed complete cut off of the PD at the level of the mid body of the pancreas, pancreas divisum. PAST MEDICAL HISTORY: As above. MEDICATIONS: On admission, Prilosec, Aleve. ALLERGIES: None known. HOSPITAL COURSE: Mr. [**Known lastname 1968**] [**Last Name (Titles) 1834**] an elective distal pancreatectomy and splenectomy on [**2133-4-8**] by Dr. [**Last Name (STitle) 468**] during which fibrotic pancreas and a large cyst was seen. Postoperatively he was admitted to the Intensive Care Unit for close monitoring. He had an epidural for analgesia. His condition remained stable and he was transferred out of the Intensive Care Unit. On postoperative day #3 he was started on po sips which he tolerated well. He was then slowly advanced to a regular diet as he tolerated. His postoperative course has been otherwise uncomplicated. Prior to discharge his JP output was sent for amylase check which revealed an amylase of 92,700. The patient is going to go home with the JP drain and with VNA care. He will follow-up with Dr. [**Last Name (STitle) 468**] in clinic. DISCHARGE MEDICATIONS: Percocet 1-2 tablets po q 4-6 hours prn. Follow-up with Dr. [**Last Name (STitle) 468**] in [**2-11**] weeks. [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**] Dictated By:[**Last Name (NamePattern1) 2209**] MEDQUIST36 D: [**2133-4-14**] 17:13 T: [**2133-4-15**] 11:31 JOB#: [**Job Number **]

[ "276.5", "577.2", "577.1" ]

icd9cm

[ [ [] ] ]

[ "41.5", "52.52" ]

icd9pcs

[ [ [] ] ]

1754, 2122

869, 1730

161, 195

224, 746

769, 851

63,961

180,869

38087

Discharge summary

report

Admission Date: [**2140-9-3**] Discharge Date: [**2140-10-12**] Date of Birth: [**2073-7-28**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 695**] Chief Complaint: Shortness of Breath Acute on Chronic renal failure Major Surgical or Invasive Procedure: [**2140-9-3**]: Echo [**2140-9-7**]: CT Abdomen [**2140-9-8**]: CT Guided drainage [**2140-9-9**]: Echo, CT Abdomen [**2140-9-13**]: [**Month/Day/Year **] [**2140-9-14**]: Exploratory laparotomy, drainage of intra- abdominal fluid collections and hematoma, interposition iliac artery graft from celiac axis to hepatic artery, Tru-Cut biopsy of the liver. [**2140-9-26**]: [**Month/Day/Year **] [**2140-9-28**]: EGD, and CTA [**2140-9-29**]: Tagged RBC scan [**2140-9-30**]: EGD/ Colonscopy w/ tissue biopsy History of Present Illness: 67F s/p liver transplant on [**2140-8-11**] for HCV cirrhosis and was discharged on [**2140-9-2**]. Patient was transferred from her rehab today after she was found to be severely short of breath with crackles on physical exam and a systolic blood pressure over 200. She was placed on oxygen and given nitropaste. In the ER the patient states she is having a hard time breathing and states she is having pain in her back. She denies chest pain or abdominal pain. Past Medical History: - HCV cirrhosis type 1a c/b ascites, jaundice, encephalopathy, 1 cm enhancing focus in liver, diagnosed 12 years ago, likely secondary to blood transfusion in [**2103**], she has never received antiviral therapy, she was diagnosed with cirrhosis 8 years ago, received ABO incompatible liver transplant [**2140-8-11**] - HTN - DM2 - Left cataract surgery - Hysterectomy for fibroids - s/p bladder prolapse surgery Social History: She is divorced with 3 children. She was living with her daughter and 3 grandchildren, has a commode her in bedroom, and lives on the [**Location (un) 1773**]. She is a retired nursing assistant. She gave up smoking approximately 4 years ago. She does not drink alcohol and never used recreational drugs. She was discharged to [**Hospital3 **] after last admission. Family History: Her maternal aunt had congestive cardiac failure. Her mother had [**Name (NI) 5895**], diabetes and hypertension. Two sisters have diabetes. Physical Exam: 99.1 77 130/80 32 95%NRB PE: Gen - A&Ox3, distress CV - RRR Pulm - bilateral crackles at the bases Abd - Soft, nontender, nondistended, well healed incision Ext - Warm Pertinent Results: On Admission [**2140-9-2**] WBC-15.9* RBC-3.40* Hgb-10.0* Hct-30.3* MCV-89 MCH-29.5 MCHC-33.1 RDW-15.2 Plt Ct-578* PT-13.4 PTT-26.6 INR(PT)-1.1 Glucose-111* UreaN-59* Creat-2.6* Na-139 K-4.7 Cl-97 HCO3-30 AnGap-17 ALT-26 AST-24 AlkPhos-336* TotBili-0.6 Lipase-70* Calcium-9.3 Phos-3.6 Mg-2.1 TSH-4.4* tacroFK-15.6 At Discharge: [**2140-10-12**] WBC-11.5* RBC-3.11* Hgb-9.6* Hct-27.8* MCV-89 MCH-30.7 MCHC-34.4 RDW-15.0 Plt Ct-511* PT-12.9 PTT-27.9 INR(PT)-1.1 Glucose-164* UreaN-48* Creat-1.6* Na-132* K-4.7 Cl-99 HCO3-24 AnGap-14 ALT-50* AST-28 AlkPhos-288* TotBili-0.3 Albumin-3.0* Calcium-8.8 Phos-3.3 Mg-2.1 tacroFK-9.4 Brief Hospital Course: 67 y/o female s/p ABO incompatible liver transplant with splenectomy on [**2140-8-11**] followed by month long post op hospitalization who now presents with shortness of breath. A cardiac echo was obtained on admission showing an EF of > 65%, however there is increased severity of mitral and tricuspid regurgitation and estimated pulmonary artery pressures from the study from of [**2140-7-12**]. Cardiology and Renal consults were obtained) Chest xray showed worsening pulmonary edema and she has worsening kidney function, and the patient received hemodialysis. The patient received intermittent hemodialysis until [**2140-9-28**]. The patient was also complaining of an increasing amount of abdominal pain. An abdominal CT was obtained on [**9-7**] showing increased size of subheaptic fluid collections; differential includes biloma with possible hemorrhage, postoperative seroma and pancreatic pseudocyst. CT guided drainage of the collection returned 1200 cc of dark brown fluid which did not have any organisms or growth on culture. The fluid was also tested for amylase which came back at about [**Numeric Identifier 16351**], and she underwent an [**Numeric Identifier **] which showed extravasation noted at the tail of the pancreas consistent with pancreatic duct leak. A 7cm by 7FR pancreatic pancreatic stent was placed. This should be removed beginning of [**Month (only) 359**]. The patient was then noted to have drop in Hct, she was transferred to the ICU and was taken to the OR with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for exploratory laparotomy, drainage of intra-abdominal fluid collections and hematoma, interposition iliac artery graft from celiac axis to hepatic artery, Tru-Cut biopsy of the liver for Intra-abdominal bleeding, fluid collection, pancreatic duct leak, hematoma, bleeding from the splenic artery/hepatic artery anastomosis. She received 14 days of Linezolid due to enterococcus growing in her peritoneal fluid. She was not febrile, however white count increased to 26,000. This decreased once infection treated. Another [**Last Name (NamePattern1) **] was performed on [**2140-9-26**] for persistently elevated Alk Phos. The biliary stent was removed and a small amount of sludge was removed by snare. During [**Date Range **], Initial cholangiogram appeared fairly normal and the anastamotic stricture was much improved in appearance. However, on balloon occclusion cholangiogram, evidence of contrast extravasation was noted from small right intrahepatic branches. She underwent successful placement of 9cm x 10Fr biliary stent to facilitate improved biliary drainage. On [**9-28**] her hct was noted to drop to 17%, and she was immediately transferred back to the ICU for transfusion and EGD after stooling large amounts of maroon stool. CT of the abdomen did not reveal any issues with the Hepatic artery anastomosis, however the study was limited by lack of contrast. An EGD was performed showing mild esophagitis, but no blood in the stomach or duodenum. She received 5 units of blood on [**9-28**] and then another 2 the following day, and Hct was back to 30%. She continued with the bloody/tarry stools, and another EGD was done on [**9-30**] with still no evidence of bleeding in the upper GI system. Coloscopy revealed diverticulosis of the transverse colon, descending colon and sigmoid colon with erythema and congestion in the whole colon compatible with portal colopathy. There was blood in the whole colon and Grade 2 external hemorrhoids. During that same time frame she also had a tagged RBC scan which showed blood flow images show normal major vascular flow. Dynamic blood pool images show no gross abnormalities, there was no evidence of intra-abdominal bleeding throughout the total imaging time of 132 minutes, and no definite evidence of intra-abdominal bleeding was found. Over the course of the next few days, the stooling became more normal, she has revceievd 2 units of RBCs over the course of the ensuing two weeks, and there has not been evidence of a re-bleed. The patient was fed via TPN while the GI bleed was ongoing. Once symptoms had resolved and patient was tolerating feeds, a post pyloric feeding tube placed during the upper GI was again utilized. Tube feeds were altered to help with tolerance. Her appetite remains very limited, and weight is 52.5 kg at time of discharge, which is almost 30 kg lost since time of transplant. Her renal function improved with creatinine around 1.5 and approximately 1.5 liters of urine daily. The hemodialysis catheter was removed. All drains have been removed since time of surgery. Immunosuppression was continued during hospitalization, Progral dosing based on daily levels. Medications on Admission: 1. docusate sodium 50 mg/5 mL Liquid [**Month/Day (4) **]: One (1) PO BID (2 times a day). 2. fluconazole 200 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO Q24H (every 24 hours). 3. acetaminophen 325 mg Tablet [**Month/Day (4) **]: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain/fever: Maximum 6 tablets daily. 4. citalopram 20 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY (Daily). 5. mycophenolate mofetil 500 mg Tablet [**Month/Day (4) **]: Two (2) Tablet PO BID (2 times a day). 6. sulfamethoxazole-trimethoprim 400-80 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY (Daily). 7. valganciclovir 450 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO 2X/WEEK (WE,SA). 8. tramadol 50 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 9. camphor-menthol 0.5-0.5 % Lotion [**Month/Day (4) **]: One (1) Appl Topical QID (4 times a day). 10. heparin (porcine) 5,000 unit/mL Solution [**Month/Day (4) **]: One (1) ml Injection [**Hospital1 **] (2 times a day): Until fully ambulatory. 11. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: Two (2) Capsule, Delayed Release(E.C.) PO Q12 (). 12. ursodiol 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day). 13. sucralfate 1 gram Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a day) as needed for Gastric Ulcer: Give at 10 AM, 2 PM and 10 PM. Must be given 2 hours separate from immunosuppressives. 14. trazodone 50 mg Tablet [**Hospital1 **]: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 15. metoprolol tartrate 25 mg Tablet [**Hospital1 **]: Three (3) Tablet PO TID (3 times a day). 16. prednisone 5 mg Tablet [**Hospital1 **]: 3.5 Tablets PO DAILY (Daily): Follow transplant clinic taper. 17. B complex-vitamin C-folic acid 1 mg Capsule [**Hospital1 **]: One (1) Cap PO DAILY (Daily). 18. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Hospital1 **]: One (1) Neb Inhalation [**Hospital1 **] (2 times a day). 19. tacrolimus 1 mg Capsule [**Hospital1 **]: Two (2) Capsule PO Q12H (every 12 hours). 20. insulin glargine 100 unit/mL Solution [**Hospital1 **]: Twenty Two (22) units Subcutaneous at bedtime. 21. epoetin alfa 3,000 unit/mL Solution [**Hospital1 **]: One (1) ml Injection 3 x/week at hemodialysis: Adjust per anemia protocol. 22. ondansetron HCl (PF) 4 mg/2 mL Solution [**Hospital1 **]: Four (4) mg Injection Q8H (every 8 hours) as needed for nausea/vomiting. 23. insulin regular human 100 unit/mL Solution [**Hospital1 **]: per sliding scale Injection q 6 hours: Follow QID finger stick blood sugars. Discharge Medications: 1. acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q8H (every 8 hours) as needed for Pain: Maximum 6 tablets daily. 2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Hospital1 **]: One (1) neb Inhalation [**Hospital1 **] (2 times a day). 3. mycophenolate mofetil 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO QID (4 times a day). 4. citalopram 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 5. diphenhydramine HCl 25 mg Capsule [**Hospital1 **]: 0.5 Capsule PO Q6H (every 6 hours) as needed for Itching. 6. fluconazole 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q24H (every 24 hours). 7. oxycodone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. 8. sucralfate 1 gram Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a day): give 2 hours separate from MMF. 9. ursodiol 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day). 10. trazodone 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime) as needed for Insomnia. 11. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 12. prednisone 5 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO once a day: Follow [**Hospital 1326**] clinic taper. 13. metoprolol tartrate 50 mg Tablet [**Hospital **]: One (1) Tablet PO TID (3 times a day). 14. sulfamethoxazole-trimethoprim 400-80 mg Tablet [**Hospital **]: One (1) Tablet PO DAILY (Daily). 15. valganciclovir 450 mg Tablet [**Hospital **]: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 16. tacrolimus 1 mg Capsule [**Hospital **]: One (1) Capsule PO Q12H (every 12 hours). 17. ondansetron 4 mg Tablet, Rapid Dissolve [**Hospital **]: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 18. NPH insulin human recomb 100 unit/mL Suspension [**Hospital **]: As directed Subcutaneous twice a day: 14 Units AM 8 units PM. 19. insulin lispro 100 unit/mL Solution [**Hospital **]: per sliding scale Subcutaneous four times a day: Per sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Acute Renal Failure Intra-abdominal bleeding, fluid collection, pancreatic duct leak, hematoma, bleeding from splenic artery/hepatic artery anastomosis. GI Bleed Malnutrition (severe) s/p ABO incompatible Liver transplant Diastolic Dysfunction 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: Please call the transplant clinic at [**Telephone/Fax (1) 673**] if patient develops fever > 101, chills, increased nausea, vomiting, inability to tolerate tube feeds, dark/tarry stools, increased abdominal pain, diarrhea, constipation, inability to tolerate medication regimen or other concerning symptoms. Labs to be obtained every Monday and Thursday with results to transplant clinic (Fax [**Telephone/Fax (1) 697**]) CBC, Chem 10, AST, ALT, AlkPhos, T Bili, Trough Prograf No Heavy Lifting [**Month (only) 116**] Shower, no tub baths or swimming Please do not adjust medications without consultation with the transplant clinic Followup Instructions: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD, [**Telephone/Fax (1) 673**], Wednesday [**10-19**]. Please call office to verify appointment time Provider: [**Name Initial (NameIs) **] 2 (ST-4) GI ROOMS Date/Time:[**2140-10-25**] 10:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2140-10-25**] 10:30 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2140-10-12**]

[ "041.04", "998.11", "998.12", "572.4", "428.31", "996.82", "404.91", "567.81", "578.9", "V58.67", "250.00", "518.82", "416.8", "569.89", "585.6", "428.0", "427.31", "262", "998.31", "E878.0" ]

icd9cm

[ [ [] ] ]

[ "50.11", "97.05", "39.49", "52.93", "39.95", "93.90", "45.13", "99.15", "45.25", "51.10", "96.6" ]

icd9pcs

[ [ [] ] ]

12729, 12795

3213, 7942

353, 862

13083, 13083

2564, 2879

13922, 14493

2194, 2339

10611, 12706

12816, 13062

7968, 10588

13266, 13899

2354, 2545

2893, 3190

263, 315

890, 1355

13098, 13242

1377, 1792

1808, 2178

29,557

182,286

34187

Discharge summary

report

Admission Date: [**2122-6-2**] Discharge Date: [**2122-6-8**] Date of Birth: [**2053-7-24**] Sex: M Service: CARDIOTHORACIC Allergies: Mercury (Elemental) / Latex Attending:[**First Name3 (LF) 165**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [**2122-6-2**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to RCA) History of Present Illness: 68 y/o male with chest pain and positive stress test who was referred for cardiac cath. Cath revealed three vessel coronary artery disease and he was then referred for surgical revascularization. Past Medical History: Hypertension, Hyperlipidemia, Prostate Cancer s/p XRT, Gout, s/p Tonsillectomy, s/p Trigger finger release Social History: Retired. Quit smoking 25 yrs ago after 1ppd x 20 yrs. Occ. ETOH use. Family History: Brother with [**Name (NI) 5290**] in 50 and 60's. 1 s/p CABG. Physical Exam: VS: 62 16 194/81 5'9" 205# Gen: WDWN male in NAD Skin: Unremarkable HEENT: EOMI PERRL Neck: Supple, FROM -JVD, -carotid bruit Chest: CTAB -w/r/r Heart: RRR -c/r/m/g Abd: Soft, NT/ND +BS Ext: Warm, well-perfused trace edema, -varicosities Neuro: A&O x 3, MAE, non-focal Pertinent Results: [**2122-6-6**] 07:30AM BLOOD WBC-5.3 RBC-3.19* Hgb-10.7* Hct-30.8* MCV-97 MCH-33.5* MCHC-34.7 RDW-17.7* Plt Ct-172 [**2122-6-2**] 01:20PM BLOOD PT-13.9* PTT-35.4* INR(PT)-1.2* [**2122-6-7**] 09:00AM BLOOD Glucose-128* UreaN-24* Creat-1.1 Na-140 K-3.5 Cl-96 HCO3-34* AnGap-14 CHEST (PA & LAT) [**2122-6-7**] 2:36 PM CHEST (PA & LAT) Reason: interval change [**Hospital 93**] MEDICAL CONDITION: 68 year old man with POD 5 CABG REASON FOR THIS EXAMINATION: interval change PA AND LATERAL CHEST ON [**2122-6-7**] AT 1436 INDICATION: Postop CABG. COMPARISON: [**2122-6-5**]. FINDINGS: I do not see the previously demonstrated left pneumothorax. There is persistent left pleural fluid, and retrocardiac area appears better aerated. No new focal consolidations were seen. Pulmonary vascular markings are within normal limits. The cardiomediastinal silhouette is unchanged. IMPRESSION: Improving chest x-ray, left pleural effusion, and some basilar atelectatic changes. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 78768**] (Complete) Done [**2122-6-2**] at 9:15:14 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2053-7-24**] Age (years): 68 M Hgt (in): 69 BP (mm Hg): 140/60 Wgt (lb): 190 HR (bpm): 60 BSA (m2): 2.02 m2 Indication: Intraoperative TEE for CABG ICD-9 Codes: 786.05, 786.51, 440.0, 413.9 Test Information Date/Time: [**2122-6-2**] at 09:15 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5740**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW1-: Machine: [**Pager number 5741**] Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Ejection Fraction: 55% to 60% >= 55% Aorta - Annulus: 2.6 cm <= 3.0 cm Aorta - Sinus Level: 3.3 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.7 cm <= 3.0 cm Aorta - Ascending: *3.6 cm <= 3.4 cm Aorta - Descending Thoracic: *2.9 cm <= 2.5 cm Findings LEFT ATRIUM: Normal LA and RA cavity sizes. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending aorta. Simple atheroma in aortic arch. Mildly dilated descending aorta. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. See Conclusions for post-bypass data Conclusions PRE-BYPASS: 1. The left atrium and right atrium are normal in cavity size. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. The ascending aorta is mildly dilated. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. 5. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 7. There is no pericardial effusion. POST-BYPASS: For the post-bypass study, the patient was A paced 1. Regional and global left ventricular systolic function are normal. Right ventricular systolic function is normal. 2. Aorta intact post decannulation. Brief Hospital Course: Mr. [**Known lastname 27636**] was a same day admit and brought directly to the operating room on [**6-2**] where he underwent a coronary artery bypass graft x 4. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one beta blockers and diuretics were started and he was gently diuresed towards his pre-op weight. Later on this day he was transferred to the telemetry floor for further care. Chest tubes and epicardial pacing wires were removed per protocol. He was tranfused 2 units for HCT 22. He worked with physical therapy during his post-op course for strength and mobility. On post-op day #6 he was ready for discharge to rehab. Medications on Admission: Atenolol 75mg 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:*2* 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. 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* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2* 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days. 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 5 days. Discharge Disposition: Extended Care Facility: [**Location (un) 582**] Of [**Location (un) 620**] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 PMH: Hypertension, Hyperlipidemia, Prostate Cancer s/p XRT, Gout, s/p Tonsillectomy, s/p Trigger finger release Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**First Name (STitle) **] in 4 weeks Dr. [**Last Name (STitle) 10543**] in [**2-8**] weeks Dr. [**Last Name (STitle) **] in [**1-7**] weeks [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2122-6-8**]

[ "V10.46", "401.9", "790.01", "458.29", "414.01", "272.4", "274.9" ]

icd9cm

[ [ [] ] ]

[ "39.61", "36.13", "99.04", "88.72", "39.63", "36.15" ]

icd9pcs

[ [ [] ] ]

7962, 8039

6011, 6845

302, 401

8255, 8261

1225, 1586

8772, 9037

858, 921

6912, 7939

1623, 1655

8060, 8234

6871, 6889

8285, 8749

936, 1206

252, 264

1684, 5988

429, 626

648, 756

772, 842

21,696

146,618

19309

Discharge summary

report

Admission Date: [**2197-7-17**] Discharge Date: [**2197-7-21**] Date of Birth: [**2142-4-9**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 18369**] Chief Complaint: Blood from ileostomy Major Surgical or Invasive Procedure: pill enteroscopy (non-invasive) History of Present Illness: Mr. [**Known lastname 52583**] is a 55 year old male with metastatic renal cell cancer diagnosed in early [**2194**], currently on Avastin therapy, Crohn's disease s/p total colectomy with ileostomy formation in [**2177**], who presents with brisk bright red blood from ileostomy this morning in oncology clinic. The patient states that he first noted bleeding from his ileostomy about 6 weeks ago, at which time he underwent a workup entailing an upper endoscopy and ileoscopy in [**State 2748**]. Per report from the patient and notes (though we don't have the actual report), the upper endoscopy demonstrated significant portal hypertension with esophageal and gastric varices. A subsequent ileoscopy revealed a bleeding, ulcerated mass in the ileum, thought to be the source, with biopsies proven to be metastatic renal cell carcinoma. Of note, he has been on Avastin (BEVACIZUMAB), a chemotherapeutic [**Doctor Last Name 360**] for his renal cell cancer since [**1-28**], with the known risk of GI bleeding. There was discussion between the patient and his oncologist at the time of his GI bleeding regarding whether or not to discontinue this medication, however the patient decided to continue. His last Avastin dose was on [**7-3**]. His hematocrit was 28.9 at this time (slightly down from his recent baseline of approx 32). As mentioned above, Mr. [**Known lastname 52583**] has had intermittent blood in his ileostomy bag for the last 6 weeks, noting bleeding again the day prior to admission. On the day of admission in oncology clinic the patient noted about 250 cc of bright red blood in the ileostomy bag and was sent to the ED. On arrival to the ED his vitals were 97.8, HR 77, BP 126/63, RR 18, 100% on RA. While in the ED he had another 250 cc of blood, and his hct was found to be 26.2, dropping to 22.8 within a couple of hours. He was given 1 L NS, however a transfusion was delayed secondary to difficulty with crossmatching (history of transfusions with resultant antibody formation). He was seen by GI and sent to the [**Hospital Unit Name 153**]. Past Medical History: 1) Oncologic history: Diagnosed with renal cell cancer in early [**2194**] after hematuria noted by PCP. [**Name10 (NameIs) 6**] abdominal ultrasound showed a large left renal mass, two suspicious lesions in the liver and tumor thrombus in the IVC. In [**5-28**] he underwent radical nephrectomy/partial small bowel resection/partial liver resection/cholecystectomy. Pathology showed a 9cm renal cell carcinoma (granular), grade IV and invading the capsule, perirenal fat and vascular structures. Three lymph nodes, the adrenal, small bowel and the margins were all were negative, although the margin was less than one millimeter at the anterior capsule. A liver nodule was positive. He has been on a number of medical regimens: Low-dose Interferon [**6-28**], but stopped [**11-29**] due to evidence of progression on CT: opacities in the liver and new right middle lobe and left lung base nodules, both subcentimeter. Mr. [**Known lastname 52583**] started the [**Doctor Last Name **] 43-9006 trial [**1-27**]. [**Doctor Last Name **] drug stopped [**11-30**] due to progression on CT. He has been on Avastin with stable response since [**94**]/[**2196**]. Course complicated by intermittent SBO, thought secondary to adhesions. 2) Crohn's disease: s/p total colectomy with ileostomy in [**2177**]. Has had 2 episodes of bowel obstruction, treated with NPO. 3) BPH, on hytrin Social History: From [**Country 5881**] originally. Married with 2 children. Working with computers. Used to smoke but quit 24 years ago; 10 PY hx. Drank socially in the past but not recently. No IVDU. Family History: Father with probable prostate ca. Brothers and sisters are healthy. Physical Exam: VS: 98.4, HR 81, BP 133/64, 16, 100% RA. Gen: Pale appearing, slim male, resting comfortably in bed, conversant. HEENT: Anicteric sclerae, moist MM. Neck: No JVD. Cor: RR, normal rate, no m/r/g. Lungs: CTA b/l, no w/r/r. Abd: NABS, soft, NT/ND. Large vertical midline scar, well healed. Ileostomy site clean, brown stool in bag. (Per ED, ostomy output guaiac positive, with bright red blood). Extr: 1+ LE edema to knees b/l (chronic), DP palpable b/l. Pertinent Results: EKG: NSR at 80 bpm, no ST/T wave changes. [**2197-7-17**] 10:24AM BLOOD WBC-3.2* RBC-3.15* Hgb-8.3* Hct-26.2* MCV-83 MCH-26.3* MCHC-31.6 RDW-19.2* Plt Ct-155 [**2197-7-17**] 12:46PM BLOOD WBC-3.3* RBC-2.78* Hgb-7.5* Hct-22.8* MCV-82 MCH-26.9* MCHC-32.7 RDW-19.3* Plt Ct-146* [**2197-7-17**] 07:48PM BLOOD Hct-25.1* [**2197-7-18**] 04:18AM BLOOD WBC-3.3* RBC-3.04* Hgb-8.3* Hct-24.5* MCV-81* MCH-27.3 MCHC-33.8 RDW-18.3* Plt Ct-146* [**2197-7-18**] 08:35AM BLOOD Hct-29.9* [**2197-7-19**] 06:30AM BLOOD WBC-3.4* RBC-3.29* Hgb-9.0* Hct-27.4* MCV-83 MCH-27.3 MCHC-32.7 RDW-18.5* Plt Ct-134* [**2197-7-21**] 08:15AM BLOOD WBC-3.6* RBC-3.39* Hgb-9.2* Hct-28.4* MCV-84 MCH-27.2 MCHC-32.5 RDW-18.6* Plt Ct-148* [**2197-7-21**] 08:15AM BLOOD WBC-3.6* RBC-3.39* Hgb-9.2* Hct-28.4* MCV-84 MCH-27.2 MCHC-32.5 RDW-18.6* Plt Ct-148* [**2197-7-17**] 12:46PM BLOOD PT-13.2 PTT-30.6 INR(PT)-1.2 [**2197-7-17**] 10:24AM BLOOD Gran Ct-2420 [**2197-7-21**] 08:15AM BLOOD Glucose-77 UreaN-15 Creat-1.8* Na-139 K-4.5 Cl-106 HCO3-23 AnGap-15 [**2197-7-18**] 04:18AM BLOOD ALT-10 AST-25 LD(LDH)-128 AlkPhos-162* TotBili-1.1 [**2197-7-18**] 04:18AM BLOOD Albumin-3.5 Iron-68 [**2197-7-18**] 04:18AM BLOOD calTIBC-299 Hapto-129 Ferritn-42 TRF-230 Brief Hospital Course: 55 yo male with metastatic renal cell cancer diagnosed in early [**2194**], currently on Avastin therapy, Crohn's disease s/p total colectomy with ileostomy formation in [**2177**], who presents with brisk bright red blood from ileostomy this morning in oncology clinic. Found to have hct drop from 29 on [**7-3**] to 23 on day of admission. 1) GI bleed: Patient with two known possible sources, given known varices, and also known mass in ileum. Given that NG lavage negative (performed on arrival to [**Hospital Unit Name 153**]), patient denies hematemesis, and bleed seems to have slowed down, unlikely variceal. Lastly, patient with Crohn's disease, and has had bleeding in the past, but none for many years, and disease activity has decreased since colectomy - not on any medications. Most likely source is known necrotic mass in ileum, which presents few therapeutic options, per GI. Will need to consider embolectomy vs. endoscopic attempt at cauterization if bleeding persists. For now, no further blood in ileostomy bag. Avastin possible diathesis. Dr. [**Last Name (STitle) **] from surgery was consulted who feels that tumor site 15cm from ileostomy is source of bleeding associated with Evastin. GI arranged a capsule endoscopy, which showed a few prominent venous blebs in jejunum in ileum as well as a few discontinuous segements of friable mucosa in jejunum and ileum. They recommended a push enteroscopy and ileoscopy with biopsy. It was felt that the friable mucosa was not likely to be the source of bleeding. Given the stabilization of bleeding, pt wanted to go home to [**State 2748**], with plans to follow-up with Dr. [**Last Name (STitle) **] for a possible resection of the involved area of small bowel with intraoperative push enteroscopy to examine the rest of the small bowel. In addition, he will need to discuss at that time when to restart Avastin. . 2) Chronic renal insufficiency: Creatinine at baseline of approximately 2.0, secondary to patient being s/p nephrectomy. . 3) Crohn's Disease: Patient with improved disease since colectomy, on no medications. . 4) Chronic anemia: Normocytic. Previous iron studies borderline - likely mixed picture of iron deficiency and chronic renal disease. Repeat iron studies were unremarkable with normal iron, normal ferritin and normal TIBC. . 5) FEN: pt initially kept NPO, given IVF. Slowly started PO diet, which he tolerated well. . 6) Pain: Patient with chronic low back pain for which he takes tylenol at home. Will write for 325-650 mg Q4-6, and check LFTs. . 7) Code: Full. . 8) Communication: With wife. . 9) Access: 2 16 guage PIV. Medications on Admission: Hytrin QDay Tylenol PRN Avastin Discharge Disposition: Home Discharge Diagnosis: Primary: Metastatic renal cell carcinoma GIB due to metastatic renal cell CA(possibly also due to Crohn's Disease) SEcondary: Crohn's Disease BPH Discharge Condition: stable Discharge Instructions: continue taking all your medications. if you develop worsening bleeding from your ostomy, lightheadedness, vomiting blood, severe abdominal pain contact your physician or return to the ER. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Where: [**Hospital6 29**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2197-8-1**] 2:40 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4053**], RN Where: [**Hospital6 29**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2197-8-1**] 3:00 Provider: [**Name Initial (NameIs) 4426**] 5 Date/Time:[**2197-8-1**] 3:00 . Contact Dr.[**Name (NI) 1482**] office, phone [**Telephone/Fax (1) 2981**], to schedule an appointment if you decide to go to [**Hospital1 18**] for resection of the tumor in [**Location (un) 86**]. Otherwise arrange for a surgical evaluation for resection of the tumor through your gastroenterologist or primary care physician. Completed by:[**2197-11-2**]

[ "555.9", "285.1", "600.00", "572.3", "198.89", "197.4", "578.9", "197.7", "V10.52", "V44.2" ]

icd9cm

[ [ [] ] ]

[ "45.19", "99.04" ]

icd9pcs

[ [ [] ] ]

8653, 8659

5932, 8571

336, 370

8850, 8859

4684, 5909

9097, 9924

4117, 4187

8680, 8829

8597, 8630

8883, 9074

4202, 4665

276, 298

398, 2484

2506, 3894

3910, 4101

14,285

169,951

53163

Discharge summary

report

Admission Date: [**2177-9-25**] Discharge Date: [**2177-9-28**] Date of Birth: [**2135-5-18**] Sex: M Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 99**] Chief Complaint: respiratory depression and cyanosis Major Surgical or Invasive Procedure: endotracheal tube OG tube placement History of Present Illness: 42 yo male found down unresponsive and cyanotic by EMS. Someone called EMS however no other person on site when EMS arrived. Pt was unresponsive with RR4. RR increased to 10 with 1mg of narcan x2. At that point, pt withdraw from pain and had slightly opened eyes with pin point pupils. He received an additional 1 mg of narcan intra-nasally. Upon arrival at [**Hospital1 18**], RR=20, HR120's, BP 170's/100. 95% on NRB but still unresponsive. He then received an additional 1mg of narcan, pupils became reactive to light. He vomited and required intubation for airway protection. As per EMS report, the police found a brown substance on the patient that may have represented heroine and smell of alcohol. Per pt wife, he was last seen by her at 7pm last night, pt recently was d/cd of all his pain meds and had an argument with her yesterday due to pain issue. In ED, Urine tox screen positive for benzos, cocaine and opiates. Serum tox pos for benzos, neg for ETOH, ASA, Acetominophen, Barb. Pt has increased Cr to 1.5, hyperglycemia to 163, hyperkalemia 6.2 and thrombocytosis (WBC 20.1). CXR showing opacity of bil upper lobes ?aspiration, also w apparent mediastinal upper widening and this is likely due to the patient's positioning and technique. Head CT pending. No Agap. ABG: 7.35 / 42 / 356 / 24 / -2, toxicology consulted. Past Medical History: PMH: HTN, DM, HepC dx in [**2168**], depression, IVDA x 5 yrs [**2152**]'s, back injury with chronic pain meds use, recently d/cd all pain meds. Asthma, bronchitis, OSA (use a machine when sleep at home), ?CAD. Social History: SHX: married with 2 kids, lives with his wife. [**Name (NI) **] worker out of hob for 2 yrs, chronic back injury from work. hx of IVDA ([**2155-6-5**]), marijuana, cocaine ([**2151**]-87), ETOH (clean from ETOH for 2 yrs; 3 detoxes since [**2159**]). Family History: non contributory Physical Exam: Temp 101 8 rectal in ED BP 127/87 Pulse 91 reg. Resp on AC, 100% FIO2, Peep 5: 100% sat Gen - intubated sedated, non-responsive HEENT - PERRL Neck - thick neck Chest - bronchial BS anterirorly with coarse sounds CV - distant , Normal S1/S2, RRR, no murmurs, rubs, or gallops Abd - Soft, distended/obese, with normoactive bowel sounds Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally Neuro - sedated on propofol, no limb movements, equivocal Bainksi, no DTRs Skin - freckles, left shin psoriatic lesion Pertinent Results: Head CT: no bleed or evidence of mass CXR: ETT tube in place, bilateral upper lobe opacities EKG: sinus tachy about 110 bpm, nl axis, nl intervals, peaked Ts in V3-V6. Pt received insulin 10U, D50 and NaHCO3, also received charcoal 50g via OG tube. Brief Hospital Course: 1. mental status: Hypoperfusion vs. drugs vs seizure. Head Ct was negative for bleed or mass. Neuro status improved with improved resp failure. 2. respiratory status: [**Month (only) **] resp. drive secondary to rep depression from cocaine. Intubated in the ED and place on AC. Over the next 24 hours, he was weaned to 40% FIO2 and PS. He was extubated 24 hours after admission and eventually able to tolerated good sats on RA. Pt remained afebril after admission and did not need any treatment for quesiton of aspiration during intubation. 3. Hyper K: Due to succinylcholine used in ED. Transiently elevated with no EKG changes, resolved in 24 hours without intervention. 4. Elevated CK: Elevated CK on admission with negative cardiac enzyme fractions. Trended down during stay. 5. HTN: Stable, on labetaolol since this is better in cocaine o/d patients. D/c on metorprolol with f/u with PCP. 6. Elevated LFTs: Question of shock liver vs. toxic metabolic injury. Also chronic hep C. Trending down. Will give pt follow up for liver clinic. 7. Elevated Cr: prerenal resolved with fluids 8. Polysubstance abuse: OGT placed for NG charcol lavage. Pt recovered from overdose. He wil reconnect with sponser for AA/NA. Since he is from NH, it is difficult for him to use any resources from here in MA. Comm: was with wife [**Name (NI) 7092**]: Full Pt was d/c'd home with one day vicodin script to f/u with PCP. Medications on Admission: wellbutrin 300 mg SR Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:*45 Tablet(s)* Refills:*2* 2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed: dispense 10 tablets. Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1. Polysubstance abuse 2. Hypertension Discharge Condition: Stable. Discharge Instructions: If you have chest pain, shortness of breath, nausea or vomiting, please call your PCP or come to the ED. Followup Instructions: Provider: [**Name10 (NameIs) 9529**],[**Name11 (NameIs) **] [**Telephone/Fax (1) 81474**] Call to schedule appointment for the next two days. Call Dr. [**Last Name (STitle) 497**] at [**Telephone/Fax (1) 2422**]

[ "908.9", "V11.3", "311", "794.8", "E980.4", "305.90", "724.2", "E929.9", "276.7", "401.9", "970.8", "786.50", "070.54" ]

icd9cm

[ [ [] ] ]

[ "96.07", "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

4883, 4889

3113, 3116

344, 381

4972, 4981

2840, 2840

5134, 5352

2268, 2286

4594, 4860

4910, 4951

4549, 4571

5005, 5111

2301, 2821

269, 306

409, 1750

2849, 3090

3131, 4523

1772, 1984

2000, 2252

28,064

148,976

8779

Discharge summary

report

Admission Date: [**2106-1-24**] Discharge Date: [**2106-2-15**] Date of Birth: [**2046-4-20**] Sex: F Service: MEDICINE Allergies: Folic Acid Attending:[**First Name3 (LF) 1990**] Chief Complaint: Intracranial Hemorrhage. Major Surgical or Invasive Procedure: Central Venous Catheter Mechanical Intubation Radiation Therapy History of Present Illness: Ms. [**Known lastname 30683**] is a 59-year-old right-handed woman who presents with 4-day history of intermittent dizziness and headaches, and was found on CT at OSH to have ICH and cerebellar infarct. She was in her USOH until Tuesday of this recent week when she developed vertigo and a severe headache. She was walking from her living room to the kitchen when she abruptly felt the room spinning around her. She managed to walk back to the living room and sat down. The episode resolved spontaneously after [**4-24**] minutes. At the same time, she developed a headache over the right frontoparietal area that was severe at onset but that worsened over the course of an hour. She describes the pain as "like a knife through my head." She noticed no other symptoms at the time, including no double vision, no difficulty speaking, and no difficulty swallowing. Her headache was controlled with 600 mg of ibuprofen. As the dizziness resolved, she did not become concerned. The vertigo returned, however; in fact, she had similar episodes about 4 times per day for the next 4 days. The headache also persisted, so that she was taking 600 mg of ibuprofen (which did control it) every 8 to 12 hours. Today, a friend who came to walk her dogs prevailed upon her to go the ED, and he drove her to [**Hospital1 9487**]. There, a CT showed several areas of intraparenchymal hemorrhage and a left middle cerebellar peduncle infarct extending into the left cerebellum with mild effacement of the fourth ventricle. She was transferred to [**Hospital1 18**], where she was treated with prn labetalol for BP control and loaded with 1000 mg dilantin. On neurologic ROS, Ms. [**Known lastname 30683**] reports some residual left LE weakness and occasional word-finding difficulty. She denied current headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, tinnitus or hearing difficulty. Denied difficulties producing or comprehending speech. Denied focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. On general review of systems, she reports chest pain that is sharp (knife-like), not associated with exertion or position, spontaneously resolving after a few minutes; it's unlike her prior anginal pain with her MIs. She denied recent fever or chills. No night sweats or recent weight loss or gain. Denied cough, shortness of breath. Denied palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Denied rash. Past Medical History: Prior (presumably hemorrhagic?) stroke in [**2105-3-15**]; per her report, she presented with lying down on a table in the ladies room of a bar, and the next thing she knew she was at [**Hospital1 2025**]. She was found to have 4 aneurysms, at least one of which was clipped. She also had a VP shunt placed following intraventricular bleeding. s/p aneurysm clipping (as above) [**2104**] at [**Hospital1 2025**] s/p VP shunt placement (as above) [**2104**] at [**Hospital1 2025**] h/o Pancreatic tumor s/p resection ~10 years ago Diabetes mellitus type 2 after pancreatic tumor resection CAD s/p MI x2 several years ago; denies stents and CABG s/p TAH B12 deficiency Hyperlipidemia Hypertension IBS s/p Tubal ligation Social History: Smokes 1 ppd x50 years. Former heavy EtOH, none since [**Month (only) 547**] [**2104**]. Denies other illicit drug use. Worked as bartender until [**2105-3-15**], now on disability. Lives in [**Location 38**] with her boyfriend. Family History: Mother died at 72 of unknown cancer, father at 83 of unknown cancer and with Alzheimer's. No other known neurologic disease. Physical Exam: Vitals: T: 97.5 P: 71 R: 16 BP: 153/68 SaO2: 99%RA General: Awake, cooperative, NAD. Appears older than stated age. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history but vague on details. Attentive, able to name [**Doctor Last Name 1841**] backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt. was able to register 3 objects and recall [**2-15**] at 5 minutes. There was no evidence of neglect, but she appeared to have apraxia (unable to demonstrate slicing bread or hammering nail). Calculation intact (9 quarters in $2.25). -Cranial Nerves: I: Olfaction not tested. II: PERRL 6 to 3mm and brisk. VFF to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: Slight right facial droop. VIII: Hearing diminished to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk throughout. Spasticity in right LE. Right-sided pronator drift. No adventitious movements noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB R 4 4+ 5 5 5 5 5 5 5 5 5 5 5 5 L 4 5 5 4+ 5 5- 5 5 5 5- 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach R 2 tr 1 3 3 L 2 1 2 2 2 Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. Wide-based, very short stride, dragging right leg behind. Unable to walk in tandem. Romberg present. Pertinent Results: 141 104 19 202 3.6 26 0.6 CK: Pnd MB: Pnd Trop: Pnd WBC: 11.4; Hct: 34.8; Plt: 256 N:41.3 L:52.1 M:4.9 E:1.3 Bas:0.3 PT: 11.5 PTT: 29.5 INR: 1.0 EKG: NSR at 68 bpm, nl axis, nl intervals, TWI in V3 and III, no ST changes. Radiologic Data: NCHCT OSH Report: "The patient is status post clipping of aneurysm with left frontoparietal craniotomy. There is a ventricular shunt catheter with tip in the third ventricle unchanged. There are multiple regions of acute hemorrhage largest in the left frontal lobe measuring 2.5 x 2.8 cm. There is a region of intraparenchymal hemorrhage in the left insular region measuring 2.1 x 1.7 cm. Smaller focal areas of intraparenchymal hemorrhage are noted in the left parietal and right temporal lobes. Subcentimeter areas of hemorrhage are noted in the corpus callosum, left posterior centrum semiovale, and the periventricular region adjacent to the right frontal [**Doctor Last Name 534**]. There is hypodensity involving the left middle cerebellar peduncle with extension into the left cerebellum with mild effacement of the fourth ventricle consistent with acute infarct. There is a remote infarct in the left posterior cerebellum. There are no extra-axial fluid collections. There is no midline shift. There is mild effacement of the fourth ventricle. The remainder of the ventricular system is stable. IMPRESSION: Multiple regions of acute intraparenchymal hemorrhage, largest in the left frontal lobe. Multiple smaller regions of hemorrhage in the white matter tracts. Acute infarct in the left middle cerebellar peduncle." Head CT with contrast: FINDINGS: A ventriculoperitoneal catheter is noted extending across the right frontal region and terminating in the third ventricle. There has been prior aneurysm clipping appearing to involve the left middle cerebral artery and probably the left carotid terminus. There has been prior left temporal and frontal craniotomy. There are at least 20 enhancing lesions in both the supra- and infratentorial region involving the [**Doctor Last Name 352**] as well as white matter. One of the largest is noted within the left cerebellar hemisphere and has central low density consistent with necrosis measuring 2.9 x 2.2 cm in total and with surrounding hypodensity which causes mass effect on the fourth ventricle. A second very large metastatic focus is noted within the left frontal region measuring 2.8 x 2.7 cm also with a necrotic component. Other metastatic foci are noted in the left frontal, left temporal, left parietal, right temporal, right cerebellar, right frontal regions, and there is also a enhancing lesion in the splenium of the corpus callosum on the right. There is prominence of the ventricular system, however not having previous comparison it is difficult to distinguish how chronic this finding is. There is no shift of normally midline structures, however the sulci in the left cerebrum are less prominent than on the right, suggesting local mass effect. Hypodensities surrounding the large left frontal lesions is also noted as well as a left temporal lesion. No definite lytic osseous lesions are noted. Patient is intubated, and there is fluid within the nasopharynx. Soft tissue structures demonstrate the ventriculoperitoneal catheter extending along the superficial tissues into the right neck. There is no definite catheter discontinuity identified. IMPRESSION: Multiple intracranial metastatic foci in both the supra- and infratentorial regions, the largest of which demonstrate cystic/necrotic central components. Surrounding low density in the left cerebellum and left frontotemporal region could represent vasogenic edema, although possibly could represent areas of prior infarct. Mass effect on the fourth ventricle with prominence of the lateral and third ventricles. However having no distant priors to compare to, it is not clear how chronic this process is. CT TORSO: 1. Extensive mediastinal lymphadenopathy with a possible central left upper lobe mass, and metastasis in the left adrenal gland as well as a right supraclavicular lymph node. The picture is most suggestive of small cell lung cancer as the primary etiology. The right supraclavicular lymph node would be amenable to biopsy. 2. Pneumobilia. Please correlate with history of ERCP/sphincterotomy. 3. Prominent pancreatic duct side branches without evidence of a pancreatic mass. [**2106-1-24**] EEG: IMPRESSION: Markedly abnormal portable EEG due to the low voltage slow and disorganized background along with bursts of generalized slowing and some diminished background voltages over the right side. The first two abnormalities signify a widespread encephalopathic condition affecting both cortical and subcortical structures. Medications, metabolic disturbances, and infection are among the most common causes. The voltage asymmetry raises concern for either material interposed between the cortical surface and recording electrodes on the right side (e.g. subdural fluid) or more widespread cortical dysfunction on that right side. There were no epileptiform features evident in the recording. MRI/MRA neck/head/brain [**2106-1-25**]: FINDINGS: There are numerous enhancing lesions throughout the brain, some with central cavitation. The largest lesions are in the left frontal area measuring 2.7 x 2.7 cm and in the left side of the cerebellum measuring 2.8 x 2.8 cm. Several of the smaller lesions are located peripherally within the brain. There is marked edema around the 2 large lesions, with mass effect on the fourth ventricle. There is dilatation of the ventricles with a ventricular shunt in place. There is no midline shift. There is superficial siderosis around the cerebrum consistent with prior subarachnoid hemorrhage. The diffusion-weighted imaging of the brain does not show any infarcts. Some of the metastases have slow diffusion. MRA NECK: There is mild stenosis at the origin of the brachiocephalic artery. The origin of the left vertebral artery also has mild stenosis. The distal cervical carotid measures 3.5 mm on the right and 2.8 mm on the left. Note is made of mild multifocal stenosis of the mid cervical portion of the ICA's bilaterally. There is a small aneurysm of the anterior genu of the right internal carotid artery. There is coil artifact and the left MCA and ICA are not well seen as a result. There is a large right supraclavicular node and mediastinal and hilar nodes as on the recent CT of the chest. There is a nodule in the left lobe of the thyroid. MRA HEAD: This study is markedly limited due to motion. IMPRESSION: No evidence of new infarct. Multiple enhancing metastases, some with central cavitation, the largest in the left frontal lobe and left cerebellum exerting mass effect on the fourth ventricle. Dilatation of ventricles without midline shift. [**2106-1-25**]: ECHO: Conclusions The left atrium and right atrium are normal in cavity size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with severe hypokinesis/akinesis of the distal half of the septum and anterior walls. The apex is akinetic. The remaining segments contract normally (LVEF = 40 %). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is an epicardial fat pad. IMPRESSION: Regional left ventricular systolic dysfunction c/w CAD (mid-LAD distribution). Mild mitral regurgitation with normal valve morphology . Other Studies: -------------- CT HEAD W/O CONTRAST [**2106-2-3**] 4:36 PM FINDINGS: Comparison is made to [**2106-1-28**]. There are no intracranial hemorrhages. The previously seen enhancing masses are not well visualized due to lack of IV contrast. Again seen is a hypodensity of the left frontal lobe surrounding a metastasis measuring approximately 2.5 cm in size. There is also a large area of edema involving the left cerebellar hemisphere as before surrounding a metastasis. The ventricles are dilated but unchanged in size since the prior study. There is a right frontal ventricular shunt with the tip of the catheter at the foramen of [**Last Name (un) 2044**] as before. Aneurysm clips are seen in the left sylvian fissure and the left paraclinoid region as before. IMPRESSION: No acute intracranial hemorrhages. No significant change in the vasogenic edema of the left frontal lobe and left cerebellar hemisphere surrounding known metastases. No significant change in the enlarged ventricles with a ventricular shunt in place. . ECG ([**2-3**]): Normal sinus rhythm, rate 82. Extensive anterolateral T wave inversions with associated Q-T interval prolongation and borderline ST segment elevation in lead V2. Also, T wave inversions inferiorly. QS complex in leads V1-V2. The findings are consistent with acute anteroseptal myocardial infarction with possible inferolateral component. Compared to the previous tracing of [**2106-2-2**] anterior T wave inversions are more pronounced consistent with evolution of myocardial infarction. There is also possible left ventricular hypertrophy. . CT C-SPINE W/O CONTRAST [**2106-2-3**] 4:36 PM FINDINGS: No prior studies are available for comparison. There are no cervical spinal fractures. There is straightening of the cervical spine, which may be positional. At C2/3, there is minimal anterior spondylolisthesis of C2 on C3. There are degenerative changes of the facet joints and the uncovertebral joints, worse on the left side which is causing severe left foraminal stenosis. There is mild canal stenosis. At C3/4, there is mild anterior spondylolisthesis of C3 on C4. There is also severe degenerative change of the right facet joint which is causing severe right foraminal stenosis. There is likely moderate left foraminal stenosis. The right facet joint may be ankylosed partially. At C4/5, there is a right central disc protrusion which is contacting the ventral cord and likely causing mild canal stenosis. There are minimal degenerative changes of the facet joints worse on the right side but without foraminal stenosis. At C5/6, there is a mild disc osteophyte complex and facet arthropathy, worse on the left side without canal or foraminal stenosis. At C6/7, there is a disc osteophyte complex causing mild canal stenosis, but no foraminal stenosis. The thyroid gland is heterogeneous in density and there may be subcentimeter nodules within the right lobe. The visualized lung apices are clear. There is a right-sided subclavian central line whose tip is not imaged. Part of a ventriculoperitoneal shunt is also noted. There are vascular calcifications of the aortic arch and the internal carotid arteries or common carotid arteries distally. IMPRESSION: No cervical spinal fractures. Degenerative changes as described above with mild canal stenoses at C2/3 and C4/5 and C6/7. . CT L-SPINE W/O CONTRAST [**2106-2-3**] 4:37 PM CT OF THE LUMBER SPINE WITHOUT IV CONTRAST: There is no evidence of acute fracture or malalignment of the lumbar spine. Vertebral body heights and disc spaces are maintained. There is no spondylolisthesis. Sclerotic degenerative changes are noted of the facet joints throughout the lumbar spine. There is no significant central canal stenosis. Degenerative vacuum disc phenomenon is noted at L4-5. There is mild degenerative sclerosis of the left sacroiliac joint. Extensive atherosclerotic calcification is noted of the abdominal aorta. IMPRESSION: No fracture or malalignment of the lumbar spine. . CT PELVIS ORTHO W/O C [**2106-2-3**] 4:37 PM CT OF THE PELVIS WITHOUT IV CONTRAST: There is no evidence of fracture, dislocation or soft tissue injury. A small marginal osteophyte is noted of the right fovea capitalis. There is no hip joint effusion. Mild enthesopathy is noted along the left femoral greater trochanter at the insertion of the gluteus medius. Mild enthesopathy is present at the hamstring origins of both ischial tuberosities. There are small degenerative marginal osteophytes of the hip joints. Mild degenerative sclerosis is noted of both sacroiliac joints. A small amount of gas within the bladder may be related to recent catheterization. The pelvic bowel is unremarkable. The patient is status post hysterectomy. Dense atherosclerotic calcifications are noted of the iliac and femoral arteries. IMPRESSION: 1. No fracture or dislocation. 2. Atherosclerotic calcification of the iliac and femoral arteries. . TTE ([**2-2**]): The left atrium is normal in size. The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with focal severe hypokinesis to akinesis of the entire anterior septum, anterior wall, and apex (EF 30-35%) . Transmitral Doppler is consistent with Grade I (mild) LV diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild mitral regurgitation is seen (within normal limits). The pulmonary artery systolic pressure could not be determined. There is an anterior fat pad. IMPRESSION: Suboptimal image quality. Regional left ventricular systolic dysfunction consistent with coroanry artery disease. . Brief Hospital Course: Hospital course: Transferred to [**Hospital1 18**] for further management of ICH. Head CT showed hemorrhagic cerebral infarct concerning for metastatic disease. CT torso shows necrotic mediastinal LAD and an adrenal mass. Her neuro exam on initial evaluation (documented above) is notable for mild apraxia, right LE hyperreflexia, mild right-sided weakness and hypertonia, and intact cranial nerves except a mild right facial droop. However, after initial evaluation, she developed a severe headache, nausea and vomiting, and became quite lethargic. She appeared to have a sluggish left pupil. She was intubated in the ED for airway protection and admitted to neurology. She has been treated with dilantin for seizure prophylaxis. She was also on decadron and mannatol for concern for cerebral edema. Cardiology was initially consulted for elevated CE and these initially were thought to be [**1-16**] demand. She is not a candidate for anticoagulation. . [**Hospital Unit Name 13533**]: In the [**Name (NI) 153**], pt received a mannitol infusion with taper per neurology recommendations. with careful monitoring of serum sodium and osmolality. IV steroids and dilantin were continued. The pathology of her lung primary returned as likely SCLC. Oncology was consulted and did not feel that further systemic chemo intervention was warranted. Palliative care was also consulted. Pt received daily whole brain XRT, and was s/p [**1-24**] sessions at time of transfer. IV access was maintained with TLC as unable to obtain PIVs. Pt's mental status improved daily although she was still not A+O x 3. We did place an NGT to begin tube feedings per S/S recommendations, however the pt self d/c'ed the NGT despite restraints. As mental status appeared to be clearing with mannitol, dilantin, steroids, and whole brain XRT, decision was made to hold off on replacing NGT until MS cleared. At time of transfer pt was hemodynamically stable and breathing room air with excellent O2 saturations. . Medical Floor Course: 1) Small Cell lung cancer with Mets to the Brain/Adrenal gland The patient continued with XRT (10 sessions total planned). Mannitol completed. She was continued on decadron IV. This will be changed to PO upon completion of XRT. She was initially maintained on Dilantin. This was later tapered off and changed to Keppra per neurology's recommendation. She had some improvement in her overall mental status during the course of her hospitalization. She still continued to have right-sided weakness. She was followed by palliative care/oncology. Meeting held with patient's sister, [**Name (NI) **], to explain poor overall prognosis even with chemotherapy - decided on no chemotherapy - plan to arrange [**Hospital1 1501**] and Hospice Care. . 2) CAD s/p STEMI The patient had episode of chest pressure and was found to have marked ST elevations anteriorly. Cardiology re-consulted. Given risk of bleeding unable to intervene. ASA restarted (after discussion with neuro). Maintained on B-blocker and statin. TTE repeated and showed decrease in EF and hypokinesis/akinesis anteriorly and at apex. Patient did not have any symptoms of heart failure. Short periods of NSVT were seen on telemetry. . 3) Hypertension Maintained on B-blocker. . 4) Urinary Tract Infection - E. Coli She was treated with a two-week course of Ampicillin for catheter-associated E. Coli UTI. . 5) Code Status After discussion with patient's sister, decision made to change code status to DNR/DNI; ultimately decided on hospice care at a skilled nursing facility. . 6) Accidental Fall The patient was placed in chair by nursing staff. Subsequently, she climbed over edge and was found on the floor. No LOC. Given difficulty obtaining history from patient, she had CT scan of head/C-spine/L-spine/Pelvis which did not show any acute process. . 7) FEN The patient was initially NPO but then subsequently cleared by speech/swallow to take puree then ground solids with thin liquids. Medications on Admission: Paxil 5 mg po daily Lisinopril, unknown dose Ibuprofen 600 mg po tid prn headache Glyburide 5 mg po daily MVI Nasonex Allergies: She states folic acid gave her hives Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 3. Dexamethasone 2 mg Tablet Sig: Three (3) Tablet PO Q8H (every 8 hours) for 1 days: (today [**2-15**] is the last day at this dose). 4. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 3 days: start [**2-16**]. 5. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 3 days: start [**2-19**]. 6. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days: start [**2-22**]. 7. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 days: start [**2-25**]. Tablet(s) 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever, headache. 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) Units, insulin Subcutaneous at bedtime. 15. Insulin Lispro 100 unit/mL Solution Sig: as per sliding scale Units, insulin Subcutaneous QACHS: see sliding scale, attached. Discharge Disposition: Extended Care Facility: [**Location (un) 38**] Landing Discharge Diagnosis: Small Cell lung cancer with hemorrhagic mets to the brain Coronary Artery Disease with ST Elevation MI E. Coli Urinary Tract Infection Type II Diabetes Mellitus h/o Pancreatic Cancer s/p resection h/o cerebral aneurysm Discharge Condition: Stable Discharge Instructions: Take all medications as prescribed. Followup Instructions: Primary Care Dr.[**First Name (STitle) **],[**First Name3 (LF) 8254**] will be on [**3-9**]@2pm [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2106-3-8**] 4:00

[ "V45.2", "431", "564.1", "303.93", "198.7", "412", "251.3", "196.0", "E879.6", "276.0", "V16.9", "410.71", "780.39", "V66.7", "E849.7", "198.3", "041.4", "414.01", "266.2", "784.69", "996.64", "V85.1", "V10.09", "401.9", "272.4", "305.1", "781.94", "162.3" ]

icd9cm

[ [ [] ] ]

[ "33.24", "96.72", "96.6", "96.04", "88.72", "38.93", "40.11", "92.29" ]

icd9pcs

[ [ [] ] ]

26268, 26325

20555, 20555

297, 363

26588, 26597

6760, 20532

26681, 26925

3992, 4119

24749, 26245

26346, 26567

24557, 24726

20572, 24531

26621, 26658

5382, 6741

4134, 4674

232, 259

391, 2987

4689, 5365

3009, 3729

3745, 3976

4,999

128,936

26861

Discharge summary

report

Admission Date: [**2159-2-9**] Discharge Date: [**2159-2-27**] Date of Birth: [**2110-7-25**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 99**] Chief Complaint: non productive cough, fevers, night sweats Major Surgical or Invasive Procedure: Placement of tracheostomy and PEG on [**2-23**] R PICC on [**2-26**] History of Present Illness: HPI: 48 yo male with h/o emphysema, COPD, extensive cigarette smoking history admitted to [**Hospital 882**] Hospital on [**1-2**] with dx of Strep mitis bacteremia [**12-21**] poor dentition (negative TTE) and Candidemia (?source) treated with 4 weeks of IV Vanco/Fluconazole and discharged on [**1-31**]. The pt was discharged to [**Hospital 100**] Rehab and developed new fevers on [**2-3**], sent back to [**Hospital1 882**] where CT abdomen revealed a possible necrotizing PNA (apparently a CT chest was not done), with edema of GB with negative US. He was started on levo/flagyl and sent back to [**Hospital 100**] Rehab. He was seen at [**Hospital1 882**] earlier on the day of admission, with c/o fevers, intermittent headaches, bitemporal X 2-3 weeks with nausea after eating eggs this morning. His temp was 100.1 satting 98% on 3L NC at [**Hospital1 882**], other VSS. ID was consulted, and recommended on transfer: For necrotizing pna- consider TB, cryptococcus, aspergillosis, PCP. [**Name10 (NameIs) **] rec adding Vanco for MRSA PNA. Flagyl and levo were continued. . In the ED, the pt states that his headaches not otherwise assoc with nausea. Admits to some photophobia. No nuchal rigidity. C/o tenderness over right chest wall and right iliac crest for several months. Also noted diarrhea X 3 days, brown watery no blood or mucus. No rashes, joint pain, abd pain. No new back pain. No penile discharge, dyuria, hematuria, no new sexual partners. Notes decreased po intake. With 1 month history of chills, night sweats (with his recent temps), and "weight loss over years." . In [**Name (NI) **], pt was put in isolation for rule out TB. Blood cx x 4, blood cryptococcal ag sent, UA (negative), urine cx, and [**Name (NI) **] urine ag sent. CXR revealed a RLL PNA with a Right hilar mass. CT of the chest was ordered, and a ddimer was found to be 2934. Past Medical History: PMHx: 1. COPD on 3L home o2 2. Bronchiectasis 3. Emphysema 4. Osteoporosis [**12-21**] steroid use assoc with COPD exacerbations 5. PPD [**11-24**] was negative [**First Name8 (NamePattern2) **] [**Hospital1 882**] record, received Flu vaccine [**8-23**], received pneumovax [**2156-6-9**]. 6. H/o small spiculated RLL nodule. h/o focal scarring with the LUL and RML. 7. H/o MRSA in sputum [**11-24**] 8. H/o renal cyst Social History: Prior to living at [**Hospital 100**] Rehab and his recent illnesses, he lived with his parents in [**Hospital1 3494**]. He quit smoking, but has a 34 year history of cigarette smoking, 2.5 ppd, + MJ in the past, none recently, no ETOH, no IVDA. Spent 1 night in jail in the past. Otherwise no TB exposures/contacts. [**Name (NI) **] notes homelessness in record. Family History: Mom-had MI at age 50, alive Physical Exam: PE: Vitals: T: 100.4 BP: 130/80 P: 105 RR: 20 O2sat: 92% on 2L NC GEN: Thin cachectic, small man breathing comfortably on NC. AOX3 and appropriate in conversation. Cooperative. HEENT: PERRL, EOMI. MMM w/ very poor dentition. No oropharyngeal lesions noted. No thrush. NECK: No cervical LAD. No JVD. CV: RRR Distant Heart sounds, RRR S1 and S2 audible without m/r/g. Lungs: With E-A changes at right base. + crackles on the right. Decreased breath sounds throughout. Small hypopgimented patches, round, ~5mm which pt says are scars from gunshot wounds. ABD: Soft, NT, ND, NABS, No masses. No HSM. EXT: Warm. 2+ DP pulses b/l. No edema. NEURO: CN 2-12 intact. No nuchal rigidity. Moving all extremities equally. Motor and sensory [**3-23**] throughout. SKIN: No visible rashes, lesions. One 1cm X 2cm hypopigmented patch right upper posterior shoulder and 2 ~5mm hypopigmented patches center of chest which pt reports are scars from gunshot wounds. Pertinent Results: . ADMISSION to [**Hospital1 882**] [**2159-2-4**] IMAGING: [**2-4**] CXR RLL infiltrate [**2159-2-5**] ABD US: normal except for a 1.8cm cystic lesion in the lower pole of the right kidney. [**2159-2-6**]: CT ABD/PEL small right lower lobe pleural effusion; possible necrotizing PNA; septated cyst in the lower pole of the right kidney which does not appear to be an abscess (recommendation to repeat son[**Name (NI) 493**] imaging in 6 months); edema of gallbladder wall . [**Hospital1 18**] Labs: see below [**2159-2-9**]: blood cx x2 pending [**2159-2-9**]: serum Cryptococcal ag negative [**2159-2-9**]: urine cx pending [**2159-2-9**]: urine [**Month/Day/Year 14616**] ag sent and pending . [**2159-2-9**]: CXR IMPRESSION: 1. Abnormal opacity in the right hilum with patchy consolidation in the right lower lobe. Findings are consistent with right lower lobe pneumonia. This may be due to a right hilar mass and could be further evaluated with chest CT. PE cannot be excluded. 2. No evidence of CHF. 3. Emphysema involving the upper lobes. . [**2159-2-9**]: CT chest IMPRESSION: 1. Extensive consolidation in right lower lobe with underlying emphysema, representing lobar pneumonia. 2. Patchy opacities in left upper lobe, with somewhat nodular appearance measuring up to 9 mm as described above, which can be related to infectious process; however, followup is recommended. 3. Extensive centrilobular emphysema. 4. Right pleural effusion. 5. A 1.1 cm right hilar node. No other mediastinal or hilar mass. [**2159-2-9**] 02:55PM BLOOD WBC-10.6 RBC-3.76* Hgb-11.7* Hct-34.2* MCV-91 MCH-31.2 MCHC-34.4 RDW-14.7 Plt Ct-342 [**2159-2-9**] 02:55PM BLOOD Neuts-81.5* Lymphs-10.8* Monos-6.3 Eos-0.9 Baso-0.5 [**2159-2-9**] 02:20PM BLOOD Glucose-96 UreaN-9 Creat-0.5 Na-141 K-4.1 Cl-101 HCO3-28 AnGap-16 [**2159-2-9**] 04:50PM BLOOD ALT-74* AST-71* AlkPhos-40 Amylase-54 TotBili-0.3 [**2159-2-9**] 04:50PM BLOOD Albumin-3.4 Calcium-8.2* Phos-2.4* Mg-1.6 Iron-18* [**2159-2-9**] 04:50PM BLOOD calTIBC-221* VitB12-558 Folate-19.5 Ferritn-298 TRF-170* [**2159-2-13**] 06:35AM BLOOD HIV Ab-NEGATIVE . [**2-26**] CXR: A right PICC line and tracheostomy tube remain in satisfactory position. Heart size is normal. Subtle bilateral infrahilar opacities are present, not significantly changed allowing for differences in technique dating back to [**2159-2-23**]. Severe upper lobe emphysema is noted. IMPRESSION: Subtle bilateral infrahilar opacities, likely due to a slowly resolving infection. Severe emphysema. . [**2159-2-26**] 05:05AM BLOOD WBC-12.1* RBC-2.94* Hgb-9.5* Hct-27.6* MCV-94 MCH-32.3* MCHC-34.5 RDW-15.7* Plt Ct-210 [**2159-2-25**] 04:41AM BLOOD PT-12.4 PTT-30.0 INR(PT)-1.1 [**2159-2-25**] 04:41AM BLOOD Glucose-98 UreaN-7 Creat-0.4* Na-140 K-3.8 Cl-96 HCO3-34* AnGap-14 [**2159-2-26**] 05:05AM BLOOD Calcium-8.9 Phos-4.3 Mg-1.6 [**2159-2-9**] 04:50PM BLOOD calTIBC-221* VitB12-558 Folate-19.5 Ferritn-298 TRF-170* [**2159-2-26**] 05:32AM BLOOD Type-MIX pO2-46* pCO2-66* pH-7.37 calHCO3-40* Base XS-9 [**2159-2-25**] 04:42AM BLOOD Type-ART pO2-89 pCO2-57* pH-7.42 calHCO3-38* Base XS-9 Brief Hospital Course: A/P 48 yo male with h/o emphysema, COPD, presents with h/o non productive cough, fevers, night sweats, weight loss, diarrhea. . 1. RLL PNA: This was thought to be likely community acquired PNA vs. MRSA PNA vs. aspiration PNA. There were possible necrotizing features seen on OSH CT, not appreciated on CT here, however PNA is consolidated, lobar RLL. Sputum cultures were sent for bacterial, fungal, PCP, [**Name10 (NameIs) 14616**], AFB cultures. A cryptococcal antigen was sent and returned negative. The patient was initially maintained on TB precautions until he ruled out w/ 3 sputum samples and a negative PPD. He was taken for bronchoscopy, and subsequently required intubation as copious pus was found in the bronchioles and his airway was compromised. He was then transferred to the MICU for vent weaning. Cultures from the bronch grew MSRA, and the patient was placed on Vancomycin with intention to treat for three weeks per ID service recommendations. Cytology from the BAL was negative for malignant cells. The patient was administered frequent nebs, and IV Solumedrol for his severe COPD. He was extubated two times, but required re-intubation for hypercarbic respiratory failure. Of note, the patient refused to try non-invasive mechanical ventilation with Bi-Pap. The decision was made with the HCP and from conversations with the patient to pursue trach and PEG placement. He underwent the procedures on [**2-23**] with thoracic surgery without complication. A repeat sputum culture grew Stenotrophomonas xanthomonas sensitive to Bactrim. Patient however appeared to be clinically stable, his WBC remained nl and he remained afebrile. Thus in discussion in ID service following him, it was decided not to treat him. Patient was also slowly tapered on his solumedrol and was subsequently placed on maintenance dose of 5 mg of Prednisone. He is to contine nebulizers as well. He is to follow up with his pulmonologist in [**Hospital1 112**] and his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] @ [**Hospital1 112**] as well (Dr. [**Last Name (STitle) **] will coordinate his follow up, spoker with her personally [**2-27**]). He is transfered to acute rehab care center for further vent weaning. Patient is to finish his course of Vancomycin Day # 18 on [**2-27**] for a total of 3 weeks. Patient will also need to have his tracheostomy sutures removed 7-10 days after his tracheostomy procedure ([**2-23**]). He may have that performed at bedside per CT surgery. . 2. Fevers: The patient continued to have daily fevers without a clear etiology and the differential was broad in this pt with comorbidities and multiple exposures and a history of immunosuppression with chronic steroids/prednisone tapers. The most likely source was his RLL PNA. His UA negative and urine cx were negative. He was cultured multiple times, blood cultures failed to show any new growth and his antibiotic coverage was not broadened. Patient subsequently defervesced on his own. He did grow out Stenotrophomonas as described above, but remained afebrile and was not treated as it may represent a colonizer. . # Aggitation - patient with increased anxiety peri-extubation and with persistent feeling of hypoxia despite maintaining good sats. His air hunger was attributed to his end stage COPD. Patient was also intermittently confused uncertain of his location. His aggitation was effectively controlled with Haldol TID as his confusion was attributed to ICU delirium. Patient also required ativan po for his aggitation prn. . 3. COPD - Patient is to be maintained on Prednisone 10. He is to continue on his nebulizers as well. Patient is to follow up with his pulmonologist @ [**Hospital1 112**]. . 4. Anemia: Baseline appears to be around 30. Patient upon d/c with stable Hct of 28-29. He did not require any transfusions while in house and our goal was Hct>21. His stools were guiac negative. Ferritin WNL, iron low and patient was started on iron replacement. His B12, folate WNL. Patient may warrant an outpt colonoscopy. . 5. Osteoporosis: from chronic steroid. Patient restarted on fosamax 70mg qfriday and Calcium 500 TID and Vitamin D 800 mg QD . 6. Hyperglycemia - patient is with new insulin requirement and hyperglemia. It may be due to high steroid doses adminstered. His insulin requirement were greatly decreasing as he was being tapered. Patient is to continue on sliding scale insulin. . 6. FULL CODE . 7. Access: L PICC Medications on Admission: 1. Spiriva 2. Advair diskus [**Hospital1 **] 3. Duonebs q4-6 hours 4. Fosamax 70mg po qweek 5. Calcium/Vit D supplementation 6. Albuterol inhalers 7. h/o prednisone tapers in the past, most recent 1.5 months ago . Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO once a day. 3. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 4. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 5. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily). 6. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 7. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation every six (6) hours. 8. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q1H (every hour) as needed. 9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation every six (6) hours. 10. Vitamin D 8,000 unit/mL Drops Sig: One (1) ml PO DAILY (Daily). 11. Calcium Carbonate 500 mg/5 mL Suspension Sig: Five (5) ML PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 12. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QFRI (every Friday). 13. Insulin Regular Human 100 unit/mL Solution Sig: 1-10 units Injection ASDIR (AS DIRECTED): per insulin sliding scale. 14. Haloperidol 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 15. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) ml Injection q6:prn as needed for aggitation. 16. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 17. Vancomycin 500 mg Recon Soln Sig: 2.5 Recon Solns Intravenous Q 8H (Every 8 Hours) for 4 days: from [**2-27**]. 18. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - Acute Rehab Discharge Diagnosis: 1. COPD exacerbation 2. MRSA pneumonia 3. Hypercarbic respiratory failure requiring tracheostomy and PEG placement 4. ICU delirium 5. Chronic Anemia 6. Osteoporosis Discharge Condition: Stable. Patient on PS via tracheostomy. Afebrile. Discharge Instructions: You will need to finish your antibiotic course of Vancomycin for next 4 days. Your ventilator settings should be further weaned down. Patient also has a murine valve that was fitted. Please take haldol and ativan prn for your anxiety. You may subsequently not need those medications as the environment changes and coping with your current situation hopefully improves. Please follow up with your outpatient pulmonary doctor, Dr. [**Last Name (STitle) 6174**], while continuing on prednisone and your inhallers. Needs Trach suture removal between Friday and Monday Followup Instructions: Please follow up with your pulmonary outpatient doctor and your PCP. [**Name10 (NameIs) 357**] call Dr. [**Last Name (STitle) **], PCP, [**Name10 (NameIs) **] make an appointment [**Telephone/Fax (1) 14288**]. . Needs Trach suture removal between Friday and Monday - 7-10 days after insertion on [**2-23**]. Completed by:[**2159-2-27**]

[ "285.29", "785.0", "V15.82", "482.41", "491.21", "790.6", "458.9", "518.81", "293.0", "733.00", "787.91", "V17.3" ]

icd9cm

[ [ [] ] ]

[ "43.11", "96.04", "31.1", "96.6", "33.24", "96.72", "38.93" ]

icd9pcs

[ [ [] ] ]

13639, 13712

7296, 11793

313, 384

13921, 13973

4176, 7273

14591, 14931

3155, 3184

12059, 13616

13733, 13900

11819, 12036

13997, 14568

3199, 4157

230, 275

412, 2300

2322, 2753

2769, 3139

15,538

175,358

45299

Discharge summary

report

Admission Date: [**2192-7-24**] Discharge Date: [**2192-8-2**] Date of Birth: [**2114-5-27**] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 14802**] Chief Complaint: bilateral subdural hematomas Major Surgical or Invasive Procedure: evacuation of left subdural hematoma History of Present Illness: 78M s/p fall while playing [**Doctor First Name 13792**] [**Doctor Last Name 13793**] [**7-9**], had known small SDHs at that time, was admitted for couple days and sent home. Per daughter, pt saw Dr. [**First Name (STitle) **] then and has f/u scheduled for 2 days from now, but has had 5 falls in the last 72 hours. He reports the falls are all due to his right leg giving out on him, which is a new symptom since his [**7-9**] fall. Most recent fall prompted his daughter bring him in today. Pt with history of Afib, CAD, s/p CEA, COPD. Previously on coumadin, then on pradaxa, now off (except ASA 81) x 2 weeks Past Medical History: - hypertension - CAD - CABG x4 in [**2176**] - COPD - right carotid endarterectomy with hypoglossal nerve injury, tongue deviates to the right - knee surgery several years ago - h/o pulmonary embolism - on Coumadin - h/o polio as a child - intermittent gout - colonic adenomas - frequent colonoscopies, usually yearly - cataract surgery - atrial fibrillation - breast cancer - aortic stenosis Social History: He is a former smoker but quit after his CABG. He smoked 2 packs a day for 51 years. He denies any significant alcohol use and denied any other drug use. Family History: non contributory Physical Exam: O: T: 98 BP: 126/65 HR: 85 R 17 O2Sats 98% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 2->1.5 EOMs intact bilat Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**1-28**] objects at 5 minutes. Language: Speech fluent but slow with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**3-31**] throughout except R hip flexor [**1-30**]. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally except over right shin (medial and lateral). Reflexes: intact bilaterally Toes downgoing bilaterally Handedness Right On Discharge: A&ox3 PERRL EOMs intact Full motor Incisions: c/d/i with staples Pertinent Results: CT/MRI: Bilateral subdural hematomas are enlarged since the [**2192-7-9**] examination, larger on the left. New hyperdense components are compatible with recent hemorrhage. Mild left suprasellar cistern effacement is unchanged. Bilateral hemispheric sulcal effacement is slightly worse, particularly on the left. The quadrageminal cistern remains preserved. No tonsillar herniation. Ct head [**7-25**] -Interval evacuation of the left chronic subdural hemorrhage with pneumocephalus, small residual hypodense subdural fluid and small hyperdense blood products. No intraparenchymal hemorrhage. 2. Slightly increased mass effect due to right mixed-density subdural hemorrhage, which is minimally larger, now with 4-mm leftward shift of normally midline structures. Pelvic x-ray [**7-25**] - No fracture. If clinical concern for fracture persists, MRI or CT would be of utility. CT HEAD W/O CONTRAST Study Date of [**2192-7-26**] 12:37 PM FINDINGS: There has been no significant interval change in the size of the bilateral subdural hematomas when compared to the most recent comparison from [**2192-7-25**]. There has been interval decrease in the amount of pneumocephalus within the left subdural space. The degree ofmass effect from the right subdural hemorrhage including a 4 mm leftward shift of midline structures has not significantly changed from the prior study. There is no evidence of new hemorrhage. The basal cisterns are preserved. There is no evidence of acute vascular territorial infarction. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. IMPRESSION: No significant interval change in the size or mass effect from the bilateral subdural hematomas compared to the most recent prior study. CT HEAD W/O CONTRAST Study Date of [**2192-7-27**] 8:03 AM IMPRESSION: Slow interval growth of the right subdural hematoma over the past 48 hours with increased leftward shift of midline structures. [**7-27**]: CT Head- IMPRESSION: 1. Interval evacuation of right subdural hemorrhage with large subdural pneumocephalus, small residual hypodense subdural fluid and small new hyperdense blood products. 2. Persistent 11 mm leftward shift of normally midline structures. Effacement of the right lateral and third ventricles, with slight left lateral ventricle dilation, is probably stable but could be minimally increased; evaluation is limited by differences in positioning. Follow up is recommended. 3. Essentially stable left subdural collection, except for minimally decreased pneumocephalus, allowing for positional differences. [**7-29**] LENI's:No evidence of deep vein thrombosis in the lower extremities. CHEST (PA & LAT) [**2192-7-31**] Patient is known with bilateral subdural hematoma. New bibasilar small pleural effusion with consolidation is highly concerning for aspiration UNILAT UP EXT VEINS US [**2192-7-31**] No deep vein thrombosis identified. Occlusive thrombus seen in the left cephalic vein at the level of the antecubital fossa. [**2192-8-1**] CT head: Status post removal of the right subdural drain with unchanged mixed density subdural. The left-sided subdural predominantly hypodense subdural, although appears slightly more prominent, could be due to interval differences in slice selection and angulation. Continued followup recommended as clinically appropriate. Air within the subdural space again identified. [**2192-8-1**] Video Swallow: Trace aspiration and penetration with thin liquids. Penetration with honey-thick and nectar-thick liquid. Delayed oral phase. Vallecular residue. [**2192-8-1**] CXR As compared to the previous radiograph, the extent of the bilateral pleural effusions and the subsequent areas of atelectasis are unchanged on the right. On the left, they have minimally decreased. Unchanged moderate cardiomegaly with sternotomy wires but unchanged, absence of overt pulmonary edema. [**2192-8-2**] LENIS: prelim-no dvt in BLE Brief Hospital Course: The patient was admitted to the Neurologic Surgery Service for management of a subdural hematoma. The patient was taken to the OR on [**7-25**] and underwent an uncomplicated surgical evacuation. The patient tolerated the procedure without complications and was transferred to the ICU in stable condition. Please see operative report for details. Post operatively pain was controlled with intravenous medication with a transition to PO pain meds once tolerating POs. Post op head CT on [**7-25**] showed interval evacuation of left SDH and slight increase in right SDH. On [**7-26**] a repeat CT head showed no significant interval change in the size or mass effect of right SDH. He was transferred to SDU in stable condition. On [**7-27**], INR 1.5, drain total from day prior to this AM ~550cc. The Head CT was consistent with slow interval growth of the right subdural hematoma over the past 48 hours with increased leftward shift of midline structures. The patient underwent craniotomy for evacuation of right hematoma after administration of FFp and Vitamin K for INR of 1.5. Surgery was without complication and the patient tolerated it well. On [**7-28**] he was neurologically stable. One drain was removed and the other was left in place and he was continued on flat bedrest with high flow oxygen. On [**7-29**] the drain was again left in place but his activity was advanced and he was encouraged to increase his PO intake. His PCP was updated on his current care. He had LENI's to evaluate his LE edema, and they were negative for DVT. On [**7-30**], repeat head CT was performed which showed improvement in midline shift and less pneumocephalus. His R subdural drain was removed and staples were placed at the incision site. His foley was replaced for urinary retention. On [**7-31**], patient was seen to be tachypnic and SOB on exertion. CXR was ordered which revealed bilateral pleural effusions and basilar consolidations. He was started on triple antibiotic coverage for treatment of HAP. His LUE was erythematous and edematous which prompted UE dopplers, he was seen to have a small clot in the cephalic vein. Vascular was consulted and recommended warm compresses and elevation. In addition, he was evaluated by speech and swallow and it was determined that he could have a regular diet with ensure. On [**8-1**], he neurological exam was improved. Medicine was consulted for pneumonia after repeat CXR. They recommended that patient have 10 days of antibiotic treatment. He also went for a video swallow where it was determined that he have a soft and thin liquid diet for aspiration. Repeat head CT was stable. His foley was removed for a voiding trial. On [**8-2**], patient was stable on examination. He was given nebulizers for wheezing and lenis were ordered to evaluate for LE clots. A PICC line was placed for administration of antibotics. Lenis were completed which prelim showed no dvt. He was stable on discharge to rehab. Medications on Admission: albuterol, ambien, ASA 81, atenolol, clobetasol, crestor, furosemide, nicorette, spiriva, tamoxifen, zestril, zoloft, colchicine Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: bilateral subdural hematomas Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? **Your wound was closed with staples. You may wash your hair only after sutures and/or staples have been removed. ?????? **Your wound was closed with 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 were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin, prior to your injury, you may safely resume taking this after your post operative follow up. ?????? **You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. Followup Instructions: ??????Please return to the office in [**6-5**] days(from your date of surgery) for removal of your staples. This appointment can be made with the Nurse Practitioner [**First Name (Titles) **] [**Last Name (Titles) **] [**Name Initial (PRE) 19158**]. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????**You may also have them removed at your rehab facility. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **] , to be seen in __4_weeks. ??????You will need a CT scan of the brain without contrast. Completed by:[**2192-8-2**]

[ "428.32", "414.00", "496", "E888.9", "786.59", "428.0", "V45.81", "V12.02", "424.1", "V10.3", "401.9", "852.21", "V12.55", "V15.82", "427.31" ]

icd9cm

[ [ [] ] ]

[ "01.31" ]

icd9pcs

[ [ [] ] ]

10266, 10336

7122, 10086

337, 376

10409, 10409

3139, 6175

11983, 12693

1629, 1647

10357, 10388

10112, 10243

10560, 11960

1662, 1915

3054, 3120

269, 299

404, 1025

2217, 3040

6184, 7099

10424, 10536

1047, 1441

1457, 1613

61,928

107,857

39062

Discharge summary

report

Admission Date: [**2110-1-10**] Discharge Date: [**2110-1-12**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1899**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: Mr. [**Known lastname 86602**] is a [**Age over 90 **] year old man with a PMHx s/f Afib, bladder cancer, perioperative MI, glaucoma, and hypertension who presented to BIDN with chest pain on the morning of [**2110-1-10**]. Mr. [**Known lastname 86602**] noted "indigestion" for several hours, admitted this to his daughter over the phone who called an ambulance. Upon presentation to [**Hospital1 **] [**Location (un) 620**], he was initially found to be in Vtach with HR to 200-210 and patient converted to NSR with 150mg bolus of amiodarone. While patient was in Vtach, BP was stable at 104/62. Once normal sinus rhythm was achieved, STE in the inferior leads were apparent. Given ASA 325mg, and Heparin 5000 bolus. He was transferred to [**Hospital1 18**] for emergent catheterization. . Upon arrival to the cath lab, SBP was initially in the low 70's following administration of nitro, but was fluid responsive to SBP up to 120's now. Catheterization showed total occlusion of the RCA with collaterals; there was minimal disease elsewhere. . Review of systems is positive for shortness of breath with stair climbing, daily cough and rhinorrhea, as well as daily palpitations. . Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, or presyncope. He 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. He denies recent fevers, chills or rigors. Past Medical History: 1. CARDIAC RISK FACTORS: Hypertension 2. CARDIAC HISTORY: - MI in [**2106**] - Afib 3. OTHER PAST MEDICAL HISTORY: - Glaucoma - Bladder Cancer Social History: Lives in [**Location **] with his wife, they are independent in ADLS/IADLS. He is retired. He occasionally drinks alcohol rarely. He smoked 30 pack years but quit 50 years ago. The rest of review of system is negative. Family History: - Father died in 70s s/p CVA. - Mother died in 40s of unknown cause - No known early cardiac demise. Physical Exam: ADMISSION PHYSICAL 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 JVD at mid-neck at 20 degrees. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . DISCHARGE PHYSICAL EXAM: unchanged Pertinent Results: ADMISSION LABS: [**2110-1-10**] 08:44PM BLOOD Hct-27.7* Plt Ct-193 [**2110-1-10**] 08:44PM BLOOD Glucose-134* UreaN-26* Creat-1.2 Na-139 K-3.7 Cl-106 HCO3-26 AnGap-11 [**2110-1-10**] 08:44PM BLOOD Albumin-3.2* Calcium-7.7* Phos-2.6* Mg-1.8 [**2110-1-10**] 08:44PM BLOOD CK-MB-16* . DISCHARGE LABS: [**2110-1-12**] 04:10AM BLOOD WBC-4.8 RBC-2.88* Hgb-8.1* Hct-25.1* MCV-87 MCH-28.0 MCHC-32.1 RDW-15.4 Plt Ct-216 [**2110-1-12**] 04:10AM BLOOD PT-39.1* PTT-42.3* INR(PT)-3.8* [**2110-1-12**] 04:10AM BLOOD Glucose-99 UreaN-24* Creat-1.2 Na-136 K-4.4 Cl-103 HCO3-27 AnGap-10 [**2110-1-12**] 04:10AM BLOOD ALT-22 AST-26 AlkPhos-40 TotBili-0.2 [**2110-1-12**] 04:10AM BLOOD TSH-1.5. . TTE [**1-11**] The left atrium is elongated. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with distal inferior and apical hypokinesis (distal LAD territory). The remaining segments contract normally (LVEF = 55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic arch 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. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w distal LAD disease. Aortic valve sclerosis without stenosis. Mild pulmonary hypertension. . CXR [**1-11**]: FINDINGS: There are no old films available for comparison. Heart is upper limits of normal in size. The aorta is minimally tortuous. There are some aortic calcifications. There is a small amount of volume loss at both bases and minimal blunting of the CP angles. There are degenerative changes of the spine with anterior osteophytes, disc space narrowing, and sclerosis. Brief Hospital Course: Primary Reason for Hospitalization: Mr. [**Known lastname 86602**] is a [**Age over 90 **] year old male with PMHx s/f CAD, AFib, and prior bladder cancer who presents with VT following a STEMI. Active Diagnoses: # STEMI: Inferior STEMI likely [**1-9**] thrombosis. No intervenable lesion on cath. No distal sites for re-anastomosis and patient's age make him a poor candidate for CABG. TTE showed mild regional LV systolic dysfunction, c/w distal LAD disease, aortic valve sclerosis without stenosis and mild pulmonary HTN. Will start medical management for MI. Patient was maintained on ASA 325mg daily, plavix loaded and then 75mg daily, metoprolol 12.5 mg [**Hospital1 **] titrated to HR 60, lisinopril 10mg, and atorvastatin 80mg. His warfarin was held for supratherapeutic INR, and he was not put on heparin as he was already anticoagulated. # RHYTHM: Pt has history of CAD and prior perioperative NSTEMI by report. Given that "indigestion" symptoms pre-dated his palpitations, it is likely that his STEMI led to a focal area of arrythmia. Also, the fact that his VT was quite regular is somewhat indicative of a focal source as opposed to prior scar. Given baseline symptoms of palpitations, chronic intermittent VT caused by myocardial scarring from prior MI may have been occurring. He was continued on metoprolol and his electrolytes were repleted. Chronic Diagnoses: # HTN: He was continued on lisinopril and he remained normotensive. # HLD: He was started on atorvastatin in lieu of home dose of simvastatin. # Anemia: Ferrous sulfate was held in hospital to avoid confusion with melena. Transitional Issues: He should receive cardiac rehab after f/u with primary cardiologist. Patient may benefit from echo in the future. He will follow-up with PCP for INR check and re-starting coumadin. Medications on Admission: - coumadin 6mg daily - simvastatin 40mg daily - lisinopril 10mg daily - metoprolol succinate 25mg daily - ferrous sulfate 650 mg daily - [**Last Name (un) **] shell 500mg daily - I-caps eye vitamins daily Discharge Medications: 1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 5. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 6. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): 1 tablet twice daily for 2 weeks (last day [**1-26**]) then 1 tablet daily. Disp:*60 Tablet(s)* Refills:*2* 7. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 9. Oyster Shell Calcium Oral Discharge Disposition: Home Discharge Diagnosis: Primary: ST elevation myocardial infarction, Coronary artery disease, ventricular tachycardia Seconary: Hyperlipidemia, atrial fibrillation, glaucoma 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 86602**], It was a pleasure taking care of you during your hospitalization. You were transferred to the [**Hospital1 18**] from our [**Hospital 620**] campus after it was noted you were in an abnormal heart rhythm known as ventricular tachycardia. This was secondary to a heart attack you suffered. You were taken to the cath lab, however there was no way to open up the blocked artery. Therefore you were treated medically for your heart attack. You were started on a medication called amiodarone to keep your heart rhythm normal. You were also seen by our physical therapists who felt you were safe to go home. . Your INR was elevated to 3.8 on your day of discharge. You should hold your coumadin until you are able to get your INR rechecked, which should be on Tuesday, [**2110-1-14**] at Dr.[**Name (NI) 86603**] office. . We made the following changes to your medications: STARTED Atorvastatin 80mg by mouth daily Aspirin 325mg by mouth daily Amiodarone 200mg by mouth twice daily for 2 weeks (until [**2110-1-26**]), then 200mg daily Clopidogrel (Plavix) 75mg by mouth daily . DECREASED lisinopril to 5mg daily . STOPPED simvastatin - The atorvastatin replaces this Coumadin - Stop taking this until told by Dr.[**Name (NI) 86603**] office to restart it - this will be done by checking your INRs . Please continue your other medications as previously prescribed. Followup Instructions: You will need to follow up with Dr.[**Name (NI) 86603**] office on Tuesday [**2110-1-14**] to have your INR checked. You will also need to schedule an appointment with her to be seen in the next week. Please call [**Telephone/Fax (1) 31529**] to schedule this appointment. . Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (STitle) 86604**] office at [**Telephone/Fax (1) 3342**] to schedule a follow-up Cardiology appointment at [**Hospital1 18**] [**Location (un) 620**] in [**3-14**] weeks. [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**] Completed by:[**2110-1-13**]

[ "412", "427.1", "444.81", "562.10", "458.29", "365.9", "401.9", "410.41", "272.4", "414.01", "790.92", "280.9", "E942.4", "V45.74", "427.31", "E934.2", "V10.51", "427.69", "V15.82" ]

icd9cm

[ [ [] ] ]

[ "88.56", "37.22" ]

icd9pcs

[ [ [] ] ]

8557, 8563

5431, 5627

262, 288

8758, 8758

3294, 3294

10370, 11006

2280, 2383

7508, 8534

8584, 8737

7272, 7485

8941, 9826

3592, 5408

2423, 3239

1941, 1967

7064, 7246

9855, 10347

212, 224

316, 1861

3310, 3576

8773, 8917

1998, 2028

5645, 7043

1883, 1921

2044, 2264

3264, 3275

25,895

125,277

15571

Discharge summary

report

Admission Date: [**2112-9-28**] Discharge Date: [**2112-10-5**] Service: MEDICINE Allergies: Lisinopril Attending:[**First Name3 (LF) 2605**] Chief Complaint: vomitting blood Major Surgical or Invasive Procedure: EGD History of Present Illness: Ms. [**Known lastname **] is a [**Age over 90 **] year old woman with PMH significant for CAD s/p MI [**11**], hiatal hernia, and hemorroids with frequent bleeing who presented today from [**Hospital 100**] Rehab where she lives after complaining of RUQ pain and vomitting blood. Upon arrival at the ED, she was found to be hemodynamically stable with a HCT of 28, which is her baseline. On EGD, an adherent clot and severe esophagitis was found, but no intervention was made. Past Medical History: HTN CRI DM1 Hypothyroid GERD DJD Macular degeneration Osteoporosis Deafness Social History: Resides at [**Hospital1 100**] Rehabilitaiton Center for Aged No tobacco or ETOH Family History: non contributory Physical Exam: Vitals: AF HR 78 BP 154/49 RR 19 100% on 2L NC Gen: lying in NAD, emesis basin at her side, blood on floor HEENT: MMM, right eye with cataract, left surgical pupil, reactive, hard of hearing Neck: supple no LAD Lungs: poor inspiratory effort, very mild weezing CVS: RRR no murmurs distant Abd: soft NT ND Ext: WWP lower extremity extensors [**4-12**], upper extremity flexors [**4-12**] Neuro: EOMI, left pupil reactive, tongue midline, facial sensation intact . Pertinent Results: [**2112-9-28**] 09:57AM WBC-13.4* RBC-3.01* HGB-9.4* HCT-28.6* MCV-95 MCH-31.1 MCHC-32.8 RDW-14.1 [**2112-9-28**] 09:57AM NEUTS-85.3* BANDS-0 LYMPHS-10.4* MONOS-2.2 EOS-2.0 BASOS-0.1 [**2112-9-28**] 09:57AM PLT COUNT-221 [**2112-9-28**] 09:57AM ALT(SGPT)-12 AST(SGOT)-16 CK(CPK)-45 ALK PHOS-71 AMYLASE-65 TOT BILI-0.2 [**2112-9-28**] 09:57AM LIPASE-33 [**2112-9-28**] 09:57AM GLUCOSE-336* UREA N-51* CREAT-1.6* SODIUM-135 POTASSIUM-5.2* CHLORIDE-99 TOTAL CO2-27 ANION GAP-14 [**2112-9-28**] 03:53PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014 [**2112-10-5**] 06:44AM BLOOD WBC-8.6 RBC-3.16* Hgb-9.5* Hct-29.5* MCV-93 MCH-30.2 MCHC-32.4 RDW-15.4 Plt Ct-148* [**2112-10-5**] 06:44AM BLOOD Plt Ct-148* [**2112-10-5**] 06:44AM BLOOD Glucose-141* UreaN-42* Creat-1.2* Na-141 K-4.3 Cl-112* HCO3-22 AnGap-11 [**2112-10-5**] 06:44AM BLOOD Calcium-8.9 Phos-2.2* Mg-1.7 Brief Hospital Course: A/P: [**Age over 90 **] yo female with h/o GERD and hiatal hernia, here with upper GIB, hemodynamically stable, also with chest pain . # GIB: Evidence on slow ongoing bleed with falling HCT. Received 1 additional unit for HCT of 27 with appropriate bump after to 31 after unit. EGD was performed and EGD showed large hiatal hernia and severe esophagitis with adherent clot and oozing blood. showed High risk for rebleed as ulcerations were not cauterized. Hct was followed closely and stabilazed. Per GI, patient will not benefit from re-scoping/further intervention given her age and co-morbidities. (HCT was stable at around 30 for 3 days. Patient had 1-2 episodes of dark stools but GI did not feel the benefit of performing an EGD). Recommended 40 mg Protonix [**Hospital1 **] and Hematocrit check in 2 days after discharge. If there is a significant drop in HCT-the patient would have to come back to ED. . # CP: Likely d/t severe esophagitis (aortic dissection and esophageal rupture ruled out. EKG with RBBB. Patient ruled out for Myocardial infarction. Aspirin was discontinued. Recurrnet chest pain was relieved by Maalox suspension. . # Elevated WBC on admission; eventually started trending down. Urine Cx grew Klebsiella. To get Ciprofloxacin for 10 days (250 mg QD) . # Endocrine: h/o hypothyroidism - was continued on levothyroxine . # DM: History of insulin dependent diabetes. Here with sugars in the 200s. She was put on ISS. . # history of falls: unwitheenessed fall, hip and arms are with no evidence of fx on chest X ray Medications on Admission: NPH 6 units [**Hospital1 **] Polyvinyl Alcohol 1.4 % 1-2 Drops Ophthalmic [**Hospital1 **] Calcium Carbonate 1,250 mg QD Carvedilol 6.25 mg two tablets [**Hospital1 **] Docusate Sodium 100 mg [**Hospital1 **] Ferrous Sulfate 325 po BID Lansoprazole 30 mg (E.C.) QD Levothyroxine Sodium 125 mcg QD Multivitamin QD Senna 8.6 mg Tablet PO HS Sertraline HCl 100 PO DAILY Simvastatin 20 mg QHS Acetaminophen 325 mg PO Q4-6H Discharge Medications: 1. Insulin Please follow your outpatient insulin regimen (NPH 6 units [**Hospital1 **]) 2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days. Disp:*6 Tablet(s)* Refills:*0* 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 6. 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* 7. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. Disp:*QS 1 month ML(s)* Refills:*0* 8. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1) Appl Rectal [**Hospital1 **] (2 times a day). 9. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO once a day. 10. Polyvinyl Alcohol 1.4 % Drops Sig: [**1-10**] Ophthalmic twice a day. 11. Calcium Carbonate 1,250 mg Capsule Sig: One (1) Capsule PO once a day. 12. FerrouSul 325 (65) mg Tablet Sig: One (1) Tablet PO twice a day. 13. Multi-Vitamin Oral 14. Sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day. 15. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 16. Acetaminophen Oral Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - Acute Rehab Discharge Diagnosis: Upper Gastrointestinal bleed Discharge Condition: Vitals stable Discharge Instructions: Please take all your medications and follow up with all your appointments. Please report to the ED or to your physician if you have any progressive black tarry stools, abdominal pain or other concerns. Followup Instructions: Please get your Hematocrit checked in 2 days to see that it is stable. . Please make an appointment to see your primary care physician [**Last Name (NamePattern4) **] [**1-10**] weeks. . [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2608**] MD, [**MD Number(3) 2609**] Completed by:[**2112-10-5**]

[ "250.00", "428.0", "530.81", "V10.3", "362.50", "285.1", "733.00", "599.0", "241.1", "530.21", "530.12" ]

icd9cm

[ [ [] ] ]

[ "99.04", "45.13" ]

icd9pcs

[ [ [] ] ]

5775, 5848

2395, 3941

234, 239

5921, 5937

1477, 2372

6187, 6534

960, 978

4411, 5752

5869, 5900

3967, 4388

5961, 6164

993, 1458

179, 196

267, 746

768, 845

861, 944

14,093

163,791

5410

Discharge summary

report

Admission Date: [**2188-2-17**] Discharge Date: [**2188-2-22**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30**] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: EGD History of Present Illness: 84M with lymphoma s/p CHOP 2weeks ago , dilated CMP, recenly d/ced from [**Hospital1 18**] after been in the hospital ([**2-4**] and [**2-11**])for GI bleed.Pt had an upper EGD which showed multiple stomach ulcers and a large 3-4 cm cratered ulcer with a necrotic center with pulsating vessel(very suspicious for malignancy) .He underwent clipping of vessels and cautherization with epinephrine . Biopsies are pending. Pt's Hc upon d/c was 36. Pt presents to ED today after feeling nauseasous and states he had 40 cc of fresh bloody emesis. In ED was found to be tachycardic up to 90-100 , BP around 120/90. He didn't c/o dizzinesss or lightheadedness. An NG tube was placed : 400 cc of coffee grounds emesis mixed c fresh red blood whihc did not clear after 2 L NS. Hct was 23. He was given 1 U PRBC and 3 lt of NS in 5 hours. BP remained stable during his ED stay. At home, patient is functional in his ADLs, grocery shopping and driving on his own, and taking care of his wife with [**Name (NI) 2481**] disease. Patient is very noncompliant at home. Past Medical History: 1. Lymphoma - Biopsy [**2-24**] showing B-cell non Hodgkins lymphoma c difficult subclassification. Originally felt to be a small lymphocytic lymphoma but new, more aggressive behavior is suggestive of NHL. Tx c XRT [**8-26**]-on CHOP-R- last chemo last Friday 2. Dilated cardiomyopathy, EF 20% 3. Chronic afib, has refused coumadin in past for side effects 4. HTN 5. Migraines 6. Arthritis 7. question OSA 8. GI bleed - [**2184**] c hgb 7.7 [**1-24**] NSAID/aspirin use, EGD showing gastritis/ulcers in fundus. 9. Hearing loss 10. ARF from hydronephrosis due to lymphoma Social History: No smoking, rare ETOH, married, lives in [**Location **], former prof. chemistry c hx exposure to organic compounds. Lives at home with his wife who has [**Name (NI) 2481**] disease. Family History: Mother c asthma, CHF, daughter died in childhood [**1-24**] neuroblastoma Physical Exam: Tc 98.5 BP 118-129/75-91 HR 90-110 afib O2sat 99%RA. Gen: NAD, pale man HEENT: NCAT, EOMI. No cervical LAD. No oral ulcers or exudates. CV: Irregularly irregular. 2/6 SEM. Lungs: CTAB. Decreased BS at bases/ Abd:+BS, soft, NT, ND. Ext: WWP. No CCE. Neuro:CN II-XII intact, strength 5/5 bilat Pertinent Results: [**2188-2-17**] 11:22PM CK(CPK)-41 [**2188-2-17**] 11:22PM CK-MB-NotDone cTropnT-0.37* [**2188-2-17**] 11:22PM HCT-27.4* [**2188-2-17**] 04:18PM HCT-29.2* [**2188-2-17**] 04:16PM POTASSIUM-3.8 [**2188-2-17**] 04:16PM CK(CPK)-42 [**2188-2-17**] 04:16PM CK-MB-NotDone [**2188-2-17**] 04:16PM MAGNESIUM-1.7 [**2188-2-17**] 11:02AM GLUCOSE-119* UREA N-44* CREAT-0.8 SODIUM-136 POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-24 ANION GAP-13 [**2188-2-17**] 11:02AM ALT(SGPT)-29 AST(SGOT)-34 LD(LDH)-260* CK(CPK)-47 ALK PHOS-78 AMYLASE-31 TOT BILI-2.0* DIR BILI-0.5* INDIR BIL-1.5 [**2188-2-17**] 11:02AM LIPASE-19 [**2188-2-17**] 11:02AM CK-MB-NotDone cTropnT-0.29* [**2188-2-17**] 11:02AM ALBUMIN-2.7* CALCIUM-7.9* PHOSPHATE-2.9 MAGNESIUM-1.8 URIC ACID-3.1* [**2188-2-17**] 11:02AM HAPTOGLOB-120 [**2188-2-17**] 11:02AM WBC-5.9 RBC-3.23* HGB-10.2* HCT-27.8* MCV-86 MCH-31.5 MCHC-36.6* RDW-15.5 [**2188-2-17**] 11:02AM PLT COUNT-208 [**2188-2-17**] 11:02AM PT-13.2* PTT-31.8 INR(PT)-1.1 [**2188-2-17**] 07:48AM HGB-9.1* calcHCT-27 [**2188-2-17**] 07:40AM HCT-26.7* [**2188-2-17**] 03:15AM UREA N-40* CREAT-0.9 SODIUM-133 POTASSIUM-4.7 CHLORIDE-101 TOTAL CO2-24 ANION GAP-13 [**2188-2-17**] 03:15AM ALT(SGPT)-35 AST(SGOT)-43* CK(CPK)-37* ALK PHOS-77 AMYLASE-29 TOT BILI-0.5 [**2188-2-17**] 03:15AM CK-MB-NotDone cTropnT-0.34* [**2188-2-17**] 03:15AM ALBUMIN-2.6* CALCIUM-7.7* MAGNESIUM-1.7 [**2188-2-17**] 03:15AM WBC-4.9# RBC-2.72*# HGB-8.4*# HCT-23.7*# MCV-87 MCH-30.9 MCHC-35.5* RDW-15.5 [**2188-2-17**] 03:15AM NEUTS-90.2* LYMPHS-4.3* MONOS-5.0 EOS-0.1 BASOS-0.5 [**2188-2-17**] 03:15AM PT-13.4* PTT-31.2 INR(PT)-1.2* [**2188-2-17**] 03:15AM PLT COUNT-218 . LABS: -At discharge: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2188-2-22**] 06:25AM 7.9 4.08* 12.5* 36.3* 89 30.6 34.4 16.0* 250 Glucose UreaN Creat Na K Cl HCO3 AnGap [**2188-2-22**] 06:25AM 156* 25* 1.0 132* 4.5 100 23 14 . [**2188-2-17**] EGD: Stomach: Excavated Lesions Multiple ulcers were found in the antrum and stomach body and incisura. Most of the ulcers were small and clean based.There was one large ulcer in the incisura, which was likely the source of bleeding and seen during the last endoscopy and had been previously injected and cauterized. On this occasion there was clot, most of which was washed off. Two areas of clot remained. Two clips were applied to larger of the two clots. 8 1 cc.Epinephrine 1/[**Numeric Identifier 961**] injections were applied to area surrounding remaining clots. Duodenum: Normal duodenum. . [**2188-2-17**] CXR: There is marked cardiomegaly, which is unchanged. There are bilateral pleural effusions, right greater than left. There are also opacities seen at the bases bilaterally, which may be secondary to underlying fluid or aspiration given the patient's clinical history. No overt pulmonary edema is identified. . [**2188-2-18**] ECG: Atrial fibrillation with PVCs or aberrant ventricular conduction LVH with secondary repolarization abnormality Extensive ST-T changes are probably due to ventricular hypertrophy Since previous tracing, no significant change . Brief Hospital Course: The patient was admitted to the ICU. #GIB: Most likely cause for GI bleeding is gastric lymphoma, considering the malignant aspect of the lesion on prior endoscopy and worsening CT scan of the abdomen showing worsening retroperitoneal masses. Pt has not been taking NSAIDs and Prednisone has been d/ced , making gastritis less likely this time. The patient underwent EGD and clipped/injected again ([**2-17**]). He was initially maintained on a PPI infusion, which was changed to Protonix 40 [**Hospital1 **] dosing. Carafate slurry was added. The patient was slowly advanced to clears. He received a total of 3 [**Location **] while in the ICU and his Hct stabilized. He remained HD stable while in the ICU. A surgical evaluation confirmed that this patient is a poor surgical candidiate and that in the event of a re-bleed, angio would be the ideal modality for treatment. Pt transferred to floor in stable condition. Pt received a total of 3 UPRBC during this admission and did not require further transfusions while on the floor. Per pt's son, there was an initial request for a bx of gastric ulcers to determine whether they were malignant or not. Multiple discussions were had with his Oncologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], regarding further XRT. In setting of high risk procedure and pt's wishes to not continue with further XRT and invasive procedures or surgery, no further EGD or gastric biopsies done. Pt's HCT remained stable, no further melana, started on clears, ADAT without problems. Pt was discharge to home with services on PPI, Carafate slurry. . #Cardiac Ischemia/NSTEMI: Pt has ischemic CM c ECHO from last admission showing new areas of hypo and dyskinesis, showed global hypokinesis and a depressed EF from 40% to 30-35%, possibly from stunned myocardium. Medical managaement was decided at that time. Now c new elevated troponin T up to 0.41. Last admission up to 1.4 Held ASA and BBlock considering stomach ulcer and hemodynamic instability. His troponins peaked at .41 and trended down .31 prior to discharge. Pt never c/o chest pain. He was restarted on his BB for HTN without any problems. . #Rhythm: pt in Afib. Coumadin contrandicated. He was restarted on his BBlock. #Pump: Pt has CHF. Not a candidate at this point for ACE, BBlock or any CHF medication d/2 hemodynamic instability. However, he was restarted on BB prior to discharge. . #Renal Insufficiency: Pt has hx of Rnal Failure c Creatinit up to 2.2 secondary to hydronephrosis d/2 retrop mass.His Cr. remained stable throughout this admission. . #Gastric lymphoma: The Heme-Onc team recommended no further treatment of the lymphoma at this time. There is an overall poor prognosis for this patient in terms of his malignancy. Per pt, he did not want further XRT/surgery or invasive procedures for his lymphoma and for his gastric ulcers. . #. CODE: Pt had initially been FULL code throughout his admission. However, per pt, son and family meeting with his oncologist Dr. [**Last Name (STitle) **] medical team and his PCP pt decided to be DNR/DNI prior to discharge. Pt understood fully and made the decision along with his son for this change in code status. . #. DISPO: Home with services. Pt refused rehab and per son/family and case management arrangements were made for home w/services. Medications on Admission: 1. Pantoprazole 40 mg Tablet, Delayed Release 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 12.5 mg Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2* 4. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2* 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Sucralfate 100 mg/mL Suspension Sig: One (1) PO four times a day. Disp:*qs 1* Refills:*2* 8. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Gastric Ulcers NH Lymphoma HTN AF Discharge Condition: Stable Discharge Instructions: IT IS VERY IMPORTANT YOU TAKE YOUR PROTONIX TWICE PER DAY, EVERY DAY. . Please take all your medications as directed and keep your follow up apointments. . If you experience any chest pain, have more blood per rectum or black/bloody stool, feel week, lightheaded or dizzy, please call your physician and go to the emergency room. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2188-3-6**] 2:30 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 5566**] [**Name Initial (NameIs) **]. HEMATOLOGY/ONCOLOGY-CC9 Date/Time:[**2188-3-6**] 2:30 . Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] [**Location (un) 2788**] CARDIOLOGY-PRIVATE Date/Time:[**2188-5-6**] 11:30 Completed by:[**2188-2-26**]

[ "427.31", "202.88", "285.1", "414.01", "591", "401.9", "531.40", "585.9", "414.8", "V15.81", "410.72", "428.0" ]

icd9cm

[ [ [] ] ]

[ "44.43", "99.04" ]

icd9pcs

[ [ [] ] ]

10333, 10391

5731, 9063

272, 277

10469, 10478

2581, 4288

10856, 11313

2177, 2252

9258, 10310

10412, 10448

9089, 9235

10502, 10833

2267, 2562

4302, 5708

221, 234

305, 1362

1384, 1959

1975, 2161

59,472

157,640

1347+55282

Discharge summary

report+addendum

Admission Date: [**2113-7-29**] Discharge Date: [**2113-8-5**] Date of Birth: [**2037-11-7**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Attending Info 8238**] Chief Complaint: fever, altered mental status Major Surgical or Invasive Procedure: -Peripherally inserted central venous catheter [**2113-7-31**] -Repositioning of PEG tube by interventional radiology [**2113-8-3**] History of Present Illness: Ms. [**Known lastname **] is a 75yo Chinese-speaking F with PMH of dementia and right sided prior stroke with residual left sided hemiparesis who speaks only a few words at baseline, AF, diastolic heart failure with mitral/tricuspid insufficiency, and diabetes. She was brought in from [**Hospital **] Health Center where she is a resident, for decreased responsiveness and fever since Monday. Temp 102-103 at NH and patient not recognizing family members as she typically does. CXray performed on [**7-24**] and again on [**7-29**] which revealed no pulmonary disease. Pt had labs remarkable for elevated white count as well as very positive UA. She was restarted on PO cipro from [**Date range (1) 1163**] and then switched to macrobid on [**7-28**]. Of note, pt was admitted most recently [**Date range (3) 8239**] for Klebsiella UTI with bacteremia, course complicated by flash pulmonary edema [**3-16**] to aggressive volume resuscitation in setting of diastolic heart failure. She was d/ced on a course of po cipro to end [**2113-7-18**]. She was also seen by speech and swallow and failed; video swallow was recommended for further evaluation to see if thickened liquids could be tolerated. In the ED, initial VS were: T101 132 147/75 12 100% She triggered in the ED for nursing concern and tacycardia to the 130s. A foley was placed and there was gross yellow pus in catheter. WBC 16.6 with 91.5% PMNs. Labs also notable for WBC 155, Cr 1.8, and lactate 2.7. She got 1L NS with plans for a second, Zosyn, and Vacno. She also got PR acetaminopen x 1. Prior to transfer, tele showing AF in the 120s-130s, 95% RA, BP 146/63. On arrival to the MICU, patient's VS. 101.4, 120s, 132/76, 93%. Family states she has had no diarrhea, moved her bowels twice yesterday after being constipated for two days. No CP, N/V, abdominal pain. No evidence of skin break down. Family unclear why she is not anticoagulated and stated that they do not remember discussing this with physicians before. They state they have never discussed this before, although last d/c summary notes this is due to her being a fall risk. Per family, pt's diapers are not changed very often, and they have found her sitting and even playing in her own stool. They feel as this may be contributing to her frequent UTIs. Two weeks ago, was starting to walk again to bathroom with assistance and walker. Past Medical History: - Dementia with Pyschosis - CVA with residual left-sided weakness - A fib - HTN - DM2 - History of respiratory Failure - Colon Polyp - Vit D deficiency - Hyperthyoidism - Endometrial Ca s/p TAH/BSO - Diastolic heart failure with previous flash pulmonary edema: At least moderate (2+) mitral regurgitation, severe [4+] tricuspid regurgitation, Dilated Right ventricular cavity with mild global free wall hypokinesis, moderate pulmonary hypertension - 1+ AR Social History: Has been living at [**Hospital **] Health Center since last d/c. No smoking, alcohol, IVDU Family History: Not applicable Physical Exam: ADMISSION EXAM General: Intermittent moaning, not responsive to questions, withdraws to tactile stimulation HEENT: Sclera anicteric, MMM, poor dentition, pupils demonstrate hippus. Neck: supple, JVP with [**Doctor Last Name **] v waves to the ear lobe, no lymphadenopathy CV: irregularly irregular, normal S1 + S2, unable to discern murmurs [**3-16**] to rate and loud breathing Lungs: rhonchorous laterally, no clear crackles Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding, gtube site is non tender non erythematous GU: +foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, no skin tenting Neuro: Deferred DISCHARGE EXAM T 99.1, P 78, BP [**Numeric Identifier 8240**], R 24, O2 99RA Gen- laying in bed with eyes closed. Opens eyes to sound or physical contact, but doesn't follow commands. Comfortable. CV- irregularly irregular with no appreciable murmurs Lung- scattered anterior crackles. Tachypneic at times, but comfortable during these episodes. Abd- soft, slightly distended, no evidence of tenderness. PEG noted. GU- Foley catheter Neuro- R gaze deviation. L hemiparesis. Pertinent Results: [**2113-7-29**] 07:35PM BLOOD WBC-16.6* RBC-3.64* Hgb-9.6* Hct-32.6* MCV-90 MCH-26.5* MCHC-29.6* RDW-17.9* Plt Ct-188 [**2113-8-5**] 06:45AM BLOOD WBC-11.9* RBC-2.85* Hgb-7.7* Hct-25.2* MCV-89 MCH-27.1 MCHC-30.6* RDW-18.3* Plt Ct-323 [**2113-7-29**] 07:35PM BLOOD Neuts-91.5* Lymphs-5.2* Monos-2.3 Eos-0.2 Baso-0.8 [**2113-7-29**] 07:35PM BLOOD Glucose-361* UreaN-66* Creat-1.8* Na-155* K-4.6 Cl-112* HCO3-32 AnGap-16 [**2113-8-5**] 06:45AM BLOOD UreaN-22* Creat-0.7 Na-148* K-3.6 Cl-112* HCO3-32 AnGap-8 [**2113-7-29**] 09:39PM BLOOD Calcium-7.6* Phos-1.8* Mg-2.2 [**2113-8-3**] 04:37AM BLOOD Calcium-8.0* Phos-2.9 Mg-1.7 [**2113-7-29**] 07:42PM BLOOD Lactate-2.7* UA [**7-29**]: 60 rbc, > 182 wbc, many bacteria, zero epithelials, pos nitrites, large leuks, +protein, +glucose Urine cx [**7-29**] ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML: Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Urine cx [**8-2**]: NO GROWTH. Blood cx [**7-29**]: ESCHERICHIA COLI. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. ESCHERICHIA COLI. FINAL SENSITIVITIES STRAIN 2. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. __________________________________________________ ESCHERICHIA COLI | ESCHERICHIA COLI | | AMPICILLIN------------ =>32 R =>32 R AMPICILLIN/SULBACTAM-- 8 S 8 S CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN/TAZO----- S S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S MRSA nasal screen: positive Blood cultures pending from [**7-31**], [**8-1**], [**8-2**], [**8-3**] CXR portable [**7-29**]: IMPRESSION: Mild pulmonary vascular congestion. Renal US portable [**7-30**]: Right kidney measures 11.9 cm. Left kidney measures 11.9 cm. There is no hydronephrosis, stone or mass seen bilaterally. A simple cyst is seen in the upper pole of right kidney. Tiny echogenic foci seen in the parenchyma of the left kidney, may reflect collapsed cyst or cortical calcifications. Bladder is decompressed with Foley. IMPRESSION: No evidence of hydronephrosis. PRELIM report of G tube replacement: Scout image of the abdomen demonstrated existing GJ tube in adequate position. Retention balloon was not visible as it was not instilled with contrast mixed. Existing fluid was aspirated from the retention balloon and the balloon was injected by 8 mL of sterile saline mixed with small quantity of Omnipaque 350. It became apparent that the retention balloon was far into the gastric lumen and was not directly apposed to the anterior wall of the stomach as is required for the effective seal function and prevention of leakage. The flexible disc around the G-tube was then approximated to the retention balloon for a tight fit and the distance between the retention disc and beginning of the hub of the feeding port measured 12 cm which is the optimal measurement for this patient. The tube was immobilized to the patient's skin surface using Flexi-Trak adhesive. Sterile dressing was applied. CONCLUSION: 1. Repositioning of the G-tube by apposing retention balloon against the anterior gastric wall and approximating flexible disc for a snug fit between the anterior gastric wall and anterior abdominal wall. 2. The tube is ready to use. Brief Hospital Course: Ms. [**Known lastname **] is a 75yo Chinese-speaking F with Hx of CVA, dementia, AF, diastolic HF, and recent admission for Klebsiella UTI and bacteremia who presents from her nursing facility with AMS and fever found to have E coli UTI with bacteremia. # E coli UTI with septicemia: Patient has a history of recurrent UTIs. Was admitted to the MICU for close hemodynamic monitoring. Renal US was negative for a renal or perinephric abscess. She was volume resuscitated with IV fluids given SIRS criteria. Upon hemodynamic stabilization, was transferred to the medical floor. Initially placed on empiric broad spectrum abx; urine and blood cultures grew E. Coli and antibiotics were narrowed to ceftriaxone for a planned 2 week course from her first negative blood culture (positive cx on [**7-29**], 1st neg culture presumed to be [**7-31**] although still pending, which means end date of [**8-13**]). # Hypernatremia, [**Last Name (un) **]: Hypovolemic with Na of 155 up from 138 prior to last d/c. Was hydrated with intraveous D5W as well as free water boluses through the G-tube. She had some episodes of tachypnea and rapid atrial fibrillation felt to be from volume overload, and required infrequent diuresis. Her Creatinine normalized by discharge. BUN remains high at 22 but much improved from 66 on admission. Na is slightly better at 148 on discharge. Her free water bolus schedule was increased so she now gets 250cc q4h. She should have sodium and renal function monitored twice weekly and fluids uptitrated accordingly. # Chronic diastolic heart failure: hx of flash pulmonary edema, severe TR, signs of right heart dysfxn, and moderate pulm artery htn. Required a couple doses of lasix for volume as above. # Afib: had RVR requiring IV rate control. Oral metoprolol aggressively uptitrated and diltiazem added. By day of discharge she was on metoprolol tartrate 50mg QID and diltiazem 90mg QID, with very good resting rates of 60-80bpm (in Afib). She will be converted to metoprolol succinate 200 daily and diltiazem 360 once daily. (On day of discharge she received short acting doses at 6am and Noon, and then one-time half doses of both long acting agents, i.e. metoprolol succinate 100mg and diltiazem XR 180mg). As for anticoagulation, CHADS2 score is 6. Unclear why not on warfarin but per report due to frequent falls. Patietn was also not on aspirin through this medication was started during hospital stay. # G-tube leak- noted to have persistent leaking of tube feeds at entry site of her G tube. Tube was repositioned by interventional radiology on [**8-3**] (see prelim report in Labs section). The retention balloon was too distal inside the gut, so they pulled it back and tightened it against the interior stomach wall disc. Distance between retention disc and hub of feeding port is 12 cm. # urinary retention- in setting of UTI, foley placed. Tried to remove it on two separate occasions, both times resulted in urinary retention and foley is placed back in. # mental status- secondary to infectious issues. At discharge her mental status does seem to be worse than her documented pre-admission baseline, specifically in that she is less verbal and interactive. She likely will continue to have stepwise decline in overall functioning. Of note, her sedating medications olanzapine and trazodone were held during this admission and removed from her medication regimen upon discharge. # goals of care- remained DNR/DNI. Had brief goals discussion w/ HCP (patient's son [**Name (NI) 8232**]. [**Name2 (NI) **] said he would indeed like hospitalization for acute issues. # Anemia- hematocrit downtrended from 32.6 on admit to 25.2 on discharge. It has been stable for the past 3 days. There is no obvious evidence of bleeding. Etiology likely due to volume shifts, chronic illness, infection, and medications. No transfusions given. # diabetes- remained hyperglycemic in setting of infection and tube feeds. Insulin NPH 20 qAM, 10qPM was uptitrated to a discharge dose of 28u qAM, 18u qPM. With this she is still hyperglycemic with sugars > 200 and warrants further uptitration. # vulvovaginitis- noted to have edema and erythema around labia with possible white discharge. Started on miconazole topical [**Hospital1 **] for 7 day course (end date [**2113-8-9**]) # circumferential wound noted on L upper arm. Staff investigated by discussing with nursing home, who confirmed that patient's son had applied cloth bands to both arms to restrain patient from pulling her feeding tube. An incident report was filed, and was determined that son's behavior was inadvertent and he did not intend any harm. He was educated on the use of appropriate restraints. Our staff did not feel the need to file any further reports on the matter. The L arm wound was dressed with sterile gauze. # patient had loose stools, flexi-seal rectal tube placed during hospital course to prevent local skin breakdown. Stable issues: # HLD- continued atorvastatin. # ? GERD: Transitioned from omeprazole to disintegrating lansoprazole via G tube. TRANSITIONAL ISSUES - consider patient should undergo outpatient video swallow for possibility of future thickened-liquid intake. - continue ceftriaxone through [**2113-8-13**] - follow up pending blood cultures - recommend check sodium and renal function twice weekly and increase free water boluses as indicated - consider repeat hematocrit in 1 week to ensure stability - check fingersticks and continue uptitrate insulin for goal sugars < 180 ideally MEDS CHANGED -started ceftriaxone -started aspirin 81 -stopped olanzapine and trazodone -increased metoprolol -added diltiazem -increased insulin NPH -started miconazole -changed omeprazole to lansoprazole Medications on Admission: -omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Year (4 digits) **]: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). -atorvastatin 40 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily). -olanzapine 2.5 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO BID (2 times a day). -colace 100mg [**Hospital1 **] PRN -Humalin 20 units in AM before AM tube feed, 10 units in the evening and sliding scale with bolus feeds -ipratropium bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours). -metoprolol tartrate 37.5 mg TID -trazodone 50 mg Tablet [**Hospital1 **]: 0.5 Tablet PO qHS. Of note, got cipro 250mg [**Hospital1 **] [**Date range (3) 8241**] and was switched to nitrofurantoin on [**2113-7-28**] at her nursing facility. Discharge Medications: 1. atorvastatin 40 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 2. docusate sodium 100 mg Capsule [**Date Range **]: One (1) Capsule PO BID (2 times a day) as needed for constipation. 3. aspirin 81 mg Tablet, Chewable [**Date Range **]: One (1) Tablet, Chewable PO DAILY (Daily). 4. acetaminophen 650 mg/20.3 mL Solution [**Date Range **]: One (1) dose PO Q6H (every 6 hours) as needed for pain/fever. 5. metoprolol succinate 200 mg Tablet Extended Release 24 hr [**Date Range **]: One (1) Tablet Extended Release 24 hr PO once a day: hold for blood pressure < 90/60 or heart rate < 55. 6. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 7. DILT-CD 180 mg Capsule, Ext Release 24 hr [**Last Name (STitle) **]: Two (2) Capsule, Ext Release 24 hr PO once a day: hold for blood pressure < 90/60 or heart rate < 55. 8. miconazole nitrate 2 % Cream [**Last Name (STitle) **]: One (1) Appl Vaginal HS (at bedtime) for 4 days: end date [**2113-8-9**]. 9. NPH insulin human recomb 100 unit/mL Suspension [**Month/Day/Year **]: One (1) injection Subcutaneous as directed: 28 units qAM, 18 units qPM. 10. insulin regular human 100 unit/mL Solution [**Month/Day/Year **]: One (1) injection Injection per standard sliding scale TID with meals and QHS. 11. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback [**Month/Day/Year **]: One (1) gram Intravenous Q24H (every 24 hours) for end date [**2113-8-13**] days. 12. heparin, porcine (PF) 10 unit/mL Syringe [**Month/Day/Year **]: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 13. ipratropium bromide 0.02 % Solution [**Month/Day/Year **]: One (1) nebulizer treatment Inhalation every six (6) hours as needed for shortness of breath or wheezing. Discharge Disposition: Extended Care Facility: [**Hospital6 1643**] Center Discharge Diagnosis: E coli urinary tract infection with septicemia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital with a Urinary Tract Infection which has spread to your blood stream. We have started you on an IV antibiotic. You also had dehydration causing damage to your kidneys which has now improved. We made several other changes to your medication regimen which can be seen in the hospital discharge summary. Followup Instructions: Per nursing home facility Name: [**Known lastname **],[**Known firstname 1105**] [**Doctor Last Name 1106**] Unit No: [**Numeric Identifier 1107**] Admission Date: [**2113-7-29**] Discharge Date: [**2113-8-5**] Date of Birth: [**2037-11-7**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Attending Info 1108**] Addendum: Regarding hospital course section on Atrial Fibrillation: Inadvertently wrote that patient will be converted to long acting Metoprolol and Diltiazem. Patient has G-tube and therefore cannot be administered long acting meds. Plan instead is to continue metoprolol tartrate 50mg q6h and diltiazem HCl 90mg q6h. Patient is NOT being given half-doses of long acting agents upon discharge; her final doses of short acting were in early afternoon today. In summary, above addendum applies to Afib section of hospital course, and to discharge medication list. Discharge Disposition: Extended Care Facility: [**Hospital 382**] Healthcare Center - [**Location (un) 382**] [**Name6 (MD) **] [**Last Name (NamePattern4) 1109**] MD [**MD Number(2) 1110**] Completed by:[**2113-8-5**]

[ "268.9", "250.02", "995.91", "V49.86", "424.0", "427.31", "272.4", "349.82", "530.81", "428.32", "428.0", "V10.42", "438.20", "112.1", "038.42", "584.9", "397.0", "599.0", "788.29", "536.42", "416.8", "276.0", "294.20" ]

icd9cm

[ [ [] ] ]

[ "97.02", "38.93", "00.14", "96.6" ]

icd9pcs

[ [ [] ] ]

19346, 19573

9245, 14978

330, 464

17801, 17801

4705, 9222

18339, 19323

3476, 3493

15809, 17633

17731, 17780

15004, 15786

17978, 18316

3508, 4686

262, 292

492, 2871

17816, 17954

2893, 3351

3367, 3460

14,975

113,621

19975

Discharge summary

report

Admission Date: [**2178-7-16**] Discharge Date: [**2178-7-30**] Date of Birth: [**2099-9-16**] Sex: M Service: MEDICINE Allergies: Amoxicillin Attending:[**First Name3 (LF) 2074**] Chief Complaint: worsening SOB and chest pressure Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: 78 M with PMH HTN, hypercholesterolemia, Parkinson's Disease, CRF (baseline Cr 1.2-1.5), presents with worsening SOB, chest pressure, N/V, sweating. Pt denied fever, chills or cough. He notes PND and orthopnea. Recieved Lasix 80IV, and NTG at HebReb with some relief. No cough, no sputum, no F/C. +PND, +orthopnea, worsening SOB since discharged from [**Hospital1 18**]. . Pt was recently discharged 1 wk ago for sepsis secondary to MRSA aspiration pneumonia (requiring pressors, intubation), stress dose steroids (adrenal insufficiency). Hospital course complicated by hypertensive episodes and acute renal failure. He was treated with and discharged on Vanco/Levo/Flagyl. . In the [**Name (NI) **], pt was found to be tachypneic, tachycardic, BP 199/113. Pt was started on NTG drip, given Lasix 80 IV x1, which improved his SOB. Pt's chest pressure improved on NTG, and he had good urine output. EKG showed rate 116, 0.[**Street Address(2) 1755**] elevations in V2-V3 (J point elevation), troponin 2.09. Past Medical History: [**Last Name (un) 3562**] disease Hypertension Chronic lower back pain Chronic renal insufficiency (baseline creat 1.2-1.5) CAD h/o melanoma s/p resection 20yrs ago Gerd BPH Social History: Lives at [**Hospital 100**] Rehab with his wife. A former International Relations professor. independent in most ADLs. Smoked previously, but quit 45 years ago, had 5 years of 1ppd. Occasional alcohol at special occasions, dinner. No IVDA. Family History: son and daughter have renal cysts Physical Exam: Vitals: BP: 160/104 P: 98 RR: 24 Oxygen sat: 96% on RA FS 172 Gen: NAD in bed, not acutely SOB HEENT: JVD to 10 cm, no LAD Lungs: Rales in bases bilaterally Heart: [**1-11**] apical SEM, no r/g Abd: Distended, +BS, obese, soft, diffusely mildly tender, 3+ hip/sacral edema, scars. Guiaic negative. Neuro: [**3-10**] motor LUE, [**4-9**] motor RUE, [**2-7**] motor LEs, 3+ lower extremity edema Pertinent Results: CXR [**7-16**]: 1. Moderate congestive failure. 2. Unchanged parenchymal opacities bilaterally within the lower lobes. These were previously described as aspiration pneumonia. 3. Small bilateral pleural effusions. . Echo [**7-10**]: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. LV systolic function appears depressed however views are technically suboptimal for assessment of regional wall motion. Resting regional wall motion abnormalities include mid to distal septal/anterior, apical and basal inferior hypokinesis (estimated ejection fraction ?35-40%. No definite apical thrombus seen but cannot exclude. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the report of the prior study (tape unavailable for review) of [**2177-1-16**], left ventricular systolic function is now significant impaired and mitral regurgitation is now more prominent. . Stress MIBI [**7-10**]: Moderate fixed inferior wall perfusion defect. Transient ischemic dilatation of the left ventricle. Moderate global hypokinesis with LV EF of 38%. . Cardiac catheterization [**7-10**]: 1. Selective coronary angiography in this right dominant circulation demonstrated three vessel disease. The LMCA was very short versus dual ostia. The LAD was calcified and diffusely diseased. There was a 50% proximal stenosis and then a 70% stenosis after the takeoff of the D1. The distal LAD had moderate diffuse disease. The D1 had moderate diffuse disease proximally. The LCx had a 60% ostial stenosis and then a serial 70% stenosis in the proximal segment. There was moderate diffuse disease in the distal LCx. The OM1 had an 80% stenosis at its origin. The L-PL had mild diffuse disease. The RCA was totally occluded which appeared chronic. There were moderate left to right collaterals. 2. Resting hemodynamics from right heart catheterization demonstrated mildly elevated right and left heart filling pressures (RVEDP=13mmHg, mean PCWP=17mmHg). There was moderate pulmonary and systemic arterial hypertension (PA=47/17mmHg, Ao=170/67mmHg). The calculated cardiac output by the Fick method was 6.4 L/min with a cardiac index of 2.8. Moderate hypoxemia was noted with an arterial oxygen saturation of 88% on 2L O2 by nasal cannula. 3. A cardiothoracic surgery evaluation is recommended. However, given that this patient may not be an ideal surgical candidate given his comorbidities, a persantine MIBI may be consider. This would allow identification of a major area at risk for ischemic which then can potentially be intervened upon via PCI. Brief Hospital Course: A/P: 78 M with PMH of HTN, hypercholesterolemia, Parkinson's ds, CRF (with baseline Cr 1.2-1.5), discharged 1 wk ago for MRSA aspiration pna (requiring pressors, intubation), d/ced on Vanco/Levo/Flagyl, presented on [**2178-7-16**] with worsening SOB, chest pressure, N/V, sweating, found to have NSTEMI. . 1. NSTEMI: Though it was a NSTEMI, his echo shows a large area of hypokinesis which is new. He was pain free after admission and his CK trended downward. His cath was initially deferred secondary to worsened CRI. During this time, he was maintained on ASA/BB/heparin/statin. He was originally started on a nitro drip but this was d/c in favor of hydralazine and isordil during this time period. His ace-i was held secondary to his worsening renal function but restarted once his kidney function normalized. As his creatinine improved he was taken to cath where he was seen to have 3VD. He was evaluated by cardiac surgery who felt that he was too high risk to intervene on. He had a stress MIBI showing global hypokinesis with transient ischemic dilitation suggesting that a focused PCI would not be effective. It was decided to medically manage the patient. . 2. SOB: On admission he was volume-overloaded by exam and CXR and was unable to lie flat for any period of time. This was also complicated by an infectious picture. He was originally maintained on a nitroglycerin drip that was titrated off over his admission and replaced by hydralazine and isordil. Because of his previous admission for PNA, vancomycin/flagyl/ceftazidime were continued for a 10d course. His CXR gradually improved and he began autodiuresing. He was able lie flat and his O2 requirement was weaned. His hydralazine and isordil were switched to an ace-i prior to d/c. . 3. Anemia: On admission, the pt had a baseline HCT of 27-33 and iron studies c/w an anemia of chronic disease. Secondary to his ischemia, he was transfused x3 units over three days to maintain his HCT over 30. He remained guaiac negative throughout his admission and was maintained on GI prophylaxis. . 4. Tachyarrhythmia: He had an episode of afib on the day after admission that was self limited and never recurred. He was maintained on bblocker for rate control throughout his admission and had no further episodes. . 5. Hypertension: His hypertension was initially managed with metoprolol which was titrated up to 75tid but further titration was limited by HR. He was initially also maintained isordil and hydralazine but these were switched to lisinopril as his creatinine normalized. His lisinopril was titrated up to 40qd on the day of discharge as his SBP was still in the 160s. He will need continued outpatient management of his blood pressure meds and will need to have his BP checked at his rehab facility. . 6. Hypercholesterolemia: He was maintained on a statin throughout his admission. . 7. Lower back pain: He received his outpatient oxycodone doses while hospitalized. . 8. Parkinson's Disease: He was maintained on carbidopa/levadopa at home doses. . 9. GERD: He was fed a cardiac diet and kept on a PPI. . 10. BPH: He remained on his outpatient meds and had a foley throughout his stay in the CCU. . 11. FEN: Lytes were repleted prn. . 12. CODE: He is a full code . Medications on Admission: aspirin 325 senna 17.2bid gabapentin 600 zoloft 100 zocor 80 oxycodone 20bid tamsulosin 0.4 imdur 60 docusate 100bid toprol 50 lisinopril 20 carbidopa/levodopa 25/100 qid amlodipine 10 tolterodine 4 prevacid 30 finasteride 5 Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Disp:*60 Capsule(s)* Refills:*2* 4. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q12H (every 12 hours). Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*0* 7. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2* 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 9. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 10. Tolterodine Tartrate 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). Disp:*60 Tablet(s)* Refills:*2* 11. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*2* 13. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 14. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 15. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] (2 times a day). Disp:*1 tube* Refills:*2* 16. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed). 17. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY Take 1 tab po qd. #30. Refills: 3 18. Furosemide 20 mg PO DAILY #30. Refills: 3 Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - LTC Discharge Diagnosis: NSTEMI Discharge Condition: Stable Discharge Instructions: 1. Please take all medications as prescribed. 2. Please keep all appointments with physicians as below. 3. Please return to the emergency room if you experience chest pain, shortness of breath, palpitations. Followup Instructions: Primary Care Appointment: [**Name6 (MD) 8741**] [**Name8 (MD) 9529**], MD Where: [**Hospital 273**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2178-8-12**] 2:30 Cardiologist Appointment: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD Where: [**Hospital 273**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 4022**] Date/Time:[**2178-9-7**] 2:30 Completed by:[**2178-7-30**]

[ "507.0", "332.0", "V10.82", "403.91", "276.2", "428.0", "285.29", "414.01", "410.71", "272.0", "530.81", "427.31", "482.41" ]

icd9cm

[ [ [] ] ]

[ "38.93", "37.23", "99.04", "88.52", "88.56" ]

icd9pcs

[ [ [] ] ]

10692, 10757

5099, 8361

305, 330

10807, 10815

2311, 5076

11074, 11501

1844, 1879

8636, 10669

10778, 10786

8387, 8613

10839, 11051

1894, 2292

233, 267

358, 1368

1390, 1565

1581, 1828

40,973

149,259

55058

Discharge summary

report

Admission Date: [**2177-7-17**] Discharge Date: [**2177-7-19**] Date of Birth: [**2116-3-11**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 8928**] Chief Complaint: Rectal bleeding Major Surgical or Invasive Procedure: None History of Present Illness: 61 year old male with past medical history of hypertension who underwent prostate biopsy today for elevated PSA. He was given ciprofloxacin yesterday and gentamicin today prior to procedure. He was noted to have rectal bleeding after his prostate biopsy along with presyncopal episode right in the recovery room. Several gauze pads were applied with poor control of bleeding. Flexible sigmoidoscopy was performed to the descending colon (50-cm from anus) which showed fresh blood and clots of blood in the left colon and rectum. The rectum was able to be completely cleared by lavage. There was no active bleeding in the rectum. Multiple diverticula in the descending and sigmoid colon, some with adherent clot. Retroflexion in the rectum revealed internal hemorrhoids. He was subsequently transferred to [**Hospital1 18**] ED for further evaluation. In the [**Hospital1 18**] ED, initial vitals were 97.6 65 109/59 18 100%RA. Labs notable for HCT of 35.8 with normal coags and platelets. CT abdomen/pelvis showed no active extravastion of contrast. He was given 2LNS. He was hemodynamically stable in the ED. GI and surgery were consulted who said they will follow. He had two ~300 cc BRBPR in the ED. He was subsequently transferred to [**Hospital1 18**] MICU for monitoring. On admission to the MICU, he had no complaints. Past Medical History: Hypertension Social History: History of smoking and alcohol abuse. Has been sober since [**2161**]. Has not been smoking > 5 years. Family History: Father, died at age 59, of throat cancer Mom, died at age 83, of cancer Mother and brother with hypertension Physical Exam: Admission Exam General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Discharge Exam VS - Temp 97.8F, BP 154/91, HR 83, R 18, O2-sat 100% RA GENERAL - well-appearing man in NAD, comfortable, appropriate HEENT - NC/AT, right pupil round/reactive to light, left eye is prosthetic. Right EOMI, sclerae anicteric, MMM, OP clear LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) NEURO - awake, A&Ox3, CNs II-XII grossly intact, moves all extremities, gait steady Pertinent Results: Admission Lab [**2177-7-17**] 05:30PM BLOOD WBC-8.8 RBC-4.15* Hgb-12.0* Hct-35.8* MCV-86 MCH-28.9 MCHC-33.4 RDW-13.2 Plt Ct-210 [**2177-7-17**] 05:30PM BLOOD Neuts-83.8* Lymphs-13.0* Monos-2.4 Eos-0.3 Baso-0.4 [**2177-7-17**] 05:30PM BLOOD Plt Ct-210 [**2177-7-17**] 05:45PM BLOOD PT-11.5 PTT-26.2 INR(PT)-1.1 [**2177-7-17**] 05:30PM BLOOD Glucose-120* UreaN-18 Creat-0.9 Na-139 K-4.1 Cl-109* HCO3-21* AnGap-13 [**2177-7-17**] 05:30PM BLOOD ALT-21 AST-20 AlkPhos-51 TotBili-0.2 [**2177-7-17**] 05:30PM BLOOD Lipase-31 [**2177-7-17**] 05:30PM BLOOD Albumin-3.9 Imaging CT Abdomen [**2177-7-17**]: IMPRESSION: 1. Mild stranding adjacent to the prostate, compatible with history of recent biopsy. No evidence of extravasation of contrast or large hematoma. 2. Mild-to-moderate dilatation of intra- and extra-hepatic bile ducts and pancreatic duct, with the common bile duct measuring up to 1.7 cm which smoothly tapers to the head of pancreas. No definite intraluminal filling defect or extrinsic mass. Nonemergent MRCP may be obtained if there is clinical concern. 3. Cholelithiasis without cholecystitis. 4. 2 mm right middle lobe pulmonary nodule which may be followed up in 12 months if there is high risk for malignancy, otherwise no additional imaging needed. 5. Diverticulosis without diverticulitis. Discharge Labs [**2177-7-19**] 07:05AM BLOOD WBC-5.0 RBC-3.74* Hgb-10.8* Hct-32.2* MCV-86 MCH-28.9 MCHC-33.5 RDW-13.3 Plt Ct-214 [**2177-7-19**] 07:05AM BLOOD Glucose-103* UreaN-10 Creat-0.9 Na-141 K-3.9 Cl-107 HCO3-28 AnGap-10 Brief Hospital Course: 61 year old male with past medical history of hypertension who underwent prostate biopsy for elevated PSA complicated by rectal bleeding. ACTIVE ISSUES 1. Rectal bleeding: This was likely secondary to prostate biopsy vs diverticular bleeding vs hemmorhoidal bleed. Hematocrit had dropped from 44 in the last Atrius records to 31 on admission. Prior to admission the patient underwent flexible sigmoidoscopy which showed fresh blood and clots. Rectum was cleared by lavage, and there was no evidence of rectal bleeding. Diverticuli were noted. He was admitted to the [**Hospital1 18**] MICU and was hemodynamically stable. Surgery consult service and GI followed. CT A/P showed no active extravastation, and there was felt to be no need for repeat colonoscopy while hospitalized. His hematocrit stablized without blood products at approximately 30 and the patient remained asymptomatic. He was transferred to the medical floor where he was monitored for one more day. He had an episode of symptomatic tachycardia and was given a small fluid bolus which resolved the tachycardia. He remained stable and was discharged with a plan to follow up for a colonoscopy as an outpatient. 2. S/p prostate biopsy- The patient was given 1 day ciprofloxacin 500mg [**Hospital1 **] for 1 day s/p biopsy per atrius urology recommendations. CHRONIC ISSUES 1. Hypertension: Held home lisinopril in setting of GI bleed. Blood pressures remained stable and he was restarted on lisinopril at discharge. . TRANSITIONAL ISSUES 1. CT of the abdomen/pelvis with incidental finding of mild-to-moderate dilatation of intra- and extra-hepatic bile ducts and pancreatic duct, with the common bile duct measuring up to 1.7 cm which smoothly tapers to the head of pancreas. No definite intraluminal fillingdefect or extrinsic mass. Nonemergent MRCP should be obtained as an outpatient per gastroenterology recommendations for further workup of this finding. 2. Incidental pulmonary nodule was seen on CXR. Due to the patient's smoking history, this should be followed up with an outpatient CT. 3. The patient should have a colonoscopy as an outpatient for further follow-up of his rectal bleeding; recommend to follow up with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10113**] as the flex sigmoidoscopy was performed by Dr. [**First Name (STitle) 10113**]. 4. The patient was given an order for a CBC to be checked on [**2177-7-21**]. This should be followed up by his PCP. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Lisinopril 5 mg PO DAILY 2. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Lisinopril 5 mg PO DAILY 2. Multivitamins 1 TAB PO DAILY 3. Outpatient Lab Work Please check CBC. ICD-9 569.3 Fax results to Dr. [**Last Name (STitle) 67691**] at [**Telephone/Fax (1) 6808**] Location: [**Hospital1 641**] Discharge Disposition: Home Discharge Diagnosis: Rectal bleeding Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you while you were hospitalized at [**Hospital1 18**]. You were admitted due to rectal bleeding after a prostate biopsy. You had a flexible sigmoidoscopy before you were admitted that showed you had diverticulosis. You had a CT scan of the abdomen which showed the same thing and no active sources of bleeding. Possible causes of your bleeding were thought to include diverticulosis versus post-procedural from your prostate biopsy or hemorrhoids. You were stabilized with IV fluids, your blood counts remained stable, and you were discharged. You should follow up as an outpatient with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10113**] for a colonoscopy. Followup Instructions: You should follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on Monday [**2177-7-21**]; please call [**Telephone/Fax (1) 2261**] on Monday morning for an appointment. You should have your blood counts checked on [**2177-7-21**]. A prescription is provided and you can take this to any outpatient laboratory; have results sent to Dr.[**Last Name (STitle) **] at [**Telephone/Fax (1) 6808**]. You should have a colonoscopy with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10113**] as an outpatient. CT of the abdomen/pelvis showed incidental finding of dilation of one of your biliary ducts. Nonemergent MRCP should be obtained as an outpatient per gastroenterology recommendations for further workup of this finding. Incidental pulmonary nodule was seen on CXR. You should have this followed up by your PCP with [**Name Initial (PRE) **] CT scan of the chest. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 8931**] Completed by:[**2177-7-20**]

[ "401.9", "576.8", "285.1", "305.03", "562.12", "E879.8", "455.2", "V15.82", "793.11", "998.11" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7725, 7731

4785, 7267

320, 327

7791, 7791

3211, 4762

8686, 9749

1865, 1976

7475, 7702

7752, 7770

7293, 7452

7942, 8663

1991, 3192

265, 282

355, 1692

7806, 7918

1714, 1728

1744, 1849

12,151

120,811

789

Discharge summary

report

Admission Date: [**2164-2-15**] Discharge Date: [**2164-2-23**] Date of Birth: [**2117-3-9**] Sex: F Service: [**Last Name (un) **] ADMISSION DIAGNOSIS: Colorectal metastases to the liver. PROCEDURES PERFORMED: 1. She had a right hepatic lobectomy. 2. CT angiography of the chest to rule out a PE. DETAILS OF HOSPITAL COURSE: Ms. [**Known lastname 2643**] is a 47 year old female who presented with synchronous colorectal metastases to the liver from a colonic primary. She underwent a colonic resection in the fall of [**2162**]. Underwent chemotherapy which resulted in a substantial reduction in the tumor volume and the liver. After completing her chemotherapy course and preoperative work up including a chest CT and PET scan, she was believed resectable. She was taken to the operating room on [**2164-2-15**] where she underwent a right hepatic lobectomy. The procedure was uncomplicated. She spent 1 day in the intensive care unit and was transferred to the floor. On postoperative day #4, she developed a marked hypoxia and tachycardia. Was transferred back to the surgical intensive care unit where she underwent work up for a pulmonary embolus. No embolus was identified. Chest x-ray was unremarkable. Over the next 24 hours her oxygen requirement decreased and she was transferred back to the floor. Hospital stay was unremarkable. The pathology report demonstrated no residual tumor within the liver specimen. She was discharged home on [**2164-2-23**]. She will follow up with Dr. [**First Name (STitle) **] in 1 week. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**] Dictated By:[**Last Name (NamePattern4) 3433**] MEDQUIST36 D: [**2164-4-2**] 07:19:44 T: [**2164-4-2**] 07:42:15 Job#: [**Job Number 5666**]

[ "197.7", "574.10", "518.0", "V10.05", "496", "285.9", "E933.1" ]

icd9cm

[ [ [] ] ]

[ "99.07", "99.04", "50.3", "51.22" ]

icd9pcs

[ [ [] ] ]

352, 1828

175, 334

1,136

139,574

185

Discharge summary

report

Admission Date: [**2192-4-19**] Discharge Date: [**2192-5-23**] Service: MEDICINE Allergies: Lisinopril Attending:[**First Name3 (LF) 1865**] Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: Mrs. [**Known lastname **] is an 84 yo f h/o CRI, HTN, GERD, colon ca, neprhotic syndrome, dc'd [**3-31**] after low anterior resection of colon. Now p/w 1wk h/o diarrhea worsened one day prior to admission, found to have wbcc 30 in ED, admitted [**4-19**] and started on both p.o. vanco and IV flagyl. Began to have brbpr on [**4-25**], on [**4-30**] had flex sigmoidoscopy showing pseudomembranes with recurrent c.diff vs. bowel ischemia as etiology. Then developed some sob/fluid overload and was started on lasix and neseritide gtt's. Had had some intermittent afib which was thought to be contributing to presumed diastolic dysfunction. Tx to CCU [**2192-5-12**] for worsening tachypnea and oliguria on nesiritide and lasix gtt. Was cardioverted chemically with good result. Also developed acute on chronic renal failure for which nephrology has been following, zenith of 6.0, now back at baseline creatinine of 2.0's. Past Medical History: Recent admission to [**Hospital1 18**] from [**2192-2-17**] to [**2192-2-29**] for treatment of likely viral gastroenteritis, PNA, transaminitis, discharged to [**Hospital **] Rehab in [**Hospital1 8**] - RAS: MRI ([**2185**]) atrophic R kidney, mod stenosis of R renal artery, L renal artery normal - CRI/nephrotic range proteinuria: [**2191**] baseline Cr 2.5; followed by Dr. [**Last Name (STitle) 1860**] (Nephrology) - PVD/Claudication - nephrotic range proteinuria - GERD - HTN: poorly controlled (SBP in 200s), Echo [**2188**] EF >55%, Mod AR, Mild MR, ascending aorta mildly dilated, Abdm aorta mildly dilated, Ao valve leaflets mildly thickened - Hyperlipidemia - Total Chol 255 ([**2190**]), LDL 138 ([**1-/2192**]), HDL 31, ([**1-/2192**]), Tg 312 ([**2191**]) - Glaucoma - Rheumatic Fever - Anemia - [**2190**]-[**2191**] mid 30s - Hyperkalemia - Osteoarthritis - Osteopenia Social History: living alone independently prior to last hospitalization. Several children and grandchildren in the area who are involved in her care. denies alcohol or tobacco use. Family History: Noncontributory. Physical Exam: tm 95.7, bp 108/50, p 93, r 25, 98% ra PERRL. OP clr JVP not appreciable. Regular s1,s2. no m/r/g LCA b/l +bs. soft. nt. nd. 2+ Lower and Upper Ext edema Pertinent Results: Admission Labs: . CBC: WBC-41.4*# RBC-4.35 HGB-13.0 HCT-37.5# MCV-86 MCH-29.8 PLT 167 DIFF: NEUTS-93.1* BANDS-0 LYMPHS-5.6* MONOS-1.1* EOS-0.1 BASOS-0.2 . CHEM 7:GLUCOSE-81 UREA N-64* CREAT-4.1*# SODIUM-135 POTASSIUM-5.1 CHLORIDE-103 TOTAL CO2-20* ANION GAP-17 ALBUMIN-1.8* CALCIUM-7.3* PHOSPHATE-4.0 MAGNESIUM-2.0 . LFTs: ALT(SGPT)-10 AST(SGOT)-24 ALK PHOS-150* TOT BILI-0.4 . CT: 1. Extensive pan colitis consistent with the clinical diagnosis of C-dif colitis. There is no evidence of toxic megacolon or perforation or abscess. 2. New small bilateral pleural effusions. 3. Small amount of ascites. . Right IJ central line with the tip in the right atrium. No evidence of pneumothorax. . Micro: Cdiff [**5-7**]: negative Cdiff [**5-6**]: negative Cdiff [**5-4**]: negative Cdiff [**5-3**]: negative Cdiff [**4-20**]: negative * Blood Cx [**4-18**]: negative Urine Cx [**4-18**]: <10,000 organisms Brief Hospital Course: 84 yo f w/ h/o CRI, htn, h/o nephrotic syndrome, w/ diarrhea, c.diff pos at rehab, failure to respond to flagyl, w/ elev wbc, and negative ct. A brief-problem based hospital course is outlined below. 1) presumed c.diff infxn- Admitted and started on p.o. vancomyin and IV metronidazole, w/ addition of levofloxacin for broad spectrum coverage given recent abd surgery. Cholestyramine was initially given for toxin binding. WBC was 30 on admission and trended down with ABX; however, C.diff toxin neg x5, so diagnosis remains presumptive. C. diff B toxin was sent and was negative as well. She completed a 3 week course of PO vanco and IV flagyl antibiotics, which was completed on [**5-14**]. She subsequently remained afebrile without further diarrhea, and was able to tolerate PO's. 2) [**Name (NI) 1866**] Pt began having episodes of BRBPR on [**4-25**] with resultant slow HCT drop. GI and surgery were consulted. Pt had no abdominal pain, but given recent surgery and low albumin, we were concerned that the bleed may be evidence of ischemic bowel or dehiscence. Pt was also having intermittent episodes of tachycardia, raising the possibility that she was having embolic phenomena with acute ischemia. However, she had no abdominal pain to suggest this. Colonoscopy was done on [**4-30**], showing severe c dif vs. ischemic bowel. Surgery found that pt was not surgical candidate and believed her bleeding and mucosal damage was [**2-29**] c dif and would continue to improve. Biopsy results showed no evidence of c.dif, but given pt's tenuous status, po vanco and iv flagyl were continued while awaiting toxin B. It is quite possible that the mucosal changes seen on colonoscopy were the result of C dif infxn, which had been treated w/ABX and resolved, leaving the mucosae to heal. As well, GI felt there may be a superimposed ischemic insult. No further work-up was performed since she had good clinical resolution of her colitis, following completion of cdiff treatment. 2) acute renal failure w/ CRI- Renal team was consulted on admisison. Baseline cr is approx 2.0. On admission this was significantly elevated to 4.1. FENA was c/w prerenal etiology and patient had R IJ placed in ED, started on NS for volume resusciation. This was undertaken slowly given that pt had an albumin of 1.4 and pleural effusions were noted on CT. Fluids were changed to 1/2NS w/ bicarb on HD2. Cr trended down each day and the patient has maintained oxygenation. Alb/cr ratio not c/w nephrotic range proteinuria- thus it was felt that the low alb was likely multifactorial. Pt initially required boluses of 500cc NS to maintain Uop ~20-30cc/hr. With hydration and improvement in her diarrhea, her Cr steadily decreased and returned to baseline of 1.6. She was seen by renal who felt that her increase in creatinine may have been secondary to ATN/hypotension and recommended avoiding aggressive overdiuresis. She did subsequently require aggressive diuresis given her rapid afib/chf with lasix and niseritide drips. However her creatinine remained at baseline of 1.7-2.0 with diuresis. She did develop a transient metabolic alkalosis, which was felt likely from volume contraction alkalosis. Therefore her lasix was weaned to 40mg daily and her bicarb trended back down to 30. Her creatinine was stable at 1.6 at the time of discharge. 3) [**Name (NI) 1867**] Pt was noted to be mildly thrombocytopenic on admisison. Unclear why it was low when patient presented. Most likely [**2-29**] extreme inflammatory/SIRS response (given elev lactate on admission). Her PLT count dropped to 95 and DIC workup and HIT Ab were sent, both negative. Her PLT count rose as her clinical condition improved and remained in normal range for the duration of her hosital course. 4) HTN - Pt's baseline SBP is in the 180s-200s range. On admission, BP was low [**2-29**] 3rd spacing and early sepsis. Her BP responded to fluids and she remained relatively normotensive. She was continued on metoprolol for HR/BP control and isordil/hydral was added for afterload reduction. 5) CHF - Evidence of CHF on initial CXR. Her EF was found to be 40% (previously normal), bringing up concern for ischemic event precipitating her failure. In support of this she was noted to have wall motion abnormalities on ECHO with inferoseptal/basal hypokinesis. Diagnostic catheritization was not performed due to her renal insufficiency and decompensated CHF. She was managed medically, and on [**5-10**] the CHF service was consulted for management. She was initiated on aggressive diuresis with IV lasix for goal -1.5L per day. She was transferred to the CCU briefly on [**5-12**] for more tailored therapy and diuresis for her CHF (lasix boluses and nesiritide) with good effect (negative approximately 500 cc overnight). She was transferred back to the floor on lasix boluses. Due to continued evidence of volume overload she was given 160mg IV [**Month/Year (2) 1868**] + started on lasix drip at 10mg/hr. Then started nesiritide [**Month/Year (2) 1868**] (1mcg/kg) followed by gtt at 0.01mcg/kg/min. Diuresed well to this and maintained BP well, however after increasing natrecor to 0.015, went back into rapid afib. Stopped natrecor on [**5-17**]. Stopped lasix gtt on [**5-18**] given persistent good diuresis. Now tapered down to 40mg daily lasix/day + afterload reduction w/ Isordil/Hydral on [**5-22**]. At the time of discharge, she was felt to be euvolemic with goal of matching ins and outs daily. We will continue her on this regimen upon discharge. 7. Atrial fibrillation: Initially converted from RAF by medical cardioversion performed with procainamide gtt in the CCU at 13mg/kg/hr x10min load followed by 2mg/hr for 2h trial. Became hypotensive to 60's systolic, but subsequently recovered. Then again went into RAF on [**5-17**] early am. Initially HR controlled w/ IV lopressor/IV dilt. Then [**Hospital 1869**] medical cardioversion w/ procainamide. Became hypotensive to 70's systolic after about 10 minutes on procainamide [**Last Name (LF) 1868**], [**First Name3 (LF) **] this was stopped and her blood pressures normalized. She then converted 10 min later to NSR. She has been in NSR the remainder of her hospital course. She is not on coumadin due to risk for bleed. In addition, amiodorone was discussed as a medical option for continued rythm control. However, given the side effect profile, the family and patient were more comfortable with holding off on adding amiodorone at this time. They understand that there is a higher risk of conversion back to atrial fibrillation and increased risk for stroke without amiodorone. We will continue rate control with metoprolol as mentioned at 25mg TID, and may titrate up as needed to maintain HR <80. 8. CAD- wall motion abnormalities on ECHO w/ inferoseptal/basal HK. currently chest pain free. continuing with medical management. On statin/b-blocker. No plan for cath at this time given her renal insuff/co-morbiditites. Also holding off on aspirin currently given her bleed risk. This will be re-addressed as an outpatient through her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. 9. Anemia- Initially had episode of GI bleed with blood loss anemia requiring 3 units of packed red blood cells. Hematocrit subsequently normalized. However, she subsequently was noted to have a low, but stable, hematocrit at 28-29. Repeat stool guaiacs were all negative and she had no further evidence of bleed or hemolysis. Iron stores were also found to be within normal limits, with low TIBC and high ferritin suggesting anemia of chronic disease. This was felt likely secondary to chronic renal insufficiency. She was started on EPO 2,000 Units q m,w,fr on [**5-22**]. The goal transfusion criteria would be 30 given her history of CAD, however, we have held off on further transfusion at this time given her known CHF with recent severe volume overload. We have set transfusion goal at hct>28, and transfused with 1 unit packed red blood cells and 20mg IV lasix for hct <28. 10. tachypnea- Resolved. Her transient tachypnea was felt likely secondary to volume overload. There was no evidence of infiltrate by CXR. Her ABG at the time on [**5-15**] showed 7.29/43/99. Her respiratory status subsequently improved that same day on [**5-15**] following IV lasix and atrovent nebulizers. Avoided albuterol nebulizers over concern for tachycardia. 11. F/E/N- Started on TPN for nutritional supplementation. She also had a swallow study which showed ability to tolerated regular solids and thin liquids. She has been taking in PO's as tolerated, but has continued to require TPN to reach nutritional goals. This will be continued upon discharge at rehab. Medications on Admission: ASPIRIN 81MG--One by mouth every day CALCIUM --One tablet three times a day CLONIDINE HCL 0.1 mg--4 tablet(s) by mouth twice a day COLACE 100MG--Take one pill twice a day as needed for constipation LASIX 20 mg--1 tablet(s) by mouth once a day LOPRESSOR 50MG--One half tablet by mouth twice a day NIZORAL 2%--Use as directed NORVASC 10MG--One by mouth every day PHOSLO 667MG--Two tabs three times a day with meals per renal PLETAL 50MG--As per dr [**First Name (STitle) 1870**] TYLENOL/CODEINE NO.3 30-300MG--One tablet by mouth q 6 hours as needed for pain ULTRAM 50MG--One half tablet by mouth twice a day as needed for leg pain VITAMIN D [**Numeric Identifier 1871**] UNIT--One tablet q week Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever, pain. 2. Brimonidine Tartrate 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 4. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-29**] Sprays Nasal QID (4 times a day) as needed for dry nasal mucosa. 5. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q3-4H () as needed. 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 7. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 9. Loteprednol Etabonate 0.5 % Drops, Suspension Sig: One (1) Ophthalmic daily (). 10. Brinzolamide 1 % Drops, Suspension Sig: One (1) Ophthalmic [**Hospital1 **] (2 times a day). 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Hydralazine HCl 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Epoetin Alfa 2,000 unit/mL Solution Sig: One (1) mL Injection QMOWEFR (Monday -Wednesday-Friday). Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: 1. Rapid Atrial Fibrillation 2. Congestive Heart Failure (EF 40%) 3. Hypotension 4. Gastrointestinal bleed 5. Coronary Artery Disease 6. Refractory C.Diff 7. Non-healing Surgical Wound 8. Deconditioning 9. Malnutrition 10. Contraction Alkalosis 11. Chronic Renal Insufficiency Discharge Condition: Stable. Discharge Instructions: You are being discharged to [**Hospital **] Rehab. Please follow-up with Dr. [**Last Name (STitle) **] 1-2 weeks after discharge from Rehab. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] 1 week after discharge from Rehab. You may call to make an appointment at [**Telephone/Fax (1) 250**]

[ "287.5", "403.91", "440.1", "530.81", "276.5", "428.30", "280.0", "112.0", "V10.05", "486", "427.31", "428.0", "584.9", "263.9", "008.45", "578.9" ]

icd9cm

[ [ [] ] ]

[ "99.04", "45.25", "38.93", "99.15", "00.13" ]

icd9pcs

[ [ [] ] ]

14322, 14401

3433, 12143

227, 233

14722, 14731

2509, 2509

14921, 15078

2300, 2318

12887, 14299

14422, 14701

12169, 12864

14755, 14898

2333, 2490

179, 189

261, 1187

2525, 3410

1209, 2100

2116, 2284

72,667

135,373

53677

Discharge summary

report

Admission Date: [**2184-4-13**] Discharge Date: [**2184-4-20**] Date of Birth: [**2152-2-8**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 371**] Chief Complaint: s/p Motor vehicle crash Major Surgical or Invasive Procedure: [**2184-4-13**] ORIF LEFT FEMUR WITH NAIL; I AND D WASHOUT LEFT LEG; ORIF LEFT HIP WITH DHS PLATE; ORIF & PINNING LEFT FOOT [**2184-4-14**] DIAGNOSTIC LAPAROSCROPY CONVERTED TO OPEN; EVACUATION OF HEMATOMA; REPAIR OF OMENTAL DEFECT; IVC FILTER; OPEN REDUCTION INTERNAL FIXACTION TIBIAL PLATEAU FRACTURE LEFT with CALLOS APPLICATION History of Present Illness: 32yo F with history of IVDU on methadone presents s/p motor vehicle crash. Pt was restrained driver, head on collision about 50mph. No LOC. Patient extracated at the scene. C/O left hip pain, leg pain and ankle pain, diffuse abdominal pain. Denies numbness or tingling of the extremity. Past Medical History: Cholecystectomy, IVDU Social History: History of IV drug abuse, occasional tobacco and alcohol use. Supported by disability. Family History: Noncontributory Physical Exam: Upon presentation to [**Hospital1 18**]: HR: 130 BP: 166/ O(2)Sat: 98 Normal Constitutional: Sever pain. HEENT: Scalp Lac, Pupils equal, round and reactive to light, Extraocular muscles intact Oropharynx within normal limits Collar Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm Abdominal: Soft, mild tendr GU/Flank: No costovertebral angle tenderness Extr/Back: Pelvis tender, L LE deformity at hip Mid thigh 20 cm wound L ankle deform Neuro: Speech fluent,mae Psych: Normal mood Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae Pertinent Results: [**2184-4-13**] 11:00PM GLUCOSE-94 LACTATE-10.6* NA+-129* K+-5.0 CL--107 TCO2-15* [**2184-4-13**] 11:00PM HGB-6.7* calcHCT-20 [**2184-4-18**] 08:07AM BLOOD WBC-7.6 RBC-2.91* Hgb-8.3* Hct-25.5* MCV-88 MCH-28.7 MCHC-32.8 RDW-15.3 Plt Ct-167 [**2184-4-18**] 08:07AM BLOOD Plt Ct-167 [**2184-4-14**] 12:08AM BLOOD Fibrino-185 [**2184-4-17**] 07:20AM BLOOD Glucose-103* UreaN-8 Creat-0.5 Na-142 K-3.6 Cl-103 HCO3-32 AnGap-11 [**2184-4-16**] 03:38AM BLOOD ALT-86* AST-183* LD(LDH)-570* AlkPhos-81 TotBili-1.1 IMAGING: [**4-13**]: CT C/S: 1. No acute fracture or traumatic malalignment of the cervical spine. 2. Mild posterior disc bulge at the C4-C5 level contacting the ventral theca without significant central canal compromise. CT head: 1. No acute intracranial process. 2. Left frontovertex laceration with underlying hematoma and possible foreign body but no underlying fracture. CT abd: 1. Minimal perihepatic hemorrhage without CT evidence of laceration or contusion. 2. Grade 1 splenic laceration with mild perisplenic hemorrhage. 3. Mild nonspecific RP stranding around IVC but contour preserved. 4. Small amount of pelvic hemorrhage. 5. Fractures of bilateral superior pubic rami, left inferior pubic ramus, left basicervical comminuted fx of left femoral neck with varus angulation of distal fracture fragment, and open comminuted fx of proximal left femoral diaphysis with valgus angulation of distal fragment. AP CXR/Pelvis: No acute traumatic injury noted within the chest. 2. Comminuted fracture of the left femoral mid diaphysis and left femoral neck. Fractures involving the superior pubic rami bilaterally and left inferior pubic ramus. Femur: Comminuted, displaced, and slightly angulated fracture involving the mid diaphysis of the left femur. [**4-14**] CXR: Interval widening of the upper mediastinum, ? vascular distension vs. mediastinal bleeding. Mild heterogeneous opacification in the left upper lung could be atelectasis alone or contusion. [**4-14**] CT LLE: Schatzker type 4, depressed, split and highly comminuted fracture of the lateral tibial plateau. Brief Hospital Course: She was admitted to the Acute Care Surgery team and taken to the operating room by Orthopedics for management of left femur fracture. She was brought to the trauma ICU intubated postop. Her scalp laceration was repaired with suturing. Due to persistent tachycardia and positive FAST exam in trauma bay (CT did not show any intra-abdominal injuries), patient was taken to OR for exploration. A bleeding omental tear was noted and repaired and her tibial fracture repaired. Postop, she received 2U PRBC. Chronic pain service was consulted for management of her methadone and acute pain. Her methadone was fractionated over the day and she was started on a Dilaudid PCA. Her pain control improved and she was extubated and transferred to the floor on [**4-16**]. Once transferred out of the ICU she continued to progress. She did have ongoing pain control issues and was initially on Dilaudid PCA and Neurontin 300 mg tid as recommended by the Chronic Pain team. Her Methadone had been restarted in divided doses totaling 180 mg (home dose 190 mg daily taken once in the morning). The PCA was eventually stopped and she was switched to oral Dilaudid and her Neurontin was increased to 600 mg tid. Her scalp sutures were removed on HD#8. She was evaluated by Physical therapy and recommended for home with services. Patent expressed a desire to have her follow up care in [**Location (un) 3844**] closer to home. She was also given the contact clinic numbers for Acute Care Surgery and Orthopedics here at [**Hospital1 18**] in the event that she had difficulty arranging her follow up in [**Location (un) 3844**]. Medications on Admission: methadone 190 mg daily Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 2. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 3. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 4. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). Disp:*180 Capsule(s)* Refills:*0* 5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for breakthrough pain. Disp:*30 Tablet(s)* Refills:*0* 6. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation. 7. promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. Disp:*30 Tablet(s)* Refills:*0* 8. methadone 10 mg/5 mL Solution Sig: One [**Age over 90 40340**]y (190) MG PO once a day: home dose. 9. Coumadin 1 mg Tablet Sig: One (1) Tablet PO every evening at 4 pm. Disp:*30 Tablet(s)* Refills:*1* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: s/p Motor vehicle crash Injuries: Scalp laceration Left femoral neck/diaphysis fracture, open Left tibial plateau fracture Left thigh laceration Grade I liver laceration Transverse mesocolon injury Bilaeral superior pubic rami fractures Left inferior pubic ramus fracture Grade I splenic laceration Acute blood loss anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were hospitalized following a motor vehicle crash where you sustained multiple injuries requiring several operations to repair some of these injuries. Your femur bone was repaired and it is very important that you do not put full weight on your left leg for the next several weeks until told by the Orthopedic specialists that you can do so. Because of your multiple orthopdic injuires you are at a greater risk for developing blood clots; a special device called an IVC filter was placed into the large vein in your torso that will catch the the majority of any blood clots that may develop. In addition to this we are recommended a medication called Coumadon (warfarin) which is a blood thinning ppill used to treat and prevent blood clots. The dose being prescribed for you is a small or mini-dose (1 mg). Blood levels at this dose are not routinely monitored. You should AVOID taking aspirin or any NSAID's such as Ibuprofen, Aleve, Motrin, Naproxen while on this medication. Once you are able to walk and put full weight on both of your legs this medication can be stopped. You are at greater risk of bleeding on this medication and if you sustain just minor cuts you may notice a prolonged time for the bleeding to stop. Sp please be careful to avoid injuries. You have indicated that you wish to follow up with providers closer to your home in [**Location (un) 3844**]. In the event of difficulties getting appointments closer to your home you have been provided with contact numbers for the Acute Care Surgery/Trauma Clinic and [**Hospital 5498**] clinic here at [**Hospital1 771**]. You are being discharged on medications to treat the pain from your operation. These medications will make you drowsy and impair your ability to drive a motor vehicle or operate machinery safely. You MUST refrain from such activities while taking these medications. Please call your doctor or return to the emergency room if you have any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. Activity: No heavy lifting of items [**9-13**] pounds for 6 weeks. After that time you may resume moderate exercise at your discretion, no abdominal exercises. Wound Care: You may shower, no tub baths or swimming. Cover your left leg in a plastic bag to keep it from getting wet. If there is clear drainage from your incisions, cover with clean, dry gauze. Your staples/stures will be removed in about 10-14 days after surgery. Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: You will need to follow up with your priamry care provider within the next 10-14 days to have your staples removed. If you are having difficulties getting an appointment please contact the Acute Care Surgery Clinic immediately here at [**Hospital1 771**] by dialing [**Telephone/Fax (1) 600**] to be seen here to have the staples removed. You will also need to follow up with an Orthopedic doctor within the next 2 weeks to have your leg staples/sutures removed. If you are having difficulty getting an appointment closer to home please call the [**Hospital **] clinic at [**Hospital1 827**] by dialing [**Telephone/Fax (1) 1228**] to make an appointment to be seen. Completed by:[**2184-4-20**]

[ "868.03", "E812.0", "873.0", "864.02", "863.44", "808.2", "865.00", "863.42", "304.00", "836.1", "820.19", "823.00", "V64.41", "838.01", "868.09", "285.1" ]

icd9cm

[ [ [] ] ]

[ "81.47", "38.7", "79.88", "54.19", "79.65", "79.35", "79.36", "54.64", "88.51", "86.59" ]

icd9pcs

[ [ [] ] ]

6561, 6644

3875, 5491

325, 660

7011, 7011

1764, 2494

10384, 11083

1142, 1159

5564, 6538

6665, 6990

5517, 5541

7162, 9982

1174, 1745

262, 287

9994, 10361

688, 977

2503, 3852

7026, 7138

999, 1022

1038, 1126

69,709

158,706

40478

Discharge summary

report

Admission Date: [**2106-4-7**] Discharge Date: [**2106-4-20**] Date of Birth: [**2033-7-15**] Sex: M Service: NEUROSURGERY Allergies: vitamin K Attending:[**First Name3 (LF) 78**] Chief Complaint: Transfer from OSH with left sided SDH Major Surgical or Invasive Procedure: [**4-7**] Left sided craniotomy for evacuation of SDH [**4-9**] Left sided craniotomy for evacuation of SDH History of Present Illness: 77 y/o M on coumadin for a-fib presents to OSH ED s/p 1 week of headache and confusion. [**Name (NI) **] wife reports that patient told her he hit his head on the car door approximately a week ago and since that time has had headache. Over the past week, the wife has noticed that her husband was not himself and more confused. She called her PCP requesting an appointment and he recommended that he be brought to the ED for further evaluation. While in ED, head CT revealed L SDH and an INR of 2.5. He was given vitamin K which he then had an allergic reaction where his throat became edematous and was subsequently intubated. He was then given factor 9 and transferred to [**Hospital1 18**] for further neurosurgical intervention. Past Medical History: hypercholesterolemia, multiple myeloma, HTN, h/o anxiety, ileostomy for ulcerative colitis Social History: Married Family History: NC Physical Exam: Gen: patient is intubated and off propofol x 5 minutes HEENT: atraumatic, normocephalic Pupils: 3-2mm bilaterally EOMs: unable to access Neuro: No EO to noxious No commands Spont/Purposeful BUE spontaneous and w/d BLE CT HEAD: 2.4 cm L SDH acute on chronic with 11mm midline shift. Labs:INR 2.7 Upon Discharge: xxxxxxxxx Pertinent Results: CT Head [**4-7**] Large left acute on chronic subdural hematoma with significant 1.7-cm midline shift and subfalcine herniation. CT Head [**4-7**] Interval placement of a left subdural drain, with interval decrease in the volume of hemorrhage. However, there is minimal overall size change or change in the degree of mass-effect. CT Head [**4-8**] 1. Moderate interval increase in the left subdural hematoma, with associated increase in the mass effect and rightward shift of midline structures.Sub-falcine and left uncal herniation 2. No other sites of intracranial hemorrhage identified. CT Head [**4-9**]: IMPRESSION: 1. Expected post-surgical changes with decrease in the size of a left subdural hematoma. 2. Interval repositioning of a drain, now within the subcutaneous tissues over the craniotomy site and no longer intracranial. CT Head [**4-10**]: IMPRESSION: 1. Unchanged left cerebral hemispheric subdural hematoma. 2. Interval decrease of midline shift to the right. 3. No new intracranial hemorrhage and no evidence of transtentorial herniation. CT Head [**4-12**]: IMPRESSION: 1. Unchanged left cerebral hemispheric subdural hematoma and associated mass effect with rightward midline shift of normally midline structures, compression of the left lateral ventricle, and left sulcal effacement. 2. No evidence of new intracranial hemorrhage or acute large vascular territorial infarction. BUE dopplers [**4-13**]: IMPRESSION: Deep vein thrombosis seen within the right basilic vein extending to the junction with one of the two right brachial veins. Occlusive thrombus also seen within the right cephalic vein. LENIS [**4-13**]: No DVT. ECHO [**4-14**]: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Preserved regional and global biventricular systolic function. Mild mitral regurgitation. Mild pulmonary hypertension. Head CT [**4-20**]: IMPRESSION: 1. Minimally decreased left hemispheric convexity subacute subdural hematoma. 2. Rightward shift of normally midline structures is not significantly changed. There is no uncal or transtentorial herniation. 3. No new hemorrhage and no evidence of infarction. Brief Hospital Course: Pt was admitted to neurosurgery service and underwent an urgent left sided craniotomy for evacuation of SDH. This procedure went well with no complications. Post operatively he was transferred back to the ICU for continued neuro monitoring and strict blood pressure control. A post op head CT showed good evacuation of SDH. His exam post operatively did improve somewhat and he began to follow commands with his LUE. On [**4-8**] he stopped following commands and a head CT showed re-accumulation of his previously evacuated SDH. ON [**4-9**] he went back to the OR for a left sided craniotomy, which showed interval decrease in midline shift. He was extubated on POD#1 and followed commands and was orientated X1. His wound drain was dc'd on post operative day 2. On POD#3 ([**4-12**]) he was found to have respiratory distress was in the process of being treated for pneumonia and fluid overload with a Lasix drip. He was less responsive than the previous day so a repeat CT was done which showed stable intracranial hemorrhages with no acute infarct or increase in cerebral edema. On [**4-13**], he appear to be improved neurologically but required a dobhoff placement for nutrition. A upper extremity U/s and LENIs were obtained [**4-14**] DVT in right basilic vein and superficial reight cephalic vein. LENIs did not show any DVTs. He was not started on anticoagulation for UE DVTs. He continued to have issues with his respiratory status and required CPAP to keep O2 saturation due to his pneumonia. Overnight on [**4-13**] patient was in rapid AFIB and cardiology/CCU was consulted. He required boluses of Metoprol and Dilt drip to convert his rhythm. He was febrile and pan-cultured. On [**4-14**] his neuro exam improved and was deemed stable for Q4h neuro checks. On [**4-15**] an attempt was made to wean the patient off the diltiazem drip for possible transfer to the Step down unit, however, he still required a Dilt drip. On [**4-18**] patient was off his Diltiazem drip with good heart rate control and started taking a PO diet w/o any swallowing difficulties, he was transferred to the floor on Telemetry. A physical therapy and occupational therapy consult was placed for assesment and placement planning. Heme/Onc was also consulted given the patients history of multiple myeloma, they said that at this point there was nothing to be done in house and that he should follow up with his oncolgoist at [**Hospital3 **]. On [**4-19**] the patient was stable while awaiting disposition. A Head CT was done on [**4-20**] to reassess prior to discharge and remained stable. He was discharged on [**4-20**] to rehab facility. Medications on Admission: coumadin 7.5mg QWED/SUN, coumadin 5mg QMON/TUES/THURS/FRI/SAT, sertaline 50mg QD, lopressor 12.5mg [**Hospital1 **], lipitor 10mgQD Discharge Medications: 1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for wheezing. 3. polyvinyl alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed) as needed for dry eyes. 4. quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection Q8H (every 8 hours). 7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. docusate sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2 times a day) as needed for no BM >24h. 9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for no BM >24h. 10. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 11. senna 8.6 mg Capsule Sig: One (1) Tablet PO HS (at bedtime) as needed for no BM >24h. 12. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever, pain. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Subdural hematoma Atrial fibrilation Pneumonia Discharge Condition: Awake, alert, needs assistance for ambulation. Discharge Instructions: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair ?????? 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. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. 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 call ([**Telephone/Fax (1) 2102**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast. **** You may resume Coumadin on [**2106-4-28**], no bolus dosing. **** ?????? Please follow-up with your Oncologist as they recommend. Completed by:[**2106-4-20**]

[ "511.9", "427.31", "401.9", "852.21", "203.00", "486", "V44.2", "414.01", "286.9", "272.0", "327.23", "453.81", "518.0", "V58.61", "E917.9", "300.00", "276.3", "412" ]

icd9cm

[ [ [] ] ]

[ "01.23", "96.6", "38.91", "01.31", "38.93", "96.71" ]

icd9pcs

[ [ [] ] ]

8464, 8536

4450, 7099

309, 419

8627, 8676

1709, 4427

10094, 10501

1338, 1342

7282, 8441

8557, 8606

7125, 7259

8700, 10071

1357, 1584

232, 271

1678, 1690

447, 1182

1593, 1662

1204, 1297

1313, 1322

14,768

127,495

50250

Discharge summary

report

Admission Date: [**2151-12-24**] Discharge Date: [**2152-1-9**] Date of Birth: [**2080-5-6**] Sex: M Service: MEDICINE Allergies: Mevacor / Pravachol / Bactrim / Adhesive Tape / Linezolid / Clindamycin Attending:[**First Name3 (LF) 3129**] Chief Complaint: Hypotension/Fevers Major Surgical or Invasive Procedure: None. History of Present Illness: This is a 71 year old male with history of renal transplant in [**2145**] on prednisone recently discharged from [**Hospital1 18**], now being admitted for persistent low-grade fevers after dialysis accompanied by hemodynamic changes including hypotension and RVR. Fevers have been low grade of around 100. Some associated chills. Patient states these have been occurring over the past 2-3 weeks, and do seem to be related to dialysis. He had previously been on dialysis before his transplant in [**2145**] for about 6 months but has not been on dialysis since then until about 3 weeks ago. He has a chronic [**Year (4 digits) **] which is non-productive for the past year. He states that he previously had such a [**Year (4 digits) **] due to rapamune toxicity which he no longer takes. He is being admitted directly. Past Medical History: # Atrial fibrillation s/p cardioversion [**2147**] # Atrial flutter s/p ablation [**2144**] with resultant atrial fibrillation - on coumadin # CAD s/p MI x2, CABG [**2138**] # Chronic systolic CHF # DM2 c/b neuropathy on insulin ([**Name (NI) **] pt) # ESRD [**1-3**] autoimmune glomerulonephritis s/p cadaveric renal transplant [**2145**] c/b delayed graft rejection, CRI. On HD TThS # Pseudogout # R adrenal lesion (stable) # Depression # h/o pulmonary nocardiosis [**2143**] # h/o bladder CA s/p surgery, BCG treatment [**2136**] # h/o GI bleed on heparin # h/o L1 compression fracture ([**2-6**]) Social History: Married and lives with his wife, daughter and grand-daughter. Retired illustrator. Quit smoking but smoked 1.5 packs per day for 25 years. Denies alcohol and IVDU. Family History: Father, died at age 56 of MI Mother, died at age 65 of CHF also had DM Physical Exam: Physical Exam on admission: Vitals: T:97.2 BP: 160/84 P: 80 R: 21 O2: 100% on RA General: Alert, oriented only to person, place, no acute distress HEENT: MMM oropharynx clear Neck: supple, JVP not elevated Lungs: crackles and expiratory wheezes at bases. CV: irreg, irreg with normal rate Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no RUQ tenderness Ext: cool extremities. Ulcerative lesions scattered all over upper and lower extremiteis RUE edematous & LLE pretibial erthema, tenderness and warmth. Left medial malleolus with deep, purulent wound and surrounding erythema. RLE with hyperpigmentation to knee. Neuro: Oriented to person, place. Following commands intermittently but moving all extremities. Sensation intact. Pertinent Results: [**12-28**] portable CXR: IMPRESSION: Improved interstitial edema with persistent opacity at left lung base. [**12-28**] CT chest/abd/pelvis: CT OF THE CHEST: Tree-in-[**Male First Name (un) 239**] opacities within the posterior right upper lobe are new since [**2151-10-25**], and may represent infection or inflammation. Patchy opacity at the left lung base persists, and there is more extensive peribronchiolar thickening and bronchiectasis at the left lung base, also concerning for recurrent infection or aspiration.Calcified focus at the left lung base may represent a granuloma. There are small bilateral pleural effusions, not significantly changed from [**2151-10-2**]. Extensive coronary artery calcification as well as calcification of the aortic valve and annulus are noted. The pulmonary artery remains prominent, measuring 4.1 cm, suggesting underlying pulmonary arterial hypertension. Mediastinal lymph nodes are numerous in number, although only a couple of precarinal and prevascular nodes are enlarged by size criteria, and are not significantly changed from multiple prior exams. Extensive calcified plaque within the descending aorta. Tiny hiatal hernia. CT OF THE ABDOMEN: On this non-contrast CT, the liver, spleen, pancreas, gallbladder, and intra- abdominal small and large bowel loops are normal. Left adrenal gland is normal. There is an unchanged tiny nodule of the right adrenal gland. The kidneys are shrunken consistent with chronic renal disease. There is a nodular contour to the gastric fundus (2:55), and soft tissue density in this area that could represent intraluminal contents although mass cannot be excluded on the provided images (appearance less marked with only possible slight wall thickening in this location in [**2151-10-2**]). Retroperitoneal nodes, some enlarged, are unchanged. CT OF THE PELVIS: Atrophied renal transplant is noted in the right lower quadrant, with a surgical clip within the upper pole. There is an unchanged (since [**2145**]) intermediate density rounded collection in the right pelvis, abutting the right common iliac vein and likely representing a lymphocele. There is no pelvic free fluid. Pelvic lymph nodes are not significantly changed, the largest measuring 2.4 x 1.8 cm in the left external iliac nodal station (2:111). There are no suspicious lytic or sclerotic lesions. There are extensive degenerative changes in the thoracolumbar spine with partial ankylosis at L5- S1 and high-grade compression deformity of the L1 vertebral body, unchanged. Multiple old right rib fractures are again noted. IMPRESSION: 1. New/worsened bibasilar tree-in-[**Male First Name (un) 239**] opacities and left lower lobe peribronchial thickening, concerning for foci of aspiration and/or infection. 2. Density at gastric fundus could represent luminal contents although soft tissue mass cannot be excluded; UGI examination or EGD could be obtained for further characterization. 3. No evidence of intra-abdominal or intrapelvic abscess. 4. Unchanged fluid collection abutting the right iliac vein, which again may represent a lymphocele. 5. Unchanged mildly enlarged lymph nodes in the torso. [**12-30**] Echo: The left atrium is mildly dilated. The right atrium is moderately dilated. The estimated right atrial pressure is 10-15mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild to moderate regional left ventricular systolic dysfunction with inferior and inferolateral akinesis. The remaining segments contract normally (LVEF = 35-40%). The right ventricular cavity is mildly dilated with borderline normal free wall function. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: No vegetations seen. Mild to moderate left ventricular systolic dysfunction, c/w CAD. Moderate tricuspid regurgitation. Moderate pulmonary hypertension [**12-30**] RUQ US: IMPRESSION: Normal right upper quadrant ultrasound without evidence of acute cholecystitis. [**12-30**] Upper and Lower Extremities US: No DVTs. [**1-1**] Ankle Plain Xrays: Three radiographs of the left ankle demonstrate soft tissue swelling overlying the lateral malleolus. No fracture is identified. The mortise is congruent. The talar dome contour is smooth. Mineralization is normal. Atherosclerotic calcifications are seen. IMPRESSION: Soft tissue swelling overlying the lateral malleolus. [**2152-1-5**] MRI of L ankle: 1. Soft tissue ulceration extending to 1 mm of cortex of lat malleolus suspicious for osteomyelitis. 2. Peroneal tenosynovitis 3. remote injury of tibio-talar ligament 4. subchondral signal changes in talar-navicular joint related to neuropathy. 5. Mild edema in calcaneous. 6. longitudinal tear of peroneus brevis tendon. *** Final read on MRI pending at time of discharge. Brief Hospital Course: # Fever/Hypotension: Pt presented with transient hypotension and AMS that was fluid bolus responsive. Although initial etiology was unclear, likely was related to a MRSA bacteremia with 2/2 blood cx bottles on [**12-28**] positive. Were worried about lung pathology at first as a CT of chest showed worsening tree and [**Male First Name (un) 239**] changes in the LLL. Although he was not hypoxic, he continued to be rhonchorus and wheezy. Abx were started - vanco, cipro and zosyn. TTE was also done and showed no vegetations. Do not think endocarditis was the cause. Patient then started to complain of worsening L ankle pain. Had chronic wound on L lateral malleolus which was likely the source of infection. Ortho was consulted and tap of ankle was performed on [**1-2**] showing finding consistent with gout and superinfection of the joint as gram stain was positive from gram positive cocci in chains and pairs. He received Vancomycin IV per HD protocol starting [**2152-1-2**]. [**Month/Day/Year **] consulted for wound care / debridement. MRI final read pending but does suggest osteomyelitis. It was decided that debridement of the joint would be difficult for the patient to tolerate given his multiple medical problems and thus he was continued on at least 6 weeks of vancomycin IV with [**Month/Day/Year **] work weekly to be followed by infectious disease for improvement in the osteomyelitis. The zosyn and cipro were discontinued given the source of the patient's fevers was likely the ankle wound. He defervesed and remained normo-tensive after the antibiotics were discontinued and continued to be stable prior to discharge. # MS changes: Altered mental status cleared after hypotension resolved. Likely secondary to MRSA bacteremia. He does remain on aspiration precautions, although per speech and swallow he can tolerate thin liquids, regular solids, and whole medications with supervision including chin tuck. # LFT Abnormalites: Elevated LDH, Alk Phos, GGT & Tbili elevated on admission.. Denies any RUQ pain and RUQ ultrasound pending. Differential includes obstructive cholestasis, acalculous cholecystitis, hemolysis, PCP, [**Name10 (NameIs) **] pulm process. Hemolysis [**Name10 (NameIs) **] unremarkable. RUQ US was negative, still no obvious etiology although have improved. # Afib: Pt with h/o Afib on coumadin, intermittently in RVR during admission. Current rates in 80ss. Was on metoprolol but then had bursts of RVR into the 120s. Was transitioned to a dilt gtt on [**1-2**] when IV metoprolol wasn't helping. Was quickly weaned off and transitioned to PO dilt of 60 mg qid. He was then transition to long-acting dilt with continued HR control. # ESRD on HD: complicated renal history s/p failed transplant, apprec renal consult. Receiving HD via fistula, renal team following. Continued Calcium Acetate TID. Of note, patient is on chronic steroid dose of prednisone 5 mg daily after failing a wean after having a failed kidney transplant. Initially thought hypotension may have been adrenal insufficiency so received one dose of high dose steroids, but then with further workup thought likely infection as outlined above. He will continue HD three times per week on discharge. # DM: On insulin, decreased while he was NPO, now is back on home regimen. # Hx of C.diff: asymptomatic but continuing PO vanco taper per ID recs given he will continue to take abx on discharge. He should continue to take this until advised to stop by the infectious disease physicians. # PPx: Systemically anticoagulated with coumadin - his inr has been below goal and he has thus been maintained on Hep SC with coumadin daily. When the INR is >2 the heparin can be stopped. PPI. bowel regimen prn # Access: PICC line was placed and then d/c'd prior to discharge. # Code: DNR/DNI # Communication: Patient and family. Medications on Admission: Meds on Transfer to ICU: Colchicine 0.6 mg PO DAILY Diltiazem 60 mg PO QID Heparin 5000 UNIT SC TID Insulin SC (per Insulin Flowsheet) Sliding Scale & Fixed Dose Midodrine 10 mg PO TID Magnesium Sulfate IV Sliding Scale Piperacillin-Tazobactam Na 2.25 g IV Q 12H Ciprofloxacin 400 mg IV Q24H Albuterol 0.083% Neb Soln 1 NEB IH Q6H Ipratropium Bromide Neb 1 NEB IH Q6H Omeprazole 40 mg PO DAILY Acetaminophen 650 mg PO Q6H:PRN Vancomycin 1000 mg IV HD PROTOCOL Senna 1 TAB PO BID:PRN Docusate Sodium 100 mg PO BID Guaifenesin [**4-9**] mL PO Q6H:PRN Calcium Acetate 1334 mg PO TID W/MEALS Miconazole Powder 2% 1 Appl TP TID:PRN Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] Amiodarone 200 mg PO DAILY PredniSONE 5 mg PO DAILY Allopurinol 100 mg PO EVERY OTHER DAY Gabapentin 300 mg PO Q48H Atorvastatin 10 mg PO Q3DAY Aspirin 81 mg PO DAILY FoLIC Acid 1 mg PO DAILY Vancomycin Oral Liquid 125 mg PO BID Discharge Medications: 1. Outpatient [**Hospital1 **] Work Please draw weekly CBC with diff, BUN, Creatinine, CRP, and ESR. Please have these results faxed to Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 18871**]. 2. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Vancomycin 1000 mg IV HD PROTOCOL 4. Folplex 2.2-25-1 mg Tablet Sig: One (1) Tablet PO once a day. 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO Q3DAY (). 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H (every 48 hours). Disp:*15 Capsule(s)* Refills:*2* 8. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 9. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 12. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Capsule(s)* Refills:*2* 13. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. Disp:*500 ML(s)* Refills:*0* 14. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 15. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) cap Inhalation once a day. 16. Insulin Lispro 100 unit/mL Insulin Pen Sig: One (1) pen Subcutaneous twice a day. 17. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day. 18. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty Five (35) units Subcutaneous QAM. 19. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fifteen (15) units Subcutaneous QPM. 20. Clobetasol 0.05 % Cream Sig: One (1) appl Topical three times a day. 21. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO twice a day. 22. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization Sig: One (1) nebulaizer Inhalation every six (6) hours as needed for shortness of breath or wheezing. 23. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 24. Diltiazem HCl 300 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily): Hold for SBP<100 HR<55. Discharge Disposition: Extended Care Facility: Blueberry [**Doctor Last Name **] Healthcare - [**Hospital1 **] Discharge Diagnosis: -Renal failure, chronic kidney disease -Bacteremia with MRSA from ankle wound and likely osteomyelitis -Atrial fibrillation with rapid ventricular response -Aspiration Pneumonia -Septic arthritis -Gout Discharge Condition: Patient was afebrile and hemodynamically stable prior to discharge. Discharge Instructions: You were admitted for low blood pressure and fevers. We think this was because of an infection in your blood that came from your ankle wound. We have treated you with antibiotics for this infection and you will continue to take these antibiotics when you leave here for at least 6 weeks. Your infectious disease doctor will tell you when to stop this. You will get this antibiotic at hemodialysis. You will need weekly blood tests to make sure the antibiotic is working. Your infectious disease doctor will look at these for you. You also had an abnormal heart rhythm called atrial fibrillation while you were hospitalized. This was treated with a new medication called diltiazem to keep your heart rate down. You should con . Medication Changes: START: Diltiazem 240mg by mouth daily START: Vancomycin IV to be dosed by the hemodialysis protocol START: Calcium Acetate 1334 by mouth three times daily START: Aspirin 81mg by mouth daily START: Guaifensin 5-10mL by mouth every 6 hours as needed for [**Hospital1 **] START: Omeprazole 40mg by mouth daily CHANGE: Gabapentin to 300mg by mouth EVERY OTHER DAY CHANGE: Vancomycin 125mg by mouth twice daily CHANGE: Bumex to 1mg by mouth twice daily . Please adhere to your follow-up appointments. They are important for managing your long-term health. . Please return to the hospital or call your doctor if you have temperature greater than 101, shortness of breath, worsening difficulty with swallowing, chest pain, abdominal pain, diarrhea, or any other symptoms that you are concerned about. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Followup Instructions: Provider: [**Name10 (NameIs) 10778**] [**Name11 (NameIs) 10779**], MD Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2152-1-20**] 11:20 Provider: [**Name10 (NameIs) 1571**] FUNCTION [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2152-1-12**] 11:10 Provider: [**Name10 (NameIs) 1570**],INTERPRET W/[**Name10 (NameIs) **] NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2152-1-12**] 11:30 Please keep your appointment with your infectious disease doctor, Dr. [**Last Name (STitle) **] on [**2-3**] at 11am in the [**Hospital **] clinic at [**Hospital3 **] Hospital. She will go over your [**Hospital3 **] and let you know if you can stop your antibiotics. . Please call for a follow up appointment with Dr. [**First Name (STitle) 3209**] ([**Telephone/Fax (1) 543**]) of [**Telephone/Fax (1) **] in [**12-3**] weeks. . Please continue your dialysis at [**Hospital3 7362**] on [**Hospital3 766**], Wednesday, and Friday.

[ "428.42", "427.31", "V10.51", "785.52", "V45.81", "274.9", "V58.61", "995.92", "682.6", "585.6", "348.30", "428.0", "008.45", "996.81", "427.32", "V58.65", "507.0", "496", "459.81", "V58.67", "711.06", "707.13", "730.26", "038.12", "357.2", "E878.0", "250.60" ]

icd9cm

[ [ [] ] ]

[ "38.93", "81.91", "39.95" ]

icd9pcs

[ [ [] ] ]

15526, 15616

8288, 12150

350, 358

15862, 15932

2919, 8264

17643, 18615

2029, 2102

13114, 15503

15637, 15841

12176, 13091

15956, 16684

2117, 2131

16704, 17620

292, 312

386, 1207

2145, 2900

1229, 1831

1847, 2013

48,716

146,505

39157+58264

Discharge summary

report+addendum

Admission Date: [**2155-4-29**] Discharge Date: [**2155-5-4**] Date of Birth: [**2075-7-11**] Sex: F Service: CARDIOTHORACIC Allergies: Vicodin Attending:[**First Name3 (LF) 1505**] Chief Complaint: increasing fatigue over last 6 months Major Surgical or Invasive Procedure: [**2155-4-29**]: Mitral valve replacement with a 27 mm Biocor tissue valve. History of Present Illness: Known MV prolapse followed by serial echos. Progressive regurgitation over last 6 months. No change since last seen. Past Medical History: Past Medical History: Mitral Regurgitation, Diabetes Mellitus type2, Hypertension, hypercholesterolemia Past Surgical History: Hysterectomy(20 years ago) Social History: Last Dental Exam: 6 months ago, due for exam in [**Month (only) 547**] Tobacco: no ETOH: no Family History: Family History: no premature CAD Race: Caucasian Lives with: alone(will stay with daughter post-op) Occupation: retired secretary Physical Exam: Physical Exam Pulse:60 Resp: 14 O2 sat: B/P Right: 130/66 Left: Height: 5'6" Weight: 136 lbs General:NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur: 4/6 SEM 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, MAE, follows commands Pulses: Femoral Right: 2+ Left: 2+ DP Right: - Left: - PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit no Right: Left: Pertinent Results: [**2155-4-29**] 01:34PM HGB-11.8* calcHCT-35 [**2155-4-29**] 01:34PM GLUCOSE-89 LACTATE-0.8 NA+-139 K+-4.1 CL--107 [**2155-4-29**] 04:21PM FIBRINOGE-135* [**2155-4-29**] 04:21PM PT-14.8* PTT-54.7* INR(PT)-1.3* [**2155-4-29**] 04:21PM PLT COUNT-122* [**2155-4-29**] 04:21PM WBC-11.4*# RBC-2.70*# HGB-7.9*# HCT-24.1*# MCV-89 MCH-29.4 MCHC-32.9 RDW-13.6 [**2155-4-29**] 04:22PM GLUCOSE-159* LACTATE-2.9* NA+-136 K+-4.0 CL--114* [**2155-5-2**] 05:25AM BLOOD WBC-9.6 RBC-2.94* Hgb-8.8* Hct-25.9* MCV-88 MCH-29.9 MCHC-34.0 RDW-14.4 Plt Ct-104* [**2155-5-2**] 05:25AM BLOOD Plt Ct-104* [**2155-4-29**] 05:30PM BLOOD PT-13.9* PTT-45.1* INR(PT)-1.2* [**2155-5-1**] 05:50AM BLOOD Glucose-97 UreaN-16 Creat-0.9 Na-137 K-4.9 Cl-106 HCO3-27 AnGap-9 Radiology Report CHEST PORT. LINE PLACEMENT Study Date of [**2155-4-29**] 5:33 PM [**Hospital 93**] MEDICAL CONDITION: 79 year old woman with s/p mv replacement REASON FOR THIS EXAMINATION: tubes/lines in correct position Final Report CHEST RADIOGRAPH INDICATION: Woman with mitral valve replacement. COMPARISON: Pre-operative chest x-ray from [**2155-4-1**]. FINDINGS: As compared to the previous radiograph, there is now status post mitral valve replacement. The tip of the endotracheal tube projects roughly 5 cm above the carina. The position and course of the nasogastric tube, the chest tubes and the Swan-Ganz catheter are normal. There is expected post-surgical mediastinal widening and a small retrocardiac atelectasis. No focal parenchymal opacities suggesting pneumonia, no pulmonary edema. No pneumothorax. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 13879**] [**Name (STitle) 13880**] DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**] [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *5.8 cm <= 4.0 cm Left Ventricle - Ejection Fraction: 55% to 65% >= 55% Findings LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo contrast is seen in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal descending aorta diameter. AORTIC VALVE: Three aortic valve leaflets. No AS. Trace AR. MITRAL VALVE: Normal mitral valve supporting structures. No MS. Moderate to severe (3+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The patient received antibiotic prophylaxis. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-CPB:1. The left atrium is moderately dilated. No spontaneous echo contrast is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular [**Hospital1 16631**] function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. 5. There are three aortic valve leaflets. There is no aortic valve stenosis. Trace aortic regurgitation is seen. 6. Moderate to severe (3+) mitral regurgitation is seen. There is severe prolapse of the anterior and posterior leaflets, mostly at the A2, P2 level. No flail segments are seen. The annulus is mildly dilated and measures 3.8 cm in the 2-chamber view. Dr. [**Last Name (STitle) **] was notified in person of the results. POST-CPB: On infusion of phenylephrine. A pacing for slow SR. Well-seated bioprosthetic valve in the mitral position. Trivial central MR. [**First Name (Titles) **] [**Last Name (Titles) 16631**] function. Normal aortic contour post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Brief Hospital Course: Ms [**Known lastname 86744**] was a same day admission to the operating room for Mitral valve repair versus replacement on [**2155-4-29**]. Please see operative report for details, in summary she had: Mitral valve replacement with a 27 mm Biocor tissue valve. Her bypass time was 72 minutes with a cross clamp of 59 minutes. She tolerated the operation well and post operatively was transferred to the cardiac surgery ICU in stable condition. In the immediate post-op period she was hemodynamically stable, woke neurologically intact and was extubated. On post-op day 1 was transferred from the ICU to the stepdown floor for continued post operative recovery. All tubes, lines and drains were removed per cardiac surgery protocol. She was started on low dose beta blocker 12.5 mg and developed first degree heart block which and her Lopressor dose was decreased to 6.25 mg [**Hospital1 **] and remained stable with SBP 110-116/60. Once on the stepdown floor her activity level was advanced with the assistance of nursing and physical therapy. She had gone into a rate controlled atrial fibrillation on post operative day 3 and continued to alternate between sinus rhythm and atrial fibrillation for the next 48 hours. On the day of discharge was noted to be in rate controlled atrial fibrillation alternating with sinus rhythm in the 80's. EKG was performed and PR interval was 180. She was not started on Amiodarone with history of second degree heart block postoperatively but Lopressor was titrated up to 25 mg [**Hospital1 **]. She was started on Coumadin for recurrent atrial fibrillation and received her first dose of 2.5 mg on [**2155-5-3**]. She is to receive 2.5 mg Coumadin on [**2155-5-4**] with visiting nurse services to draw INR and call results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office at [**Telephone/Fax (1) 6256**]. Dr[**Name (NI) 39832**] office will be contact[**Name (NI) **] regarding following INR levels. She was discharged home with visiting nurses on POD 5 in stable condition. Medications on Admission: Medications at home: Lisinopril 10' Lovastatin 10' ASA 81' Norvasc 5' Evista 60' MVI Calcium 600' Metformin 500' Allergies: NKDA 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*65 Tablet(s)* Refills:*0* 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. 7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses. Disp:*60 Tablet(s)* Refills:*0* 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 9. Lovastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 **] VNA, [**Hospital1 1559**] Discharge Diagnosis: s/p Mitral valve replacement with a 27 mm Biocor tissue valve. [**2155-4-29**] Past Medical History: Mitral Regurgitation, Diabetes Mellitus, Hypertension, hypercholesterolimia Past Surgical History: Hysterectomy(20 years ago) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Incisional pain managed with Tramadol Sternal wound healing well: no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: Dr [**Last Name (STitle) **] on [**5-22**] @9:15AM at [**Hospital3 1280**] Heart Center Please call to schedule appointments with: PCP: [**Name10 (NameIs) 9529**],[**Name11 (NameIs) **] [**Telephone/Fax (1) 82564**] in [**2-5**] weeks Cardiologist: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 20259**] in [**2-5**] 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** Labs: PT/INR for Coumadin ?????? indication Atrial fibrillation Goal INR 2.0-2.5 First draw [**2155-5-5**] Results to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] phone [**Telephone/Fax (1) 6256**] Completed by:[**2155-5-4**] Name: [**Known lastname 13719**],[**Known firstname 1940**] Unit No: [**Numeric Identifier 13720**] Admission Date: [**2155-4-29**] Discharge Date: [**2155-5-4**] Date of Birth: [**2075-7-11**] Sex: F Service: CARDIOTHORACIC Allergies: Vicodin Attending:[**First Name3 (LF) 741**] Addendum: Discharge labs as follows [**2155-5-4**] WBC 6.0 Hgb:9 Hct 26.7 Plts 179 Na 141 K 4.2 Cl 105 CO2 29 BUN 11 Crea 0.8 Glu 107 Mg 2.7 Patient was given a rx for FeSO4 325 mg po daily and senna 2 tabs po BID PRN constipation x 1 month. She is to have a Hct drawn with her PT/INR with results called in to Dr.[**Name (NI) 13721**] office. Discharge Disposition: Home With Service Facility: [**Hospital1 **] VNA, [**Hospital1 6688**] [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2155-5-4**]

[ "433.10", "433.30", "V58.61", "427.31", "564.09", "V88.01", "426.11", "V12.54", "401.9", "E878.1", "272.0", "250.00", "424.0", "997.1" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.23" ]

icd9pcs

[ [ [] ] ]

12592, 12787

6484, 8534

312, 390

10184, 10184

1667, 2499

11103, 12569

857, 972

8715, 9817

2536, 2578

9934, 10013

8560, 8560

10425, 11080

8581, 8692

10134, 10163

4992, 6461

987, 1648

234, 274

2607, 4948

418, 537

10199, 10401

10035, 10111

731, 825

20,312

189,515

50239

Discharge summary

report

Admission Date: [**2150-5-6**] Discharge Date: [**2150-5-12**] Date of Birth: [**2088-4-12**] Sex: M Service: HISTORY OF PRESENT ILLNESS: Patient is a 62-year-old African American male with a history of insulin dependent diabetes, hypertension, and hepatitis B, who presented on [**5-6**] with dehydration, hyperglycemia and hyperkalemia. The patient had developed nausea, vomiting, diarrhea and nonproductive cough approximately 10 to 14 days previous. He denied any fevers, chills, dyspnea, chest pain, headache, focal weakness, visual change, rashes or arthralgias. He admitted to loose stools without hematochezia. His abdominal pain was diffuse and described as crampy. The patient denied any unusual ingestion, sick contacts or recent travel. Initially denied any recent alcohol or drug use. However, his history had subsequently followed heavy alcohol of beer and scotch over the [**Hospital1 107**] day weekend. On presentation to the Emergency Department, the patient was found to be tachycardic, hyperglycemia and hyperkalemic. A right femoral line was placed. His initial bicarbonate was less than 4 and he had a blood pH of 7.07 and an anion gap of 34. His potassium was 8.1 and a blood sugar was 759 on arrival. Patient received Kayexalate, sodium bicarbonate and insulin drip and calcium gluconate as well as intravenous fluids, Ceftriaxone, Flagyl and Zantac in the Emergency Department. He was subsequently transferred to the Medical Intensive Care Unit. PAST MEDICAL HISTORY: Diabetes mellitus insulin dependent, although adult onset, hypertension, bilateral glaucoma, burns to the bilateral upper extremities, hepatitis B, history of lacunar infarcts, history of a positive PPD and echocardiogram in [**2140**] showing mild aortic insufficiency. MEDICATIONS ON ADMISSION: Ambien 10 mg po q.h.s., enteric coated aspirin 325 mg po q.d., Univasc 7.5 mg po q.d., NPH insulin 30 units subcutaneous q.a.m., timolol eye drops 0.5% to both eyes, one drip t.i.d., trusopt eye drops 2% to both eyes, one drop t.i.d., Xalatan eye drops one drop to each eye q.h.s., Tylenol #3 1 tablet po q. 6 hours prn and Prilosec 20 mg q.d. ALLERGIES: Question of codeine, although patient does take Tylenol #3 without problem making this unlikely. FAMILY HISTORY: Coronary artery disease in both brother and sister. SOCIAL HISTORY: The patient is married with children. He is on disability. He has a 20 pack year history of smoking and quit 20 years ago. He works in a liquor store. PHYSICAL EXAMINATION: Temperature of 98.7. Blood pressure 180/80. Pulse of 120. Respiratory rate was 28. He was 96% on 100% nonrebreather mask. General: Very thin frail male sitting upright in mild distress. Head, eyes, ears, nose and throat: Normocephalic, atraumatic. Pupils equal, round and reactive to light. His pupils were myotic. Extraocular movements were intact. Oropharynx was clear. He had dry mucous membranes. No lymphadenopathy. The jugular venous pressure was flat. His trachea was midline. His lung exam was clear to auscultation bilaterally. Heart revealed tachycardic, normal S1, S2, no S3, a laterally displaced point of maximal impulse and no murmurs, rubs or gallops. Abdomen was soft and diffusely tender, nondistended. There was normal active bowel sounds. There was no hepatosplenomegaly. There was no rebound or guarding. His back revealed mild left CVA tenderness. Extremities revealed poor skin turgor. It was cool. Pulses were intact. There was trace edema, dry eczema was noted laterally. There are multiple burns and surgical scars noted on his upper extremities. Neurological: Patient was alert and oriented times three, otherwise nonfocal gross motor exam. He had guaiac positive stool. LABS ON ADMISSION: Included a white count of 17.6, hematocrit of 35.6, platelets 242,000. He had an MCV of 107. His sodium was 124, although this corrected to 134 given his glucose of 759. His potassium was 8.1. Chloride of 86, bicarbonate of less than 5, BUN of 47 and creatinine of 2.3. An arterial blood gas in the Medical Intensive Care Unit showed a pH of 7.13, PC02 of 17 and a p02 of 382 on 100% nonrebreather. His lactate was 2.4. LFTs: ALT of 36, AST 45, alkaline phosphatase 111, T bilirubin 1.4, CK of 61, albumin of 3.2, globulin of 5.4, protein of 8.6. Serum tox and a urine tox were both negative. A urinalysis showed greater than 1000 glucose, greater than 80 ketones. His chest x-ray showed no acute infiltrates or effusions. There is no cardiomegaly. An nasogastric tube was well-placed. A KUB showed no evidence of obstruction or free air. Electrocardiogram showed sinus tachycardia with left axis deviation, left interventricular conduction delay. There was normal R wave progression. Peak T waves across the precordium with elevated J point in V2, V3 and V4. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit. He received an insulin glucose tolerance test with fingerstick blood sugars q. 1 hour. He also received intravenous hydration with normal saline at 200 cc an hour for two liters. He had serial Chem-10 done every six hours to correct his electrolytes including calcium, magnesium, and phosphorus. In addition, his cardiac enzymes were cycled to rule out ischemia as it was initially unclear what was the initial trigger to his DKA. By the second day of his admission, his anion gap had closed, and since insulin GTT had been discontinued he was placed on a NPH 30 units prior to discontinuing the insulin GTT. He was also given four units of regular insulin as well before the drip was stopped. On the second day blood cultures did in fact also came back gram positive for cocci in the blood. This was felt likely secondary to the femoral line insertion. He was treated empirically with a dose of vancomycin and the femoral line was ultimately pulled. A left subclavian line was placed under sterile conditions in its place after the femoral line was pulled. Patient was subsequently transferred to the Medical floor for observation as well as to receive diabetic education from the teaching nurse. On the floor, his stay was remarkable only for a drop in his hematocrit to a low of 23. Given his history of guaiac positive stools, it was felt that this was most likely related to this. He did in fact receive two units of packed red blood cells and will need follow-up after discharge. In addition, his blood pressure was under suboptimal control on the floor with it ranging anywhere between 140 and 180 systolic, therefore, his Univasc was titrated up during his admission with moderate effect on his blood pressure. The patient subsequently felt much better and appeared well. He was tolerating food without any problem. [**Name (NI) **] was subsequently discharged to follow-up with Dr.[**Name (NI) 97576**] nurse [**Last Name (Titles) 3525**]. DISCHARGE MEDICATIONS: 1. Univasc 15 mg po q.d. 2. NPH insulin 30 units subcutaneous q.a.m., 10 units subcutaneous q.p.m. 3. Prilosec 20 mg po q.d. 4. Enteric coated aspirin 325 mg po q.d. 5. Ambien 10 mg po q.h.s. 6. Timolol eye drops 0.5% both eyes, one drop t.i.d. 7. Trusopt 2% eye drops both eyes t.i.d. 8. Xalatan eye drops to each eye q.h.s. DISCHARGE DIAGNOSIS: Alcohol induced nausea, vomiting with subsequent diabetic ketoacidosis. [**Name6 (MD) **] [**Name8 (MD) 21809**], M.D. [**MD Number(1) 21812**] Dictated By: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. MEDQUIST36 D: [**2150-8-6**] 23:03 T: [**2150-8-6**] 23:03 JOB#: [**Job Number **]

[ "276.4", "276.0", "996.62", "303.90", "276.5", "577.0", "250.12", "401.9", "584.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

2296, 2349

6936, 7271

7293, 7641

1824, 2279

4884, 6913

2544, 3777

155, 1502

3792, 4866

1525, 1797

2366, 2521

20,578

108,226

21786

Discharge summary

report

Admission Date: [**2196-10-26**] Discharge Date: [**2196-11-7**] Date of Birth: [**2127-7-19**] Sex: F Service: ORTHOPAEDICS Allergies: Iodine Attending:[**First Name3 (LF) 52022**] Chief Complaint: Right knee pain Major Surgical or Invasive Procedure: Right total knee replacement Central line placement History of Present Illness: 69 [**Last Name (un) **] woman with h/o PVD, DVT, and OA. complaining of severe, incapacitating right knee pain. Patient has been complaining of increasing knee pain over the past few years, now limiting daily activities. Past Medical History: hypertension renal insuffiency hx left leg DVT dementia schizo-affective disorder major depressive disorder osteroarthritis both knees Social History: resident of [**Hospital1 **] Seniior Care pf [**Location (un) 55**] health care proxy : [**Name (NI) 622**] [**Last Name (NamePattern1) **] [**Name (NI) **]( daughter) [**Telephone/Fax (1) 57213**] ambulates with walker and assistance history of falls no history of smoking or alcohol use Family History: unknown Physical Exam: Gen-Alert/oriented, NAD VS-98.2, 160/92, 70, 16, 96%RA HEENT-PERRL CV-RRR Lungs-CTA bilat Abd-soft NT/ND EXT: RLE-incision clean/dry/intact without evidence of infection. +[**Last Name (un) 938**]/FHL/AT. Pertinent Results: [**2196-10-26**] 11:23PM CK-MB-3 cTropnT-0.04* [**2196-10-26**] 06:39PM WBC-22.0*# RBC-3.16* HGB-10.5* HCT-29.9* MCV-95 MCH-33.1* MCHC-35.0 RDW-16.1* [**2196-10-26**] 12:02PM HGB-11.9* calcHCT-36 Brief Hospital Course: Patient had been followed by Dr. [**Last Name (STitle) **] in clinic where it had been recommended that patient have an elective right total knee replacement. Consent was obtained prior to surgery. Patient was admitted on [**2196-10-26**] for right total knee replacement. During surgery patient had significant blood loss because a tourniquet was not used, due to the fact that patient has severe arterial insufficiency. Please see op-note [**2196-10-26**]. Post-op patient was taken to the Medical/surgical intensive care unit for treatment of hypovolemia. Over the next two days in the unit patient was stabilized. After three days in the unit patient was transferred to the orthopedic floor. HCT remained stable at 30. However INR was elevated at 4.6, Coumadin was held. Patient developed hypernatremia. Patient was started on D5W for treatment of free water deficit. Hypernatremia improved with IV fluids,but sodium remained elevated at 149. Discharge was arrangeded with geriatric team with the plan that chemistries would be followed at rehabilitation center. Patient remained afebrile/vital signs stable. HCT remained stable. Patient was discharged to rehab in stable condition. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. Tolterodine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: Three (3) Capsule, Sust. Release 24HR PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Carbidopa-Levodopa 25-100 mg Tablet Sustained Release Sig: One (1) Tablet PO BID (2 times a day). 8. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): Per slide scale. 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): PLease hold for SBP <100 or HR <60. 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 14. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Oxycodone 5 mg Tablet Sig: Three (3) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 16. Risperidone 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 17. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 19. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily). 20. Divalproex 125 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO TID (3 times a day) for 3 days. 21. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime for 3 weeks: Goal INR 2.0 Please check 2xweekly -PLease have HO adjust dose to meet goal INR. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] of [**Location (un) 55**] Discharge Diagnosis: Right total knee replacement hypernatremia Discharge Condition: stable Discharge Instructions: Please cont with weight bearing as tolerated right leg with a walker assist. Cont. with physical therapy. Oral pain medication as needed. Coumadin for anti-coagulation, goal INR 2.0-2.5, please check INR 2x weekly, please have HO adjust to meet goal INR. Please call/return if any fevers, increased discharge from incision or trouble breathing. Physical Therapy: Activity: Activity as tolerated Pneumatic boots Right lower extremity: Partial weight bearing Left lower extremity: Full weight bearing CPM as tolerated Treatments Frequency: Please keep incision clean/dry. -once incision is dry may leave open to air -Please do not soak or scrub incision -If incision gets wet, please pat dry. -staples to be removed at follow-up appt. Coumadin: Goal INR 2.0-2.5, please check INR prior to first dose at rehab. Please check INR 2x weekly, please have HO adjust dose to meet goal INR. -once pt is discharge home, please call results to [**Telephone/Fax (1) 9118**] attn [**Doctor Last Name **] Brown Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] Phone:[**Telephone/Fax (1) 10657**] Date/Time:[**2196-11-11**] 10:45 Please follow-up with PCP:[**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 719**] next week. For follow-up on elevated sodium levels. Please call this week for appt. Completed by:[**2196-11-7**]

[ "998.11", "585.9", "715.36", "295.70", "584.9", "790.92", "V49.72", "285.1", "518.5", "794.31", "276.0", "401.9", "998.0", "V12.51", "443.9" ]

icd9cm

[ [ [] ] ]

[ "38.93", "81.54", "96.04", "96.71", "99.04" ]

icd9pcs

[ [ [] ] ]

4771, 4843

1552, 2742

289, 343

4930, 4939

1326, 1529

5991, 6362

1076, 1085

2765, 4748

4864, 4909

4963, 5308

1100, 1307

5326, 5486

5508, 5968

234, 251

371, 594

616, 753

769, 1060

66,068

183,626

42716

Discharge summary

report

Admission Date: [**2153-6-25**] Discharge Date: [**2153-6-29**] Date of Birth: [**2088-1-24**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Aortic valve replacement (25mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**]) [**6-25**] History of Present Illness: 65 year old male who was found to have aortic stenosis on outside study. Echocardiogram repeated revealing severe aortic stenosis ([**Location (un) 109**] 1.0cm2, peak gradient 99mmHG, EF 55%). He reports having to stop at the top of a flight of stairs due to shortness of breath. He admits to increasing fatigue over the last few months and is now taking naps daily. He was referred for a cardiac catheterization which showed essentially clean coronaries. He was seen by Dr. [**Last Name (STitle) **] for an aortic valve replacement and has undergone dental work in preparation for surgery. He returns today for preadmission testing for surgery [**2153-6-19**]. Past Medical History: Severe aortic stenosis Hypertension Hyperlipidemia History of rheumatic fever Diabetes mellitus type 2 Peripheral vascular disease Tobacco abuse Obesity Obstructive sleep apnea, uses CPAP with O2 concentrator Hypothyroid Venous stasis, skin [**Month/Day/Year 5235**] arthritis (knees) Left foot fracture Left wrist fracture Bells palsy, resolved Kidney stone S/P "ulcers" in eye caused by virus right arthroscopic knee surgery Umbilical hernia repair [**2124**] and [**2127**] Tonsillectomy Social History: He lives with his wife and works as a production coordinator. Mr. [**Known lastname **] is a current smoker, smoking twelve cigarettes per day for fifty years. He consumes less than one alcoholic beverage per week. Family History: Mr. [**Known lastname 92319**] mother had a myocardial infarction in her sixties. Physical Exam: Pulse:85 Resp:20 O2 sat:95/RA B/P Right:138/66 Left: 135/68 Height:5'[**51**]" Weight:380 lbs General: NAD, AAOx3 Skin: Dry [X] [**Year (2 digits) 5235**] [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [x] grade II/VI SEM Abdomen: Obese. Soft [x] non-distended [x] non-tender [x] Extremities: Warm [x], well-perfused [x] [**1-8**]+ LE Edema with chronic venous stasis changes Varicosities: None [x] Neuro: Grossly [**Month/Day (2) 5235**] [x] Pulses: Femoral Right: palp Left: palp DP Right: palp Left: palp PT [**Name (NI) 167**]: palp Left: palp Radial Right: palp Left: palp Carotid Bruit Right: none Left: none Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 92320**] (Complete) Done [**2153-6-25**] at 10:34:16 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. [**Hospital1 18**], Division of Cardiothorac [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2088-1-24**] Age (years): 65 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: AVR ICD-9 Codes: 786.05, 786.51, 424.1 Test Information Date/Time: [**2153-6-25**] at 10:34 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2012AW-1: Machine: us4 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *6.2 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 50% to 55% >= 55% [**Last Name (NamePattern4) **] - Ascending: 3.0 cm <= 3.4 cm Aortic Valve - Mean Gradient: 54 mm Hg Aortic Valve - LVOT diam: 2.3 cm Aortic Valve - Valve Area: *1.2 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. LEFT VENTRICLE: Low normal LVEF. RIGHT VENTRICLE: Mild global RV free wall hypokinesis. [**Last Name (NamePattern4) **]: Normal ascending [**Last Name (NamePattern4) 5236**] diameter. Simple atheroma in descending [**Last Name (NamePattern4) 5236**]. AORTIC VALVE: Moderate AS (area 1.0-1.2cm2) Moderate (2+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. Conclusions Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is low normal (LVEF 50-55%). with mild global free wall hypokinesis. There are simple atheroma in the descending thoracic [**Last Name (NamePattern4) 5236**]. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: The patient is in NSR, on no inotropes. There is a new aortic tissue valve in place with no AI and no leak. Residual mean gradient = 6 mmHg. Preserved biventricular systolic fxn. No MR. [**First Name (Titles) **] [**Last Name (Titles) 5235**]. [**2153-6-29**] 05:02AM BLOOD WBC-10.5 RBC-3.36* Hgb-10.9* Hct-32.8* MCV-98 MCH-32.5* MCHC-33.4 RDW-13.4 Plt Ct-87* [**2153-6-25**] 02:50PM BLOOD PT-12.9* PTT-31.1 INR(PT)-1.2* [**2153-6-29**] 05:02AM BLOOD Glucose-125* UreaN-28* Creat-0.9 Na-142 K-3.7 Cl-105 HCO3-32 AnGap-9 Brief Hospital Course: The patient was brought to the Operating Room on [**6-25**] where the patient underwent an aortic valve replacement. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Please see the operative note for details. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically [**Month/Year (2) 5235**] and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. He was thrombocytopenic post-operatively but was heparin dependent antibody negative and his platelets slowly began to recover. The patient was transferred to the telemetry floor for further recovery on post-operaive day two. Chest tubes and pacing wires were discontinued without complication. For DVT prophylaxis he was given subcutaneous heparin and venodyne boots, which he should continue at rehab until he is more mobile. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD four the patient's wound wound was healing and pain was controlled with oral analgesics. The patient was discharged to [**Hospital3 7665**] in good condition with appropriate follow up instructions. Medications on Admission: . Information was obtained from . 1. Levothyroxine Sodium 300 mcg PO DAILY 2. Lisinopril 20 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY 4. meloxicam *NF* 15 mg Oral daily 5. MetFORMIN (Glucophage) 1000 mg PO BID 6. Niacin 500 mg PO DAILY 7. Simvastatin 20 mg PO DAILY 8. Chantix *NF* (varenicline) 1 mg Oral [**Hospital1 **] Discharge Medications: 1. Levothyroxine Sodium 300 mcg PO DAILY 2. Niacin 500 mg PO DAILY 3. Simvastatin 20 mg PO DAILY 4. Lisinopril 20 mg PO DAILY 5. Hydrochlorothiazide 25 mg PO DAILY 6. MetFORMIN (Glucophage) 1000 mg PO BID 7. meloxicam *NF* 15 mg ORAL DAILY 8. Chantix *NF* (varenicline) 1 mg Oral [**Hospital1 **] 9. Acetaminophen 650 mg PO Q4H:PRN pain/fever 10. Albuterol Inhaler 4 PUFF IH Q4H:PRN wheezes 11. Aspirin EC 81 mg PO DAILY 12. Bisacodyl 10 mg PR DAILY:PRN constipation 13. Docusate Sodium 100 mg PO BID 14. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] 15. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 16. Heparin 5000 UNIT SC TID 17. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 18. Metoprolol Tartrate 25 mg PO BID Hold for HR < 55 or SBP < 90 and call medical provider. 19. Milk of Magnesia 30 ml PO HS:PRN constipation 20. Potassium Chloride 20 mEq PO Q12H Hold for K+ > 4.5 21. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain 22. Furosemide 40 mg IV BID taper per clinical exam and weight. patient has normal EF and was not previously on lasix Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: aortic stenosis Discharge Condition: Alert and oriented x3 nonfocal Lift only Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call 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** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] [**2153-7-10**] at 10:30 Surgeon Dr. [**Last Name (STitle) **] [**2153-7-25**] at 1:45pm [**Telephone/Fax (1) 170**] Cardiologist Dr. [**Last Name (STitle) **] (Dr.[**Name (NI) 8664**] office will call patient) Please call to schedule the following: Primary [**First Name (STitle) 92321**], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**4-12**] weeks ([**Telephone/Fax (1) 83249**] **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:[**2153-6-29**]

[ "305.1", "327.23", "278.00", "443.9", "244.9", "395.0", "716.96", "V85.43", "V13.01", "401.9", "433.10", "459.81", "250.00", "287.5", "276.2", "272.4" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

9083, 9130

6174, 7571

330, 440

9190, 9332

2772, 6151

10204, 10922

1896, 1979

7954, 9060

9151, 9169

7597, 7931

9356, 10181

1994, 2753

271, 292

468, 1132

1154, 1647

1663, 1880

3,242

175,206

1064

Discharge summary

report

Admission Date: [**2168-8-26**] Discharge Date: [**2168-9-2**] Service: MEDICINE Allergies: Penicillins / Percocet / Heparin Agents Attending:[**First Name3 (LF) 106**] Chief Complaint: SOB Major Surgical or Invasive Procedure: thoracentesis History of Present Illness: Ms. [**Known lastname 6940**] is an 86 year old female with diastolic CHF, afib, CAD, [**Known lastname 1192**] MS/MR, s/p bioprosthetic AVR ([**2162**]) and h/o CVA who presents with shortness of breath on transfer from [**Location (un) 5871**]/OSH. . Patient was doing okay at home, 24hr home O2 3-4L, until this morning when her daughter thought she was more short of breath and tachypneic. Per daughter, patient had a high "salty" diet on Sunday, but otherwise denies medication changes, fevers, chills, nausea, vomiting, dysuria, cough, chest pain and palpitations at home. She has stable lower extremity edema, which does not seem to have worsened as well as orthopnea. She also has constipation alleviated with lactulose regularly 3-4times weekly. She endorses compliance with her medications, including lasix, metoprolol, diltiazam and aspirin. She has not had any recent changes in her medications. . She went to [**Hospital 5871**] hospital and found to have bilateral rales with diminished breath sounds. An ABG was 7.5/44/60/33 and she was desated to 70s% on RA. Labs notable for hct of 30, WBC 11.6. A CXR showed pulmonary edema with large R sided pleural effusion. She got 80mg iv lasix, 120mg of dilt po and placed on BIPAP briefly and transferred her to [**Hospital1 18**]. She was transferred on NRB. . At [**Hospital1 18**], her VS were T97.3 HR90 BP99/49 RR24 95% NRB. She was unable to be weaned off NRB, desating to 80s. She has put out ~600cc of urine. An ECG was notable for afib hr 98bpm, unchanged from baseline. . Her VS on transfer are: BP 106/74, HR 94, RR 22, 97-98% NRB. Full code for now. Daughter is with her. . Of note, patient was recently admitted in [**2168-7-7**] for CHF exacerbation. She had a TTE on that admission that showed [**Year (4 digits) 1192**] MS/MR/TR, severe pulm artery systolic hypertension, EF 65%. She was found to have a pleural effusion that was tapped and showed transudative fluid, culture/cytology negative. She was diuresed with lasix and her symptoms improved. TIA in 10/[**2168**]. No other CVA or TIA. . On review of systems, s/he denies any prior history of deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: (+)Dyslipidemia, (+)Hypertension 2. CARDIAC HISTORY: CAD -CABG: None. -PERCUTANEOUS CORONARY INTERVENTIONS: -Successful LAD/D1 bifurcation PTCA in [**2152**] -Rotational atherectomy of the first diagonal branch [**2153**] -PACING/ICD: None Others: - AF on coumadin -Bovine aortic valve relacement in [**2162**], complicated by brief episode of atrial fibrillation. Has been on coumadin in the past but not currently. -Right carotid endarterectomy in [**2158**] -Peripheral vascular disease -Fall with left hip fracture in [**2163**]. ORIF left intertrochanteric femur fracture -Vertebral compression fracture, T8, [**2164**] -Bilateral osteoarthritis of the knees -Constipation -Status post bilateral cataract extraction -Diverticulosis Social History: Lives in [**Hospital1 6930**] with daughter [**Name (NI) 2411**], currently at [**Hospital 100**] Rehab after hospitalization at [**Hospital1 **] [**Location (un) 620**]. Walks with a cane, good social support, non smoker, rare alcohol use. Denies any other illicit drug use. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: 102/55 85 15 97% NRB, 6L GENERAL: petite elderly female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP wnl. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: +scoliosis and kyphosis. Resp were unlabored, no accessory muscle use. decreased breath sounds b/l, bibasilar rales extending up mid lung fields ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: 3+ pitting edema b/l extending to knees SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ Left: Carotid 2+ DP 2+ Pertinent Results: [**2168-8-25**] 11:44PM BLOOD WBC-8.2 RBC-4.10* Hgb-11.0* Hct-33.7* MCV-82 MCH-27.0 MCHC-32.8 RDW-17.5* Plt Ct-307 [**2168-8-27**] 06:05AM BLOOD WBC-6.4 RBC-3.88* Hgb-10.2* Hct-32.3* MCV-83 MCH-26.2* MCHC-31.5 RDW-17.3* Plt Ct-298 [**2168-8-28**] 05:03AM BLOOD WBC-6.9 RBC-4.17* Hgb-11.0* Hct-34.6* MCV-83 MCH-26.5* MCHC-32.0 RDW-17.5* Plt Ct-297 [**2168-8-25**] 11:44PM BLOOD Neuts-86.4* Lymphs-8.8* Monos-4.3 Eos-0.3 Baso-0.3 [**2168-8-25**] 11:44PM BLOOD PT-26.8* PTT-34.8 INR(PT)-2.6* [**2168-8-27**] 06:05AM BLOOD PT-28.5* INR(PT)-2.8* [**2168-8-28**] 09:41AM BLOOD PT-29.7* PTT-36.1* INR(PT)-2.9* [**2168-8-25**] 11:44PM BLOOD Glucose-130* UreaN-23* Creat-0.7 Na-132* K-4.0 Cl-90* HCO3-31 AnGap-15 [**2168-8-26**] 02:59PM BLOOD Creat-0.7 Na-138 K-3.1* Cl-93* [**2168-8-27**] 12:49AM BLOOD Na-138 K-3.7 Cl-94* [**2168-8-27**] 06:05AM BLOOD Glucose-112* UreaN-22* Creat-0.8 Na-139 K-3.2* Cl-90* HCO3-41* AnGap-11 [**2168-8-27**] 06:32PM BLOOD UreaN-30* Creat-0.9 Na-136 K-5.2* Cl-90* HCO3-36* AnGap-15 [**2168-8-28**] 05:03AM BLOOD Glucose-122* UreaN-32* Creat-0.9 Na-138 K-3.9 Cl-89* HCO3-40* AnGap-13 [**2168-8-25**] 11:44PM BLOOD proBNP-5178* [**2168-8-25**] 11:44PM BLOOD cTropnT-<0.01 [**2168-8-27**] 06:05AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.2 [**2168-8-28**] 05:03AM BLOOD Calcium-9.7 Phos-3.6 Mg-2.1 . MICRO [**2168-8-26**] 12:21 am URINE Site: CATHETER **FINAL REPORT [**2168-8-28**]** URINE CULTURE (Final [**2168-8-28**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ 8 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . Chest xray portable AP [**8-25**] CHEST, AP SEMI-UPRIGHT: There has been interval reaccumulation of a large right pleural effusion, with silhouetting of the right heart border and hemidiaphragm. A [**Month/Year (2) 1192**] loculated effusion persists along the lateral left hemithorax. Left lower lobe atelectasis is unchanged. [**Month/Year (2) **] cardiomegaly, vascular congestion, and pulmonary edema have slightly increased. CABG changes are present. There is continued tortuosity and calcification of the aorta. IMPRESSION: 1. Recurrent large right pleural effusion and loculated [**Month/Year (2) 1192**] left effusion. 2. [**Month/Year (2) **] congestive heart failure. Brief Hospital Course: 86yo elderly female w hx of CAD, ARV, mod-severe MS [**First Name (Titles) **] [**Last Name (Titles) **] HTN on ECHO [**7-/2168**] managed on 24hr Home O2 3-4 liters, chronic afib on coumadin, and vasculopathy transferred from OSH for management acute SOB x 2 days found to have [**Year (4 digits) **] edema and recurrent pleural effusion. . **Pt made CMO for untreatable valve disease, afib, and pulmonary htn. Her SOB worsened gradually during her admission and she was made CMO by family on [**9-2**]. Palliative care was consulted. She was started on IV morphine drip titrated for comfort. She passed on [**9-2**] afternoon with family at bedside and pastoral care. . . . # SOB: Chronic complaint, currently on home o2 since [**10/2167**], acutely worsening in last 2 days. P/w rales and chest xray findings suggestive of [**Year (4 digits) **] edema and recurrent pleural effusion. Diagnosis most likely heart failure [**2-9**] valvulopathy with contribution from chronic afib. Pt also with evidence of [**Month/Day (2) **] htn on recent TTE and is on home O2. Other less likely etiologies include MI, infection, pna but no chest pain, biomarkers negative, leukocytosis negative, afebrile. Therapeutic approach was aggressive diuresis in setting of volume overload and dCHF. Thoracentesis was felt to be too invasive at this time given recurrence of symptoms. She was continued on O2 therapy and weaned from NRB to face shovel to **NC. Home o2 3-4L via NC (ultimate goal). She was diuresed with IV lasix pushes and metolazone, and monitored for urine output. She was started on IV lasix drip on [**8-30**] due to inadequate clinical improvement on IV pushes. She was continued on home meds metoprolol and diltiazem for rate control. Her SOB improved only minimally with diuresis and thoracentesis was attempted on [**8-31**] to palliate her symptoms and improve her oxygenation status. We attempted to wean from shovel but patient continued to desat to low 80s with tachycardia to 130s w exertion, eating. . # Afib: Pt denies palpitations, although SOB likely exacerbated by her chronic afib. Maintained on coumadin anticoagulation therapy for arrhythmia which was continued as an inpatient. Given her TIA in [**10/2168**], her CHAD2 score= 5, it is believed that pt is high risk for stroke. She was continued on metoprolol and diltiazem for rate control. Per PCP, [**Name10 (NameIs) **] has been anticoagulated since [**2168-8-15**] and was not candidate for cardioversion given <4 wks therapeutic level on coumadin. . # CAD: s/p atherectomy [**2153**], single vessel disease w diffuse atherosclerosis. Currently on statin, asa therapy. EKG at baseline. Continued on statin, asa therapy as inpatient. Cardiac biomarkers were negative on admission and there was no need to trend CE's given no EKG changes, and pt lack of chest pain. . # UTI: Pt found to have asymptomatic UTI from ED culture - ecoli. Started on Ciprofloxacin po renally dosed x 14days. . # Valve disease: h/o of AVR and known MS/MR noted to be mod-severe on last TTE 7/[**2168**]. Valvulopathy likely contributing to her symptoms of SOB and DOe. There was no need to repeat ECHO given recent documentation. Dr. [**Last Name (STitle) **] reviewed her ECHO findings and confirmed her non-candidacy for valvuloplasty given MR [**First Name (Titles) **] [**Last Name (Titles) 6941**], and per report not a surgical candidate for valve replacement as well. . #Constipation: managed on lactulose at home 3-4x weekly. She was maintained on bowel regimen. Medications on Admission: Acetaminophen 650 mg PO/NG Q6H:PRN pain Aspirin 81 mg PO/NG DAILY Morphine Sulfate 1-2 mg IV Q6H:PRN sob Bisacodyl 10 mg PR HS:PRN constipation Omeprazole 20 mg PO DAILY Calcium Carbonate 500 mg PO/NG TID Ciprofloxacin HCl 500 mg PO/NG Q12H uti, tx 2wk course start [**Date range (1) 6942**] Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation Diltiazem Extended-Release 300 mg PO DAILY Simvastatin 20 mg PO/NG DAILY Docusate Sodium 100 mg PO BID Simethicone 40-80 mg PO/NG QID:PRN bloat, abd pain Furosemide 20 mg/hr IV DRIP INFUSION Lactulose 30 mL PO/NG Q8H:PRN Constipation Vitamin D 1000 UNIT PO/NG DAILY Metoprolol Tartrate 12.5 mg PO/NG TID Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: Deceased Followup Instructions: Deceased

[ "V66.7", "599.0", "564.00", "V58.61", "041.4", "V42.2", "511.9", "V12.54", "401.9", "518.81", "789.00", "428.33", "V45.82", "272.4", "394.2", "416.8", "427.31", "V46.2", "414.01", "428.0" ]

icd9cm

[ [ [] ] ]

[ "34.91" ]

icd9pcs

[ [ [] ] ]

11997, 12006

7747, 11269

249, 264

12058, 12068

4872, 7724

12125, 12136

3973, 4088

11968, 11974

12027, 12037

11295, 11945

12092, 12102

4103, 4853

2972, 3660

206, 211

292, 2872

2894, 2952

3676, 3957

48,342

193,957

7317

Discharge summary

report

Admission Date: [**2124-5-30**] Discharge Date: [**2124-6-2**] Date of Birth: [**2058-1-31**] Sex: F Service: MEDICINE Allergies: Lipitor / Latex / Statins-Hmg-Coa Reductase Inhibitors Attending:[**First Name3 (LF) 12174**] Chief Complaint: Nausea, hematemesis Major Surgical or Invasive Procedure: EGDx2 without banding or coagulation History of Present Illness: 66F with known EtOH cirrhosis c/b 2 cords Grade II varices s/p banding in [**2124-3-9**] who presents with nausea, vomiting, and dark stools. She reports 5 episodes of dark stools on day of admission, including one in ED, one episode of dark emesis at home on DOA and one episode here in the ED. She denies any dark stools or nausea prior to yesterday. She called her sister in law after the episode of emesis at home and came into the hospital. She had oral surgery performed on day prior to admission for dental implants and tolerated it well without complications. She was seen in [**Company 191**] yesterday afternoon and no labs were checked as she seemed to be improving. Of note, the patient presented to the [**Hospital1 18**] ED on [**5-26**] with fatigue and malaise and increased salivation. Hct noted to be stable at 35 at that time. She was given IVF and discharged home feeling improved. She admitted to not taking many of her medications recently, including nadolol for bleeding ppx, as she felt that she was "taking too many" and she wanted to discuss with Dr. [**Last Name (STitle) **]. In the ED, initial VS were: 98 104 114/46 18 99% RA. Labs were notable for a Hct of 25.5 (from 35.9 on [**5-26**]), PLT 186, INR 1.7, WBC 14.7 with 85%N, K 5.2, BUN 63, Cr 0.8. Exam notable for guaiac positive black stool and being fully oriented and alert. She was given 1L NS, pantoprazole 80mg IV, Zofran 4mg IV, Ceftriaxone 1 gram IV, octreotide bolus and gtt was started. She was ordered for 2u PRBCs. Hepatology was consulted and recommended admission to MICU with plan to scope tonight. 3 large bore PIVs were placed. VS at transfer: 98.5 96 96/60 16 100% RA. On arrival to the MICU, patient reports nausea still present but improved, denies abdominal pain, fevers, dizziness/LH. Past Medical History: -EtOH cirrhosis child's B - esophageal varicies - iron deficiency anemia - ovarian cancer - asthma - chronic pancreatitis - esophageal ring - peripheral neuropathy - Hypertension - Elevated cholesterol - Allergic rhinitis - s/p left lateral colectomy [**2-/2118**] for a large high grade - dysplastic sigmoid adenoma/diverticulitis Social History: The patient is married and lives with her husband, is retired. Her Husband broke his leg in [**Month (only) 116**] and is using a cane at home. Last drink [**2121-5-25**]. Used to drink ~2 bottles of wine per day. No smoking or other drug use Family History: sister with breast cancer at age 57, mother [**Name (NI) 2481**] disease, father died of an MI at age 48 Physical Exam: Admission Physical: . General: Alert, oriented, no acute distress, cachectic and jaundiced, no asterixis HEENT: Sclera anicteric, MMM, oropharynx with dried blood, 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, distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: appropriate, moving all extremities . Discharge Physical: . Physical Exam: Vitals: 98.4 90/50 74 18 94%RA General: anxious but in NAD HEENT: Sclera anicteric, MMM, bruising along right perioral area 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, distended, bowel sounds present, no organomegaly no fluid wave appreciated GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: appropriate, moving all extremities Pertinent Results: [**2124-5-30**] 10:53PM BLOOD WBC-14.7*# RBC-2.64*# Hgb-8.4*# Hct-25.5*# MCV-97 MCH-31.8 MCHC-32.9 RDW-14.5 Plt Ct-186 [**2124-5-31**] 06:35AM BLOOD WBC-11.7* RBC-3.18* Hgb-10.1* Hct-29.7* MCV-94 MCH-31.8 MCHC-34.1 RDW-15.0 Plt Ct-120* [**2124-5-31**] 02:05PM BLOOD Hct-26.4* [**2124-5-31**] 09:35PM BLOOD Hct-24.2* [**2124-6-1**] 06:48AM BLOOD WBC-10.3 RBC-2.61* Hgb-8.1* Hct-23.8* MCV-91 MCH-31.1 MCHC-34.0 RDW-17.0* Plt Ct-108* [**2124-6-1**] 01:25PM BLOOD Hct-29.1* [**2124-6-1**] 03:36PM BLOOD Hct-26.2* [**2124-6-1**] 05:30PM BLOOD Hct-26.7* [**2124-6-2**] 12:48AM BLOOD WBC-9.6 RBC-3.31*# Hgb-10.3*# Hct-29.8* MCV-90 MCH-31.1 MCHC-34.6 RDW-16.7* Plt Ct-96* [**2124-6-2**] 05:45AM BLOOD WBC-9.2 RBC-3.32* Hgb-10.4* Hct-30.0* MCV-90 MCH-31.4 MCHC-34.8 RDW-17.1* Plt Ct-93* [**2124-6-2**] 05:10PM BLOOD WBC-9.1 RBC-3.36* Hgb-10.6* Hct-30.4* MCV-91 MCH-31.6 MCHC-34.9 RDW-17.0* Plt Ct-124* [**2124-5-30**] 10:53PM BLOOD PT-17.8* PTT-26.9 INR(PT)-1.7* [**2124-5-31**] 06:35AM BLOOD PT-15.9* PTT-27.3 INR(PT)-1.5* [**2124-6-1**] 06:48AM BLOOD PT-16.5* PTT-27.0 INR(PT)-1.6* [**2124-6-2**] 05:45AM BLOOD PT-13.6* PTT-26.1 INR(PT)-1.3* [**2124-5-30**] 10:53PM BLOOD Glucose-291* UreaN-63* Creat-0.8 Na-131* K-5.2* Cl-96 HCO3-21* AnGap-19 [**2124-5-31**] 06:35AM BLOOD Glucose-283* UreaN-62* Creat-0.8 Na-131* K-5.2* Cl-99 HCO3-21* AnGap-16 [**2124-6-1**] 06:48AM BLOOD Glucose-131* UreaN-41* Creat-0.7 Na-130* K-4.5 Cl-102 HCO3-23 AnGap-10 [**2124-6-2**] 05:45AM BLOOD Glucose-139* UreaN-29* Creat-0.7 Na-132* K-4.4 Cl-103 HCO3-21* AnGap-12 [**2124-5-30**] 10:53PM BLOOD ALT-35 AST-36 AlkPhos-73 TotBili-1.0 [**2124-5-31**] 06:35AM BLOOD ALT-33 AST-33 AlkPhos-68 TotBili-2.5* [**2124-6-1**] 06:48AM BLOOD ALT-29 AST-32 AlkPhos-54 TotBili-3.0* [**2124-6-2**] 05:45AM BLOOD ALT-36 AST-42* AlkPhos-66 TotBili-3.4* [**2124-5-30**] 10:53PM BLOOD Lipase-53 [**2124-5-30**] 10:53PM BLOOD cTropnT-<0.01 EGD [**2124-5-31**] Findings: Esophagus: Protruding Lesions A few cords of Grade I varices were seen in the lower third of the esophagus and middle third of the esophagus. There was no active bleeding. There was no high risk lesion seen. There was some patchy linear ulcerations without high risk lesions seen in the distal third of the esophagus. There was no clear lesion to band. Scaring from prior banding sites were noted. Stomach: Contents: Melena was seen in the fundus and stomach body pbscuring complete view. There was no red blood; there was no active bleeding. Duodenum: Contents: Melena was seen in the whole examined duodenum. There was no red blood; there was no active bleeding seen. Impression: Varices at the lower third of the esophagus and middle third of the esophagus Blood in the fundus and stomach body Blood in the whole examined duodenum Otherwise normal EGD to third part of the duodenum EGD [**2124-6-2**] Findings: Esophagus: Other Prior scar from banding noted. White plaques, likely mucus, seen in the distal esophagus. No varices noted Stomach: Other Portal hypertensive gastropathy of the whole stomach Gastritis with some thickened folds and erosions in antrum Duodenum: Normal duodenum. Impression: Prior scar from banding noted. White plaques, likely mucus, seen in the distal esophagus. No varices noted Portal hypertensive gastropathy of the whole stomach Gastritis with some thickened folds and erosions in antrum Otherwise normal EGD to third part of the duodenum Brief Hospital Course: 66F with alcoholic cirrhosis c/b grade II varices, encephalopathy, ascites who presents with nausea and melena and found to have acute on chronic anemia, likely due to upper GI bleed. # UGIB: Known iron deficiency anemia at baseline with Hct usually around 35, now with acute drop to 25 with BUN of 60s out of proportion to creatinine, most likely due to upper GI bleed, though must also consider blood loss from recent oral surgery. EGD showed superficial ulcerations on varices but no stigmata of recent bleed (no banding or interventions required), however there was diffuse black blood throughout the stomach and duodenum. Hemodynamically stable excluding mild tachycardia. Transfused 2u PRBC and stabilized until HD#2 when she had a melanotic BM with bright red blood and HCT drop with transient hypotension concerning for brisk UGIB. This was felt to be unlikely as recent EGD did not show any lesion that could account for such a bleed, so HCTs were trended which slowly downtrended requiring another uPRBC. Repeat EGD on HD3 showed similar findings to previous without intervention. The etiology for her bleeding was likely due to portal hypertension and variceal bleeding since the patient admitted to self-discontinuing many of her important medications at a whim. She was instructed to never do this again and to consult her physician before discontinuing any medication in the future. # Alcoholic cirrhosis: Radiographic evidence on recent MRI. Complicated by encephalopathy, ascites, varices. MELD=12, Childs class B. After stabilization in HCT and repeat EGD, was continued on her home medications. Transitional Issues: - medication compliance issues Medications on Admission: AZELASTINE [ASTELIN] - (Prescribed by Other Provider) - 137 mcg (0.1 %) Aerosol, Spray - 2 squirts(s) nasally once daily as needed for allergy symptoms CEPHALEXIN - (Prescribed by Other Provider) - 500 mg Capsule - 1 Capsule(s) by mouth twice daily for infection in the mesh ERGOCALCIFEROL (VITAMIN D2) [DRISDOL] - 50,000 unit Capsule - 1 Capsule(s) by mouth Q week FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose Disk with Device - 1 puff(s) inhaled twice a day rinse after use FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth daily FUROSEMIDE - 40 mg Tablet - 2 Tablet(s) by mouth in am and 2 in pm GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth two to three times daily INSULIN ASPART [NOVOLOG] - (Dose adjustment - no new Rx) - 100 unit/mL Solution - 16U before breakfast, 14 U before dinner n INSULIN GLARGINE [LANTUS SOLOSTAR] - 100 unit/mL (3 mL) Insulin Pen - Take 10 unit at bedtime IRON POLYSACCH COMPLEX-B12-FA [NIFEREX-150 FORTE] - 150 mg-25 mcg-1 mg Capsule - 1 Capsule(s) by mouth once daily LACTULOSE - 10 gram/15 mL Solution - 15 ml(s) by mouth three times a day LIPASE-PROTEASE-AMYLASE [CREON] - 12,000 unit-[**Unit Number **],000 unit-[**Unit Number **],000 unit Capsule, Delayed Release(E.C.) - 2 Capsule(s) by mouth each meal NADOLOL - 20 mg Tablet - 0.5 (One half) Tablet(s) by mouth once a day NYSTATIN-TRIAMCINOLONE - 100,000 unit/gram-0.1 % Cream - Apply to affected areas once daily as needed PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth twice a day PENCICLOVIR [DENAVIR] - 1 % Cream - apply to affected area twice a day as needed for with herpetic outbreaks PROCHLORPERAZINE MALEATE - (Prescribed by Other Provider) - 5 mg Tablet - [**1-10**] Tablet(s) by mouth as needed for nausea RIFAXIMIN [XIFAXAN] - 550 mg Tablet - one Tablet(s) by mouth twice a day SPIRONOLACTONE - 100 mg Tablet - 2 Tablet(s) by mouth in am and 2 tablets in pm TRIAMCINOLONE ACETONIDE - - twice a day NOT for face, armpit, or groin TRIAMCINOLONE ACETONIDE - 0.1 % Ointment - apply to affected area on stomach twice a day ; do not apply to genital region, armpits or face VALACYCLOVIR - 1,000 mg Tablet - 2 Tablet(s) by mouth twice a day; Take 2 doses at onset of symptoms (2 tabs in AM and 2 tabs in PM) CALCIUM CARBONATE-VITAMIN D3 [CALCARB 600 WITH VITAMIN D] - (OTC) - 600 mg-400 unit Tablet - 1 Tablet(s) by mouth twice a day CETIRIZINE - (On Hold from [**2124-5-2**] to unknown for excessive saliva) - 10 mg Tablet, Chewable - 1 Tablet(s) by mouth once a day DIPHENHYDRAMINE HCL - (OTC) - 25 mg Capsule - 1 Capsule(s) by mouth at bedtime MAGNESIUM CHLORIDE [MAG 64] - 64 mg Tablet Extended Release - 2 Tablet(s) by mouth daily THIAMINE HCL - 100 mg Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. azelastine 137 mcg Aerosol, Spray Sig: Two (2) squirts Nasal once a day as needed for allergy symptoms. 2. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 3. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 5. furosemide 40 mg Tablet Sig: Two (2) Tablet PO twice a day. 6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO three times a day. 7. insulin glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous at bedtime. 8. insulin aspart 100 unit/mL Solution Sig: Subcutaneous twice a day: 16u before breakfast, 14u before dinner. 9. iron polysacch complex-B12-FA 150-25-1 mg-mcg-mg Capsule Sig: One (1) Capsule PO once a day. 10. lactulose 10 gram/15 mL Solution Sig: Fifteen (15) ML PO TID (3 times a day). 11. Creon 12,000-38,000 -60,000 unit Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO three times a day: with each meal. 12. nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 13. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 14. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. spironolactone 100 mg Tablet Sig: Two (2) Tablet PO twice a day. 16. Valtrex 1 g Tablet Sig: Two (2) Tablet PO twice a day as needed for herpetic outbreaks. 17. Calcarb 600 With Vitamin D 600 mg(1,500mg) -400 unit Tablet Sig: One (1) Tablet PO twice a day. 18. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO at bedtime. 19. Mag 64 64 mg Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day. 20. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. 21. sucralfate 100 mg/mL Suspension Sig: Ten (10) mL PO four times a day for 4 weeks. Disp:*QS QS* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: GI bleeding Alcoholic cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for gastrointestinal bleeding. You had two endoscopies, which did not show any clear source of bleeding but did show diffuse blood throughout the stomach and intestines. You told us that you stopped taking many of your medications because you felt that you were taking too many. YOU CANNOT DO THIS AGAIN. It is very possible that you had bleeding from your stomach because you decided to stop some medications without consulting your doctor first. Please note the following changes to your medications: START Sucralfate 2g by mouth twice per day for one month then stop Be sure to resume nadolol to prevent further bleeding episodes. Many different creams were noted on your medication list, please review these medications with your doctor to decide which among them remain necessary. Followup Instructions: Department: LIVER CENTER When: TUESDAY [**2124-6-6**] at 8:00 AM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: CARDIAC SERVICES When: THURSDAY [**2124-6-22**] at 1 PM With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: THURSDAY [**2124-6-22**] at 2:00 PM With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "V10.43", "V58.67", "356.9", "456.20", "250.00", "733.90", "572.3", "280.0", "577.1", "571.2", "537.89", "285.1", "303.93", "493.90" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

13901, 13907

7489, 9108

335, 374

13982, 13982

4057, 7466

14969, 15864

2831, 2938

11963, 13878

13928, 13961

9188, 11940

14132, 14629

3546, 4038

9129, 9162

14659, 14946

276, 297

402, 2198

13997, 14108

2220, 2554

2570, 2815

54,401

129,326

46372

Discharge summary

report

Admission Date: [**2173-4-11**] Discharge Date: [**2173-4-16**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 613**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] yo M w/ presents from nursing home for fever, also with low O2 sat to 89 on 6L, normally has 2 -2.5L home O2. Pt's family notes that symptoms began on Friday when he was confused and hallucinating. His wife visited him yesterday, and he was complaining of severe shortness of breath when playing cards. Nebulizers at that time helped. However, this morning, the nursing home called the pt's family, informing them that they were going to send him to the ED. The pt also reports that the pt has been couhing and was needing 3L O2, with a temperature of 100.4. The pt endorses shortness of breath, unclear of when it started, but also endorses a productive cough of yellow sputum, denies hemoptysis. Pt denies leg swelling, though endorses 3-pillow orthopnea and PND. He denies chest pain, nausea, abd pain. He denies hematuria but endorses dysuria that has been going on "for a while." He also endorses good PO intake. In the ED, initial vs were: 92 131/65 32 89% 6L. Exam was significant for very mild wheezes, decreased breath sounds on the right, no abdominal pain. Labs were remarkable for lactate 1.4, neg troponin, WBC 4.7, HCT 39.7 (baseline ~38), proBNP 3338. EKG with afib @ 117, RBBB. Patient was given oxycodone 5mg, albuterol/ipratropium neb, 1gm vancomycin, 4.5gm zosyn (for T 100.5), and 5mg metoprolol IV for afib with RVR with excellent response. CXR showed possible PNA and CTA Chest was was negative for PE, but confirmed a small consolidation within the right lower lobe. Vitals on Transfer: 98.0 137,55, 98, 28, 97% 4lnc. On the floor, pt was accompanied by family who provided the collateral information above. Upon discussion w/ nursing home, it is reported that pt is normally O2 dependent, but was dipping down into the high 80s on his usual 2L NC, along with decreased lung sounds. He, however, has remained afebrile, without chills, chest pain, diarrhea, complaints of dysuria/hematuria. Productive cough was not documented and pt is reported as being occasionally incontinent. Review of sytems: (+) Per HPI (-) Denies fever, chills. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No hematuria. Denies arthralgias or myalgias. Past Medical History: CAD ? MI HTN A-fib COPD on 2L home O2 asthma depression/anxiety T12 compression fracture Multiple hip fractures back surgery [**70**]-15 years ago multiple hip surgeries in the late [**2130**] right eye blindness Degenerative disk disease. Low back pain. Lumbar radiculitis. Social History: Has been at [**First Name8 (NamePattern2) 3075**] [**Last Name (NamePattern1) **] nursing home for almost 2 years. Non-ambulatory at baseline, uses wheelchair (> 1 year). Uses urinal at nighttime, but intermittently incontinent per nursing home. Quit smoking over 30 years ago, no alcohol or drugs. Family History: Mother - heart disease and "eye trouble" Physical Exam: ADMISSION PHYSICAL EXAM Vitals: T 100.7 BP 155/97 P 95 R 22 O2 90% 3L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MM dry, oropharynx clear. R eye blue and blind. Lungs: Clear to auscultation bilaterally. Rhonchi in RLL, but otherwise no wheezes, rales CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: softly distended, minimally TTP in LLL, bowel sounds present, no guarding Ext: Cool, 1+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS [**2173-4-11**] 09:20AM BLOOD WBC-4.7 RBC-3.98* Hgb-12.6* Hct-39.7* MCV-100* MCH-31.8 MCHC-31.8 RDW-12.9 Plt Ct-123* [**2173-4-11**] 09:20AM BLOOD Neuts-66.0 Lymphs-18.2 Monos-8.2 Eos-6.3* Baso-1.4 [**2173-4-11**] 09:20AM BLOOD PT-11.5 PTT-32.6 INR(PT)-1.1 [**2173-4-11**] 09:20AM BLOOD Glucose-95 UreaN-14 Creat-1.0 Na-141 K-4.0 Cl-101 HCO3-32 AnGap-12 [**2173-4-12**] 05:50AM BLOOD ALT-13 AST-24 AlkPhos-66 TotBili-0.6 [**2173-4-11**] 09:20AM BLOOD proBNP-3338* [**2173-4-11**] 09:20AM BLOOD cTropnT-0.01 [**2173-4-11**] 09:20AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.1 [**2173-4-12**] 05:50AM BLOOD VitB12-349 Folate-11.6 [**2173-4-12**] 05:50AM BLOOD TSH-1.3 [**2173-4-11**] 09:33AM BLOOD Lactate-1.4 [**Hospital3 **] [**2173-4-12**] 05:50AM BLOOD ALT-13 AST-24 AlkPhos-66 TotBili-0.6 [**2173-4-11**] 09:20AM BLOOD proBNP-3338* [**2173-4-11**] 09:20AM BLOOD cTropnT-0.01 [**2173-4-12**] 05:50AM BLOOD VitB12-349 Folate-11.6 [**2173-4-12**] 05:50AM BLOOD TSH-1.3 [**2173-4-13**] 06:48PM BLOOD Vanco-25.5* [**2173-4-13**] 05:55AM BLOOD Digoxin-0.7* [**2173-4-11**] 09:33AM BLOOD Lactate-1.4 [**2173-4-13**] 10:36AM BLOOD Lactate-0.8 DISCHARGE LABS [**2173-4-15**] 05:21AM BLOOD WBC-4.6 RBC-4.04* Hgb-12.7* Hct-41.1 MCV-102* MCH-31.6 MCHC-31.0 RDW-12.7 Plt Ct-73* [**2173-4-15**] 05:21AM BLOOD PT-11.2 PTT-35.4 INR(PT)-1.0 [**2173-4-15**] 05:21AM BLOOD Glucose-88 UreaN-18 Creat-1.0 Na-140 K-3.7 Cl-101 HCO3-30 AnGap-13 [**2173-4-15**] 05:21AM BLOOD Calcium-8.2* Phos-2.8 Mg-2.1 MICROBIOLOGY [**2173-4-11**] 9:20 am BLOOD CULTURE Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Anaerobic Bottle Gram Stain (Final [**2173-4-12**]): Reported to and read back by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] @ 1622 ON [**4-11**] - [**Numeric Identifier 6650**]. GRAM POSITIVE COCCI. IN CLUSTERS. [**2173-4-12**] URINE CULTURE no growth [**2173-4-12**] and [**2173-4-14**] BLOOD CULTURES NGTD IMAGING [**2173-4-11**] CHEST (PORTABLE AP): Low lung volumes with bibasilar atelectasis. Difficult to exclude small right pleural effusion. No definite evidence of pneumonia. If there is continued clinical concern for the same, repeat radiograph in PA and lateral projections would be helpful. [**2173-4-11**] CTA CHEST W&W/O C&RECONS, NON-CORONARY: Extensive mediastinal and hilar lymphadenopathy, with narrowing of right lower lobe bronchi, causing moderate right lower lobe atelectasis, with a small right pleural effusion and small right lower lobe consolidation. Multiple right pulmonary nodules measure up to 11 mm. The findings are suspicious for a neoplastic process. Reactive lymphadenopathy from infection is also possible. No pulmonary embolus detected to the subsegmental levels. Moderate atherosclerotic soft plaque throughout the thoracic aorta. Severe coronary vessel disease. Calcifications within the aortic valve. Please correlate with any prior echocardiograms. Cholelithiasis. Gynecomastia. [**2173-4-13**] Ultrasound of lower extremity: TECHNIQUE: Grayscale and Doppler son[**Name (NI) 493**] images obtained of the common femoral veins bilaterally, left superficial femoral vein, left popliteal vein, and left calf veins. The visualized vessels are patent and compressible. Normal augmentation. No thrombus is identified. There is arterialization of the SFV waveform with lack of forward flow in diastole which could be in keeping with congestive heart failure. IMPRESSION: 1. No evidence of DVT. [**2173-4-13**] CXR: FINDINGS: In comparison with study of [**4-13**], there are continued low lung volumes with enlargement of the cardiac silhouette and pulmonary edema. Bibasilar atelectasis and probable small pleural effusions. Overall, there is little change from the previous study. [**2173-4-14**] CXR: FINDINGS: Mild pulmonary edema and bibasilar atelectasis, left side more than right and small bilateral pleural effusions are unchanged over past 24 hours. Mediastinal congestion is also similar. IMPRESSION: Mild pulmonary edema, bibasal atelectasis and small pleural effusions are unchanged over last 24 hours. [**2173-4-15**] CXR: FINDINGS: Compared to the prior radiograph, there is now mroe prominent interstitial thickening consistent with worsening pulmonary edema. Again seen are small bilateral pleural effusions, cardiomegaly and retrocardiac opacification, likely atelectasis. There is no focal consolidation or pneumothorax. Aorta is tortuous. IMPRESSION: 1. Worsening moderate pulmonary edema. 2. Stable bibasilar atelectasis and pleural effusions. Brief Hospital Course: Mr. [**Known lastname **] is a [**Age over 90 **] year old gentleman with a PMH COPD on 2L home oxygen and atrial fibrillation, who was admitted from nursing home with fever and hypoxia, who was treated empirically for RLL HCAP with vancomycin and Zosyn. Hospital course was complicated by atrial fibrillation with RVR and hypotension, requiring brief MICU stay for closer monitoring. He then experienced worsening respiratory failure and was made CMO prior to discharge with plan for hospice. ACTIVE ISSUES: # Hypoxic Respiratory Distress: Patient presented with hypoxia to 89% on 6L supplemental oxygen by nasal cannula. Hypoxia occurred in the setting of baseline COPD requiring 2L of home oxygen. In this circumstance, patient's poor lung function was most likely exacerbated by a possible right lower lobe pneumonia, noted on CXR but not on CTA. Additionally, x-ray imaging showed some evidence of pulmonary edema. Patient was evaluated by Speech and Swallow and was determined to have no overt aspiration. CTA showed no evidence of pulmonary embolism. Troponins were negative. The patient was placed on 4L NC, and initially satted in the low to mid-90s. He was temporarily on NRB and facemask, during which time he developed afib with RVR and hypotension (se below). Pneumonia was treated empirically with vancomycin and Zosyn. On [**4-13**] he experienced flash pulmonary edema in response to an episode of agitation and hypertension. His respiratory function continued to be poor with NRB or high-flow face mask requirement despite diuresis and antibiotics. This was thought to be due to HCAP, likely post-obstructive, combined with flash pulmonary edema and underlying COPD. He was not able to cough, and therefore was unable to clear any infectious component. His prognosis was thought to be poor given his lack of response to treatment and progressive respiratory decline. After transitioning to inpatient hospice, the patient continued ipratropium nebulizers as needed for comfort. He used a highflow facemask for supplemental oxygen. Episodes of respiratory distress were treated with morphine and lorzepam as needed. The patient ultimately expired, with primary cause of death respiratory failure. # Fever: Low grade fever prior to admission and in ED was attributed to possible RLL PNA. One set of BCx's did grow CONS, but this was probably a contaminant. Other cultures returned negative. As above, CTA was negative for PE. Patient was treated empirically with vanc/Zosyn. This was switched to an oral regimen with Augmentin and azithromycin on [**4-14**]; antibiotics were continued until decision was made to pursue comfort-focused care. # Afib: Patient had been well-controlled on digoxin and atenolol for afib in the past. However, he developed RVR with rates up to 200. An acute episode was controlled with metoprolol tartrate 5 mg IV x3, diltiazem 5 mg IV x2 and metoprolol tartrate 25 mg PO x1, with subsequent return of rate to low 100s. Trigger for afib with RVR was likely multifactorial from systemic stress of infection, volume overload and possible hypercarbia. Patient was asymptomatic during this episode. He was then started on metoprolol tartrate with good rate control. This was later held for a day due to hypotensive episode on HD3, then restarted to avoid Afib with RVR and subsequent flashing. # Hypotension: On HD3, after receiving beta blockers and calcium channel blockers for rate control, patient developed hypotension to SBPs in the 70s-80s. This was most likely secondary to medication effects and volume overload with relative intravascular repletion. Differential also included pulmonary embolism, myocardial infarction, sepsis and hypovolemia. LLE Doppler was negative for DVT. EKG without any acute changes. Patient appeared euvolemic on exam, but exhibited pulmonary edema on CXR. He was transferred to the MICU for further management and closer monitoring. His anti-hypertensive medication was held and his BP returned to [**Location 213**] levels. # Thrombocytopenia: Pt's plt count now downtrended to 78 at its nadir, but had values in the low 100s (113, 134) in [**6-/2172**] as well. Unclear what pt's baseline is. No obvious signs of bleeding. Other possible etiology is possible MDS. LFTs were normal. # AMS The patient experienced some delirium with reduced orientation. This was most likely due to pneumonia and respiratory distress. He had baseline dementia. # ARF. Increased creatinine from 1.0 to 1.3 on MICU admission, returned to baseline 1.1. Likely result of poor forward flow in the setting of AF with RVR and may have pre-renal given poor po intake, elevated BUN. # AF. Controlled with metoprolol and digoxin. Metoprolol was briefly held for hypotension. Has CHADS at least 2, but not anticoagulated, likely due to history of falls. # Lung mass. Incidental finding on CT chest. This was not formally discussed with the patient or his family. They prefer to focus on comfort. # Goals of care: The patient's respiratory status continued to degrade despite antibiotics and diuresis. He was uncomfortable on turning and dyspnic with mild exertion. The patient and family were against intubation. He was maintained on non-rebreather and high-flow face mask with some episodes of dyspnea and shortness of breath. These were managed with morphine IV and then PO. The Palliative Care team was consulted for assistance with symptom management. A family meeting was held on [**4-15**] during which time the patient's poor prognosis was reviewed. They chose to focus on comfort measures and hospice placement. Antibiotics and most medications were discontinued. Hospice care was continued on the medical floor, and he died comfortably. . TRANSIIONAL ISSUES: N/A Medications on Admission: 1. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 2. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) puff Inhalation [**Hospital1 **] (2 times a day). 4. pravastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 8. lactulose 10 gram/15 mL Syrup Sig: Two (2) ML PO BID (2 times a day). 9. oxycodone 5 mg Tablet Sig: [**12-21**] Tablet PO Q6H (every 6 hours) as needed for pain. 10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 11. furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 12. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) puff Inhalation three times a day. 13. senna 8.6 mg Tablet Sig: Two (2) Tablet PO twice a day. 14. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once a day as needed for constipation. 15. oxycodone 5 mg Tablet Sig: 0.5 (half) Tablet PO q6h:PRN as needed for moderate-severe pain. 16. digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day. 17. Lorazepam 0.5mg tab: one-half tab (0.25mg) PO TID prn anxiety 18. Mucinex 600mg tab: 1 tab PO BID Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: respiratory failure with HCAP and acute on chronic diastolic CHF Discharge Condition: expired Discharge Instructions: n/a Followup Instructions: n/a [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "V46.2", "V66.7", "287.5", "428.0", "584.9", "348.30", "428.33", "493.20", "427.31", "401.9", "518.81", "486", "E947.8", "458.29" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

15779, 15788

8496, 8992

258, 265

15896, 15905

3778, 5323

15957, 16084

3212, 3254

15751, 15756

15809, 15875

14277, 15728

15929, 15934

3269, 3759

5367, 8473

211, 220

9007, 14251

2338, 2581

293, 2320

2603, 2879

2895, 3196

47,698

146,249

22587

Discharge summary

report

Admission Date: [**2133-12-23**] Discharge Date: [**2133-12-26**] Date of Birth: [**2078-3-30**] Sex: F Service: NEUROSURGERY Allergies: Morphine Attending:[**First Name3 (LF) 1835**] Chief Complaint: L occipital grade II oligodendroglioma Major Surgical or Invasive Procedure: L craniotomy and cranioplasty [**2133-12-23**] History of Present Illness: This is a 55 year old F with history of Left parieto-occipital grade II oligodendroglioma presents for elective resection Past Medical History: mild protein S abnormality with 5 miscarriages, migraines since age 20, GERD, hypertension, hiatal hernia, restless leg syndrome, vertigo, and renal calculi, sleep apnea Social History: Lives with her husband. Two children. Works as a teachers assistant and at a retail store. Family History: NC Physical Exam: On Admission1/11/[**2133**]:alert and oriented to person place and time pupils are equal and reactive speech is clear pt follow commands consistently strength sensation is full no pronator drift face is symetric toungue is midline On DISCHARGE1/14/[**2133**]: alert and oriented to person place and time pupils are equal and reactive speech is clear pt follow commands consistently strength sensation is full no pronator drift face is symetric toungue is midline incision is closed with disolvable sutures. There is no drainage, no erythema, no edema The patient is tolerating a regular diet well and ambulates with a steady gait independently. Pertinent Results: Radiology Report MR HEAD W/ CONTRAST Study Date of [**2133-12-23**] 10:01 AM RADIOLOGY IMPRESSION: 1. Redemonstration of the previously noted left parietal lesion, measuring approximately 1.4 x 1.6 cm demonstrated for surgical mapping. 2. Paranasal sinus disease as described above. Radiology Report CT HEAD W/O CONTRAST Study Date of [**2133-12-23**] 7:59 PM RADIOLOGY FINAL IMPRESSION 1. Status post craniotomy and resection of the left parietal lesion with expected locules of air and blood products within the resection bed as well as pneumocephalus as described above- attention on close followup. Expected post-operative air and blood products in the extracranial soft tissues adjacent to the craniotomy site. Evaluation of the lesion resected is limited. 2. Paranasal sinus disease as above. Pathology Report Tissue: Parietal tumor. Study Date of [**2133-12-23**] Report not finalized. Assigned Pathologist [**Doctor Last Name **],HASINI Radiology Report MR HEAD W & W/O CONTRAST Study Date of [**2133-12-24**] 4:20 PM IMPRESSION: 1. Status post interval resection of recurrent left parieto-occipital oligodendroglioma with expected post-surgical changes at the resection site in this first postoperative baseline study. 2. Diffuse thickening and enhancement of the leptomeninges, likely reactive in nature. 3. Tiny, band-like area of hyperintensity along the resection site 4. Additional small focus of restricted diffusion in the left frontal white matter Brief Hospital Course: This is a 55 year old female with history of left parieto-occipital grade II oligodendroglioma presents for elective resection and cranioplasty. She was taken to the OR on [**12-23**]. She tolerated the procedure well, was extubated in the operating room, and brought to the intensive care unit post-operatively for further management and care. She had a post-op Head Ct which showed expected post-op change. On [**12-24**] she was stable in the ICU and was planned for MRI scan. She had her MRI scan which showed post-surgical changes and she was transferred to the floor. On the morning of [**12-25**] on AM rounds, she was neurologically intact. The patient's incision was clean,d ry, and intact. The patient worked with Physical therapy to determine disposition. Physical therapy cleared her for home without any need for services. On [**12-26**], the patient had some slight nausea which was relived with Zofran. The patient had a slight headache, but otherwise was doing quite well. The patient expressed an interest in possible disposition home. The patient was tolerating a regular diet and had no further nausea or vomiting. She was ambulating independently with a steady gait. The patient strength and sensation was full. The patient's incision was well approximated without drainage. There was no erythema or edema. The incision was closed with disolvable sutures. the patient was voiding on her own. The patient will follow up in the Brain [**Hospital 341**] Clinic in two weeks for post operative evaluation and wound check. Medications on Admission: valium, diovan, fluoxetine, HCTZ, keppra, ativan, prilosec, niacin, mucinex Discharge Medications: 1. valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO EVERY OTHER DAY (Every Other Day): as taken at home. 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily): as taken at home and while taking steroid medication. 4. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). Disp:*40 Tablet(s)* Refills:*2* 5. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO QPM (once a day (in the evening)). Disp:*60 Tablet(s)* Refills:*2* 6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for Pain: do not drive while taking this medication, do not take if lethargic. Disp:*40 Tablet(s)* Refills:*0* 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): take while taking narcotic pain medication. Disp:*60 Tablet(s)* Refills:*2* 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): take while taking narcotic pain medication. Disp:*60 Capsule(s)* Refills:*2* 10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain or fever > 101.4: do not exceed 4 gram in 24 hours this will cause liver failure. 11. dexamethasone 1 mg Tablet Sig: Three (3) Tablet PO four times a day for 3 doses: when completed you will start the 2 mg dosing. Disp:*9 Tablet(s)* Refills:*0* 12. dexamethasone 1 mg Tablet Sig: Two (2) Tablet PO four times a day for 2 days: start [**2133-12-27**] after 3 mg dosing completed. Disp:*16 Tablet(s)* Refills:*0* 13. decadron Sig: One (1) mg four times a day for 2 days: after 2 mg po q 6 hour dosing completed. Disp:*8 * Refills:*0* 14. decadron Sig: One (1) mg PO twice a day for 2 days: to start after 1 mg po q 6 hour dosing completed. Disp:*4 * Refills:*0* Discharge Disposition: Home Discharge Diagnosis: L parieto-occipital grade II oligodendroglioma Discharge Condition: alert and oriented to person, place, and time strength is full sensation is intact disolvable sutures wound is clean, dry, intact patient is able to ambulate independently with a steady gait Discharge Instructions: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You have dissolvable sutures you may wash your hair and get your incision wet day 3 after surgery. You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. 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 ??????You do not yet have an appointment in the Brain [**Hospital 341**] Clinic as you are being discharged home on the weekend and the office is not open today. PLEASE CALL FOR AN APPOINTMENT ON MONDAY MORNING to be seen in TWO WEEKS. Your wound will be evaluated at that time as well. 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. Completed by:[**2133-12-26**]

[ "333.94", "787.02", "553.3", "345.40", "327.23", "346.90", "530.81", "289.81", "191.3", "401.9", "780.4", "348.5" ]

icd9cm

[ [ [] ] ]

[ "01.59", "02.06" ]

icd9pcs

[ [ [] ] ]

6716, 6722

3015, 4566

314, 363

6813, 7006

1517, 2992

8596, 9265

832, 836

4693, 6693

6743, 6792

4592, 4670

7030, 8573

851, 1498

236, 276

391, 514

536, 707

723, 816

59,347

121,579

37418

Discharge summary

report

Admission Date: [**2145-3-5**] Discharge Date: [**2145-3-11**] Date of Birth: [**2085-1-26**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1**] Chief Complaint: Hypotensive and Stent fallen out of Ostomy Major Surgical or Invasive Procedure: Sunday, [**2145-3-7**] Colonoscopy History of Present Illness: 60 year old female who is well known to our service status post Left colostomy and sigmoid resection on [**2145-1-25**]. She had a prolonged hospitalization complicated by renal failure, ostomy retraction and wound infection. She was discharged to rehab on [**2145-2-24**]. She presents with episodes of hypotension and syncopal events and the colostomy stent falling out on [**2145-3-1**]. The Colostomy stent was pulled out on [**2145-3-1**] when she was changing the ostomy appliance. She was told to come in to get it replaced on the [**3-2**] but she could not due to previous obligations. She left the rehab due her mother being critically ill on [**2145-3-1**]. She has also had a couple of episodes of passing out. She says that she never has any loss of consciousness but her son is responsibly concerned. She denies any nausea or vomiting. Denies fever, chills or night sweats. She has a wound VAC in place over her midline incision. She has had no ostomy output since the [**3-1**]. She has not urinated since the night prior to admission. Past Medical History: PMHx: HTN, Chronic back pain, Morbid obesity, Chronic constipation [**3-2**] narcotics, Immobility secondary to degenerative disk disease resulting in weak (L)LE. . PSHx: Multi-level laminectomy [**2135**] and [**2138**] followed by fusion, Repair of large incarcerated ventral hernia with mesh sublay complicated by wound infection requiring incision and drainage, debridement and VAC placement [**2143-5-17**], Pilonidal cyst excision complicated by persistent drainage [**2143-2-14**], Tubal Ligation. Social History: Widow. 45 pack-year smoking history. Quit smoking one year ago. Denies alcohol or illicit substance use. Family History: Non-contributory. Physical Exam: Vital Signs: T 96.2 HR 82 BP 94/57 RR 18 O2 Sat 100% RA General: No acute Distress Neuro: Awake, alert, cooperative with exam, normal affect, oriented to person, place and date. Lungs: Clear to Auscultation bilaterally Cardiac: Regular rate and rhythm, S1/S2 Abdomen: Soft, nondistended, minimally and diffusely tender, ostomy is retracted with fibrinous exudate, able to pass finger through ostomy and feel stool which is brown. Midline incision had a wound VAC in place which was removed with no evidence in infection, some fibrinous material with good granulation tissue. Rectal: Normal tone, no gross blood, with incision of on old pilonidal which had good granulation tissue. Pertinent Results: [**2145-3-5**] 07:00PM BLOOD WBC-10.7 RBC-2.84* Hgb-8.3* Hct-26.3* MCV-93 MCH-29.2 MCHC-31.6 RDW-14.6 Plt Ct-495* [**2145-3-8**] 03:46AM BLOOD WBC-11.1* RBC-2.74* Hgb-8.0* Hct-24.7* MCV-90 MCH-29.1 MCHC-32.3 RDW-14.5 Plt Ct-484* [**2145-3-10**] 02:31AM BLOOD WBC-7.8 RBC-2.64* Hgb-7.8* Hct-24.1* MCV-91 MCH-29.7 MCHC-32.6 RDW-14.4 Plt Ct-415 [**2145-3-11**] 07:00AM BLOOD WBC-11.3* RBC-2.96* Hgb-8.6* Hct-27.6* MCV-93 MCH-29.1 MCHC-31.2 RDW-14.2 Plt Ct-440 [**2145-3-5**] 07:00PM BLOOD PT-14.4* PTT-30.9 INR(PT)-1.2* [**2145-3-6**] 02:52AM BLOOD PT-15.3* PTT-32.2 INR(PT)-1.3* [**2145-3-7**] 03:04AM BLOOD Plt Ct-515* [**2145-3-11**] 07:00AM BLOOD Plt Ct-440 [**2145-3-6**] 03:42PM BLOOD Glucose-146* UreaN-37* Creat-2.8*# Na-138 K-3.8 Cl-105 HCO3-20* AnGap-17 [**2145-3-7**] 05:00PM BLOOD Glucose-143* UreaN-28* Creat-1.7* Na-138 K-3.5 Cl-105 HCO3-24 AnGap-13 [**2145-3-9**] 03:20AM BLOOD Glucose-95 UreaN-18 Creat-1.1 Na-143 K-3.7 Cl-106 HCO3-27 AnGap-14 [**2145-3-10**] 02:31AM BLOOD Glucose-91 UreaN-15 Creat-1.1 Na-141 K-3.4 Cl-105 HCO3-30 AnGap-9 [**2145-3-7**] 03:04AM BLOOD Vanco-9.3* [**2145-3-9**] 03:20AM BLOOD Vanco-30.2* [**2145-3-10**] 06:32AM BLOOD Vanco-24.6* [**2145-3-6**] 03:19AM BLOOD Type-ART Temp-37 pO2-76* pCO2-41 pH-7.24* calTCO2-18* Base XS--9 Intubat-NOT INTUBA [**2145-3-7**] 05:24PM BLOOD Type-ART pO2-76* pCO2-36 pH-7.42 calTCO2-24 Base XS-0 Intubat-NOT INTUBA [**2145-3-5**] 6:40 pm BLOOD CULTURE **FINAL REPORT [**2145-3-11**]** Blood Culture, Routine (Final [**2145-3-11**]): NO GROWTH. [**2145-3-5**] 10:25 pm URINE Site: CATHETER **FINAL REPORT [**2145-3-7**]** URINE CULTURE (Final [**2145-3-7**]): NO GROWTH. [**2145-3-8**] 7:44 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2145-3-11**]** MRSA SCREEN (Final [**2145-3-11**]): No MRSA isolated. Brief Hospital Course: Patient was admitted to the SICU for hypotension. She required Levophed for a matter of days to maintain normal MAPs. The pressors were able to be weaned over the matter of days. During this time she received substantial fluid resuscitation. She developed non-oliguric renal failure. Renal team was following, was unclear of the etiology but believed it may have been a combination of pre-renal azotemia from dehydration and malnutrition, as well as some type of RTA or interstitial nephritis, possibly from large doses of NSAIDs. Her renal failure resolved by the time of transfer to the floor. She was tolerating a regular diet and her ostomy output began to improve with mag citrate and a bowel regimen. She also was noted to have a lesion on her right calf, that appeared to be a pressure ulcer of some sort with some blood under the skin, with a small area of necrotic tissue presumably from pressure necrosis. This was managed conservatively. She had some cellulitis which did resolve with antibiotics, but it was not believed that the patients septic physiology was due to this. It was still unclear what caused her septic physiology, but it did improve prior to discharge to the floor. . Foley was discontinue in the floor, no problems voiding. On the floor patient was stable, asymptomatic, vital signs within normal limits, creatinine values continue to be normal and ostomy out up for 24h was 870. At this point she is doing so good, we consulted physical therapy for discharge recommendations. Physical therapy work with her and recommended discharge to rehabilitation center for further management. Medications on Admission: 1. Albuterol Sulfate prn Wheezes 2. Colace 100 mg PO BID 3. Escitalopram 30 mg PO Daily 4. Hydrochlorothiazide 25 mg PO Daily 5. Hydromorphone 2- 4 mg PO Q 3-4 prn pain 6. Regular insulin sliding scale 7. Metoprolol Tartrate 25 mg PO BID 8. Miconazole powder 9. Protonix 40 mg PO Daily 10.MiraLax 17 grams PO Daily 11.Senna 8.6 mg PO BID Discharge Medications: 1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for yeast infection. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Tablet(s) 3. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: Two (2) Tablet Sustained Release 12 hr PO Q8H (every 8 hours). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-30**] Sprays Nasal TID (3 times a day) as needed for dry nose. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Diazepam 5 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) as needed for leg spasm. 10. Escitalopram 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 11. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 10 days. 12. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Inhalation every 4-6 hours as needed for cough. 13. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO once a day: Hold for SBP < 100. 14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day: Hold for SBP < 100 or HR < 60. 15. Miralax 17 gram Powder in Packet Sig: One (1) PO once a day as needed for constipation. 16. Insulin Sliding Scale Regular Q 6h Glucose Insulin Dose 0-70 mg/dL Proceed with hypoglycemia protocol 71-119 mg/dL 0 Units 120-159 mg/dL 4 Units 160-199 mg/dL 6 Units 200-239 mg/dL 8 Units 240-279 mg/dL 10 Units 280-319 mg/dL 12 Units > 320 mg/dL Notify M.D. Discharge Disposition: Extended Care Facility: [**Location (un) 6598**] Manor Discharge Diagnosis: 1. Severe dehydration 2. Status post ex lap sigmoidectomy, end colostomy ([**1-25**]) for complicated diverticulatis 3. Retracted colostomy 4. Acute renal failure 5. Fecal impaction 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: Continue to ambulate several times per day, and drink adequate amounts of fluids. Follow up Ostomy out up. Please inform your doctor if no ostomy out up for > 2 days or substantial decrease from base line. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Followup Instructions: Dr. [**Last Name (STitle) 1120**] Please call to schedule an appointment in 1 moth. ([**Telephone/Fax (1) 3378**] Completed by:[**2145-3-11**]

[ "707.8", "038.9", "584.9", "682.6", "276.51", "560.39", "V15.81", "569.62", "278.01", "995.92", "707.20", "E878.3", "275.41", "707.09", "E849.8" ]

icd9cm

[ [ [] ] ]

[ "45.23", "38.93" ]

icd9pcs

[ [ [] ] ]

8524, 8581

4712, 6336

354, 390

8807, 8807

2883, 4689

10385, 10530

2146, 2165

6725, 8501

8602, 8786

6362, 6702

8977, 10362

2180, 2864

271, 316

418, 1478

8821, 8953

1500, 2007

2023, 2130

27,266

129,216

47563+59005

Discharge summary

report+addendum

Admission Date: [**2197-11-24**] Discharge Date: [**2197-12-1**] Date of Birth: [**2136-3-16**] Sex: F Service: CARDIOTHORACIC Allergies: Latex Attending:[**First Name3 (LF) 1505**] Chief Complaint: sternal wound drainage Major Surgical or Invasive Procedure: [**11-25**] sternal debridement, [**11-27**] bilateral pec flaps, PICC line placed [**11-30**] History of Present Illness: 61 yo s/p CABG [**10-20**] for left main dz discharged home with visiting nurse. Returned to wound clinic and found to have sternal drainage along w/wound erythema on [**11-3**], started on Keflex and stopped on [**11-10**] after area of purulent drainage found by Dr [**Last Name (STitle) **]. Continued to have drainage and fevers and then presented to [**Hospital3 **] ER and referred to [**Hospital1 18**] for further management. Brought to the operating [****] for exploration and sternal debridement then returned for flap closure on [**11-27**] Past Medical History: S/p CABG [**10-20**] TAH/BSO, recurrent [**Last Name (LF) 100387**], [**First Name3 (LF) **] Social History: SOCIAL and FAMILY HISTORY: Social history is significant for the current tobacco use of 1PPD for more than 30 years. Patient has made numerous attempts to quit smoking including chantix, patch, hypnosis, and acupuncture. There is no history of alcohol abuse, though she drinks 3 glass of wine per day. She denies history of withdrawal tremors or seizures. Patient is married and lives in [**Location 3610**]. She works at [**Company 23186**] but is a former secretary. . Family History: There is no family history of premature coronary artery disease or sudden death, but patient has fa father with a history of bladder cancer and relatives who have had strokes. Physical Exam: Admission VS:HR 76 143/68 16 98% on RA Gen:NAD Neuro:Non-focal Pulm:decreased L base, o/w CTA CV:RRR. sternum stable, erythema along incision, 2 open areas at base, lowest area tracks posterior-superior, cellulitis on r breast Abdomen:soft Ext:warm, well perfused. LLE SVG harvest well healed. Discharge VS 98.0 73 144/68 18 92% RA Gen:NAD Neuro:Alert, non focal exam Pulm: Clear- anterior exam CV:RRR, no murmurs. midline incision no drainage, minimal erythema. JP drain x3 Abdm: soft, NT/+BS Ext: warm, well perfused, no edema Pertinent Results: [**2197-11-24**] 04:50PM GLUCOSE-115* UREA N-13 CREAT-0.8 SODIUM-139 POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-27 ANION GAP-15 [**2197-11-24**] 04:50PM CK(CPK)-22* [**2197-11-24**] 04:50PM cTropnT-<0.01 [**2197-11-24**] 04:50PM WBC-23.3*# RBC-4.47# HGB-13.8 HCT-42.0# MCV-94 MCH-30.9 MCHC-32.9 RDW-13.9 [**2197-11-24**] 04:50PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-1+ TEARDROP-1+ [**2197-11-24**] 04:50PM PLT SMR-NORMAL PLT COUNT-252# [**2197-11-24**] 04:50PM PT-13.4 PTT-27.4 INR(PT)-1.1 [**2197-12-1**] 04:23AM BLOOD WBC-8.2 RBC-3.44* Hgb-10.5* Hct-30.9* MCV-90 MCH-30.4 MCHC-33.8 RDW-13.6 Plt Ct-429 [**2197-12-1**] 04:23AM BLOOD Plt Ct-429 [**2197-11-25**] 02:24PM BLOOD PT-15.4* PTT-31.0 INR(PT)-1.4* [**2197-11-30**] 05:41AM BLOOD Glucose-87 UreaN-12 Creat-0.7 Na-138 K-3.9 Cl-102 HCO3-29 AnGap-11 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname 95**] [**Hospital1 18**] [**Numeric Identifier **]Portable TTE (Complete) Done [**2197-12-1**] at 9:47:27 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. Division of Cardiothoracic [**Doctor First Name **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2136-3-16**] Age (years): 61 F Hgt (in): 61 BP (mm Hg): 144/68 Wgt (lb): 142 HR (bpm): 65 BSA (m2): 1.63 m2 Indication: Endocarditis ICD-9 Codes: 424.90, 410.92, 424.1 Test Information Date/Time: [**2197-12-1**] at 09:47 Interpret MD: [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) **], RDCS Doppler: Full Doppler and color Doppler Test Location: [**Location 13333**]/[**Hospital Ward Name 121**] 6 Contrast: None Tech Quality: Suboptimal Tape #: 2007W077-0:12 Machine: Vivid [**6-24**] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 3.5 cm <= 4.0 cm Left Atrium - Four Chamber Length: 4.5 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.7 m/s Left Atrium - Peak Pulm Vein D: 0.5 m/s Left Atrium - Peak Pulm Vein A: 0.3 m/s < 0.4 m/s Right Atrium - Four Chamber Length: 4.7 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.4 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.2 cm Left Ventricle - Fractional Shortening: *0.27 >= 0.29 Left Ventricle - Ejection Fraction: 40% to 50% >= 55% Left Ventricle - Lateral Peak E': *0.08 m/s > 0.08 m/s Left Ventricle - Septal Peak E': *0.04 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 12 < 15 Aorta - Sinus Level: 3.3 cm <= 3.6 cm Aorta - Ascending: *3.5 cm <= 3.4 cm Aorta - Arch: 2.6 cm <= 3.0 cm Aortic Valve - Peak Velocity: 1.5 m/sec <= 2.0 m/sec Mitral Valve - E Wave: 0.7 m/sec Mitral Valve - A Wave: 0.8 m/sec Mitral Valve - E/A ratio: 0.88 Mitral Valve - E Wave deceleration time: 197 ms 140-250 ms TR Gradient (+ RA = PASP): 16 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Mildly depressed LVEF. No resting LVOT gradient. No VSD. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Mildly dilated ascending aorta. Focal calcifications in ascending aorta. Normal aortic arch diameter. Focal calcifications in aortic arch. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild to moderate ([**12-20**]+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral annular calcification. Mild thickening of mitral valve chordae. Calcified tips of papillary muscles. No MS. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal tricuspid valve supporting structures. No TS. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. Normal main PA. No Doppler evidence for PDA PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal image quality - poor parasternal views. Suboptimal image quality - poor apical views. Left pleural effusion. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 40-50 %) secondary to hypokinesis of the inferior and posterior walls and akinesis of the apex. There is no ventricular septal defect. The ascending aorta is mildly dilated. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate ([**12-20**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2197-10-18**], the findings are similar. IMPRESSION: no vegetations seen on any valve If clinically suggested, the absence of a vegetation by 2D echocardiography does not exclude endocarditis. Electronically signed by [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2197-12-1**] 10:31 Brief Hospital Course: Patient was evaluated in the emergency room, where an initial debridement of the sternal wound was performed. She was admitted to the cardiac surgery floor and was started on vanco and cipro. Her wound was further debrided and it was decided to take her to the operating room on [**11-25**] where she underwent sternal debridement and vac placement. She returned to the operating room for flap closure with the plastic surgery service on [**11-27**]. Following debridement the patient was followed by cardiac surgery, plastic surgery and the infectious disease services. She had an echocardiogram to r/o endocarditis and a right PICC line placed for long term antibiotic coverage and on POD [**5-22**] it was decided she was ready for discharge home with visiting nurses Medications on Admission: Simvastatin 20' ASA 81' Amiodarone 200' Metoprolol XL 100' Omeprazole 20' Centrum Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day): resume preop schedule. Disp:*0 ML(s)* Refills:*0* 6. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 7. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous twice a day for 6 weeks: until [**1-12**]. Disp:*84 grams* Refills:*0* 8. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day: resume preop schedule. 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: sternal wound infection, now s/p sternal wound debridement, bilat pec flaps [**11-27**] PMH: s/p CABGx3 [**2197-10-20**](LIMA->LAD, SVG->OM, SVG->RCA), s/p TAH/BSO, recurrent [**Last Name (LF) 100387**], [**First Name3 (LF) **] Discharge Condition: Good. Discharge Instructions: Keep wounds clean and dry. Take all medications as prescribed. Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Followup Instructions: Dr. [**First Name (STitle) **] in 1 week [**Telephone/Fax (1) 1416**], patient to call for appointment Dr. [**Last Name (STitle) **] in 2 weeks [**Telephone/Fax (1) 170**], patient to call for appointment Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Hospital **] clinic [**Telephone/Fax (1) 6313**] in ---weeks, patient to call for appointment Completed by:[**2197-12-1**] Name: [**Known lastname **],[**Known firstname 300**] E Unit No: [**Numeric Identifier 16131**] Admission Date: [**2197-11-24**] Discharge Date: [**2197-12-1**] Date of Birth: [**2136-3-16**] Sex: F Service: CARDIOTHORACIC Allergies: Latex Attending:[**First Name3 (LF) 741**] Addendum: Pt to have follow up appoint w/Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**Hospital **] clinic on [**1-9**] at 1:30PM Discharge Disposition: Home With Service Facility: [**Hospital1 328**] VNA [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2197-12-1**]

[ "998.31", "V45.81", "305.1", "V09.0", "518.0", "730.08", "410.82", "041.11", "998.59", "414.01" ]

icd9cm

[ [ [] ] ]

[ "77.61", "34.79", "34.01", "86.74", "38.91", "99.21", "38.93", "88.72", "93.59" ]

icd9pcs

[ [ [] ] ]

11762, 11939

8178, 8950

296, 393

10604, 10612

2346, 6811

10840, 11739

1600, 1777

9082, 10253

10352, 10583

8976, 9059

10636, 10817

6855, 8155

1792, 2327

234, 258

421, 975

997, 1091

1107, 1118

32,670

187,678

7160

Discharge summary

report

Admission Date: [**2164-5-17**] Discharge Date: [**2164-5-24**] Date of Birth: [**2083-3-2**] Sex: M Service: MEDICINE Allergies: Penicillins / Amiodarone / Clindamycin Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Shortness of breath, weight gain Major Surgical or Invasive Procedure: Placement of R internal jugular central venous line. Placement of L internal jugular dialysis [**Last Name (un) **]. Continuous venovenous hemodialysis. History of Present Illness: This is a 81 year-old male with a history of systolic and diastolic CHF (EF 25-30%), tachy-brady syndrome awaiting pacemaker, h/o atrial fibillation, CAD s/p stent LAD X 2, stent LCx X 1, DM II, and CRI who presents from rehab with increasing shortness of breath and weight gain. The patient reports he has been in "poor health" since having a partial colectomy in [**State 108**] this past [**Month (only) 956**] for colon CA. Since then, he has experienced a 15 lb weight gain with worsening SOB. He was recently admitted to [**Hospital1 18**] between [**4-13**] - [**4-28**] for cough and was found to have a MRSA presumed hospital acquired pneumonia. He was treated with a 14 day course of vancomycin and ceftriaxone. During the hospital course, the pt was diagnosed with tachy-brady syndrome as well as sotalol toxicity in the setting of ARF, and EP was consulted who planned on pacemaker placement once his ID issues had further resolved and discontinued sotalol. Hospital course was also c/b a L brachial vein DVT and was started on lovenox. He was discharged to rehab where he was switched to IV lasix for diuresis and followed by the renal team for worsening Cr up to 1.5; however, on review of OMR it appears pt's Cr had been at 1.5 prior to discharge. Per rehab notes, pt's weight was 208 lbs on [**5-14**] and had increased to 212 lbs on [**5-16**] with a concordant increase in O2 requirement, sating 91% on 5L NC. His lasix was increased from 40 mg IV bid to 80 mg IV bid with reported poor urinary output. The pt reports he has difficulty ambulating to the restroom without shortness of breath. Denies CP, lightheadedness. Endorses palpitations on the night prior to presentation. In the ED, initial vitals were T:96.4 HR:105 BP:122/68 RR:21 O2Sat:100% NRB, weaned down to 96% 3L NC. EKG showed no new ischemic changes, CXR revealed worsening R and L sided pleural effusions, R > L. He was given vancomycin 1 gm IV X 1, ceftriaxone 2 gm IV X 1, azithromycin 500 mg IV X 1 for possible HAP, started on lasix gtt @ 4 cc/hr and was admitted for further evaluation and management. Past Medical History: Coronary Artery Disease - s/p LAD PCI '[**52**], s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] LAD [**8-5**] LE edema L>R chronic Basal cell carcinoma Diabetes mellitus X >40 yrs Osteoarthritis Congestive Heart Failure (EF 25-30%) Atrial Fibrillation/Flutter - Flutter Dx [**2155**], underwent successful ablation [**8-/2155**] - Status post cardioversion, but reverted to atrial fib '[**57**] - Amiodarone DC'd [**3-3**] concern of pulmonary tox [**2157**] Viral cardiomyopathy Chronic Renal Insufficiency Cr 1.0-1.3 H/o MRSA PNA s/p partial colectomy for colon CA - not yet followed up with oncologist (doesn't know Dr [**Last Name (STitle) **]) - was told CA not metastatic Social History: Social history is significant for the absence of current tobacco use. Smoked [**2-1**] cigarettes/day X [**11-14**] yrs, quit 60 yrs ago. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: Admission: VS - 97.5 129/66 97 22 91% 2L NC FS 133 Wt 103 kg Gen: elderly male, speaking in short senteces with mild SOB. 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 15 cm. CV: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were mildly unlabored, some accessory muscle use. Absent breath sounds over R lung base, decreased BS half-up R lung field, decreased breath sounds at L lung base with rales. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. well healed surgical scar. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, scars, or xanthomas. Stage II decub ulcer over coccyx. Pertinent Results: CXR [**5-17**]: Interval enlargement of the right pleural effusion with atelectasis of the right lower lobe difficult to entirely exclude consolidation given the opacity introduced by the effusion and atelectasis. If indicated, consider decubitus views to assess for mobility of effusions. . CXR [**3-24**]: Improved pulmonary edema. Persistent right greater than left pleural effusions and cardiomegaly. . Echo: The left atrium is dilated. The right atrium is markedly dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is moderate global left ventricular hypokinesis (LVEF = 30-40 %). There is no ventricular septal defect. The right ventricular cavity is dilated with severe global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. 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 mild pulmonary artery systolic hypertension. There is no pericardial effusion. . Renal U/S 1. No evidence of hydronephrosis. 2. Septated cyst within the left kidney, which does not meet US criteria for a simple cyst. A 6-month follow-up ultrasound is recommended to ensure stability. . CBC [**2164-5-17**] 06:50PM BLOOD WBC-7.2 RBC-3.05* Hgb-9.3* Hct-30.1* MCV-99* MCH-30.6 MCHC-31.0 RDW-21.3* Plt Ct-282# [**2164-5-19**] 05:04AM BLOOD WBC-7.1 RBC-2.61* Hgb-8.0* Hct-25.2* MCV-96 MCH-30.5 MCHC-31.6 RDW-22.5* Plt Ct-245 [**2164-5-20**] 02:48AM BLOOD WBC-9.4 RBC-2.72* Hgb-8.2* Hct-26.0* MCV-96 MCH-30.3 MCHC-31.7 RDW-22.7* Plt Ct-286 [**2164-5-21**] 05:50AM BLOOD WBC-8.0 RBC-2.99* Hgb-9.1* Hct-28.5* MCV-95 MCH-30.4 MCHC-31.8 RDW-22.5* Plt Ct-216 [**2164-5-22**] 05:23AM BLOOD WBC-6.0 RBC-2.94* Hgb-9.2* Hct-28.4* MCV-97 MCH-31.2 MCHC-32.2 RDW-21.5* Plt Ct-179 [**2164-5-23**] 05:25AM BLOOD WBC-7.3 RBC-3.07* Hgb-9.6* Hct-30.0* MCV-98 MCH-31.1 MCHC-31.8 RDW-22.6* Plt Ct-150 . Chem 7 [**2164-5-17**] 06:50PM BLOOD Glucose-165* UreaN-63* Creat-1.8* Na-141 K-5.0 Cl-100 HCO3-29 AnGap-17 [**2164-5-18**] 09:00AM BLOOD Glucose-88 UreaN-68* Creat-2.0* Na-143 K-5.4* Cl-100 HCO3-31 AnGap-17 [**2164-5-19**] 05:04AM BLOOD Glucose-212* UreaN-73* Creat-1.9* Na-132* K-4.5 Cl-94* HCO3-31 AnGap-12 [**2164-5-19**] 03:08PM BLOOD Glucose-120* UreaN-76* Creat-2.6* Na-142 K-4.5 Cl-101 HCO3-30 AnGap-16 [**2164-5-20**] 02:48AM BLOOD Glucose-199* UreaN-66* Creat-2.3* Na-138 K-4.7 Cl-101 HCO3-28 AnGap-14 [**2164-5-20**] 09:04AM BLOOD Glucose-123* UreaN-59* Creat-2.1* Na-137 K-5.0 Cl-102 HCO3-26 AnGap-14 [**2164-5-20**] 06:34PM BLOOD Glucose-192* UreaN-49* Creat-1.9* Na-137 K-4.8 Cl-103 HCO3-25 AnGap-14 [**2164-5-21**] 12:14PM BLOOD Glucose-110* Na-137 K-4.9 Cl-107 HCO3-25 AnGap-10 [**2164-5-21**] 06:20PM BLOOD Glucose-185* UreaN-30* Creat-1.5* Na-137 K-5.1 Cl-107 HCO3-23 AnGap-12 [**2164-5-22**] 12:22AM BLOOD Na-135 K-5.3* Cl-107 HCO3-21* AnGap-12 [**2164-5-22**] 11:53AM BLOOD Glucose-172* Na-136 K-4.9 Cl-108 HCO3-22 AnGap-11 [**2164-5-22**] 06:35PM BLOOD Glucose-260* UreaN-20 Creat-1.2 Na-133 K-5.0 Cl-105 HCO3-22 AnGap-11 [**2164-5-23**] 05:25AM BLOOD Glucose-59* UreaN-16 Creat-1.0 Na-138 K-4.6 Cl-106 HCO3-24 AnGap-13 [**2164-5-23**] 12:22PM BLOOD K-4.5 . Brief Hospital Course: Pt has diastolic and systolic congestive heart failure with EF 35-30%. The patient was admitted with CHF exacerbation. He had become more refractory to IV lasix diuresis with worsening weight gain and DOE. Also with finding of anasarca on exam, concerning for poor nutritional status and/or nephrotic syndrome. On the floor he had worsening shortness of breath. He had a right thoracetesis performed showing a transudative fluid. As his SOB worsening and as he became hypotensive, he was transfered to the CCU. He had right IJ central line placed. In the CCU, he was placed on lasix drip, diuril and milrinone. His blood pressure continued to trend down and he had almost no urine output despite maximum doses of lasix drip and diuril. When his mental status and BP declined, milrinone was discontinued, and he was placed on levophed. An arterline line was placed to better monitor BP. A left IJ dialysis catheter was also placed. The nephrology team began ultrafiltration. Lasix and diuril were discontinued. As fluid was removed, his mental status and blood pressure improved. He was weaned off the levophed. After a family meeting, it was decided that the patient should have 1-2 days more of UF in order to remove as much fluid as possible, and then he should be discharged with hospice. The palliative care team assisted with hospice arrangement and comfort recommendations. A total of 10 liters of fluid were removed over his length of stay. He was discharged on lasix 80 [**Hospital1 **]. . # Code: DNR/DNI Medications on Admission: Lasix 80 mg IV q12h ASA 81 mg daily Norvasc 7.5 mg daily Lisinopril 5 mg daily (d/c'd [**5-4**]) Colace 100 mg [**Hospital1 **] Senna prn Miconazole powder prn Atrovent nebs prn Saline nasal spray 2 sprays [**Hospital1 **] Metformin 1000 mg [**Hospital1 **] (d/c'd [**5-10**]) Lovenox 80 mg q12h (d/c'd [**5-4**]) Repaglinide 0.5 mg mg [**Hospital1 **] Sitagliptin 100 mg daily Heparin 5000 units q12h Tylenol prn RISS Sugar free robitussin q4h prn Discharge Medications: 1. Furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 2. Roxanol Concentrate 20 mg/mL Solution Sig: 5-20 mg PO q1-q3 as needed for pain: hospice patient. Disp:*45 mL* Refills:*0* 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed: hospice patient. Disp:*60 Tablet(s)* Refills:*0* 4. Lorazepam 2 mg/mL Concentrate Sig: 0.25-2 mg PO q2-3 hour PRN: hospice patient. Disp:*10 mL* Refills:*2* 5. Levsin 0.125 mg/mL Drops Sig: One (1) mL PO every 4-6 hours as needed for secretions: hospice patient. Disp:*10 mL* Refills:*0* 6. ABHR (Ativan-Benadryl-Haldol-Reglan) Sig: One (1) suppository every 4-6 hours as needed for discomfort: hospice patient. Disp:*3 suppositories* Refills:*0* 7. acetaminophen suppository Sig: One (1) suppository every 4-6 hours as needed for fever or pain: hospice patient. Disp:*1 suppository* Refills:*3* 8. Haloperidol gel 1 mg/mL Sig: 0.5-1 mL mL every 4-6 hours as needed for agitation: hospice patient. Disp:*3 mL* Refills:*0* 9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. Disp:*1 pack* Refills:*0* 10. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Liquid Sig: [**6-9**] MLs PO Q6H (every 6 hours) as needed. Disp:*40 ML(s)* Refills:*2* 11. Sodium Chloride 0.65 % Aerosol, Spray Sig: Two (2) Spray Nasal [**Hospital1 **] (2 times a day) as needed. Disp:*1 bottle* Refills:*0* 12. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-1**] Drops Ophthalmic PRN (as needed). Disp:*1 bottle* Refills:*2* 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. Disp:*1 ampule* Refills:*0* 14. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) ampule Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. Disp:*1 ampule* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 269**] Hospice [**Location (un) 270**] East Discharge Diagnosis: Congestive heart failure. Discharge Condition: Fair. No complaints of pain or dyspnea. Approximately 10 liters removed at dialysis. Discharge Instructions: We are discharging you home with hospice services. Our hope is that you will be comfortable and enjoy your time with your family. The medications prescirbed are to make you feel comfortable. These medications include lasix which may help keep fluid from accumulating. Followup Instructions: Hospice care.

[ "427.81", "585.9", "V10.05", "707.03", "250.00", "428.0", "427.31", "785.51", "425.4", "584.9", "428.43" ]

icd9cm

[ [ [] ] ]

[ "34.91", "39.95", "38.93", "38.95" ]

icd9pcs

[ [ [] ] ]

12018, 12104

8057, 9574

339, 496

12174, 12263

4557, 8034

12581, 12598

3576, 3658

10073, 11995

12125, 12153

9600, 10050

12287, 12558

3673, 4538

267, 301

524, 2619

2641, 3367

3383, 3560

11,671

133,408

5248

Discharge summary

report

Admission Date: [**2146-8-24**] Discharge Date: [**2146-9-1**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 106**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: VVI Pacemaker Placed History of Present Illness: 88M with h/o biventricular CHF LVEF 35%, CAD s/p CABG, afib who presents with increasing SOB and lower extremity edema. He has noted 13lb weight gain as well. He denies CP, palpitations, dizziness, light-headedness. No f/c. He developed these syptoms in the setting of increased intake of salty food. He states he takes his medications carefully as prescribed and has a VNA to help him. Of note, was admitted from [**7-28**] -[**8-2**] at [**Hospital1 18**] for CHF exacerbation. He was admitted in [**Month (only) **] for sepsis/PNA. In the ED, the pt was noted to be satting in the 80s on RA, with a-fib in the 50s. BP was mostly in 90s systolic though occasionally in the 80s. Syptoms and exam were c/w CHF, though lasix was held off on given the low BP in setting of slow HR. The patient was admitted to CCU . On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable LE edema, SOB as per HPI and for absence of chest pain, palpitations, syncope or presyncope. Past Medical History: 1. Coronary artery disease, status post coronary artery bypass graft in [**2136**] 4 VD. 2. Congestive heart failure with an ejection fraction of 35% with diastolic and systolic dysfunction. ([**5-16**] ECHO) 3. Hyperlipidemia. 4. Paroxysmal atrial fibrillation, on Coumadin. 5. Status post appendectomy. 6. History of lower gastrointestinal bleed. 7. Glucose intolerance. 8. Right carotid stenosis of 60% to 69%. 9. History of Escherichia coli urosepsis. 10. History of low blood pressure 11. melanoma removed from arm 12. basal cell ca. 13. gout 14. hypothyroidism Social History: He lives with his sister who is in her 90's. He uses a walker to get around but mostly stays at home, doesn't drive. He denies any tobacco history. Rare glass of wine. Family History: Positive for coronary artery disease and breast cancer. Physical Exam: VS: T 97.6 BP 104/40 HR 42 RR 17 100 O2 % on 2L Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of 8cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Chest: crackles LL b/l No chest wall deformities, scoliosis or kyphosis. Abd: soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: 2+ edema b/l. erythema b/l. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: [**2146-8-24**] 08:30PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.006 [**2146-8-24**] 08:30PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD [**2146-8-24**] 08:30PM URINE RBC-2 WBC->50 BACTERIA-MOD YEAST-NONE EPI-0-2 [**2146-8-24**] 07:56PM PT-16.7* PTT-29.7 INR(PT)-1.5* [**2146-8-24**] 12:30PM GLUCOSE-107* UREA N-19 CREAT-1.3* SODIUM-140 POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-26 ANION GAP-17 [**2146-8-24**] 12:30PM estGFR-Using this [**2146-8-24**] 12:30PM CK(CPK)-35* [**2146-8-24**] 12:30PM CK-MB-4 cTropnT-0.03* [**2146-8-24**] 12:30PM DIGOXIN-1.0 [**2146-8-24**] 12:30PM WBC-9.6 RBC-4.50* HGB-12.7* HCT-38.0* MCV-85 MCH-28.3 MCHC-33.5 RDW-18.9* [**2146-8-24**] 12:30PM NEUTS-71.2* LYMPHS-20.8 MONOS-5.7 EOS-1.8 BASOS-0.5 [**2146-8-24**] 12:30PM PLT COUNT-236 [**2146-8-24**] CXR FINDINGS: Single upright portable chest radiograph demonstrates stable to minimally increased right small pleural effusion. There is improved aeration of the right lower lung. Stable opacity projecting over the right mid-thorax, likely representing pleural fluid loculated within both the major and minor fissures, which slightly limits evaluation for underlying infiltrate. The heart is moderately enlarged, unchanged. There is no left pleural effusion. There is no pneumothorax. Median sternotomy wires are noted. Osseous structures are unchanged. IMPRESSION: 1. Limited portable chest radiograph demonstrates stable to minimally increased right pleural effusion. 2. Improved aeration of the right lower lung. 3. Moderate cardiomegaly, unchanged . urine cx SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | STAPH AUREUS COAG + | | AMPICILLIN------------ <=2 S CIPROFLOXACIN--------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R LINEZOLID------------- 2 S NITROFURANTOIN-------- <=16 S <=16 S OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R TETRACYCLINE---------- =>16 R <=1 S TRIMETHOPRIM/SULFA---- S VANCOMYCIN------------ =>32 R <=1 S Brief Hospital Course: 88 yo male w h/o biventricular CHF LVEF 35%, CAD s/p CABG, afib who presents with CHF exacerbation and slow AF vs AF with 3rd degree heart block. . Hospital course by problem . 1 CHF Patient presented in CHF exacerbation after food indiscretion. Complicating failure was a bradyarrhythmia (discussed below). Patient was diuresed and provided with a VVI pacer (actually a BiV pacer with only a V pacing lead) to improve heart rate. After acute exacerbation, he was restarted on his home medications. Lasix was converted to bumetanide for better PO absorption and then sent home on po regiment of 2 mg [**Hospital1 **]. Spironalactone, beta blockade, ace-i, and digoxin were restarted. PT cleared patient for home and patient was amenable. He will follow up with his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1007**] and Dr. [**Last Name (STitle) **] in cardiology. He will continue with home VNA and home weight evaluation. He will follow up in device clinic, Dr. [**Last Name (STitle) **], and his PCP. [**Name10 (NameIs) **] was also instructed to more diligently control his diet. . 2 Bradycardia Patient presented with complete heart block with a junctional rhythm which exhibited alternating signs of both left and right heart block. A VVI pacer was implanted with good capture and without acute complications of bleeding or infection. He will follow in the device clinic for follow up. . 3 CAD History of CAD s/p CABG. Aspirin, statin, were continued. Beta blocker was restarted after acute exacerbation was cleared. No evidence of acute myocardial ischemia was identified during hospitalization with negative cardiac enzymes. . 4 UTI Patient suffered from a VRE and MRSA UTI several weeks prior to admission. Again these organisms were isolated from urine culture in setting of an inflammatory urine analysis. He was started on Linezolid and will continue outpatient for a total 12 day course. . 5 Hypothyroidism Home levothyroxine was continued. . 6 ARF Presented in ARF with 1 --> 1.3 bump in creatinine. This improved with diuresis and suspected improved forward flow. Ace-I was restarted prior to discharge. . Medications on Admission: asa 81' lipitor 40' dig 0.125' lasix 100' Toprol 25' levothyroxine 25' coumadin 3 qHS tamsulosin 0.4 qHS Combivent q6 colchicine 0.6' allopurinol 50' Discharge Medications: 1. Outpatient Lab Work INR check on [**2146-9-3**]. 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-11**] Puffs Inhalation Q6H (every 6 hours) as needed. 5. Allopurinol 100 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Warfarin 2.5 mg Tablet Sig: As directed Tablet PO As directed: Please take two tablets every day until INR checked on [**2146-9-3**], then adjust per doctor's orders. Disp:*60 Tablet(s)* Refills:*2* 9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 6 days. Disp:*12 Tablet(s)* Refills:*0* 11. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* 12. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 13. Bumetanide 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 14. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Complete Heart Block Congestive Heart Failure Urinary Tract Infection Discharge Condition: Improved, with paced heart rate of 75 and improved congestive heart failure. Wt on discharge is 94.5 kg. Discharge Instructions: You were admitted because of slow heart rate, for which you had a pacemaker placed. You also had heart failure and so you should eat a low salt diet and weigh yourself every morning. You should call your cardiologist if your weight goes up by 3 pounds. You should also restrict your fluid intake to avoid getting more fluid overloaded. Please continue the antibiotic, linezolid, for urinary tract infection for another 6 days. You were started on two new mewdications, lisinopril, for your blood pressure, and spironolactone, for heart failure. Also, your coumdain dose was increased, and you will need to have your INR checked in 2 days to seee if your coumdain dose needs to be adjusted. Finally, your lasix was changed to a different form, called Bumetanide, which should be taken twice per day and should work better for you. Please note these changes. Please go to the device clinic on [**2146-9-2**] at 2:30PM to have your pacemaker checked. Please follow up on other appointments as scheduled. Followup Instructions: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2146-9-2**] 2:30 Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2146-9-5**] 10:00 Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 2934**] Date/Time:[**2146-9-9**] 3:20 Follow Up with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1007**] in one week.

[ "V58.61", "274.9", "244.9", "428.0", "428.43", "272.4", "427.31", "426.0", "599.0", "V45.81", "584.9" ]

icd9cm

[ [ [] ] ]

[ "37.71", "37.82" ]

icd9pcs

[ [ [] ] ]

9386, 9443

5639, 7792

268, 291

9557, 9664

3271, 5616

10716, 11160

2410, 2468

7992, 9363

9464, 9536

7818, 7969

9688, 10693

2483, 3252

221, 230

319, 1617

1639, 2207

2223, 2394

26,519

157,268

43112

Discharge summary

report

Unit No:[**Unit Number 92950**] Admission Date: [**2188-12-24**] Discharge Date: [**2189-1-9**] Date of Birth: Sex: Service: The patient is a 61 year old female who has a significant history for coronary artery disease. She had a coronary artery bypass graft in [**2188-5-20**], which was complicated by graft failures requiring coronary artery bypass graft. She also had repeat catheterization and coronary artery stenting complicated by ventricular fibrillation. She had an automatic implantable cardiac defibrillator placed at that time. She had a prolonged Intensive Care Unit stay and had placement of a tracheostomy and a percutaneous gastrostomy tube. PAST MEDICAL HISTORY: Living related renal transplant in [**2186-2-19**]. Type 1 diabetes mellitus. Prior to this admission, the patient has had several long hospital courses. The first was in [**2188-8-20**], and the second as stated was in [**2188-9-20**], into [**2188-11-20**]. Her hospitalization required ventilatory support and the patient had been treated for pneumonia. On her last hospital stay [**Month (only) **] through [**Month (only) 404**] as stated, the patient developed acute on chronic renal failure. She had a tracheostomy and was slowly weaned for ventilation failure and was treated for line infections. The patient was eventually transferred to rehabilitation for further care. The patient, however, represented to [**Hospital1 190**] on [**2188-12-24**], with complaints of abdominal pain. Coronary artery disease, status post coronary artery bypass graft in [**2188-5-20**], complicated by thrombosis of her bypass grafts and ventricular fibrillation . The patient had an automatic implantable cardiac defibrillator placed. The patient had a prolonged ventilatory wean and was tracheostomy dependent and had a gastrostomy tube placed. The patient has a history of type I diabetes mellitus. The patient developed acute renal failure, status post her ventricular fibrillation arrest and has current end stage renal disease and is on hemodialysis. The patient had a living related renal transplant in [**2185**], with graft failure in [**2188-10-20**], again during the ventricular arrest. The patient is status post cerebrovascular accident and has a depressed ejection fraction. The patient has a history of methicillin resistant Staphylococcus aureus bacteremia and aseptic thrombophlebitis. The patient has a history of chronic colonization of pseudomonas in her sputum. The patient has a history of tracheostomy and a percutaneous endoscopic gastrostomy tube. The patient has a history of being Heparin antibody positive and a history of zoster. HISTORY OF PRESENT ILLNESS: The patient is a 61 year old female with a history of diabetes mellitus, coronary artery disease, end stage renal disease, who was recently discharged on [**2188-11-25**], to [**Hospital **] Rehabilitation. She was doing well until five days prior to admission when she began having left lower quadrant abdominal pain and epigastric pain. She stated that the pain was constant for five days but slowly increased. The patient denied other symptomatology. PHYSICAL EXAMINATION: On admission, the patient was afebrile with a temperature of 97.0, blood pressure 181/63. On physical examination, she was an ill appearing female who was uncomfortable. Her neck had trach capped, the site was clean. Chest had crackles at the bases. The abdomen was soft, but distended. She was quiet. She had mild epigastric tenderness with left lower quadrant tenderness without any frank rebound or guarding. There was some purulent discharge from her percutaneous endoscopic gastrostomy site. She had pitting edema in her extremities. LABORATORY DATA: Her laboratory examination was significant for a white blood cell count of 9.4, creatinine of 1.8, albumin 2.9. KUB was performed which demonstrated no obstruction and that she was full of stool. IMPRESSION: The initial impression was that this was a 61 year old female with long medical history as stated who had abdominal pain which was quite concerning. The plan was to keep her NPO and continue decompression and obtain an abdominal CT scan. The patient was initially seen and admitted to the medical night float service and they decided to get a surgical consultation. Surgical consultation was obtained. She again was tender in the left lower quadrant. She had no guarding and she had no rebound. She had some voluntary guarding. On rectal examination, she had stool in her vault. She was guaiac negative. She was a diabetic female who remained on high dose steroids. She was discharged to rehabilitation on 60 mg of steroids, who presented with abdominal pain and tenderness on examination. The patient had nasogastric tube placed. CAT scan was obtained. CAT scan showed free abdominal air. The patient was taken to the operating room for exploratory laparotomy. At this point, it was found that the gastrostomy tube had eroded through her stomach and was freely floating in her abdominal cavity. She had a gastrotomy that was spilling into her contents. During the operation the gallbladder was necrotic and we performed open cholecystectomy, performed a biopsy of the liver and repaired the stomach where the old gastrostomy tube site was in place in a two layer closure. The skin incision over the gastrostomy tube was left open. The patient remained intubated and was taken to the Intensive Care Unit for postoperative care. The patient's postoperative course was a stormy course over the next two weeks. The patient developed progressive multisystem organ failure despite the institution of CVPHD to manage her dialysis needs as well as her fluid status. We rapidly tapered her steroids from 60 down to a lower dose for immunosuppressive medication. She developed paroxysmal atrial fibrillation and she was placed on Amiodarone. She developed large pleural effusions which were tapped and she had a chest tube placed to drain large pleural effusions. She developed progressive hypotension requiring multiple pressors and she required progressive and increasing amounts of ventilatory support including high dose FIO2. Throughout her hospital course, we had constant communication with the family to discuss her care and her plans. She also developed recurrent herpes infection which she had previously. However, despite our maximum care including multiple pressors, CVPHD, multiple broad spectrum intravenous antibiotics and despite pulmonary consultations and infectious disease consultation, the patient did not make any progress and progressed with multisystem organ dysfunction and multisystem organ failure despite being on Vancomycin, Imipenem, Acyclovir, having multiple line tips cultured and being pancultured. The patient had a repeat CT scan that did not demonstrate any focal abdominal collections or any abscesses. Despite our maximum care, on [**2189-1-8**], we had discussion with the family about making the patient DNR. On [**2189-1-9**], she was made comfort measures only. Her pressors were discontinued and she subsequently expired thirty minutes later. Time of death was pronounced at 1559 on [**2189-1-9**]. [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 4841**] Dictated By:[**Last Name (NamePattern4) 7704**] MEDQUIST36 D: [**2189-4-27**] 17:33:16 T: [**2189-4-27**] 18:24:44 Job#: [**Job Number **]

[ "482.1", "567.2", "996.59", "707.0", "785.51", "250.41", "585", "574.00", "428.0" ]

icd9cm

[ [ [] ] ]

[ "96.72", "34.91", "38.93", "39.95", "44.69", "51.22", "50.12", "96.6", "33.21", "99.15" ]

icd9pcs

[ [ [] ] ]

3168, 7440

2687, 3145

689, 2658

64,845

169,442

9867

Discharge summary

report

Admission Date: [**2117-5-28**] Discharge Date: [**2117-6-1**] Date of Birth: [**2053-10-5**] Sex: M Service: MEDICINE Allergies: Ciprofloxacin / Flagyl / Ursodiol / Quinolones Attending:[**First Name3 (LF) 1377**] Chief Complaint: melena, coffe ground emesis Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy with variceal banding History of Present Illness: Mr. [**Known lastname 33139**] is a 63M w/hx hepatitis B (good viral suppression on tenofovir), who is listed for liver transplant following left hepatic lobectomy and caudate lobe resection [**6-22**] for echinococcal cyst complicated by a bile leak, sclerosing cholangitis and liver failure. He also has known Grade II esophageal varices as well as GAVE. He presented to [**Hospital1 18**] [**2117-5-28**] from his rehab with one episode of coffee-ground emesis and melena. He saw his PCP the day prior to admission and noted he had been having normal BMs up to that point. . In the ED, the patient underwent NG lavage which revealed coffee-ground contents but no bloody contents. His Hct was noted to be 27--> 25.7 down from 31 the day prior. He was started on octreotide and protonix gtt and admitted to the SICU under the transplant surgery service. There he had EGD which revelaed 3 cords of nonbleeding grade II varices in the lower third of the esophagus that were banded successfully. He was transfused 2 units of RBCs for goal Hct >30. He remained hemodynamically stable with no evidence of ongoing blood loss. . On [**5-30**] he was transferred out of the ICU to the liver service. At the time of evaluation, the patient denied complaints other than ear wax. He was hemodynamically stable. He continued to have dark MBs, but reported no nausea or emesis. He denied CP, SOB, dysuria. ROS was positive for chronic cough, recent fall during previous hospitalization, and pruritus. . Review of systems: (+) Per HPI (-) Denies fever, chills, denies headache, sinus tenderness, rhinorrhea or congestion, shortness of breath. Denied chest pain or tightness, palpitations. No dysuria. Denied arthralgias or myalgias. Past Medical History: -Extended left hepatic lobectomy, cholecystectomy, caudate lobe resection, and intraoperative ultrasound for an echinococcal cyst [**2116-6-29**] -CAD: Cath [**2112**]: moderate CAD with two stenotic lesions in small obtuse marginal branches and mild CAD with a 40% stenosis in the proximal mid RCA, no stents -PUD [**2116-6-13**] -Hep B -Hypertension -Diabetes type 2 (with retinopathy and peripheral neuropathy) -Hypercholesterolemia -Peripheral vascular disease s/p right SFA angioplasty [**2108**] -Anemia/thrombocytopenia (Bone Marrow Biopsy [**12/2115**]) suggestive of early myelodysplasia -Chronic kidney disease, stage II -Right eye cataract -Left flexor tenosynovectomy for trigger finger [**1-/2116**] -Surgery for right retinal detachment [**8-/2113**] -Right eye vitrectomy [**8-/2112**] -Excision of a fibrokeratoma of his left plantar forefoot [**6-/2109**] Social History: He is originally from [**Country 5881**]. He lives in [**Hospital1 392**] with his wife. [**Name (NI) **] is retired and used to own an automobile service station. He does not smoke (quit 20 years ago); he rarely drinks ETOH, no drug use. Family History: Mother and sister with diabetes mellitus Physical Exam: VS - T:98.1 BP:120s/50s HR:50s RR:18 SpO2:99% on RA I/Os 2150/750 GENERAL - well-appearing man in NAD, comfortable, appropriate HEENT - NC/AT, EOMI, sclerae icteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - distended, + BS, soft/NT, no rebound/guarding, + splenomegaly EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (DPs) SKIN - excoriations over legs, arms, abdomen and chest LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**6-17**] throughout, no asterixis Pertinent Results: [**2117-5-27**] 06:40PM BLOOD WBC-4.9 RBC-3.24* Hgb-10.1* Hct-31.6* MCV-97# MCH-31.0# MCHC-31.9 RDW-18.7* Plt Ct-103* [**2117-6-1**] 05:20AM BLOOD WBC-3.9* RBC-3.21* Hgb-10.1* Hct-30.4* MCV-95 MCH-31.6 MCHC-33.4 RDW-19.7* Plt Ct-107* [**2117-5-27**] 06:40PM BLOOD PT-15.1* INR(PT)-1.3* [**2117-6-1**] 05:20AM BLOOD PT-15.8* PTT-29.3 INR(PT)-1.4* [**2117-5-27**] 06:40PM BLOOD UreaN-35* Creat-1.2 Na-135 K-5.4* Cl-104 HCO3-24 AnGap-12 [**2117-6-1**] 05:20AM BLOOD Glucose-78 UreaN-23* Creat-1.1 Na-140 K-4.6 Cl-111* HCO3-21* AnGap-13 [**2117-5-27**] 06:40PM BLOOD ALT-60* AST-94* AlkPhos-346* TotBili-8.9* [**2117-6-1**] 05:20AM BLOOD ALT-46* AST-72* LD(LDH)-183 AlkPhos-273* TotBili-5.2* [**2117-5-29**] 04:21AM BLOOD Albumin-2.3* Calcium-7.6* Phos-3.2 Mg-1.9 [**2117-6-1**] 05:20AM BLOOD Albumin-2.5* Calcium-8.1* Phos-2.5* Mg-2.0 [**2117-5-28**] 10:47AM BLOOD Lactate-2.2* . EGD [**2117-5-28**] Findings: Esophagus: Protruding Lesions 3 cords of grade II varices were seen in the lower third of the esophagus at 12 o'clock, 3 o'clock and 7 o'clock. The varices were not bleeding. Stomach: Normal stomach. Duodenum: Normal duodenum. Other procedures: 3 bands were successfully placed in the lower third of the esophagus at 3 cords of varices at: 12 o'clock, 3 o'clock and 7 o'clock. Good hemostasis after banding. Impression: Varices at the lower third of the esophagus (ligation) Otherwise normal EGD to third part of the duodenum Brief Hospital Course: Mr. [**Known lastname 33139**] was a 63 year-old man with hepatitis B and cholestatic liver disease who presented with an upper GI bleed and was found to have non bleeding esophageal varices on EGD that required banding x 3 with subsequent resolution. . #. Upper GI bleed: The patient presented with melena and coffee ground emesis and was found to have grade II esophageal varices from his liver disease visible on EGD without stigmata of bleeding from the varices. The varices were banded and hematocrit remained stable. He completed a 5 day course of ceftriaxone and tolerated a regular diet. On the day of discharge, he was hemodynamically stable, tolerated and full breakfast and was ambulating well and independently. He was discharged on daily high dose omeprazole. . #. Hep B and Cholestatic liver disease: His liver disease remained stable throughout admission and he remained on the transplant list. His symptoms of pruritus had improved and he was continued on tenofovir, rifaximin, lactulose, spironolactone and lasix. He also received sarna lotion and diphenhydramine for pruritis, which remained well controlled. . #. Malnutrition: Patient's appetite continued to improve throughout admission. On the day of discharge, he tolerated a full breakfast well. This improvement in nutirition status was expected to continue following dishcarge. . #. Hypertension: He was continued on home dose nadolol. . . #. Diabetes: He was continued on his home dose continue glargine 44 units at bedtime and insulin sliding scale. This remained stable throughout his hospitalization. Medications on Admission: Glargine 48 qHS Sucralfate 1 gm [**Hospital1 **] aspirin 81 daily Sarna VitB12 1000 daily Vit E lasix 40 mg daily Lactulose fluticasone spray [**2-14**] dronabinol 5 mg q day nadolol 20 mg rifaximin 550 mg [**Hospital1 **] sertraline 50 mg q day spirinolactone 75 mg q day omeprazole 20 mg EC tenofavir 300 mg Q day testosterone 5 mg patch q day Discharge Medications: 1. Lantus 100 unit/mL Solution Sig: 44units Subcutaneous at bedtime. 2. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO every four (4) hours. 3. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime. 4. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. insulin aspart 100 unit/mL Solution Sig: Sliding Scale Subcutaneous as directed. 6. sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day. 7. Ocean Nasal 0.65 % Aerosol, Spray Sig: One (1) Nasal once a day. 8. nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day. 9. spironolactone 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 10. dronabinol 5 mg Capsule Sig: One (1) Capsule PO once a day. 11. testosterone 5 mg/24 hr Patch 24 hr Sig: One (1) Transdermal once a day. 12. calcium carbonate 500 mg (1,250 mg) Tablet, Chewable Sig: Two (2) Tablet, Chewable PO every four (4) hours as needed for heartburn. 13. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. 14. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 15. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1) Tablet PO once a day. 16. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 17. Os-Cal 500 + D Oral 18. rifaximin 550 mg Tablet Sig: One (1) Tablet PO twice a day. 19. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every six (6) hours as needed for itching. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Gastrointestinal bleed Hepatitis B Cholestatic Liver Disease Hypertension Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 33139**], You were admitted to the hospital for dark vomiting and stool concerning for bleeding. You were found to have had bleeding from blood vessels in your esophagus. These blood vessels were treated to help prevent further bleeding. Because you had lost so much blood, you needed a transfusion of 2 units of red blood cells. Please follow closely with your outpatient gastroenterologist. Please take your medications as prescribed and keep your outpatient appointments. . The following changes have been made to your home medications: 1. Your Omeprazole has been INCREASED to 40mg daily. 2. Your Spironolactone has been INCREASED to 100mg daily. . No other changes have been made to your home medicaiton. Followup Instructions: Department: TRANSPLANT When: WEDNESDAY [**2117-6-2**] at 2:20 PM With: TRANSPLANT [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: TRANSPLANT CENTER When: WEDNESDAY [**2117-6-2**] at 3:00 PM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: [**Hospital3 249**] When: TUESDAY [**2117-6-8**] at 11:30 AM With: [**First Name11 (Name Pattern1) 1980**] [**Last Name (NamePattern4) 1981**], MD [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: TRANSPLANT CENTER When: FRIDAY [**2117-6-18**] at 2:00 PM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]

[ "070.32", "V12.71", "440.20", "V49.83", "456.20", "403.90", "357.2", "440.4", "250.60", "585.2", "263.9", "362.01", "571.5", "250.50", "537.82" ]

icd9cm

[ [ [] ] ]

[ "42.33" ]

icd9pcs

[ [ [] ] ]

9062, 9119

5530, 7114

334, 385

9252, 9252

4070, 5507

10160, 11457

3305, 3347

7510, 9039

9140, 9231

7140, 7487

9403, 9948

3362, 4051

9966, 10137

1923, 2134

267, 296

413, 1904

9267, 9379

2156, 3033

3049, 3289

63,539

175,322

43504

Discharge summary

report

Admission Date: [**2195-5-6**] Discharge Date: [**2195-5-8**] Date of Birth: [**2115-11-6**] Sex: F Service: MEDICINE Allergies: Erythromycin Base / Sulfa (Sulfonamide Antibiotics) / clindamycin Attending:[**First Name3 (LF) 3918**] Chief Complaint: Melena Major Surgical or Invasive Procedure: Capsule endoscopy History of Present Illness: 79 year female with hx of recurrent BRBPR secondary to cecal AVMs while thrombocytopenic, MDS transformed to AML now day 2 cycle 3 of decitabine therapy p/w melena. The pt has an extensive history of hematochezia and melena in the setting of low platelets and cecal AVM bleeds, most recently in the end of [**Month (only) 958**]. She reports that on Sunday she had significant PO intake and dietary indiscretions with subsequent abdominal cramping and diarrhea. She denied hematochezia at the time, though stated the cramping/diarrhea felt similar to bleeds she had had in the past. On Tuesday the pt initiated cycle 3 of decitabine. Overnight she noted significant nightsweats soaking the bedsheets and mattress, with increased fatigue this morning. This morning she also experienced one black, sticky bowel movement, without noticable odor. She endorsed some crampy abdominal pain but denied lightheadedness, dizziness, sob, cp. She denies n/v, hematochezia. She presented to BMT for day 2 of decitabine and was subsequently directly admitted from clinic to the MICU for concern re: GI bleed. . On arrival to the ICU, the pt was hemodynamically stable, with HR 70s-80s and SBPs in the 110s. She endorsed fatigue and crampy abdominal pain, but denied other symptoms. . Review of systems: (+) Per HPI (-) Denies fever, chills, 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, constipation. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - diverticulosis complicated by bleeding - bleeding anal fissures - bleeding AVMs ([**2-/2195**]) - GERD - emphysema(mild) - dental extraction - myelodysplastic syndrome dx [**8-/2194**] with persistent blastemia - hysterectomy at age 39 - hemorrhoidectomy x 4 - colon polyps, AVM - bilateral bunion surgery - hypertension - hyperlipidemia - proctalgia fugax - TMJD Social History: The patient is married and lives with her husband. She has three grown children. Has a twin sister who lives 5 houses down from her. Ex-[**Year (4 digits) 1818**], quit 14 year ago; has 35 pack year history. Denies any illicit drug use. Family History: No known fhx of MDS or leukemia. Physical Exam: ADMISSION EXAM: Gen: A&Ox3, NAD CV: rrr nl s1s2 Lungs: CTAB Ab: ntnd, mild discomfort in the lower quadrants Ext: no edema Skin: no petechiae Rectal: dark brown stool, guiaic+ . DISCHARGE EXAM: Vitals: T: 98 BP: 129/52 P: 98 HR 75 R:16 O2: 98RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly; capsule endoscopy pack present GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: no focal deficits Psych: calm, cooperative Pertinent Results: ADMISSION LABS: [**2195-5-6**] 09:20AM BLOOD WBC-8.1 RBC-2.74* Hgb-8.0* Hct-26.3* MCV-96 MCH-29.3 MCHC-30.5* RDW-17.8* Plt Ct-740* [**2195-5-6**] 09:20AM BLOOD Neuts-47* Bands-0 Lymphs-17* Monos-0 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Blasts-36* [**2195-5-6**] 05:30PM BLOOD WBC-7.4 RBC-2.30* Hgb-7.0* Hct-21.9* MCV-95 MCH-30.6 MCHC-32.1 RDW-18.0* Plt Ct-675* [**2195-5-6**] 09:20AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-NORMAL Macrocy-2+ Microcy-NORMAL Polychr-1+ [**2195-5-6**] 11:17PM BLOOD PT-15.0* INR(PT)-1.4* [**2195-5-6**] 11:17PM BLOOD Glucose-101* UreaN-17 Creat-0.8 Na-139 K-4.4 Cl-102 HCO3-29 AnGap-12 [**2195-5-6**] 11:17PM BLOOD Calcium-8.2* Phos-4.5 Mg-2.4 . Discharge Labs: [**2195-5-8**] 05:05AM BLOOD WBC-8.6 RBC-3.88* Hgb-11.4* Hct-36.0# MCV-93 MCH-29.4 MCHC-31.7 RDW-17.8* Plt Ct-864* [**2195-5-6**] 09:20AM BLOOD Neuts-47* Bands-0 Lymphs-17* Monos-0 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Blasts-36* [**2195-5-8**] 05:05AM BLOOD Plt Ct-864* [**2195-5-8**] 05:05AM BLOOD PT-14.3* PTT-35.4 INR(PT)-1.3* [**2195-5-8**] 05:05AM BLOOD Glucose-93 UreaN-18 Creat-0.9 Na-136 K-3.9 Cl-97 HCO3-27 AnGap-16 [**2195-5-8**] 05:05AM BLOOD Calcium-8.8 Phos-4.7* Mg-2.3 . Brief Hospital Course: Primary Reason for Admission: 79 year old female with hx of recurrent BRBPR secondary to cecal AVMs, MDS transformed to AML now day 2 cycle 3 of decitabine therapy p/w melena. . Active Problems: . # Melena: The pt has an extensive hx of GI bleeds from cecal AVMs in the setting of thrombocytopenia. On admission to the ICU she had plts in the 600-700s, however presents with an episode of melena. Though she remains hemodynamically stable, her HCT decreased from 26 to 21, concerning for GI bleed. Pt received 2u pRBC with appropriate bump in HCT. She was also started on IV PPI. Cauterization was considered, but no endoscopy was performed as she was hemodynamically stable without evidence of active bleed. Capsule endoscopy was performed, the results of which were pending at the time of discharge. . # MDS with AML transformation: Day of admission was day 2 of cycle 3 decitabine. Decitabine was held in setting of GI bleed. This will be continued per her outpatient Oncologist. . Transitional Issues: Ms [**Known lastname 73078**] will be contact[**Name (NI) **] with the results of her Capsule Endoscopy once complete. Depending on the findings, GI will dictate further workup and/or intervention. She will f/u with Heme/Onc [**2195-5-12**]. Medications on Admission: omeprazole ondansetron HCl polyethylene glycol 3350 17 gram docusate sodium loratadine magnesium hydroxide [Milk of Magnesia] multivit-mineral-iron-lutein [Centrum Silver Ultra Women's] Chemo: Decitabine Discharge Medications: 1. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 2. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 3. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) PO once a day as needed for constipation. 4. loratadine 10 mg Tablet Sig: One (1) Tablet PO daily (). 5. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) mL PO at bedtime. 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: GI Bleeding Secondary Diagnosis: MDS with transformation to AML Diverticulosis Cecal AVMs Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms [**Known lastname 73078**], It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted for bleeding and were given blood transfusions in the ICU. You had a capsule endoscopy, the results of which are pending at this time. You blood counts improved appropriately and given you are not having active bleeding, we feel you are now safe to return home. We made no changes to your medications on this admission. Followup Instructions: You will be contact[**Name (NI) **] by Dr [**First Name8 (NamePattern2) **] [**Name (NI) **] regarding the results of your capsule endoscopy on Monday [**5-11**]. If you do not receive a phone call from Dr. [**Last Name (STitle) **], please call [**Telephone/Fax (1) 463**] and ask for her by name. Department: BMT/ONCOLOGY UNIT When: TUESDAY [**2195-5-12**] - we will call you with the time Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: Main Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**]

[ "578.9", "492.8", "205.00", "728.85" ]

icd9cm

[ [ [] ] ]

[ "99.25", "45.19" ]

icd9pcs

[ [ [] ] ]

6819, 6825

4772, 5757

331, 350

6978, 6978

3573, 3573

7590, 8196

2710, 2744

6277, 6796

6846, 6846

6049, 6254

7129, 7567

4261, 4749

2759, 2937

2953, 3554

5778, 6023

1667, 2046

285, 293

378, 1648

6898, 6957

3589, 4244

6865, 6877

6993, 7105

2068, 2435

2451, 2694

26,767

180,702

3830

Discharge summary

report

Admission Date: [**2193-3-16**] Discharge Date: [**2193-3-21**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 358**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: endoscopic retrograde cholangiopancreatography with sphincterotomy (no stent) History of Present Illness: [**Age over 90 **] yo F who presented to OSH with abdominal pain, primarily in epigastrium, nausea, and dry heaving. She was taken to [**Hospital1 **] where she developed fevers, began to have some vomiting, and was given IVFs, antibiotics, anti-emetics, and analgesic medications. At [**Hospital3 2737**], she had a temperature to 101.7. She was given Zofran, Fentanyl 25 mcg x 2, blood cultures, ertapenem 1 gm IV x 1. The patient developed the pain yesterday afternoon and it continued to get worse throughout the evening. Of note, she had a similar episode about 3-4 weeks ago, though did not last as long. At that time, she had abdominal pain, nausea, and dry heaves, but denied fever at the time. She went to see her PCP who thought that maybe she had a viral illness and she got better. Though according to the patient's daughter, since that episode, she has not quite felt the same. In the ED:, the VS 102.1, 67, 145/42, 24, 95% RA. She received morphine 0.5 mg, zofran, levofloxacin 500 mg IV x 1, and flagyl 500 mg IV x 1. Past Medical History: Hypertension Anxiety Gout ? heart murmur palpitations Social History: Lives alone. Does all of her own ADLs. Walks with a cane. Per daughter, no h/o tobacco, ETOH, or drug use. Family History: no history of GI malignancy Physical Exam: Afebrile, VSS, HR from 70-130 day prior to discharge. Gen -- elderly, pleasant, NAD HEENT -- right facial ecchymosis lateral to eye, op clear/dry Heart -- regular, no murmru Lungs -- clear Abd -- soft, benign, +BS Ext -- bilateral arm ecchymoses, no edema Neuro/psych -- alert/oriented x3, full affect Pertinent Results: Admission Labs: [**2193-3-16**] 01:25AM BLOOD WBC-6.3 RBC-4.34 Hgb-12.8 Hct-36.9 MCV-85 MCH-29.4 MCHC-34.6 RDW-14.5 Plt Ct-194 [**2193-3-17**] 06:00AM BLOOD WBC-14.6*# RBC-3.15* Hgb-9.9* Hct-27.7* MCV-88 MCH-31.3 MCHC-35.6* RDW-15.0 Plt Ct-84* [**2193-3-16**] 01:25AM BLOOD Neuts-59 Bands-14* Lymphs-21 Monos-1* Eos-0 Baso-0 Atyps-5* Metas-0 Myelos-0 [**2193-3-17**] 06:00AM BLOOD Neuts-79* Bands-10* Lymphs-1* Monos-1* Eos-0 Baso-0 Atyps-9* Metas-0 Myelos-0 [**2193-3-16**] 05:31AM BLOOD PT-15.8* PTT-30.5 INR(PT)-1.4* [**2193-3-16**] 01:25AM BLOOD Glucose-127* UreaN-24* Creat-1.2* Na-135 K-5.8* Cl-100 HCO3-16* AnGap-25* [**2193-3-16**] 05:31AM BLOOD Glucose-92 UreaN-21* Creat-1.0 Na-140 K-2.8* Cl-106 HCO3-18* AnGap-19 [**2193-3-16**] 01:25AM BLOOD ALT-772* AST-1389* AlkPhos-321* TotBili-2.4* [**2193-3-16**] 01:25AM BLOOD Lipase-66* [**2193-3-16**] 01:25AM BLOOD Albumin-3.5 Calcium-8.5 Phos-1.8* Mg-1.1* [**2193-3-16**] 01:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ================== CHEST PORT. LINE PLACEMENT [**2193-3-20**] 10:19 AM FINDINGS: The left subclavian PICC line placed had its tip in the internal jugular vein portion of the neck. The heart size is top normal. Bibasilar opacities secondary to effusion atelectasis are seen. IMPRESSION: 1. The left subclavian PICC line tip needs to be adjusted as it is in the neck portion of the left internal jugular vein. 2. Bibasilar effusion and atelectasis. Small-to-moderate in amount are noted. This information was communicated by phone to the nurse who introduced the PICC line. ================== ERCP Findings: Esophagus: Limited exam of the esophagus was normal Stomach: Limited exam of the stomach was normal Duodenum: Limited exam of the duodenum was normal Major Papilla: Prominent major papilla Cannulation: Cannulation of the biliary duct was performed with a sphincterotome using a free-hand technique. Biliary Tree: Cholangiogram showed multiple stones in the CBD. The CBD was dilated to 12 mm. The intrahepatic ducts were minimally dilated. The cystic duct did not fill. Pancreas: Limited pancreatogram in the head of the pancreas during biliary cannulation appeared normal. Procedures: 1. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. 2. Multiple stones were extracted with a balloon catheter Impression: 1. Prominent major papilla 2. Cannulation of the biliary duct was performed with a sphincterotome using a free-hand technique. 3. Cholangiogram showed multiple stones in the CBD. The CBD was dilated to 12 mm. The intrahepatic ducts were minimally dilated. The cystic duct did not fill. 4. Limited pancreatogram in the head of the pancreas during biliary cannulation appeared normal. 5. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire.Pus and sludge was seen to flow after sphincterotomy. 6. Multiple stones were extracted with a balloon catheter Recommendations: Juices today when awake, alert and at baseline Continue IV antibiotics Remain on antibiotics for total of 7 days Follow-up with Dr. [**Last Name (STitle) **] ======================== Discharge Labs: E.coli grew from blood cultures x 2 at [**Hospital3 **]. Bacteroides fragilis grew from blood cultures x 2 at [**Hospital1 18**]. [**2193-3-21**] 07:15AM 8.4 3.59* 10.8* 31.4* 87 29.9 34.3 15.0 125* DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos [**2193-3-17**] 06:00AM 79* 10* 1* 1* 0 0 9* 0 0 RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy Polychr [**2193-3-16**] 01:25AM NORMAL1 NORMAL NORMAL 2+ NORMAL NORMAL 1 NORMAL MANUALLY COUNTED BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [**2193-3-21**] 07:15AM 125* BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino FDP [**2193-3-17**] 08:17PM 10-40 [**2193-3-17**] 08:17PM 577* Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2193-3-21**] 07:15AM 94 14 0.8 135 3.2* 106 20* 12 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2193-3-21**] 07:15AM 87* 34 172 168* 0.9 OTHER ENZYMES & BILIRUBINS Lipase [**2193-3-18**] 04:45AM 39 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2193-3-21**] 07:15AM 7.3* 2.0* 2.1 Brief Hospital Course: A/P: [**Age over 90 **] yo female with h/o HTN, anxiety, gout, who presents with abdominal pain, nausea, and vomiting with RUQ revealing cholecystitis with obstructing stone and CBD dilatation. 1) Cholangitis: Likely the patient's pain a few weeks ago was also secondary to passing a gallstone. Her symptoms, fever, and exam are all consistent with cholangitis. S/p ERCP with sphincterotomy, removal of stones and passage of purulent fluid. Pt now bacteremic with GNRs, likely biliary source. Marked Leukocytosis with 10% bandemia. IV ciprofloxacin and flagyl initiated [**3-16**], recommend 14 day course in light of bacteremia. PICC placed for IV abx at rehab. Ms. [**Known lastname 17204**] improved rapidly after ERCP and was transferred to the medical floor without any additional complications. She remained afebrile and her obstructive biliary labs improved daily. The surgical team evaluated her for cholecystectomy, which she and her family do not wish to pursue at this time. 2)Hypotension. Had held anti-hypertensive meds peri ERCP. In ERCP suite pt became hypotensive in the setting of receiving propofol, dexmedetomidate. Temporarily placed on peripheral neo for procedure and transfer to floor. Bolused throughout the day and evening with improvement, MAPs ~60-65. UOP stayed around 30cc/hour. Pt without complaint. Mentating well the entire time. Sepsis/shock secondary to biliary sepsis. After transfer to floor, home antihypertensives reiniitated without difficulty. 3)Cardiac pauses/AV block -- She had three episodes of documented [**1-25**] second pauses on telemetry. She received one dose of amiodarone in the ICU for rapid atrial fibrillation that may have contributed to her arrhythmias. She was asymptomatic. Pacer placement was discussed, and her primary cardiologist was called regarding the pauses while she was in the ICU. The patient and family do not wish to pursue pacer placement at this time. They will follow up with Dr. [**Last Name (STitle) 17205**] as an outpatient. 4)paroxysmal atrial fibrillation -- Asymptomatic, stable blood pressure. In NSR on discharge. Continue metoprolol. Her dose was increased from 25 mg po bid to 50 mg po bid and had a 7 second pause, so dose was decreased. Patient and family are aware. She reports "years" of palpitations, so she may have PAF for some time. Long term anticoagulation with coumadin was discussed, but she does not want to pursue. She should hold off on aspirin therapy for at least seven days from sphincterotomy as well. 5) Anxiety -- no symptoms. Discharged to [**Hospital1 100**] Senior Life. Medications on Admission: HCTZ 25 mg daily Amlodipine/Benzapril 5/10 mg daily Atenolol 50 mg [**Hospital1 **] Imdur 30 mg daily Allopurinol 100 mg QOD Lumigan 1 drop each eye at bedtime Alphagan one drop each eye every 12 hrs Actonel 35 mg weekly Lomotil Meclizine 12.5 mg PRN Ativan 0.5 mg PRN Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Bimatoprost 0.03 % Drops Sig: One (1) Ophthalmic daily (). 4. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 6. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 9. Ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 7 days: end date [**2193-3-28**]. 10. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours) for 7 days. 11. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 12. Saline Flush 0.9 % Syringe Sig: Five (5) mL Injection [**Hospital1 **]:PRN. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: 1. cholecystitis 2. E.coli and bacteroides bacteremia/biliary sepsis 3. paroxysmal atrial fibrillation 4. Few episodes of complete heart block with 3-7 second pauses 5. hypertension 6. gout 7. anxiety Discharge Condition: afebrile, PICC in left antecubital fossa (placed [**3-20**]), alert/oriented, no delerium, ambulates with assistance. Discharge Instructions: You were admitted with cholecystitis. You underwent ERCP and had gallstones extracted. You will be discharged to [**Hospital1 100**] Senior Life for the remainder of your care. Please call your primary physician with questions or concerns. Return to the emergency department with fever, chills, abdominal pain, jaundice or any other alarming symptoms. Followup Instructions: Please call your cardiologist, Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) 17205**] at [**Telephone/Fax (1) 17206**] for follow up within two weeks. Please call your primary physician, [**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 17207**] to arrange follow up when discharged from [**Hospital1 100**] Senior Life. House physician at [**Name9 (PRE) 17208**] to follow while inpatient there.

[ "426.0", "427.31", "574.31", "274.9", "496", "276.7", "576.1", "V12.79", "401.9", "458.29", "300.00", "790.7" ]

icd9cm

[ [ [] ] ]

[ "38.93", "51.85", "51.88" ]

icd9pcs

[ [ [] ] ]

10440, 10525

6415, 9031

276, 356

10770, 10890

2013, 2013

11294, 11779

1647, 1676

9351, 10417

10546, 10749

9057, 9328

10914, 11271

5229, 6392

1691, 1994

222, 238

384, 1429

2030, 5212

1451, 1507

1523, 1631

3,702

182,277

15082

Discharge summary

report

Admission Date: [**2123-9-14**] Discharge Date: [**2123-10-6**] Date of Birth: [**2050-8-12**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old gentleman with a history of atrial fibrillation on Coumadin and chronic EtOH abuse, who fell walking his dog. Patient was transferred from an outside hospital to [**Hospital1 346**] for further management of a large parietal-temporal hemorrhage. PAST MEDICAL HISTORY: 1. Atrial fibrillation. 2. Prostate cancer status post prostatectomy. 3. Asthma. 4. Myocardial infarction. PHYSICAL EXAMINATION: On physical examination, the patient is not following commands. Draws upper and lower extremities on the right side. Left lower and left upper withdraws to pain. Pupils are equal and 3 mm and brisk. Has swelling over the right eye. He had an immediate repeat head CT scan on admission which showed bifrontal subarachnoid hemorrhage and continued right parietal-temporal hemorrhage with no midline shift. The patient was intubated and transferred to the Intensive Care Unit for close monitoring. Patient on [**2123-9-15**] opened his eyes. Pupils are 5 down to 3 mm, briskly reactive, following commands in the right upper extremity and bilateral lower extremities. No movement of the left upper extremity. The patient received fresh-frozen plasma to correct his INR to keep it below 1.3. On [**2123-9-17**], the patient was extubated. Neurologically, awake and attentive. Pupils 5 down to 4 mm and brisk, following commands in all extremities except for the left upper extremity which was weak from admission without change. The patient is being treated with Levaquin for Klebsiella in his urine. Patient was transferred to the regular floor on [**2123-9-18**], continued to require no significant respiratory care. Was awake, moving all extremities except for the left upper extremity, following commands. He was seen by Physical Therapy and Occupational Therapy, and was planning for discharge to rehabilitation once medically stable. On [**2123-9-20**], the patient was in respiratory distress. The patient was given nebulizer treatments and respiratory status stabilized. The patient had a swallow evaluation which he failed and had to have PEG placement. GI was consulted, and patient had ultrasound to rule out ascites prior to PEG placement due to his long EtOH history. The patient was found to have no evidence of ascites and a PEG was placed by the GI service without complication. The patient had a repeat MRI scan on [**2123-9-25**] which showed a small new thalamic hemorrhage. The patient had flaccid left upper extremity moving the right upper extremity better than previous day, and the patient was perseverating. Continued to have respiratory distress, and requiring multiple breathing treatments as well as chest PT. On [**2123-9-26**], the patient was transferred to the Intensive Care Unit due to decreased O2 sats down to 92%. Patient requiring aggressive pulmonary toilet. The patient remained in the Intensive Care Unit until [**2123-9-28**], the patient became unresponsive. A repeat scan shows a complete left PCA stroke and left new frontal stroke. The previous scan from [**9-23**] showed a thalamic and left PCA stroke. MRA at that time showed a worsening of the left MCA and distal left P2 stenosis. The patient was open his eyes to verbal stimuli, following commands in the upper extremity. Continues to be weak in the left upper extremity as before. Right upper extremity was moving spontaneously. Pupils were 5 down to 2 mm. The patient continued to have problems with respiratory distress and was diagnosed with methicillin-resistant Staphylococcus aureus from a line on [**2123-10-5**], and was being treated with Vancomycin and Cipro. On [**2123-10-6**], a code was called for patient and respiratory arrest. The patient was coded at approximately 4:20 am, the code proceeded until 4:42 am when the patient was pronounced dead at 4:42 am. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2124-3-2**] 10:10 T: [**2124-3-2**] 10:31 JOB#: [**Job Number **]

[ "427.31", "790.7", "507.0", "789.5", "E885.9", "800.15", "518.5", "303.00", "427.5" ]

icd9cm

[ [ [] ] ]

[ "96.6", "38.91", "43.11", "96.72", "96.04", "38.93" ]

icd9pcs

[ [ [] ] ]

590, 4250

160, 437

459, 567

18,054

138,511

2872

Discharge summary

report

Admission Date: [**2147-11-22**] Discharge Date: [**2147-12-11**] Date of Birth: Sex: Service: CHIEF COMPLAINT: Fell out of a tree, developed neck pain and tingling of the bilateral fourth and fifth fingers at approximately 12:30 on the day of admission. HISTORY OF PRESENT ILLNESS: This is a 75 year-old white male retired carpenter who was trimming branches in a tree when he fell approximately six to eight feet landing on his outstretched arms and hands and noted tingling and pins and needle sensation in the bilateral fourth and fifth fingers and ulnar side of the hands. He also noted pain across the upper back and the base of his neck. He denies hitting his head or any loss of consciousness. He further denies any weakness of the arms, legs, feet or hands. He denies any bowel and bladder dysfunction. The patient reports he was ambulating. He went to his primary care physician who obtained plain films of the cervical spine, which raised the question of a significant dislocation. A cervical collar was applied to the patient and he was sent orthopedics the [**Hospital1 1444**] Emergency Room for further evaluation. A CT scan in the Emergency Room was positive for a grade three high grade C7-T1 bilateral pedicle fracture with subluxation of C7 anteriorly onto T1. PAST MEDICAL HISTORY: Pertinent for cardiomyopathy with the left ventricular ejection fraction of 25 to 30%. History of hypertension. History of prostate disease. The records indicate a history of increased PSA and that the patient refused further workup at the time of discovery of the elevated PSA. He also has a history of atrial fibrillation and cardioversion in [**2145-3-18**] and is followed by Dr. [**Last Name (STitle) **] of the [**Hospital1 69**] Cardiology Service for this. He also has history of hypercholesterolemia. PREVIOUS SURGICAL HISTORY: Pertinent for a tonsillectomy as an adolescent. MEDICATIONS: Amiodarone 200 mg po q.d., aspirin 325 mg po q.d., Lipitor 10 mg po q.d., Hydrochlorothiazide 12.5 mg po q.d., Lisinopril 40 mg po at h.s. q.d. and Terazosin hydrochloride 2 mg po at h.s. q.d. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: His temperature was 99.2. Blood pressure 183/44. He was bradycardic at 49. Respiratory rate 17. O2 saturation 97% on room air. He was a 75 year-old white male who appeared a bit younger then his stated age. He was normocephalic, atraumatic. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements intact. ENT was within normal limits. There were no cervical nodes and trachea examination was further deferred due to the presence of a hard cervical collar. The neck was in the cervical collar, but showed mild tenderness overlying the C7-T1 area. Chest and lungs were clear to auscultation and percussion. Heart was in normal sinus rhythm bradycardic without murmurs, rubs or gallops. Abdominal examination showed the bowel sounds to be present in all four quadrants, nontender, nondistended abdomen without hepatosplenomegaly. The bladder was a bit distended to within two fingerbreadths below the umbilicus and the extremities were without clubbing, cyanosis or edema. Neurological examination revealed the patient to be awake, alert, conversant and oriented times three with fluent speech and the smile was equal and tongue was midline. He was moving all extremities through full range of motion and the pupils are equal, round and reactive to light and accommodation. Extraocular movements intact. Cranial nerves II through XII were intact. The strenght of the bilateral deltoids were [**4-22**], biceps [**4-22**], triceps 4+/5 bilaterally equal. Wrist extensors and finger flexion grasp was [**4-22**]. Interosseous was 4+/5 bilaterally equal. The lower extremity strength in all muscle groups was [**4-22**] bilaterally equal. Sensory examination was intact to light touch and pin prick and two point discrimination throughout. However, the patient noted mild hyperesthesias mildly along the distal ulnar C7-T1 nerve root distribution primarily in the ulnar side of the hands and the fourth and fifth fingers bilaterally. There was no distinct sensory level to pin or light touch on the trunk and the position sense of the toes was intact bilaterally. There was no clonus and no drift. Deep tendon reflexes were 2+ bilaterally equal in the arms and legs with the exception of mildly diminished, but equal 1+ deep tendon reflexes at the Achilles and the plantar responses were down going bilaterally. Rapid alternating movements showed finger to nose and heel to shin all within normal limits. The gait and Romberg was not tested due to clinical and radiographic findings and the presence of a cervical collar with subluxation and fracture. LABORATORY EXAMINATION ON ADMISSION: White blood cell count 18.1 with 93.1 neutrophils, 4.4 lymphocytes, 2.2 monocytes, .1 eosinophils and .1 atypicals. The hematocrit was 36.6, platelets 223, coags were within normal limits with an INR of 1.2. His electrolytes were within normal limits, BUN 31, creatinine 1.6, glucose 125. A type and screen showed O positive blood with a negative screen. CT scan of the cervical spine showed a positive wedge compression fracture of the body of T1 and bilateral pedicle fractures of C7 with anterior subluxation of C7 and T1 grade 3 consistent with a high grade subluxation. The plain C spine films showed a malalignment of C7-T1 with the body of T1 not well seen and the posterior displacement of the spinous process evident. HOSPITAL COURSE: Due to the clinical findings the patient was admitted to the hospital and shortly after admission the patient had [**Location (un) 976**] [**Doctor Last Name 3012**] tongs applied with weights for extension of the neck and the patient tolerated the procedure and placement of the [**Location (un) 976**] Well tongs quite well and he was seen in consultation by the Medicine Service and was admitted to the Neurosurgical Intensive Care Unit for stabilization and monitoring. He was subsequently taken to the Operating Room on the morning of the [**2148-11-23**] where under general endotracheal anesthetic the patient underwent a C7-T1 posterior wiring of the spinous process with good results and good positioning of the C7-T1 subluxation. The patient tolerated the procedure well. He returned to the Neurosurgical Intensive Care Unit for recovery in stable condition. However, the patient failed to awaken from anesthesia and was found to have no evidence of eye opening to noxious stimuli. The pupils were 6 mm and unreactive bilaterally. There was trace corneals bilaterally, but no movement of the arms or legs. The blood pressure was 200/70 and the patient emergently was taken for a CT scan to rule out intracranial hemorrhage or massive cerebrovascular accident or a pontine angle hemorrhage. The cranial CT demonstrated some blood in the bilateral occipital horns and a small amount of convexity traumatic subarachnoid hemorrhage. There was only mild ventriculomegaly and there was no mass effect or shift. However, due to the findings the patient was returned to the Neurosurgical Intensive Care Unit and after attempts to reach the patient's family were unsuccessful, the patient had a ventriculostomy drain placed and he tolerated this procedure well. His ventricular drain and intracerebral pressures remained in normal physiologic ranges and on the morning following surgery the patient began to awaken, he was easily arousable and began to show evidence of moving all extremities spontaneously. He was mouthing words over his endotracheal tube and following simple commands. Due to the improvement in his clinical condition, the ventricular drain was removed and the patient spent the next several days in the Neurosurgical Intensive Care Unit with stabilization of his mental status and he remained hemodynamically stable. The patient was subsequently transferred to the hospital floor where he began a rigorous course of physiotherapy and occupational therapy. He was seen in consultation by the Medicine and Hematology/Oncology Service for a persistent elevated white blood cell count and shortly prior to discharge the patient had a febrile episode and was found on cultures to have a positive sputum culture and was placed on Vancomycin and Levaquin. The patient was subsequently discharged to a rehab center with a PICC line in place for continuation of the Vancomycin antibiotic treatment for his positive culture and he was discharged to rehab on the [**2147-12-11**] with follow up to see Dr. [**Last Name (STitle) 1327**] in the clinic in approximately two weeks time. CONDITION ON DISCHARGE: Stable and improving. [**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**] Dictated By:[**Name8 (MD) 5474**] MEDQUIST36 D: [**2148-4-8**] 19:18 T: [**2148-4-9**] 11:10 JOB#: [**Job Number 13946**]

[ "E884.9", "518.5", "425.4", "997.09", "805.07", "805.2", "427.31", "401.9" ]

icd9cm

[ [ [] ] ]

[ "81.05", "38.93", "81.03", "77.79" ]

icd9pcs

[ [ [] ] ]

5597, 8705

2203, 4831

139, 283

312, 1318

4846, 5579

1341, 2180

8730, 9003

1,241

195,017

51522

Discharge summary

report

Admission Date: [**2136-8-30**] Discharge Date: [**2136-9-28**] Date of Birth: [**2071-12-4**] Sex: M Service: MEDICINE Allergies: Penicillins / Bactrim Attending:[**First Name3 (LF) 348**] Chief Complaint: Right frontal hemorrhage Major Surgical or Invasive Procedure: Left-sided emergent external ventricular drainage placement. Lumbar puncture History of Present Illness: 64yo right handed man with PMH significant for HTN, DMII, HCV, and recent discharge from [**Hospital1 18**] for ataxia presents from [**Hospital3 **] with altered consciousness. He reportedly called his wife c/o N/V, and soon after the [**Hospital1 **] staff found him on the floor responsive only to sternal rub. He was brought to the [**Hospital1 18**] ED. . In the ED, HCT was performed and showed a large R frontal hemorrhage filling the right ventricles. He was intubated for airway protection. An EVD was placed at the bedside. . Of note, he was recently discharged from [**Hospital1 18**] after an admission for ataxia, etiology undetermined. This was thought to be secondary to stroke vs seizure. At the time, an MRI showed two frontal lesions, one which was thought to be secondary to hemorrhage, one thought to be secondary to infarction. He was discharged to [**Hospital3 **]. . He was extubated on [**8-31**] after some improvement in mental status and stable respiratory status. He was following commands, speaking in 1-word phrases, and moving his R side freely, but had no spontaneous movement of his L side. Neurology Consult was also following. He was receiving tPA [**Hospital1 **] via EVD until [**9-3**]. He began to spike to [**Age over 90 **]F on [**9-2**] and was pancultured and his central line removed. His mental status was noted to be declining, now only responding to painful stimuli with occasional spontaneous eye opening. Renal consult was called [**9-4**] for worsening renal failure. He was reintubated on the afternoon of [**9-4**] for airway protection with worsening mental status. He was transferred to the MICU service on [**9-4**] as it was felt that his primary problems are not surgical. . In the ICU, the patient continued to spike fevers, but work up for source has been unrevealing. LP was done [**9-12**] and showed 4+ PMNs on gram stain, no organizms. The patient has been covered with Vanco and Ceftazadime. His 14-day course is scheduled to end [**2136-9-25**]. He also grew MRSA from sputum. The patient had to have tracheostomy and PEG tube placement for failure to wean from vent. His ICU course was also c/b elevation in LFTs and statin was held. He eventually was weaned off the vent and has been stable on 35% trach mask. To floor from MICU. Past Medical History: * HCV -- genotype 1 initially diagnosed in [**2128**], likely secondary to h/o IVDU in [**2089**]; currently on trial with PEG interferon; liver biopsy [**3-/2133**] showed stage-IV disease * HTN * Diabetes type II * Retinal embolus * Gout * Left ankle osteochondral defect (will have surgery involved grafts from patella) * Pruritis Social History: lives alone, separated from wife, grown children. Works as a painter. Was at [**Hospital3 **] after discharge from hospital. H/o IVDU [**2091**]. Occ EtOH. . He is African-American with a history of IV drug abuse in [**2091**]. Diagnosed with HCV in [**2128**]. Occ ETOH. Denies current/recent IVDU. Lives alone, separated from wife, grown children. He is a painter, and does not have much business currently given the season. Family History: Family history is positive for liver cancer in his father who was a heavy drinker. Physical Exam: PE: VS: BP 180/76, HR 65, RR 17, SaO2 100%/FM Genl: lying in bed, not moving HEENT: NCAT, MMM, facemask in place CV: RRR, nl S1, S2 Chest: CTA bilaterally anteriorly Abd: soft, ND, BS+ Ext: warm & dry . Neurologic examination: MS: required noxious stimuli for responsiveness, able to say his name, dysarthric, unable to understand answers to other orientation questions. Follows simple commands (show me your thumb, stick out your tongue). CN: pupils reactive 3->2mm, does not track but resists doll's eyes, so unable to determine EOM. Corneal reflexes intact. Face symmetric. Gag intact (per neuro resident). Tongue midline. Motor: L hemiparesis, no movement to noxious stimuli. RUE and RLE move spontaneously. Unable to perform formal strength testing, but grip [**3-30**], can lift arm against gravity. Sensory: no response to noxious stim on L DTRs: 1+ BR, [**Hospital1 **], tri, absent in LUE and BLE. R toe downgoing, L mute. Pertinent Results: Imaging: . [**9-26**] EEG- not finalized **** . [**9-26**] colonoscopy- Polyps in the transverse colon and sigmoid colon(polypectomy) Grade 2 internal hemorrhoids.Normal mucosa in the colon . CT HEAD W/O CONTRAST [**2136-9-26**] 4:15 PM Again seen is a right medial frontal lobe intraparenchymal hemorrhage with extensive surrounding vasogenic edema with expected evolution of blood products. There is no change in the extent of edema. There has been complete resolution of the left frontal lobe hemorrhage and bilateral intraventricular hemorrhages seen on the prior examination. Vasogenic edema remains present in the left frontal lobe. There is no new acute intracranial hemorrhage or midline shift. There is no hydrocephalus. Visualized paranasal sinuses are clear. A burr hole defect is seen in the left frontal bone. IMPRESSION: No new acute intracranial hemorrhage. Evolution of blood products with persistent vasogenic edema in both cerebral hemispheres as described above. . [**2136-9-20**] CHEST (PORTABLE AP): No failure, no infiltrates. . [**2136-9-19**] LIVER OR GALLBLADDER US: No evidence of focal mass within the liver. No evidence of biliary ductal dilatation. . [**2136-9-18**] UNILAT UP EXT VEINS US: Venous thrombosis of left cephalic vein surrounding a PICC line. . [**2136-9-17**] CHEST (PORTABLE AP): Repositioning of PICC line as described. . EEG ([**9-11**]): This is an abnormal EEG due to the unreactive, slow and disorganized background activity. This EEG suggests a moderate to moderately severe encephalopathy, which may be seen with infections, medications, toxic metabolic abnormalities or ischemia. . [**2136-9-11**] CT HEAD W/O CONTRAST: 1. Considerable interval improvement in the appearance of bilateral intraventricular hemorrhages, without hydrocephalus. 2. Similar appearance of intraparenchymal hemorrhage along the left frontal catheter tract. 3. Slightly improved right frontal intraparenchymal hemorrhage. . [**2136-9-11**] CHEST (PORTABLE AP): Tip of the endotracheal tube is in standard placement, approximately 4.5 cm above the carina. Cuff is no longer as severely hyperinflated. Lungs are clear. Heart size top normal. No pleural abnormality. Nasogastric tube ends in the upper stomach. . [**2136-9-10**] CHEST (PORTABLE AP): 1. Endotracheal tube terminating 6.4 cm above the carina. More optimal positioning would be achieved if the tube is advanced 1-2 cm. 2. Overdistention of the endotracheal tube cuff at the thoracic inlet. . [**2136-9-9**] CHEST (PORTABLE AP): Pulmonary vascular congestion, increased since prior examination. . [**2136-9-7**] CHEST (PORTABLE AP): Dobbhoff tube now in the expected location of the gastric fundus. . [**2136-9-7**] CHEST (PORTABLE AP): Feeding tube has been withdrawn to the level of the thoracic inlet that needs to be repositioned. ET tube is in standard placement. Heart size top normal. Pulmonary vascular congestion has improved. Lungs are essentially clear though low in volume. There is no pleural abnormality. . [**2136-9-5**] CT HEAD W/O CONTRAST: 1. Stable appearance of bilateral intraventricular hemorrhages and of intraparenchymal hemorrhages within the right centrum ovale and recent catheter tract. 2. Status post ventriculostomy removal. . [**2136-9-5**] LIVER OR GALLBLADDER US: No ascites. . [**2136-9-5**] CHEST (PORTABLE AP): Mediastinal and pulmonary venous congestion are new, and mild cardiomegaly has worsened, consistent with cardiac decompensation and/or volume overload. Lungs are low in volume but clear of any focal abnormality. ET tube is in standard placement and a feeding tube ends in the upper stomach. . [**2136-9-4**] CT HEAD W/O CONTRAST: 1. New hemorrhage along the catheter tract, extending into the left frontal [**Doctor Last Name 534**] of the lateral ventricle. Otherwise, no significant interval change. 2. No evidence of hydrocephalus. . [**2136-9-4**] RENAL U.S. PORT: No evidence of hydronephrosis. . [**2136-9-4**] CHEST (PORTABLE AP): Endotracheal tube located approximately 6 cm above the carina, as detailed above. . [**2136-9-4**] BILAT LOWER EXT VEINS: No DVT. . [**2136-9-4**] CT HEAD W/O CONTRAST: 1. New hemorrhage along the catheter tract, extending into the left frontal [**Doctor Last Name 534**] of the lateral ventricle. Otherwise, no significant interval change. 2. No evidence of hydrocephalus. . CXR ([**9-3**])- The lungs remain clear of focal consolidation and the lateral costophrenic sulci are sharply marginated. The right CVL has been removed and there is no PTX. A Dobbhoff catheter is seen with the tip just below the left hemidiaphragm high in the left upper quadrant of the abdomen. . CT head ([**9-3**])- New hemorrhage along the catheter tract, extending into the left frontal [**Doctor Last Name 534**] of the lateral ventricle. Otherwise, no significant interval change. No evidence of hydrocephalus. Findings discussed with Dr. [**Last Name (STitle) **] on the same day. . MRI/A brain ([**8-31**])- The previously described intraparenchymal hematoma on the MR [**First Name (Titles) **] [**2136-8-16**] has enlarged. However, compared to the head CT of [**2136-8-30**], there has been no change. There is mild associated mass effect without evidence of herniation. Since the head CT of [**2136-8-30**], there has been development of a moderate-to-large left subgaleal hematoma. . CT head ([**8-30**])- Large right parenchymal hemorrhage with blood dissecting into the ventricles, with associated hydrocephalus. Brief Hospital Course: This patient was seen in the ED with a right frontal hemorrhage and IVH. An EVD was immediately placed, and the patient admitted to the Neurosurgery service to the ICU. The patient received TPA through his drain every 12hrs. In the ICU, he remained stable with progressive improvement of neurological function. On POD3, the patient was alert in the morning with possible left-sided neglect. He had no new issues. He remained in the ICU on this day for blood pressure control. On POD4 he had a head CT which showed improvement in the IVH. . MICU Course: Pt was transferred to the MICU on [**2136-9-4**] for declining mental status in face of fever (began [**2136-9-2**]) of ? source. Upon admission to the MICU, pt was re-intubated due to inability to protect airway. The following issues were addressed while pt was in the MICU: . # Fever w/ Declining Mental Status: Pt's MS began to decline while fevers began, w/o significant change in CT scans of head. WBC was normal at transfer. Differential included: 1. Seizure - Pt was started on oxycarbamazapine and Keppra, and EEG was ordered to r/o possibility of subclinical seizures, but results were suggestive of global encephalopathy (repeated [**9-11**] w/o significant change). Seizure meds were subsequently discontinued, and neuro consultation continued to follow w/o further recs regarding this issue. 2. Increased ICP - Neurosurgery was consulted for possible IC cath blockage (possible ALOC due to increased ICP), but ICP was unremarkable; EVD was discontinued on [**9-5**], and neurosurgery signed-off w/o ability to explain declining MS. Pt also received a f/u CT head on [**9-11**] with improved ICH and no signs of increased ICP. 3. ID - Given intracranial instramentation, both bacterial meningitis and viral encephalitis were considered. LPs produced CSF for analysis on [**9-2**] and [**9-12**]; the [**9-2**] sample failed to reveal a pathogen and revealed only 1+ PMNs; the [**9-12**] CSF was significant for 4+ PMNs but failed to reveal an insulting pathogen. Per neuro and ID recs, pt was changed to ceftriaxone (with vanc continued) for possible bacterial meningitis on [**9-11**]; pt was then switched to ceftaz with vanc to complete a 2 week course (from [**9-11**] start date). Acyclovir was added [**9-12**] for possible HSV encephalitis per neuro recs, but was discontinued per renal recs on [**9-15**] (? possible acyclovir renal toxicity). Pt continued to spike fevers until [**9-14**], but after that day, remained afebrile (but for occassional low-grade fevers) throughout the remainder of his ICU course. 4. Uremia - given acute on chronic renal failure, ALOC due to metabolic abnormality secondary to renal failure was explored. Renal consultation, while concerned about the cause of pt's acute on chronic renal failure, did not believe that renal function was causative of ALOC, and did not recommend HD. They continued to follow as pt was transferred to the floor. 5. Hepatic Encephalopahty - given HCV cirrhosis, hepatic encephalopathy was investigated. Pt lacked asterixis on exam, and LFTs were not suggestive of acute decompensation during the declining mental status. LFTs only began to rise on [**9-11**], with significant elevation on [**9-19**]; however, this change was not temporally associated with pt's ALOC, and was not considered to be causative. . Ultimately, pt's mental status showed a mild improvement throughout the course of his MICU stay, with pt able to track examiners with his eyes when on his right; pt was still ignoring his left side upon transfer to floor; movement of right arm was noted, no other motor activity was appreciated. . # Acute on chronic renal failure: Cr reached a maximum of 3.8 vs. 2.0 at baseline and at admission. Renal consultation and testing concluded that acute on chronic renal failure was secondary to septic ATN with possible acyclovir toxicity (given appearance of acyclovir crystals in urine). Acyclovir was discontinued, copious diuresis was initiated to pass crystals, and pt was transfused to improve renal perfusion/oxygenation. These measures helped reduce Cr to 2.6 on transfer to the floor. . # UTI - Pt was found to have a UTI while Foley cath was in place on [**9-8**], with UCX failing to reveal insulting pathogen (likely due to broad-spectrum coverage of abx prior to drawing of samples). Pt was treated empirically by continuing cefepime and vanc (initially started for fever of unkwown source). . # Hepatitis w/ Pancreatitis - LFTs and amylase/lipase were noted to be elevated in an obstructive pattern on [**9-19**]; RUQ U/S failed to reveal cholelithiasis or CBD dilation; CPK was assayed, and was elevated, which in the context of elevated LFTs and pancreatic enzymes, was highly suggestive of statin toxicity. Pt's statin was discontinued, and LFTs began to resolve. . # Hypertension: Initially very difficult to control on multiple medications, including nicardipine gtt as needed to keep SBP < 160. Ultimately, pt's BP began to stabilize, nicardipine drip was discontinued [**9-14**]; from there, BP was well-controlled on amlodipine, hydral, labetalol, and isordil. . # Respiratory failure: Pt was re-intubated in the ICU for failure to protect his airway given declining mental status. Pt was maintained on AC with multiple failed attempts to prepare for extubation. Ultimately, a tracheostomy was placed on [**9-14**] by IP service (please see operative report for details), and maintained on trach mask at FiO2 0.4. Pt maintained excellent oxygenation, and f/u CXRs failed to reveal infiltrates or pulmonary edema. Pt was stable on trach mask when transferred to the floor. . # DM: Pt's insulin requirement varied, and glycemic control was difficult to stabilize. Pt was placed on an insulin drip on [**9-17**], with drastic improvement in glycemic control. Insulin requirement was totaled, and pt was transitioned back to SC insulin with much-improved control upon transfer to the floor. . # Anemia: consistent with chronic inflammation and possible underlying GI bleed (guiac + stools). Pt was on Epo and iron, and as HCT slowly trended down during the course of his MICU stay, he received a transfusion of 2 PRBCs on [**9-19**]. HCT remained relatively stable post-transfusion as pt was transferred to the floor. . # HCV: Last viral load 11,500,000 in [**5-31**]. Completed 84wks of PEG-IFN in COPILOT study with Dr. [**Last Name (STitle) **], d/c'd for intolerable side effects. INR normal but low albumin, so likely some synthetic dysfunction. Liver biopsy in [**5-31**] with Stage 4 fibrosis. Not actively treated while in the MICU. . # FEN: tube feeds, PEG placed [**9-14**], electrolytes repleted prn. . -When patient transferred to floor [**9-22**], vanc/ceftriaxone for possible meningitis, with tracking eye movements, afebrile, trach mask 35%, hypernatremia resolving, renal failure improving, PEG tube in place, diabetes controlled on regimen, but course complicated by question of seizures, and lower GI bleed. . #?seizures: myoclonic jerking in rythmic patter 3 days prior to discharge. CT head with no evidence of new bleed. Preliminary for EEG with no evidence of seizure. Ativan given and dilantin loaded. Started on Dilantin 100 TID with continuing of jerking movements continuous, leaning towards a status epilepticus picture, vs myoclonic jerks. Neuro felt picture likely represents Epilepsia Partialis Continua. Dilantin increased to 100 QAM, 100 QPM and 200 QHS. To follow dilantin levels and Ativan as needed by rehabilitation center with close monitoring and neuro follow- up. Large intracranial bleed, meningitis, metabolic disturbances, all make patient prone to seizure activity. . #Lower GI bleed: frank blood per rectum 4 days prior to discharge. 4 PRBC in total given. Colonoscopy with evidence of large sessile polyp in transverse colon and sigmoid colon. Grade II external hemmorhoids as well. History of jejunal AVM, and esophageal varices. DDAVP given, in the setting of possible uremic bleeding. Polypectomy performed at colonoscopy [**9-27**] with guiac negative stools subsequently. As per GI, large sigmoid polyp and hemorrhoids likely culprit. . #Meningitis/[**Name (NI) **] Pt started on [**9-12**] with Vanc and ceftriaxone for temp to 103 and numerous WBC's on lumbar puncture. Pt afebrile on floor. WBC remained in the 11.0 range. Antibiotics for 16 day course. DC'd [**9-27**]. Subsequent LP not performed prior to stopping antibiotics as per neuro recs. VRE +, MRSA in sputum. C-diff neg. . #Htn- BP to highest SBP 195, patient had not received calcium channel blocker during episodes of lower GI bleed. Continued labetolol, amlodipine, and Imdur. . #ARF- resolved, hydration maintained. Lanthanum discharged prior to DC. Felt acute renal failure possible result of septic non oliguric acute tubular necrosis.Cr 2.9 [**9-1**]. Declining MS since [**9-1**]. UA with muddy brown casts, with persistent fevers Renal suspected unresponsiveness not due to uremia, but due to neuro/infectious process. Paitent had Cr increase to 3.5 likely from acyclovir. Chronic renal insufficiency with creatinine at 2. Current creatinine at discharge 1.4. . #Hypernatremia- likely from post-ATN diuresis, rec for D5W with NA up to 150 with resultant Na at 143 upon discharge. . #UE DVT- Patient unable to be anticoagulated given bleed. Swelling persisted. . Pt discharged to rehabilitation facility with follow up with renal, neuro, in addition to repeat colonoscopy in 6 months. With dilantin level to be checked daily until stable, insulin regimen to continue, and monitoring for bleeds, with increasing in antihypertensives as needed for goal SBP<150. Medications on Admission: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 2. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Humulin N 100 unit/mL Suspension Sig: One (1) Subcutaneous once a day: 60 units. 5. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID 7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY 9. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): start [**8-20**]. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for Itching. 12. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 13. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 14. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. Lorazepam 1 mg Tablet Sig: 0.5-1 Tablet PO Q4-6H (every 4 to 6 hours) as needed for severe tremor inhibiting sleep. 16. Procrit 4,000 unit/mL Solution Sig: One (1) mL Injection once a week: Inject subcutaneously. 17. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**5-3**] Puffs Inhalation Q4H (every 4 hours) as needed. 5. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 6. Isosorbide Dinitrate 10 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 8. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-28**] Drops Ophthalmic Q1H (every hour) as needed for eyes open. 9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 12. Epoetin Alfa 20,000 unit/2 mL Solution Sig: 5000 (5000) units Injection QMOWEFR (Monday -Wednesday-Friday). 13. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 14. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 15. Pantoprazole 40 mg IV Q12H 16. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Forty (40) units Subcutaneous breakfast and dinner: 40 units breakfast 40 units dinner with Humalog sliding scale as printed, attached to paperwork. . 17. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO QAM and QPM: 100 mg QAM, 100 mg QPM. 200 mg QHS. 18. Phenytoin Sodium Extended 200 mg Capsule Sig: One (1) Capsule PO at bedtime: 100 mg QAM, 100 mg QPM, 100 mg QHS . 19. Ativan 1 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for seizure, severe agitation. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Primary: R parenchymal hemorrhage dissecting into the ventricles with EVD placement ?meningitis ?Epilepsia partialis continua lower GI bleed upper extremity DVT ARF PEG tube placement respiratory depression- s/p tracheostomy Buttock ulceration hypernatremia elevated LFT's . Secondary: DM II CRI Anemia htn ?bronchoalveolar Ca HCV Gout retinal embolus hypercholesterolemia Discharge Condition: aphasic, tracheostomy tube, afebrile, feedings by PEG tube. Discharge Instructions: You were admitted with right frontal hemorrhage, with placement of EVD, treated for a possible meningitis, suffered a lower GI bleed, and possible seizures. Condition is stable at this time. -Please continue all medications and treamtments as you had in the hospital. -Antibiotics for meningitis completed at this time. -Please continue tube feeds, renal, hypertension, and seizure medications as in the hospital -Please return to the hospital if you are experiencing bleeding, further deterioration in mental status, worsening of jerks and movements, fever, diarhhea, or other symptoms concerning. Followup Instructions: Please call [**Hospital6 **] for appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Informed of status. [**Telephone/Fax (1) 250**] colonoscopy in 6 mnths, please see attached paperwork. Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 1941**]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2136-10-15**] 8:00 Neurology Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2136-10-16**] 3:00 Renal

[ "453.40", "070.54", "285.1", "996.64", "585.9", "348.4", "322.9", "431", "584.9", "211.3", "518.5", "345.70", "331.4", "250.00", "403.90" ]

icd9cm

[ [ [] ] ]

[ "31.1", "43.11", "38.93", "45.41", "99.10", "96.6", "03.31", "02.39" ]

icd9pcs

[ [ [] ] ]

23258, 23328

10110, 10966

306, 385

23746, 23808

4585, 10087

24455, 25015

3532, 3617

21296, 23235

23349, 23725

19818, 21273

23832, 24432

3632, 3835

242, 268

413, 2712

10981, 19792

3859, 4566

2734, 3070

3086, 3516

30,833

147,559

24569

Discharge summary

report

Admission Date: [**2170-11-26**] Discharge Date: [**2171-2-28**] Date of Birth: [**2090-10-11**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 4659**] Chief Complaint: Transfered from outside hospital for cardiac catheterization and EP consult, developed Lower gastrointestinal bleed and found cecal tumor. Underwent a hemicolectomy. Developed anastomotic leak. Major Surgical or Invasive Procedure: Cardiac catheterization Transesophageal echocardiogram DC cardioversion Colonoscopy Status Post R Hemicolectomy [**2170-12-4**] Percutaneous drain placement on [**2170-12-14**] G - Tube Placement [**2171-1-9**] Cholecystostomy tube placement on [**2171-1-11**] History of Present Illness: 80 year old male with hx of prior CABG, MI, ischemic CM with an EF of 35% who was admitted last month to [**Hospital3 **] with CHF and new afib. He was rate controlled and had a stress test that showed anterior reversibility and a fixed inferior defect. Cath was recommended but pt refused at that time. He was started on coumadin. He notes worsening DOE over the past 6 months or so but has difficulty giving a clear timeline to his symptom progression. He used to be very active, now leads a more sedentary lifestyle. At home, he denies significant improvement in his symptoms. He was able to go back to work ~2h per week (works as CPA) for the last week of [**Month (only) 1096**]. He sleeps on 1 pillow and denies PND. No f/c/s, no cough, no lightheadedness or dizziness. He presented to his outpatient cardiologist on [**2170-11-22**] and was readmitted again to [**Hospital3 **] for CHF. He was reportedly ruled out with negative CE. BNP was 356. CXR was clear. He was diuresed with IV lasix 40mg [**Hospital1 **]. Weight dropped 192--> 187 lbs. He was also loaded with 600mg plavix yesterday. INR on arrival to [**Hospital3 **] on [**11-22**] was 6.8 (up to 8.4 on [**11-23**])and Coumadin put on hold and received 3 doses of SQ Vit K. He has remained chest pain free. He is being referred to [**Hospital1 18**] for cardiac cath as well as EP consult for possible cardioversion and ?ICD. Past Medical History: 1) CAD--IMI s/p thrombolysis and rescue angioplasty of the RCA in the early [**2152**]'s, CABG x 3 [**2153**] at [**Location (un) **] Hospital with vg to lad, vg to OM and vg to ramus. Cath done here [**4-25**] due to NSTEMI showed occluded vg to rca and occluded vg to OM. s/p POBA to native ramus. 2) Systolic CHF, acute on chronic 3) Atrial fibrillation - newly dx in [**10-27**], on coumadin 2) hypertension 3) DM type II 4) Hyperlipidemia 5) BPH s/p TURP 6) benign tumor removed from left side of the neck, 7) s/p bilateral inguinal hernia repair 8) h/o basal cell CA s/p rsx . Cardiac Risk Factors: +Diabetes, +Dyslipidemia, +Hypertension . Social History: Lives with wife. [**Name (NI) 1403**] 3h/d as CPA. Remote 40-50 pack year history, quit 45 years ago. Drinks 2 glasses of wine per week. . Family History: Non-contributory . Physical Exam: VS - T 97.4 BP 111/66 HR 81 RR 20 94% on 2L Gen: WDWN middle aged male lying in bed in NAD. Oriented x3. Mood, affect appropriate. Speaking in short sentences. HEENT: NCAT. Sclera anicteric. Lazy right eye, L eye EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. MMM. No xanthalesma. Neck: Supple with JVP of [**7-31**] cm. CV: PMI located in 5th intercostal space, midclavicular line. irreg, irreg. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Crackles to 2/3 up lung fields b/l, no wheeze or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: [**12-23**]+ [**Month/Day (3) **] edema, 1+ RLE edema to calves b/l. Per pt, [**Name (NI) **] is chronically swollen (grafts taken from this leg). No femoral bruits. R groin dressing c/d/i, no hematoma. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ Femoral 1+ DP 1+ Left: Carotid 2+ Femoral 1+ DP 1+ . Pertinent Results: PERTINENT LABS: Lab values on [**2171-2-28**] WBC 6.6 HCT 29.3 PT 27.1 PTT 41.4 INR 2.7 Na 143, potassium 4.3 chloride 104 bun 41 cre. .7 glucose 144. . . STUDIES: . [**2170-11-26**] Cardiac cath: 1. Coronary angiography in this right dominant system revealed three vessel coronary artery disease. The LMCA had an ostial 40% stenosis. The LAD was occluded proximally. The LCx was occluded proximally. The Ramus was patent. The RCA was known to be occluded. 2. Arterial conduit angiography revealed that the LIMA-LAD was widely patent. The SVG-OM was also widely patent. 3. Resting hemodynamics revealed borderline left and right sided filling pressures with mean PCW of 15 mmHg and RVEDP of 10 mmHg. There was mild pulmonary arterial systolic hypertension with PASP of 36 mmHg. There was systemic arterial systolic and diastolic hypotension with SBP of 90 mmHg and DBP of 51 mmHg. 4. Left ventriculography was deferred. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease (occluded native coronaries except patent ramus intermedius) 2. Widely patent SVG-OM and LIMA to LAD. 3. Mildly elevated right heart pressures. . [**2170-11-27**] CXR (PA and lateral): Small bilateral effusions. Chronic congestion with basilar opacification thus pneumonia cannot be excluded. . [**2170-11-27**] TEE: 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 stretched patent foramen ovale is present with left to right shunting at rest. Left ventricular wall thicknesses and cavity size are normal. LV systolic function appears depressed. There is septal and anterior hypokinesis (the apex is not well visualized). There are diffuse simple and complex (>4mm) nonmobile atheroma in the aortic arch and descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. IMPRESSION: No thrombus identified. Stretched PFO. Extensive plaque in aorta. Depressed LV systolic function. . [**2170-11-29**] Scrotal ultrasound: 1. No evidence of epididymitis/orchitis. 2. Bilateral small hydroceles. . [**2170-11-30**] Colonoscopy: 1. A single flat sessile polyp of benign appearance was found in the ascending colon.The polyp was about 1.5cm wide and had a villous like appearance.The polyp site was injected with [**Country 11150**] ink.Polypectomy was not done due to recent anticoagulation. Cold forceps biopsies were performed for histology at the polyp in ascending colon. 2. A frond-like/villous 3.5 cm mass of malignant appearance was found at the cecum near ileocecal valve. The mass was friable with superficial ulceration. Cold forceps biopsies were performed for histology at the mass in cecum. 3. Multiple diverticula were seen in the descending colon and sigmoid colon.Diverticulosis appeared to be of moderate severity. . Radiology: [**12-27**] CT abd: collections smaller, well contained, drain not manipulated. Distended, edematous gallbladder with stones, stranding but anasarca as well [**12-26**] ECHO :30-35%, 3+ MR, new dilation Right Ventricle not on ECHO done [**2167**] [**1-8**] HIDA:delayed, pretreat w CCK [**1-14**] CT abd/pelvis: Interval decr intra-abdominal collection. Pigtail catheter within this collection. Persistent communication with the bowel and right lateral abdominal wall skin surface. Microbiology: [**12-31**] Rectal Swab:VRE pos [**1-8**] Ucx:Yeast, UA+ [**1-8**] Cdiff: [**1-9**] Peritoneal fluid: 3+GPC pairs, chains, clusters, 3+GNRs, 3+GPRs [**1-11**] Bile(Perc Chole):1+ Leukocytes, Cx P [**1-16**] UA: +yeast (mod), WBC [**4-30**] [**2171-2-24**] Gram negative rods in urine [**2171-2-23**] Stool negative for clostridium difficile. Pathology: PATH: [**11-30**] colonoscopy Bxs: Cecum mass & ascending colon polyp->adenoma [**12-4**] R hemicolectomy Bxs: T2No adeno, diverticulosis PERTINENT LABS:[**2170-11-26**] 11:57PM GLUCOSE-178* UREA N-29* CREAT-1.5* SODIUM-142 POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-31 ANION GAP-12 [**2170-11-26**] 11:57PM ALT(SGPT)-16 AST(SGOT)-31 ALK PHOS-42 TOT BILI-0.6 [**2170-11-26**] 11:57PM WBC-5.9 RBC-3.29* HGB-10.1* HCT-30.4* MCV-92 MCH-30.7 MCHC-33.3 RDW-13.8 Brief Hospital Course: Patient is an 80 yo male with h/o CAD s/p CABG, CHF, Afib, HTN, hyperlipidemia, and DM, admitted with decompensated systolic CHF and transferred from OSH for cardiac cath as well as EP consult for possible cardioversion and ICD evaluation. Now back in afib despite cardioversion. Also found to have cecal mass c/b LGIB while on heparin/coumadin. Underwent a right hemicolectomy on [**2170-12-4**], postoperative course protracted related to anastomotic leak. . #. Cecal mass/LGI bleed: The patient developed lower GI bleeding after initiation of anticoagulation with heparin and coumadin. He had several large bloody bowel movements with bright red blood. Hematocrit dropped from 32.6 to 29.3. He was transfused with 2 units RBC and hematocrit remained stable around 33. He was hemodynamically stable throughout. GI was consulted and he underwent colonoscopy on [**11-30**], which revealed a frond-like/villous 3.5 cm mass of malignant appearance in the cecum. Surgery was consulted... R hemicolectomy performed on [**2170-12-4**]. Anastomotic leak developed with insertion of percutaneous drain on [**2170-12-14**]. . #. Acute on chronic systolic congestive heart failure: The patient has a known history of ischemic cardiomyopathy and was originally admitted to the OSH in decompensated heart failure. EF at OSH was 35-40%. He had also had an admission for CHF exacerbation to the same OSH one month prior. It was felt that his recent decompensation may have been secondary to his new onset atrial fibrillation vs progression of his disease. Prior to transfer, he was being diuresed at OSH with lasix 40mg IV BID and had lost 5 lbs. At [**Hospital1 18**], he was continued on a statin and beta blocker. He was diuresed with IV lasix as his blood pressure allowed and was felt to be euvolemic on the day of surgery. He may be a candidate for ICD placement in the future. Throughout hospitalization has has bilateral crackles in bases and bibasilar small pleural effusions. Most recent CXR on [**2-26**] shows Mild pulmonary edema and small-to-moderate left pleural effusion that are new. He was treated with lasix 40mg for 2 days in a row. Currently he is [**Age over 90 **]-98% saturated on 2 liters nasal prongs with lasix 20mg to be given every other day. . #. Atrial fibrillation: He has a history of sustained atrial fibrillation diagnosed on his recent OSH admission in [**10-27**]. He was treated with rate control and anticoagulation. It was felt that his atrial fibrillation may be contributing to his decompensated heart failure. Alternatively, his worsening heart failure may have triggered atrial fibrillation. He was transferred to [**Hospital1 18**] for possible DC cardioversion. On [**11-27**] he underwent TEE which showed no thrombus and he was successfully cardioverted with 200 joules. However, the next day he reverted back into atrial fibrillation. He remained well rate-controlled. On admission to the OSH, his INR was supratherapeutic with a peak value of 8.4. He was reportedly reversed with 3 doses of subcutaneous vitamin K and his INR on admission here was 1.4. Was supratherapeutic on admission to OSH, now subtherapeutic at 1.4. His coumadin was re-started on admission to [**Hospital1 18**]. However, it was held when he developed GI bleeding and he was maintained on a heparin drip for anticoagulation. He was started on PO Digoxin on [**1-8**] as well as lopressor 100mg po tid per Cardiology to control his rate. Currently INR 2.7 with daily coumadin dosing 1-2.5mg. . #. CAD: He has known CAD, s/p CABG in [**2153**] (LIMA to LAD, SVG to OM, SVG to RCA), followed by MI and occlusion of his SVG-RCA graft. Cardiac cath on admission to [**Hospital1 18**] was unchanged from his prior cath in [**2167**], showing three vessel coronary artery disease (occluded native coronaries except patent ramus intermedius) and widely patent SVG-OM and LIMA to LAD. Thus it was felt that CAD was an unlikely etiology for his worsening CHF. He was continued on ASA, plavix, statin, BB. Currently on lopressor 100mg po tid and carvedilol 3.125mg po bid. . #. DM2: He is controlled with glyburide at home, however his oral hypoglycemics were held while in house. He was covered with a humalog insulin sliding scale. FS ranged 100's to low 200's. Insulin in TPN. [**First Name8 (NamePattern2) **] [**Last Name (un) **] consult recommendations he was started on glargine 12 units daily with sliding scale insulin every 6 hours depending on fingersticks. Blood sugars have been running 110-250. . #. Hypertension: Currently normotensive, On carvedilol 3.125mg po bid, metoprolol 100mg po tid and intravenous lasix prn. . #. Acute renal failure: Unclear baseline. Has risk factors for CKD including DM, HTN. Creatinine was elevated to 1.5 on admission. Likely element of contrast ATN vs pre-renal from CHF. Last bun and creatinine on [**2171-2-28**] was 41 and .7. . #. UTI: Pt complained of dysuria and foul-smelling urine on the day after admission (s/p foley catheter). Positive UA and Ucx with >100K E coli. He was treated with a 7 day course of bactrim. Developed another UTI by U/A - 7 day course of cipro given [**Date range (3) 62060**]. [**12-27**] and [**1-11**] yeast in urine, treated with fluconazole. On [**2171-2-24**] urine culture positive for gram negative rods, started on cipro, then sensitivities showed KLEBSIELLA PNEUMONIAE, switched to bactrim ss po bid x 7 days, foley catheter changed on [**2-26**]. . #. Scrotal erythema/tenderness: Pt complained of scrotal swellling and tenderness during the admission. On exam, the scrotum was diffusely erythematous and tender to palpation. No significant swelling was noted. No fluctuance or evidence for fluid collection or abscess. Scrotal US revealed bilateral small hydroceles but no evidence of epididymitis/orchitis. This was felt to be a candidal infection and he was treated with miconazole powder. . #. Hyperlipidemia: He was continued on a statin, per his outpatient regimen. . #. Nutrition - Patient unable to maintain adequate calories by mouth. PEG tube placed by interventional radiology on [**2171-1-9**]. Developed fistula with tubefeedings so TPN restarted. Tube feedings restarted and gradually progressed to goal and TPN tapered to off. Unable to tolerate goal tubefeeds at 85cc an hour, had nausea and high residuals. So changed to Nutren Pulmonary tube feedings, more concentrated with goal at 55 cc an hour. Tolerating that well with no residuals. Abdominal Wound - looks clean and dry. One drain on right side that goes into abscess has little drainage. Wound care specialist has placed an ostomy bag over drain to protect skin. This should be changed prn. The expectation is that this drain will fall out on it's own within 2-3 weeks. If this does not happen, Dr. [**Last Name (STitle) **] will need to take it out. Please call her office to arrange an appointment at [**Telephone/Fax (1) 51009**]. Discharge Plans: To [**Hospital1 **] Rehabilitation, Dr. [**Last Name (STitle) **] has spoken to Dr. [**Last Name (STitle) 62061**] who will take over patient's care. Dr. [**Last Name (STitle) **] would like to be called with any questions or concerns. Medications on Admission: HOME MEDICATIONS: ASA 325mg daily Tricor 145mg daily Ditropan 15mg [**Hospital1 **] Amlodipine 5mg daily Crestor 20mg daily Diovan 80mg daily Metoprolol 100mg [**Hospital1 **] Glyburide 7.5mg [**Hospital1 **] Imdur 60mg daily Coumadin 5mg daily Discharge Medications: 1. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H (every 6 hours) as needed. 2. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 4. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 5. Nitroglycerin 0.4 mg Tablet, Sublingual [**Hospital1 **]: One (1) Tablet, Sublingual Sublingual PRN (as needed). 6. Rosuvastatin 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3 times a day). 8. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 9. Carvedilol 3.125 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 10. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 11. Docusate Sodium 100 mg Capsule [**Hospital1 **]: Two (2) Capsule PO BID (2 times a day). 12. Paroxetine HCl 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 13. Furosemide 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 14. Insulin Glargine 100 unit/mL Solution [**Hospital1 **]: Twelve (12) units Subcutaneous once a day. 15. Medication Sliding Scale Regular Insulin q 6 hours based on fingerstick blood sugars. 16. Coumadin 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO at bedtime: Please adjust to INR Last INR on [**2-28**] 2.7. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Atrial fibrillation Lower Gi bleed with cecal mass (confirmed adenocarcinoma) R hemicolectomy with anastomotic leak Cholecystitis (RUQ pain, fever, and elevated lft's) Discharge Condition: Stable Discharge Instructions: Please call your doctor or return to the emergency room if you have any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * 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. * 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. Followup Instructions: Please call Dr.[**Name (NI) 6218**] office at [**Telephone/Fax (1) 51009**] for any concerns/issues/questions. If the right side drain does not fall out in [**12-23**] weeks this needs to be discontinued by Dr. [**Last Name (STitle) **]. Please call Dr.[**Name (NI) 6218**] office to make an appointment. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**] Completed by:[**2171-2-28**]

[ "428.23", "153.4", "272.4", "575.10", "293.0", "998.6", "V10.46", "211.3", "401.9", "427.31", "414.01", "428.0", "998.59", "V15.3", "584.9", "250.00", "414.02", "112.2", "997.4", "412", "599.0" ]

icd9cm

[ [ [] ] ]

[ "51.01", "38.93", "88.56", "88.72", "45.93", "54.91", "37.23", "45.25", "99.04", "45.73", "99.61", "96.6", "99.15" ]

icd9pcs

[ [ [] ] ]

17603, 17675

8475, 15635

518, 781

17887, 17896

4171, 4171

18926, 19403

3048, 3068

15931, 17580

17696, 17866

15661, 15661

5108, 8132

17920, 18903

3083, 4152

15679, 15908

285, 480

809, 2206

8147, 8452

2228, 2876

2892, 3032

24,556

178,767

13809+13838

Discharge summary

report+report

Admission Date: [**2181-8-16**] Discharge Date: Date of Birth: [**2115-1-26**] Sex: M Service: CARDIOTHORACIC SURGERY This is an addendum to the [**8-25**] discharge summary. On [**8-26**], postoperative day #6, the patient continues to do well and was started on hydralazine 5 mg q 6 to help control the hypertension. On postoperative day #7, the patient continued to do well and had no other issues. The patient will be discharged today as planned. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern4) 959**] MEDQUIST36 D: [**2181-8-27**] 07:33 T: [**2181-8-27**] 09:25 JOB#: [**Job Number 41493**] Admission Date: [**2181-8-16**] Discharge Date: [**2181-8-25**] Date of Birth: [**2115-1-26**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old male patient of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], who was referred for outpatient cardiac catheterization after undergoing a positive stress test. He has a history of carotid artery disease, and a stress test in [**2178-2-1**] revealed a small mild anterior reversible defect. The patient states he has had chronic stable angina over the past several years with angina occurring once every several days with exertion, which was also responsive to sublingual nitroglycerin. Recently, however, he has had two prolonged episodes that occurred at rest and did not easily respond to nitroglycerin. One episode lasted several hours and he subsequently saw his primary care physician and his cardiologist, where he had a stress test done on [**2181-8-6**], which was significant for chest pain, ST depression in the V2 and V3 leads, leads 1 and aVL. He did have dyspnea on exertion and shortness of breath associated with his angina. He denies any claudication, orthopnea, paroxysmal nocturnal dyspnea, lightheadedness, or lower extremity edema. His coronary artery disease risk factors include hypertension and previous tobacco history. He is nondiabetic. PAST MEDICAL HISTORY: Significant for spinal stenosis, coronary artery disease, neuropathy of his feet, and severe arm pain and tingling, which is treated with prednisone. He has no history of any transient ischemic attacks, cerebrovascular accidents, or gastrointestinal bleeds. PAST SURGICAL HISTORY: Significant for a left carotid endarterectomy in [**2178**] and two prior back surgeries. ALLERGIES: No known drug allergies. MEDICATIONS AT HOME: Aspirin, Toprol 50 mg p.o. once daily, prednisone 5 mg p.o. once daily, hydrochlorothiazide 25 mg p.o. once daily, Imdur 30 mg p.o. once daily, M.V.I., Darvocet, Ritalin p.r.n., amitriptyline 75 mg p.o. q.h.s. HOSPITAL COURSE: The patient underwent cardiac catheterization on [**2181-8-16**], which revealed an ejection fraction of approximately 55%, 50% discrete right coronary artery proximal stenosis, 95% mid RCA, 80% discrete stenosis of the proximal left anterior descending coronary artery, 70% of the mid left anterior descending coronary artery, 70% diagonal 1 stenosis, 80% midcircumflex, and 70% distal circumflex. The patient was referred to Dr. [**Last Name (STitle) 1537**] for coronary artery revascularization. The patient underwent coronary artery bypass grafting x 5 on [**2181-8-20**]. The patient received a left internal mammary artery graft to the left anterior descending coronary artery, saphenous vein graft to the obtuse marginal #1, and a sequential graft to the obtuse marginal #2, saphenous vein graft to the diagonal #1, and saphenous vein graft to the right posterior descending coronary artery. The patient tolerated the procedure well without any complications, and was transferred to the intensive care unit in stable condition. The patient was kept intubated overnight and was successfully extubated the following day on postoperative day one. He was subsequently transferred to the floor later that day on postoperative day one in stable condition. On postoperative day two he remained afebrile with stable vital signs in a regular rhythm. During the evening of postoperative day two the patient was noted to go into atrial fibrillation. He was treated with Lopressor intravenous push. Amiodarone drip was started and the patient was noted still to be tachycardic with little response to the amiodarone. A diltiazem drip was also started, as the patient did have V wires in place. The patient's blood pressure remained stable during the entire episode. On the night of postoperative day two the patient was noted to be in some respiratory distress. An electrocardiogram was obtained, which did not show any acute changes. The patient was noted to have coarse breath sounds bilaterally. A chest x-ray was obtained, which revealed fluid overload. Thus, 80 mg of intravenous Lasix was given with a good response of the patient, both with urine output and symptomatically with increasing oxygen saturation. Thus, he was maintained on intravenous Lasix during the rest of his hospital course, and subsequently his oxygen saturation and breathing pattern improved dramatically. On postoperative day three the patient was noted to convert to a normal sinus rhythm. His diltiazem drip was discontinued. His amiodarone drip was changed to p.o. dosing. Currently the patient is postoperative day four. He is doing extremely well. He remains afebrile with stable vital signs and normal sinus rhythm. His current Lopressor dose is now at 100 mg p.o. b.i.d. He is currently maintained on intravenous Lasix 20 mg b.i.d. and is diuresing well with decreasing oxygen requirement and improving oxygen saturation. Physical therapy was consulted. The patient was noted to require much assistance with ambulation. Thus, it is believed that a short rehabilitation stay will be of much benefit to the patient in order to return to his preoperative ambulatory status. As he is currently awaiting rehabilitation placement, the patient will be discharged to rehabilitation. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSES: Coronary artery disease status post coronary artery bypass grafting x 5. DISCHARGE MEDICATIONS: 1. Lopressor 100 mg p.o. b.i.d. 2. Lasix 20 mg p.o. t.i.d. x seven days and then once daily. 3. K-Dur 20 mEq p.o. b.i.d. x 7 days then once daily. 4. Aspirin 81 mg p.o. once daily. 5. Norvasc 10 mg p.o. once daily. 6. Prednisone 5 mg p.o. once daily. 7. Dilaudid 2-4 mg p.o. q. 4-6 hours p.r.n. 8. Amiodarone 400 mg p.o. t.i.d. x 3 days, then 400 mg p.o. b.i.d. x 7 days, then 400 mg p.o. once daily x 7 days, then 200 mg p.o. once daily. 9. Colace 100 mg p.o. b.i.d. 10. Albuterol nebulizers q. 4-6 hours p.r.n. DISCHARGE INSTRUCTIONS: 1. The patient should be ambulating with assistance until able to ambulate at his preoperative status. 2. Aggressive chest physical therapy should be given. 3. The patient should be maintained on a cardiac diet. 4. He should follow up with Dr. [**Last Name (STitle) 1537**] in approximately three weeks. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Name8 (MD) 3181**] MEDQUIST36 D: [**2181-8-24**] 12:04 T: [**2181-8-24**] 13:26 JOB#: [**Job Number 41551**]

[ "998.12", "496", "427.31", "424.1", "443.9", "414.01", "997.1", "428.0", "411.1" ]

icd9cm

[ [ [] ] ]

[ "39.61", "36.14", "88.53", "88.42", "88.56", "36.15", "37.21" ]

icd9pcs

[ [ [] ] ]

6171, 6245

6268, 6782

2827, 6116

6806, 7380

2598, 2809

2447, 2576

917, 2140

2163, 2423

6141, 6150

377

139,824

13744

Discharge summary

report

Admission Date: [**2168-3-4**] Discharge Date: [**2168-4-4**] Date of Birth: [**2098-8-23**] Sex: F Service: HISTORY OF PRESENT ILLNESS: On presentation, [**3-4**], the following history was obtained by the Intensive Care Unit resident. Patient is a 69-year-old female with a history of congestive heart failure, chronic obstructive pulmonary disease, status post recent admission to [**Hospital3 417**] Hospital for pneumonia complicated by chronic obstructive pulmonary disease exacerbation on a prednisone taper. She was discharged back to the nursing home four days prior to admission where she was recovering well until the night prior to admission. She was witnessed to have three generalized tonic-clonic seizures lasting approximately 20 minutes. EMS was called and patient was intubated in the field for status. Arrived at [**Hospital3 417**] Hospital with continued seizures, treated with Ativan 4 mg, Valium 5 mg and loaded with 5 phenytoin. Head CT revealed diffuse white matter disease with evidence of edema, but no bleed. Lumbar puncture was slightly bloody, although decreased white count from tubes one through four. She was transferred to [**Hospital6 1760**] for further management. She was given Ceftriaxone 2 grams at [**Hospital3 417**] Hospital. Patient had been treated for a urinary tract infection with Bactrim and was noted to have a zoster rash on her back, which was noted at [**Hospital3 417**] Hospital. She was started on acyclovir at the time. According to the patient's family, she was more lethargic during the day, [**3-3**], although, the family was told that her vitals were okay. On arrival to [**Hospital1 **], the patient was sedated and intubated. CT scan was reviewed with Radiology and felt not to be consistent with subarachnoid hemorrhage. Medical Intensive Care Unit Team was called and admitted the patient. She was not able to give any history of her own at that time. PAST MEDICAL HISTORY: 1. Possible multifocal atrial tachycardia. 2. Chronic obstructive pulmonary disease. 3. Cardiomegaly. 4. Congestive heart failure. 5. Hypertension. 6. Obesity. MEDICATIONS ON ADMISSION: Digoxin .25 mg po q.d., Lasix 40 mg po q.d., potassium chloride 10 mg po q.d., diazepam 2 mg po t.i.d., Azmacort 2 mg po q.i.d., famotidine 20 mg po q.h.s., multivitamin 1 tablet po q.d., Vitamin C 500 mg po b.i.d., Bactrim Double Strength b.i.d., theophylline 200 mg po b.i.d., fluticasone salmeterol 1 puff po b.i.d., acyclovir 800 mg po q.i.d., Tylenol prn. ALLERGIES: Patient has no known drug allergies. SOCIAL HISTORY: She lives at a nursing home, former tobacco user with 60+ pack year history of smoking, quit six years prior to admission. Patient was full code on admission. PHYSICAL EXAMINATION ON ADMISSION: Temperature was 97.3. Heart rate 86-96. Blood pressure 105-117/55-63, breathing at 12-13, 02 saturation 98%. Arterial blood gas was 7.43, 44, 86 on SIMV with pressures 700 x 12, FIO2 of .5, PEEP of 5, pressure support was 5. She has anicteric pupils, equal, round and reactive to light. No doll's eyes. Oropharynx showed ETT in place. She had a supple neck. Lungs were clear to auscultation bilaterally. Her heart was irregularly irregular with no murmurs, rubs or gallops. Her abdomen is soft, nontender, nondistended, positive bowel sounds times four. She had 1+ edema. Patient was sedated and unresponsive to voice, withdrawing toes, spontaneously opens eyes. LABORATORIES FROM [**Hospital3 **] HOSPITAL: White blood cell count 15.3, hematocrit 56.2 with a differential of 90 neutrophils, 4 lymphocytes, 4 monocytes, platelets 136,000, INR 1.4, PTT is 25, sodium 140, potassium 4.5, chloride 99, bicarbonate 33, BUN 44, creatinine 1.3, glucose 125, albumin 3.7, calcium 9, magnesium 2.1, TSH was 5.3, T4 7, T3 uptake 41, theophylline was 6.4, which is subtherapeutic. Therapeutic range is [**9-25**]. Digoxin 1.4. Ammonia was 36. ALT 31, AST 25, alkaline phosphatase 112, T bilirubin .8, total protein 6.9. Electrocardiogram shows sinus arrhythmia with ST elevations in V1 and V2 and nonspecific ST-T wave changes. Cerebrospinal fluid tube one shows 2 white cells, 150 red cells, glucose of 75, protein 225. Head CT demonstrated white matter disease, left cerebral edema with compression of the lateral ventricle, no gross shift, question of air bubbles. HOSPITAL COURSE: [**Hospital **] hospital course can best be summarized day to day as her main problems were her neurologic problems and pulmonary problems and these were overlapping issues. The patient's work-up at [**Hospital1 **] included an MRI of her head which showed diffuse cerebral edema. MRA and MRV were normal and electroencephalogram showed frontal spike on the left with a diffusely slow background. Treatment included reloading the patient with phenytoin steroids and acyclovir for presumed HSV encephalitis. Follow-up MRIs did not demonstrate progression and in fact showed resolution of her cerebral edema. The culture results from [**Hospital3 417**] Hospital revealed HSV2 positive PCRs. It is felt to be positive for her aseptic meningitis or asymptomatic shedding from a sacral nerve root. The Infectious Disease Service was not convinced that her clinical picture was consistent with HSV2, they felt it was more likely to be consistent with HHV6. The patient completed her acyclovir however, and this is not a further issue. The patient was noted to be more responsive and was finally extubated in the Intensive Care Unit on [**2168-3-13**]. She was transferred to the Medical Service for further management. Her neurologic exam at that time showed that her eyes were open at baseline. She was able to follow examiner with her eyes. Her speech was slow, dysarthric with simple sentence production and soft voice. She was moving all four extremities, left greater than right, was capable of following one and two step commands with variable re-productability, cannot print by correct date or location but knew her name. Cranial nerves respond to visual threat. Full elevation and depression of eyes, right lateral gaze was intact, capable of moving eyes to the left, but incomplete motion. Eyes were in mid position at baseline. Facial sensation was difficult to assess, motion was noted to be decreased in her lower face on the right side. Her hearing was grossly intact. Palate was up bilaterally. Head turning and shoulder shrug were difficult to assess. The patient had full tongue motion. Her strength and normal bulk increased tone on right side, left side was stronger than right, but capable of moving all four extremities. Patient was hyperreflexic in the right upper extremity, diffusely decreased lower extremity reflexes, toes are downgoing bilaterally. Sensory examination showed that the patient was capable of localizing painful stimuli. She had no tremors. Cerebellar signs were difficult to elicit. Patient's course on the Medical Floor: On [**3-16**], the patient was noted to be more responsive. Repeat MRI showed some regression of the T2 hyperintensity white matter changes, especially in the centrum semiovale and a possible increase in cerebral blood flow. The patient continued to feel better. On [**3-17**], she was suctioned aggressively for several episodes of desaturation. On [**3-18**], the patient had no significant shortness of breath. A rash was noted for the first time. It is felt to be consistent with Dilantin Infatabs rash. The Infatabs were changed back to the regular formulation and the rash slowly, but incompletely resolved. On [**3-19**], the patient was noted to have several desaturations which responded to aggressive suctioning. On [**3-20**], the patient was once again suctioned with improvement in her respiratory status. On [**3-21**], the patient was examined during morning pre rounds and found to have an arterial blood gas of pH 7.25, PCO2 of 95, PO2 of 56. She was intubated and taken back to the Medical Intensive Care Unit. The patient self extubated on [**3-22**] and returned to the regular medical floor on [**3-23**]. The patient was started on CPAP while on the regular medical floor. She tolerated this treatment the first night. The patient on the morning of [**3-25**] was noted to have decreased oxygen saturations. She was found to have an 02 saturation of 57%. An arterial blood gas was done at that time pH 7.38, PO2 was 32, PCO2 was 69. Her BiPAP was adjusted and she was administered a nebulizer. Follow-up arterial blood gas was pH 7.39, pCO2 72, PO was 79. Patient was maintaining at her previous baseline. She was left in no apparent distress at that time on oxygen by shovel mask. The patient developed decreased oxygen saturations at 5:30 a.m. on [**3-26**]. She was reintubated and taken back to the Intensive Care Unit. After a long and protracted course in the Intensive Care Unit, the decision was made by the patient's family to make the patient "Do Not Resuscitate, Do Not Intubate." She was extubated as she was tolerating spontaneous breathing trials. The patient's respiratory status did not improve. The decision was made to make her comfort measures only. The patient was called out to the regular medical floor on [**2168-4-3**]. On the morning of [**2168-4-4**], she was found on pre rounds. Her pupils were unreactive. She had no heart sounds, no breath sounds, no spontaneous movements, no response to pain, no radial or femoral pulses. The patient was pronounced dead on [**4-4**] at 8 a.m. DISCHARGE CONDITION: Dead. DISCHARGE DIAGNOSES: Identical to her admission diagnoses with the addition of: 1. Encephalitis. 2. Cerebral edema. 3. Seizure disorder. Patient did not have any seizures during this hospitalization. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-761 Dictated By:[**Last Name (NamePattern1) 5476**] MEDQUIST36 D: [**2168-4-5**] 15:20 T: [**2168-4-5**] 15:20 JOB#: [**Job Number 41360**]

[ "780.39", "136.9", "518.81", "599.0", "323.6", "276.2", "780.09", "428.0", "491.21" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.04", "38.91", "96.72" ]

icd9pcs

[ [ [] ] ]

9556, 9563

9585, 10000

2165, 2577

4386, 9534

154, 1949

2791, 4368

1971, 2138

2594, 2776

28,735

190,935

31275

Discharge summary

report

Admission Date: [**2128-7-10**] Discharge Date: [**2128-7-16**] Date of Birth: [**2101-4-15**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 358**] Chief Complaint: hematemesis Major Surgical or Invasive Procedure: endoscopic ultrasound GDA embolization through interventional radiology. History of Present Illness: 27M C5 fracture with quadreplegia, s/p splenectomy in '[**25**], pancreatic mass, h/o LE DVT s/p IVC filter, also recent admit at [**Hospital1 2177**] for UGIB, required transfusion of 6 units, found to have gastric varices, also MRSA bacteremia, Rx'd Bactrim through [**7-12**]; now presents with 6 episodes of hematemesis, total volume "a cupful." . On arrival in ED, tachycardic with BP 120-140/90s; Hct 29 (was 30 at recent discharge from [**Hospital1 2177**]). Getting IVF, PPI IV; placed two PIV. Liver fellow aware and planning scope once arrives in ICU. . Of note, patient's PCP reported that patient is heavy/binge drinker; pt admits to last EtOH on [**6-26**]. . ROS: diaphoresis and shaking chills, due to autonomic instability Past Medical History: # C5 traumatic fracture sustained in diving accident with resultant quadriplegia # s/p splenectomy for splenic rupture in [**2124**] # LE DVT s/p IVC filter which is now clotted # MRSA bacteremia in [**6-19**], currently on Bactrim (to complete course [**7-12**]) # recurrent UTIs; pt has indwelling suprapubic catheter [**1-16**] quadriplegia # gastric varices, diagnosed after UGIB in [**6-19**] at [**Hospital1 2177**] # duodenal AVMs, diagnosed with UGIB as above Social History: EtOH as above. Smokes 1 pack per week cigarettes. Admits to cocaine 2x/month and occasional marijuana use. Family History: Mother died of breast cancer. Grandmother with gastric cancer. Physical Exam: 98.1 134/75 97 17 100%RA GEN: laying flat in bed, quadriplegic; diaphoretic HEENT: NC/AT PERRL OP clear CHEST: CTA ant and lat fields CV: s1, s2 no m/r/g ABD: flat, NABS, nontender. suprapubic catheter clean, multiple surgical scars. EXT: 2+ pitting edema bilaterally to knees SKIN: well-tanned Pertinent Results: [**2128-7-10**] 11:45AM WBC-12.6* RBC-3.55* HGB-9.4* HCT-29.7* MCV-84 MCH-26.6* MCHC-31.8 RDW-21.5* [**2128-7-10**] 11:45AM NEUTS-81.1* LYMPHS-10.3* MONOS-5.6 EOS-2.3 BASOS-0.9 [**2128-7-10**] 11:45AM PLT COUNT-828* [**2128-7-10**] 11:45AM ALBUMIN-3.4 CALCIUM-8.8 PHOSPHATE-4.7* MAGNESIUM-2.3 [**2128-7-10**] 11:45AM ALT(SGPT)-6 AST(SGOT)-14 ALK PHOS-86 AMYLASE-64 TOT BILI-0.4 [**2128-7-10**] 08:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018 [**2128-7-10**] 08:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-50 BILIRUBIN-SM UROBILNGN-NEG PH-7.0 LEUK-SM [**2128-7-10**] 08:15PM URINE RBC-21-50* WBC-21-50* BACTERIA-MOD YEAST-MANY EPI-0-2 [**2128-7-10**] 08:15PM URINE CA OXAL-FEW [**2128-7-16**] 01:50AM BLOOD WBC-8.5 RBC-3.59* Hgb-9.9* Hct-30.2* MCV-84 MCH-27.6 MCHC-32.7 RDW-19.8* Plt Ct-834* [**2128-7-16**] 01:50AM BLOOD Glucose-108* UreaN-4* Creat-0.3* Na-136 K-3.4 Cl-100 HCO3-26 AnGap-13 [**2128-7-11**] 11:11AM BLOOD ALT-2 AST-9 LD(LDH)-183 AlkPhos-70 Amylase-50 TotBili-0.4 [**2128-7-11**] 11:11AM BLOOD Lipase-74* [**2128-7-16**] 01:50AM BLOOD Triglyc-67 MRCP/MRA [**2128-7-14**]: IMPRESSION: 1. Large gastroduodenal artery pseudoaneurysm causing mass effect upon the pancreatic head and obstruction of the distal pancreatic duct within the head of the pancreas. The GDA pseudoaneurysm demonstrates a rim of thrombosis. While the pseudoaneurysm is intimately associated with the main pancreatic duct, a definite communication could not be identified on this examination. 2. Marked irregular diffuse dilatation of the main pancreatic duct containing innumerable stones and debris. 3. Acute on chronic pancreatitis with 4.3 x 3.0 cm posterior peri-pancreatic fluid collection/phlegmon abutting the right lateral aspect of the SMA. 4. Marked lateral deviation of either the SMV or venous collaterals formed secondary to occlusion of the SMV due to the large GDA pseudoaneurysm. 5. Splenosis status post splenectomy. 6. Trace amount of ascites. Embolization [**2128-7-15**]: IMPRESSION: Successful embolization of a gastroduodenal artery pseudoaneurysm with 10 coils (5 mm x 6 cm). Brief Hospital Course: # hematemesis: Admitted initially to MICU for resucitation, then transferred to [**Hospital Ward Name **] hospitalist service. Underwent endoscopic ultrasound for further evalutaion (as recent [**Hospital1 2177**] admission commented on gastric varices and possible pancretic mass)and noted to have a small gastric ulcer and active oozing from the pancreatic duct. Doppler ultrasound showed possible pseudoaneurysm near the head of the pancreas. MRCP/MRA with results shown in the labs area of this discharge summary confirmed gastroduodenal artery aneurysm, and additionally commented on chronic pancreatitis. Sucessful embolization was performed by interventional radiology of the GDA pseudoaneurysm the day prior to discharge. He was transfused 3 units pRBCs during his stay, mainly because of autonomic symptoms, not because of evidence of active blood loss. Given the gastric ulcer, he was advised to avoid NSAIDs and continue a [**Hospital1 **] ppi. # MRSA UTI: surveillance cultures neg; isolate was Bactrim sensitive at [**Hospital1 2177**], so continued Bactrim DC [**Hospital1 **] through [**7-12**]. No documentation of bacteremia on [**Hospital1 2177**] records, however TTE was performed at [**Hospital1 2177**], with no evidence of vegetations. . # chronic pancreatitis with duct stones/sludge: Extensive binge drinking history supportive of pancreatitis. Because of his C5 quadreplegia, he does not experience symptoms. After discussion with gastroenterology, the ductal sludging and stones are recommended to be followed as an outpatient (after acute illness). He was advised to abstain from alcohol. # h/o DVT/IVC filter: Given recent acute bleeding, and presence of IVC filter, anticoagulation will be deferred to the patient's primary physician. Medications on Admission: iron protonix colace bactrim DS [**Hospital1 **] through [**7-12**] lorazepam qhs prn Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. 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:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. 5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for pain for 5 days. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: upper gastrointestinal bleeding gastroduodenal artery pseudoaneurysm, s/p embolization chronic pancreatitis recent MRSA urinary tract infection Discharge Condition: stable, with stable hematocrit and no evidence of active bleeding. Discharge Instructions: You were admitted with a GI bleed, likely related to an aneurysm in your abdomen (near your pancreas). You also have chronic pancreatitis. You should not drink alcohol under any circumstance. Please call your doctor or return to the hospital with any concerns or questions, particularly bleeding from your rectum or throwing up blood, fever greater than 101, or difficulties with your autonomic dysreflexia. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in Gastroenterology on Tuesday, [**7-20**] at 9am for your bleeding and pancreatitis. Please see your primary care physician [**Name9 (PRE) 8453**],[**Name9 (PRE) **] [**Name Initial (PRE) **] [**Telephone/Fax (1) 8454**] on Tuesday [**7-27**] at 9:30 am follow up appointment with blood count check (Hematocrit).

[ "344.03", "577.1", "790.7", "907.2", "285.1", "V09.0", "599.0", "V12.51", "E929.8", "442.84", "041.11" ]

icd9cm

[ [ [] ] ]

[ "44.44", "88.47", "99.04" ]

icd9pcs

[ [ [] ] ]

6848, 6854

4366, 6146

326, 401

7042, 7111

2197, 4343

7570, 7940

1802, 1866

6282, 6825

6875, 7021

6172, 6259

7135, 7547

1881, 2178

275, 288

429, 1170

1192, 1662

1678, 1786

69,343

100,217

41329

Discharge summary

report

Admission Date: [**2126-3-22**] Discharge Date: [**2126-4-6**] Date of Birth: [**2065-5-2**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 8404**] Chief Complaint: COPD; s/p fall Major Surgical or Invasive Procedure: EGD endotracheal intubation mechanical ventilation central intravenous line placement arterial line placement History of Present Illness: Mr [**Known lastname **] is a 60 M w/ end-stage COPD on home O2, CHF and 3 prior suicide attempts who presents to [**Hospital1 18**] ED s/p witnessed mechanical fall down one entire flight of stairs after tripping over his O2 tubing. Per wife and 14 year old son, he was found with empty bottles of anti-hypertensives and anti-epileptic medications including proprolol, gabapentin and mirtazipine that were prescribed to a friend. [**Name (NI) **] had been slurring his words and walking hunched over all day yesterday after having been out at night for 3 hours without telling his wife where he was going. Upon his return, he fell down the stairs after tripping over his O2 tubing. Per wife who subsequently called 911, he did not lose consciousness and was able to ask for a tissue prior to arrival of EMS. He presented to the ED A&Ox1-2 MAE and following commands. On initial trauma exam, there was no spinal tenderness and good rectal tone without gross blood. During his ED course, the pt rapidly deteriorated from a respiratory standpoint and required intubation to maintain SaO2 > 80s. Pt was a difficult intubation and aspirated thick olivey liquid in the field, for which he was treated with CTX/Flagyl. (He had a heavy dinner consisting of mashed potatoes, meatloaf, a scone and ice cream). . CT head/C-spine/torso shwoed injuries c/w C4 pedicle fx, T12/L1 compression fxs and T12 spinous process fractures. He also has R clavicular fx and R pareital subgaleal hematoma as well as multiple skin and soft tissue injuries Neurosurgery was consulted for evaluation of spinal injuries and recommended C-spine immobilization w/ logroll precautions in place, order for TLSO brace and MRI C& L-spine w/n 48h to assess ligamentous injury. . VS prior to xfer: Afebrile, 118 114/85 24 92% on 450/24/100/14peep . In [**Name (NI) 10115**] pt is intubated and sedated, not following commands as on propofol but [**Name8 (MD) **] RN was awake and answering questions appropriately before propofol bolus was given. Per patient's wife who is in the process of getting divorced from him, he has had multiple suicide attempts in the past and this was one of them. His 1st 2 prior attempts were narcotics overdoses and his 3rd was antifreeze ingestion. He apparantly has been having suicidal ideation since [**2124-10-3**] but exhibited markedly worsened depressive behaviour over the past few weeks when he lost his job and filed for bankruptcy. Per wife, they recently had a meting with their attorney to declare bankruptcy and sell their house. His wife then told him she wanted to get separated and they recently looked at rooms for him to move into. She believes this may have precipitated his recent suicide attempt. . All other ROS otherwise negative Past Medical History: -COPD -CHF -dementia -depression Social History: Used to work at the State House for the [**Location (un) **] of [**State 350**]. Now unemployed, sleeps [**1-19**] h/day. lives at home w/ wife [**Name (NI) **] to whom he has been married for the past 20 years, and rheir 14 y/o son [**Name (NI) 43984**]. Also has 2 children from previous marriage, ages 30 and 32, has 6 month old grand-daughter. +smoking history, heavy EtOH and prescription narcotic abuse in the past. Past suicide attempts. Family History: Non-contributory Physical Exam: ADMISSION EXAM: VS: afebrile, 107 110/78 24 94% on AC settings GEN: intubated, sedated, currently not following commands in the setting of having received propofol bolus HEENT: C-collar in place, pt has multiple scattered facial excoriations and ecchhymoses, pupils constricted but reactive b/l CV: tachycardic rate, no murmurs appreciated LUNGS: anteriorly ABD: +BS obese soft ND GU: multiple scattered violaceous scrotal petechiae EXT: L-olecranon process ecchymoses and skin breakdown with fresh blood, R-olecranon process ecchymoses SKIN: R-hip/buttocks area large ecchymoses w/ some skin breakdown NEURO: intubated, sedated, not following commands . DISCHARGE EXAM: patient was made Comfort Measures Only and expired Pertinent Results: ADMISSION LABS: [**2126-3-22**] 02:25AM BLOOD WBC-21.1* RBC-4.68 Hgb-15.5 Hct-46.6 MCV-100* MCH-33.0* MCHC-33.2 RDW-13.6 Plt Ct-226 [**2126-3-22**] 02:25AM BLOOD Neuts-57.9 Lymphs-37.5 Monos-3.1 Eos-0.7 Baso-0.8 [**2126-3-22**] 02:25AM BLOOD PT-11.6 PTT-23.7 INR(PT)-1.0 [**2126-3-22**] 02:25AM BLOOD Glucose-138* UreaN-38* Creat-2.4* Na-142 K-4.5 Cl-97 HCO3-35* AnGap-15 [**2126-3-22**] 02:25AM BLOOD ALT-20 AST-32 AlkPhos-131* TotBili-0.2 [**2126-3-22**] 09:08AM BLOOD Albumin-4.2 Calcium-9.0 Phos-4.2 Mg-2.3 [**2126-3-22**] 09:53AM BLOOD Lactate-1.1 . DISCHARGE LABS: patient expired ................................................................ MICROBIOLOGY: c diff positive ................................................................ IMAGING: [**2126-3-22**] CXR: The lungs are low in volume and show bilateral interstitial opacities. The cardiac silhouette is enlarged. The mediastinal silhouette and hilar contours are normal. No pleural effusions are present. . [**2126-3-22**] CT Head w/o con: Right subgaleal vertex hematoma. No intracranial hemorrhage. . [**2126-3-22**] CT C-Spine w/o con: 1. Left left superior articular facet fracture at C4. 2. A small amount of air noted along the PLL at C5 is likely related to degenerative disc disease. There are disc osteophyte complexes at C4/5 and C6/7. 3. Retrolisthesis of C4 on C5. . [**2126-3-22**] CT Chest/Abd/Pelvis w/o con: 1. Compression fractures of the T12 and L1 vertebral bodies and fracture of the T12 spinous process as described above. 2. Fracture of the right distal clavicle (features are consistent with a chronic finding). 3. Ground-glass opacities in the right upper and middle lobes and atelectasis and consolidation in right lower lobe could represent sequelae of aspiration or pneumonia. However, given the history of trauma, pulmonary hemorrhage cannot be excluded. . [**2126-3-23**] TTE: The left ventricle is not well seen. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The aortic root is mildly dilated at the sinus level. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. IMPRESSION: Very suboptimal image quality due to patient's body habitus. Left ventricular systolic function is probably normal, a focal wall motion abnormality cannot be fully excluded. The right ventricle is not well seen. No significant valvular abnormality seen. . [**2126-3-23**] MRI Spine: 1. Mild to moderate compressions of the superior endplate of T12 and L1 without retropulsion or spinal stenosis. 2. Multilevel degenerative changes. Moderate spinal stenosis seen at L4-5 level and mild-to-moderate spinal stenosis seen at L3-4 level. Bilateral spondylolysis of L5 with grade 1 spondylolisthesis of L5 over S1 and foraminal narrowing. . [**2126-3-28**] RUE U/S: 1. Superficial thrombophlebitis involving the right cephalic vein. 2. No evidence of deep venous thrombosis within the right subclavian, axillary, or brachial veins. Brief Hospital Course: 60M w/ COPD, CHF, s/p mechanical fall down a flight of stairs w/ multiple spinous fx, subgaleal hematoma, and difficult intubation for respiratory failure c/b aspiration event. . # RESPIRATORY FAILURE/ASPIRATION: Patient haS primarily hypercarbic respiratory failure w/ primary respiratory acidosis as pH 7.22 PCO2 83 PO2 136 but this is also oxygenation failure as ABG was on 100% FiO2 so indicates high A-a gradient. Patient has end-stage COPD and likely has PCO2 in the 60s. Acute precipitant of respiratory failure is likely toxic ingestion superimposed on underlying severe lung disease. Upon DL for intubation, gross food particles evident in airway, thick olive paste secretions from NG. Marked leukocytosis at 27.3. He was started on ceftriaxone and flagyl for his presumed aspiration pneumonia. Sputum cultures grew out GPCs, so he was started on vancomycin and flagyl was discontinued. He eventually was switched to vancomycin and cefepime, he eventually concluded a 7 day course. Unfortunately, he developed ARDS and could not be successfully weaned down on any of his ventilator settings. A family meeting was held, and the decision was made to make the patient comfort measures only (he was originally DNR, but not DNI). He was terminally extubated and expired on [**2126-4-6**] at 4:15pm. The medical examiner accepted the case for review. . # FEVERS: His temperature started to spike on HD #2. His antiobiotics were broadened and he was repeatedly pan-cultured. With these, he was found to have c diff + stool. He was treated with oral vancomycin and iv flagyl. He continued to periodically spike fevers during the course of his stay, in spite of treatment with antibiotics. As above he was eventually made CMO and terminally extubated. . # SPINAL TRAUMA: T12 and L1 compression fractures with fracture of the T12 spinous process as well as Left pedicle fracture at C4 w/ retrolisthesis of C4 on C5. Neurosurgery evalutated the patient, but no surgical intervention. [**Location (un) 2848**] J collar applied and TLSO brace were applied whenever he was >30. . # ATRIAL FIBRILLATION: He has episodes of atrial fibrillation with RVR during his hospital stay which were generally well controlled with diltiazem. . # ATTEMPTED SUICIDE: Unclear what medications the patient took and if it clearly was a suicide attempt. U tox was negative. Patient does have history of multiple past suicide attempts and he has been increasingly depressed recently. Intent was to set him up with psychiatry, social work, however patient was made CMO and expired. . # HYPERKALEMIA: He was newly hyperkalemic upon presentation at 6.2, likely secondary to acute kidney injury. An EKG was done w/no evidence of cardiac dysfunction. This resolved with resuscitation. . The patient was maintained on a ppi for Gi prophylaxis, pneumoboots and subcutaneous heparin while he was in the hospital. He was given tube feedings for nutrition. Eventually, the decision was made by his health care proxy and his entire family after an extensive family meeting to make the patient comfort measures only. He was terminally extubated, made comfortable with scopolamine and fentanyl. He expired on [**2126-4-6**] at 4:15pm. The medical examiner was contact[**Name (NI) **] given that the death involved a trauma and a possible suicide attempt. The ME accepted the case for review. Medications on Admission: amlodipine 10mg daily lasix 40mg daily lexapro 20mg daily metoprolol 50mg daily lamotrigine 100mg [**Hospital1 **] ventolin inhaler symbicort inhaler spiriva inhaler Discharge Medications: not applicable Discharge Disposition: Expired Discharge Diagnosis: hypoxia, respiratory failure, chronic obstructive pulmonary disease, status post fall Discharge Condition: Expired Discharge Instructions: not applicable Followup Instructions: not applicable [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 8405**]

[ "276.7", "518.84", "920", "008.45", "491.21", "250.00", "V49.86", "V15.82", "564.09", "805.2", "451.82", "276.2", "E880.9", "584.9", "V62.84", "782.1", "428.0", "278.03", "294.8", "997.31", "278.01", "507.0", "285.9", "E879.8", "427.31", "805.04" ]

icd9cm

[ [ [] ] ]

[ "96.6", "96.72" ]

icd9pcs

[ [ [] ] ]

11334, 11343

7723, 11078

318, 429

11472, 11481

4519, 4519

11544, 11653

3743, 3761

11295, 11311

11364, 11451

11104, 11272

11505, 11521

5090, 7700

3776, 4432

4448, 4500

263, 280

457, 3207

4535, 5074

3229, 3264

3280, 3727

23,507

100,253

22039+57277

Discharge summary

report+addendum

Admission Date: [**2164-9-10**] Discharge Date: [**2164-9-18**] Date of Birth: [**2138-7-2**] Sex: F Service: MED Allergies: Reglan Attending:[**First Name3 (LF) 1055**] Chief Complaint: low back pain vaginal bleeding Major Surgical or Invasive Procedure: ultrasound guided D+C History of Present Illness: 26 yo G1P1 s/p NSVD 9 weeks ago w/ persistent LBP, low grade fevers and some vaginal bleeding. She presented to [**Hospital 1562**] [**Hospital **] clinic on [**2164-9-7**] and had a D&C & hysteroscopy and was sent home. She developed nausea, vomiting and epigastric abdominal pain that radiated to her back and presented to [**Hospital 1562**] Hospital on [**2164-9-8**]. At [**Hospital 1562**] Hospital, she had a chest CT that was unremarkable. 3 hrs post-IV contrast and 45min post-phenergan she developed acute respiratory distress and was intubated. She received solumedrol, sc epinephrine, benadryl. She was hypertensive to the 150/100's and a subsequent CXR showed pulmonary edema. She was transferred to the ICU. CTA on [**9-9**] was neg for PE, pos for b/l pleural effusions and pulmonary edema. She was diuresed, and her cardiac enzymes were noted to be elevated. A TTE at that time was notable for EF 40%, and her enzymes were attributed to demand ischemia and diastolic dysfunction. CXray w/ pulm edema and pt transfered [**Hospital1 18**] ICU for further evaluation. Past Medical History: sinus congestion s/p appy Social History: lives at home w/ husband, 9 week old dtr, [**Name (NI) **]; no drugs, EtOH, Family History: noncontributory Physical Exam: 98.9 122/65 134 23 100%; AC 500 18 5 40%; RSBI 40 on SBT; Gen: cauc W lying in bed in NAD awake, alert, responding appropriately, intubated HEENT: PERRL, EOMI Heart: tachy, RRR, S1, S2, no m/r/g Lungs: CTBLA, no rales Abd: + epigastric tenderness, umbilical tenderness w/ palpation, shifting dullness Ext: no edema, nail polish b/l Pertinent Results: [**9-17**]: Neck U/S: Negative ultrasound of the right neck, without evidence of vascular occlusion, dissection, or gross neck mass. [**9-12**]:Pelvic U/S: Vascular, echogenic and shadowing structure within the uterine cavity. Given the vascularity, the findings are concerning for retained products of conception. [**9-11**]: CT Chest w/o contrast: 1) Diffuse bilateral pulmonary consolidative opacities, which may represent a multifocal pneumonia or ARDS. Moderate sized bilateral pleural effusions are present. 2) Ill-defined pancreas with associated peripancreatic fat stranding consistent with acute pancreatitis. No focal fluid collections are present. 3) Non-obstructing, small, right renal calculus. 4) High density material within the uterine cavity likely representing residual blood products. [**9-10**]: TTE: 1. The left atrium is mildly dilated. 2. The left ventricular cavity is mildly dilated. There is moderate global left ventricular hypokinesis. Overall left ventricular systolic function is moderately depressed. 3. Mild (1+) mitral regurgitation is seen. 4. There is mild pulmonary artery systolic hypertension. [**2164-9-12**]: Pathology- Product of conception: 1. Necrotic calcified and hyalinized placental tissue. 2. Implantation site fragments. [**2164-9-15**] TSH <0.02; Free T4 3.3 [**2164-9-10**] 11:28PM CK-MB-19* MB INDX-4.9 cTropnT-0.81* [**2164-9-10**] 11:28PM WBC-18.1* RBC-2.87* HGB-9.1* HCT-26.0* MCV-90 MCH-31.8 MCHC-35.2* RDW-16.7* [**2164-9-10**] 11:28PM PLT COUNT-50* [**2164-9-10**] 11:28PM PT-16.0* PTT-23.7 INR(PT)-1.6 [**2164-9-10**] 11:28PM FDP-80-160* [**2164-9-10**] 01:56PM GLUCOSE-175* UREA N-42* CREAT-1.1 SODIUM-144 POTASSIUM-3.7 CHLORIDE-112* TOTAL CO2-20* ANION GAP-16 [**2164-9-10**] 01:56PM ALT(SGPT)-104* AST(SGOT)-186* LD(LDH)-2329* CK(CPK)-420* ALK PHOS-53 AMYLASE-404* TOT BILI-4.3* [**2164-9-10**] 01:56PM LIPASE-178* [**2164-9-10**] 01:56PM CK-MB-21* MB INDX-5.0 cTropnT-0.82* [**2164-9-10**] 01:56PM ALBUMIN-3.0* CALCIUM-8.4 PHOSPHATE-3.6 MAGNESIUM-1.7 [**2164-9-10**] 01:56PM HAPTOGLOB-<20* Brief Hospital Course: 1. Respiratory Distress - the patient arrived to the ICU intubated. Chest x-ray w/ bilateral interstitial infiltrates. Etiology likely multifactorial including ARDS secondary to pancreatitis/retained products of conception and pulmonary edema given cardiac EF of 35%. Over the course in the ICU, the patients pulmonary status rapidly improved w/ diuresis. She was extubated on HD 3. On HD 5, she was transferred to the floor on 6L nasal cannula. She continued to receive gentle diuresis while on the floor. By HD 6, she only required 3L nasal cannula and by HD7, she had oxygen saturation of 96-99% on Room Air. She no longer received diuresis on her last hospital day. On discharge, her oxygen saturation was 98-99% on Room Air. She will have a follow up [**Month/Day/Year 113**] in [**12-20**] weeks to evaluate for resolution of her cardiomyopathy. 2. Fever - the likely source of the patient's fever was pancreatitis and/or the her retained products of conception. The patient was initially started on broad spectrum antibiotics including zosyn, clindamycin, and doxcycline. As culture data returned her antibiotic regimen was weaned appropriately. On HD 7, she was changed from IV meds to po levo/flagyl for possible pneumonia vs myometritis. Since she had no laboratory/radiological evidence of either condition, her antibiotics were stopped on HD 8. She remained afebrile off of antibiotics. 3. Pancreatitis - On admission, the patient was kept NPO w/ NG tube to suction. By hospital day 3 the patient was having bowel movements and with no abdominal pain. She was started on a regular diet which she tolearted well. The pt did not have further nausea/abdominal pain. Although her amylase/lipase trended up throughout the admission, she was not symptomatic so it was decided to stop trending her enzymes. She was seen by GI the day before discharge and it was decided that she should follow up for an MRCP then with Dr. [**Last Name (STitle) 3315**] for o/p work up of the etiology of her pancreatitis. 4. Anemia - The patient was given several units of blood (total 6U) for low blood counts while she was in the ICU. It was thought that the etiology of her anemia was a combination of low grade DIC (as her platelets also decreased, her DDimer was elevated and her fibrinogen nadired at 250) and blood loss during her U/S guided D+C. She was transferred to the floor on [**9-14**] (HD 5) and from that point on her hematocrit was stable between 25-28. She did not require any blood transfusions while on the floor. 5. Thrombocytopenia- On admission, the patient's platelets were 44. The differential for her low platelets included DIC, HIT (pt given lovenox) and HELLP. Her PTT/INR was 22.3/1.5,D-dimer 4514, fibrinogen-258 which was suggestive of low grade DIC (although if truly DIC picture would expect fibrinogen to be lower). A HIT antibody was sent which was negative. The timing and clinical picture (9 wks s/p SVD and no labs suggestive of hemolysis, no hypertension) was less consistent with HELLP syndrome. Her platelets trended up throughout the admission. At discharge, the patient's platelets were 480. 6. ARF - the patient's baseline creatine is 0.5 and at admission was 1.2. Initial urine lytes before hydration were consistent w/ a pre-renal picture. Subsequently, however, muddy brown casts consistent with ATN were noted in the patient's urine. Over the course of her ICU stay, the patients Cr trended downward as she autodiuresed well. Her creatinine remained at her baseline on her last three hospital days. 7. Hyperthyroidism-On admission, the patient was tachycardic ~130s (sinus). It was thought that the tachycardia was secondary to volume depletion vs infection. Her HR ranged from 100-170s, but trended in 100-120s with gentle hydration/antibiotics. On the day of transfer to the floor, the patient remained in the 120s so other sources of sinus tachycardia, including thyroid function, were evaluated. Her TSH was <0.02 and her free T4 was elevated. She was started on low dose beta-blocker for control of her heart rate. It was titrated up over a few days to maintain a HR 60-80 with hopes that by controlling her HR it would be less stressful to her heart and her cardiomyopathy would resolve. Endocrine was consulted for the question of hyperthyroid therapy and they felt that PTU or methmimazole would not be necessary during this admission and rate control would be sufficient. They also wanted to send several tests to evaluate for thyroiditis, hashimotos, and [**Doctor Last Name 933**] disease (her mother has had a thyroidectomy for [**Name (NI) 933**]). She will follow up with Endocrine as an o/p for the results of these labs and possible further treatment. 8. Elevated Blood Sugars-Throughout the admission, her fasting fingersticks ranged from 100-170. In the setting of illness, these numbers were not acted on but she was told to follow up for a fasting glucose as an outpatient. 9. Retained Products of Conception-THE POC were removed on [**2164-9-12**]. The patient had minimal vaginal bleeding after the procedure. An intraop US showed no further retained POC. The pathology from the DandC was consistent with necrotic villi. She will follow up with her OB/GYN as o/p in 2 weeks. 10. Anisocoria-On the day of transfer to the floors, it was noted that the patient's pupils were not equal R>L by more than 1 mm. (comparison of old pictures showed this was not previously the case.) Over the next two days, it was also noted that she developed ptosis of the right eyelid. She was seen by neurology, who thought the presentation was consistent with Horners and could be secondary to right IJ placement. An US of her neck was done which was negative for carotid dissection, hematoma, mass. At no point did the patient have other focal neurological symptoms. It was thought that the anisicoria should resolve on its own and the pt could follow up with neurology in the future if it did not resolve. Medications on Admission: motrin, vit, tylenol #3, amoxicillin; Discharge Medications: 1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. Disp:*120 Tablet, Chewable(s)* Refills:*1* 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 3. Multi-Vitamin W/Minerals Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Hyperthyroidism Pancreatitis Heart Failure Retained Products of Conception Discharge Condition: stable Discharge Instructions: 1. Hyperthyroidism, please continue to take the lopressor 37.5 mg twice a day. You do not need medicine specifically for your thyroid at this time, but you should follow up with endocrinology for further management of your hyperthyroidism. Please call your primary care physician sooner if you experience increased palpitations, diarrhea, lightheadedness, fatigue. 2. Heart Failure Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 5 lbs. Adhere to 2 gm sodium diet. Also, you need to have a transthoracic echocardiogram in [**12-20**] weeks to reevaluate your heart function. 3. Pancreatitis-you should eat a low fat diet.You should eat [**2-21**] small meals a day, instead of 3 large meals a day. You should follow up for an MRCP at the scheduled time below. Please make an appointment with Dr. [**Last Name (STitle) 3315**] for some time after the MRCP is completed. (Dr. [**Last Name (STitle) 3315**] - [**Telephone/Fax (1) 4538**]) 4. Elevated glucose on finger sticks-you should follow up with your primary care physician for [**Name Initial (PRE) **] fasting blood glucose to evaluate for glucose intolerance. Your blood sugars were mildly elevated while you were in the hospital 100-150s. Followup Instructions: Please follow up with your primary care physician within the next week. Please follow up with your OB/GYN in 2 weeks. Provider: [**Name10 (NameIs) **] LAB TESTING Where: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) CARDIOLOGY Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2164-10-10**] 9:00 Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 9671**](Endocrinology) Where: [**Last Name (un) **] Phone:[**Telephone/Fax (1) 2378**], Date/Time:[**2164-10-18**] 1:00 (please arrive at 12:30 pm to register) ---please have your thyroid function tests-TSH, free T4, total T3 checked before this visit Provider: [**Name10 (NameIs) 706**] MRI Where: [**Hospital6 29**] [**Hospital6 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2164-9-29**] 10:45 Please make an appointment to follow up with Dr. [**Last Name (STitle) 3315**] [**Telephone/Fax (1) 4538**](after [**2164-9-29**] so he has the results of your MRCP). Name: [**Known lastname 10702**],[**Known firstname 194**] Unit No: [**Numeric Identifier 10703**] Admission Date: [**2164-9-10**] Discharge Date: [**2164-9-18**] Date of Birth: [**2138-7-2**] Sex: F Service: MEDICINE Allergies: Reglan Attending:[**First Name3 (LF) 1852**] Chief Complaint: see main summary Major Surgical or Invasive Procedure: Intubated -admission - [**2164-9-13**] D&C/hysteroscopy-[**9-12**]-pathology consistent with necrotic villi History of Present Illness: see main summary Past Medical History: benign enlarged thyroid sinus congestion s/p appy Social History: lives at home w/ husband, 9 week old dtr, [**Name (NI) 10704**]; no drugs, EtOH, Family History: noncontributory Physical Exam: see summary Pertinent Results: see previous summary Brief Hospital Course: Anisicoria-Previously noted as Right pupil greater than left-this was an error, the left pupil was larger than the right. Both were round and reactive to light both directly and consensually. No APD. In the dark the right pupil is 7.5mm and left is 9mm. In the light right pupil is 5mm and left is 6mm. With accomodation, the anisocoria decreases (both eyes constrict to accomodation). Ptosis of right eyelid. Hospital course concerning the anisicoria as previously noted. Medications on Admission: as in previous summary Discharge Medications: 1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. Disp:*120 Tablet, Chewable(s)* Refills:*1* 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 3. Multi-Vitamin W/Minerals Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Hyperthyroidism Pancreatitis Heart Failure Retained Products of Conception Discharge Condition: stable Discharge Instructions: 1. Hyperthyroidism, please continue to take the lopressor 37.5 mg twice a day. You do not need medicine specifically for your thyroid at this time, but you should follow up with endocrinology for further management of your hyperthyroidism. Please call your primary care physician sooner if you experience increased palpitations, diarrhea, lightheadedness, fatigue. 2. Heart Failure Weigh yourself every morning, [**Name8 (MD) 233**] MD if weight > 5 lbs. Adhere to 2 gm sodium diet. Also, you need to have a transthoracic echocardiogram in [**12-20**] weeks to reevaluate your heart function. 3. Pancreatitis-you should eat a low fat diet.You should eat [**2-21**] small meals a day, instead of 3 large meals a day. You should follow up for an MRCP at the scheduled time below. Please make an appointment with Dr. [**Last Name (STitle) **] for some time after the MRCP is completed. (Dr. [**Last Name (STitle) **] - [**Telephone/Fax (1) 10705**]) 4. Elevated glucose on finger sticks-you should follow up with your primary care physician for [**Name Initial (PRE) **] fasting blood glucose to evaluate for glucose intolerance. Your blood sugars were mildly elevated while you were in the hospital 100-150s. Followup Instructions: Please follow up with your primary care physician within the next week. Please follow up with your OB/GYN in 2 weeks. Provider: [**Name10 (NameIs) 10706**] LAB TESTING Where: GZ [**Hospital Ward Name 10707**] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) CARDIOLOGY Phone:[**Telephone/Fax (1) 10708**] Date/Time:[**2164-10-10**] 9:00 Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 10709**](Endocrinology) Where: [**Last Name (un) 616**] Phone:[**Telephone/Fax (1) 10710**], Date/Time:[**2164-10-18**] 1:00 (please arrive at 12:30 pm to register) ---please have your thyroid function tests-TSH, free T4, total T3 checked before this visit Provider: [**Name10 (NameIs) 10711**] MRI Where: [**Hospital6 189**] [**Hospital6 10711**] Phone:[**Telephone/Fax (1) 491**] Date/Time:[**2164-9-29**] 10:45 Please make an appointment to follow up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 10705**](after [**2164-9-29**] so he has the results of your MRCP). [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 692**] MD [**MD Number(2) 693**] Completed by:[**2164-9-20**]

[ "518.82", "287.5", "584.5", "995.92", "038.9", "242.90", "648.14", "577.0", "245.9", "286.6", "428.0", "666.24", "379.41", "V18.1", "670.04" ]

icd9cm

[ [ [] ] ]

[ "96.6", "99.05", "96.71", "38.93", "99.04", "69.02", "99.07" ]

icd9pcs

[ [ [] ] ]

14725, 14731

13780, 14254

13328, 13438

14850, 14858

13735, 13757

16116, 17265

13671, 13688

14327, 14702

14752, 14829

14280, 14304

14882, 16093

13703, 13716

13272, 13290

13466, 13484

13506, 13557

13573, 13655

23,368

150,155

53093

Discharge summary

report

Admission Date: [**2137-8-28**] Discharge Date: [**2137-9-6**] Date of Birth: [**2072-12-8**] Sex: M Service: NEUROSURGERY Allergies: Sulfa (Sulfonamides) / Percocet / Ambien / Dilaudid Attending:[**First Name3 (LF) 1835**] Chief Complaint: Elective admission for Thoracic Fusion s/p T8 fracture Major Surgical or Invasive Procedure: [**2137-8-28**]:THORACIC INSTRUMENTED FUSION T5-T11 History of Present Illness: Patient is a 64M who presents for elective admission for thoracic fusion, following a T8 fracture. Past Medical History: CABG, HTN, Hypercholesterolemia, Asthma, T8 fracture Social History: Married, resides at home with wife Family History: Non-contributory Physical Exam: On Discharge: Patient is alert, oriented to person, place and date. PERRL. Face is symmetric. He has full strength and sensation in all four extremities except for [**2-24**] in left deltoid. Bladder function is intact. Abdomen is non-distended. Wound is clean, dry and intact with non-absorbable nylon suture and 3 staples. TLSO fits that patient properly. Pertinent Results: Labs on Admission: [**2137-8-28**] 03:07PM BLOOD WBC-7.7# RBC-3.75* Hgb-11.3* Hct-33.6* MCV-89 MCH-30.2 MCHC-33.7 RDW-13.4 Plt Ct-252 ---------------- IMAGING: ---------------- CT T-Spine(Post-op): FINDINGS: The patient is status post posterior fusion extending from T5-T11. There is significant artifact arising from metallic components within the hardware. At the level of T6, the surgical screws terminate lateral to the vertebral body on both sides. At the level of T7, the left screw terminates laterally to the vertebral body. At level T9, the left surgical screw is located laterally to both the left pedicle as well as the vertebral body throughout its entire length. The remaining screws appear intact and appropriately positioned, with no evidence of loosening. There is an old left 1st rib fracture (T1). The overall configuration of the vertebral bodies is unchanged from prior CT examination from [**2137-8-13**]. The T8 compression fracture is unchanged in appearance from prior examination, and still demonstrates retropulsion. IMPRESSION: 1. Stable T8 compression fracture. 2. Multiple surgical screws seen in levels T6, T7, and T9 do not terminate in the vertebral bodies. At level T9, the left surgical screw is located completely lateral to both the pedicle and vertebral body. 3. There is no evidence of hardware loosening. EKG [**8-28**]: Sinus rhythm. Left axis deviation. Inferior myocardial infarction of indeterminate age. Compared to the previous tracing of [**2137-8-23**] there is no significant difference. Intervals Axes Rate PR QRS QT/QTc P QRS T 70 178 90 384/401 61 -36 42 KUB [**8-31**]: FINDINGS: There is marked gaseous distention of the colon and small bowel. Air is seen in the rectum. This finding likely represents ileus. Stool is seen in the cecum. CT Abdomen/Pelvis [**8-31**]: CT ABDOMEN WITH IV CONTRAST: There is trace left pleural effusion. Dependent atelectatic changes are also noted in the lung bases. The patient has had prior CABG. No pericardial effusion is seen. An NG tube is seen coiled in the fundus of the stomach. The liver, spleen, pancreas, adrenal glands, kidneys, and ureters are unremarkable except to note a 2.7 cm cyst in the interpolar left kidney. The patient is status post cholecystectomy. Atherosclerotic calcifications are noted along the abdominal aorta, without aneurysmal dilatation. No lymph node enlargement is seen meeting size criteria for adenopathy. The stomach and small bowel are not dilated. Orally administered contrast has reached the mid to distal small bowel. The colon, however, is distended, measuring up to 8.1 cm at the hepatic flexure. Air-fluid level is noted throughout the colon, a nonspecific finding. No bowel wall thickening, pneumatosis intestinalis, or free air is noted within the abdomen. There is trace fluid in the pelvis and also along the paracolic gutters bilaterally; fluid is noted to be closely associated with the colon along the right paracolic gutter (2:56, 301b:31). CT PELVIS WITH IV CONTRAST: Gas is noted within the urinary bladder, which is collapsed, with Foley catheter in place. The prostate is enlarged, measuring up to 5.6 cm in transverse dimension. The rectosigmoid colon appears normal in caliber but is also noted to have air-fluid level. No free air or adenopathy is noted within the pelvis. Trace fluid is seen within the pelvis. OSSEOUS STRUCTURES: Patient is noted to have had recent spinal fusion with bilateral pedicle screws and fusion rods noted from the visualized T5 through T11, spanning across T8, where there has been loss of vertebral body height compared to [**2137-6-13**], now to approximately 50%, similar to that seen on pre-operative CT T-spine of [**2137-8-13**]. Bone graft donor site is noted along the right iliac crest, with multiple small bony fragments and subcutaneous gas noted within the site. Subcutaneous gas is also noted along the left lower anterior abdominal wall. Sclerotic focus in the left iliac [**Doctor First Name 362**], and also smaller focus on the right, are not changed from the recent comparison study. IMPRESSIONS: 1. No definite features of colitis, such as wall thickening or loss of normal haustral pattern. However, there is abnormal fluid-filled distention of the colon with paracolic fluid, particularly along the proximal colon, concerning for colitis. No free air, pneumatosis or small bowel obstruction. Patent large mesenteric vessels. Clinical correlation recommended. 2. Status post CABG and cholecystectomy. 3. Trace left pleural effusion with bibasilar dependent atelectasis. 4. Status post T-spine fusion with burst fracture and retropulsion at T8 unchanged from [**2137-8-13**]. 5. Subcutaneous gas at the right iliac crest donor site. Given recent surgery on [**2137-8-29**], findings likely postoperative in nature. 6. Bubbles of gas along the left lower anterior abdominal wall, probably due to recent injections. Brief Hospital Course: Patient is 64M who presented on [**2137-8-28**] for elective admission for thoracic spine fusion for a known T8 fracture. Post-operatively, he was taken to the PACU for post-anesthesia monitoring. Approximately 3hours after surgery, he complained of a "brick sitting on his chest", which he stated was reminiscent of a prior MI. A stat EKG, enzymes, and aspirin were given. EKG did not reveal any acute changes, and a set of three enzymes did not reveal any evidence of cardiac event. He was then transferred to the neurosurgery floor. On POD#1, his Foley catheter was removed, pain medications further adjusted, and assisted to get OOB to work with nursing and physical therapy. He was determined to be safe for disposition to home. However, on the morning of [**8-31**], he was significantly nauseated and developed abdominal distention. A KUB image was obtained, and findings consitent with post-operative ileus were found. A [**Last Name (un) 1372**]-gastric tube was placed for decompression, and he was placed on bowel rest(NPO). Later in the afternoon, he was found to be febrile to 101, mildly tachycardic, and still not quite feeling well despite NGT placement, so he was transferred to the ICU for further management and evaluation. A CT of the abdomen and pelvis was performed, which did NOT show any free air, or mesenteric obstruction. There was however findings that could be consistent with colitis. General surgery was consulted for further management. They placed a rectal tube to further facilitate mesenteric decompression, and propylactic antibiotics Unasyn/Flagyl) were started. The patient improved significantly over the next several days. His rectal tube and foley wer removed on [**2137-9-3**] and his TLSO was refitted. He was transferred to the neurosurgical floor on [**9-4**] and the general surgery team removed his NGT. His diet ws slowly advanced late that day and he was tolerating a regular diet by [**9-5**]. On [**2137-9-6**] he was afebrile and tolerating a diet well. He was ambulating with his TLSO in place. There was 3 additional staples placed in the inferior portion of his incision due to small amount of sero-sanguanous draingage. His sutures were removed from the iliac crest bone graft site. The patient was evaluated by physical therapy who felt that he was safe to be discharged with no services. He was discharged home with his wife on [**2137-9-6**]. Medications on Admission: 1. Amlodipine 2. ASA 3. Calcium 4. Simvastatin 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. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Methocarbamol 500 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*60 Tablet(s)* Refills:*0* 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: No driving while on this medication. Do not take more than 4grams Tylenol/day. Disp:*50 Tablet(s)* Refills:*0* 7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 9. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 4 days. Disp:*16 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: T8 Fracture Ileus Discharge Condition: Neurologically Stable Discharge Instructions: Spine Surgery Diet: ?????? You may resume your normal diet. ?????? You can help avoid constipation by eating a balanced diet including: fruits, vegetables, and whole grains (like multi-grain bread, cereals, and bran muffins). ?????? You may also take fiber supplements and over-the-counter stool softeners or laxatives such as Colace or Dulcolax Activity: ?????? Walk at least three times a day and gradually increase your distance and light activities each day. ?????? Do not exercise other than walking until after your first 6-week office visit. ?????? Do not sit longer than one hour at a time for the first two weeks ?????? get up and move around. ?????? You will be more comfortable reclining in an easy chair or on pillows in bed than sitting upright. ?????? Avoid twisting, turning, stopping, bending or reaching over your head for six weeks. ?????? Do not return to the gym, play golf, swim, run, mow grass until 3 months after surgery. ?????? Avoid exercises like aerobics, heavy house cleaning and lifting over [**3-31**] pounds (a gallon of milk weighs 8.5 pounds). ?????? Do your breathing exercises every two hours. ?????? Use your incentive spirometer 10 times every hour that you are awake. ?????? Do not drive if you are taking pain medications, muscle relaxants, or if you are in pain. ?????? You may resume sexual activity when this is comfortable for you. ?????? You can return to work when you feel ready. However, you must stay within the [**3-31**] pound weight lifting restriction ?????? half days might be better at first. Spine patients: ?????? Do not drive 1-2 weeks after surgery. ?????? Do not ride in the car longer than one hour at a time ?????? get out to stretch your back each hour. **Make sure to continue to wear your Back brace, until you are seen in follow up by Dr. [**Last Name (STitle) **]. Wound Care: ?????? You may shower after sutures/staples have been removed. Prior to that time frame, you may take a sponge bath, or shower such that the water does not directly run over your incision. You [**Month (only) **] NOT soak the incision in a bathtub or pool for 4 weeks. If your wound gets wet, gently [**Last Name (LF) **], [**First Name3 (LF) **] NOT RUB the wound dry. ?????? Your incision was closed with stitches. 3 staples were also placed on the day of discharge. ?????? Your dressing was removed 2 days after surgery. If there is still a small amount of bloody drainage, you can place a new sterile gauze dressing, otherwise you can leave the wound open to air Pain: ?????? The second day after surgery will be the most painful due to swelling and the anesthetic wearing off, and increased muscle spasms as the lower back muscles begin to heal. ?????? You may also experience some back pain from muscle spasm as you increase your daily activity, this is to be expected and will improve with time. ?????? Around the fifth week after surgery, you may experience discomfort for a few days due to scar tissue forming. ?????? You may also have some pain, numbness and tingling in the legs and feet for the first 6-8 weeks as normal nerve function returns. ?????? Some pain is normal as you resume your daily activities. You may tire more easily for several months after surgery. 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 be comfortable enough to walk. ?????? Do not use alcohol while taking pain medication. ?????? Medications that may be prescribed include: ?????? Narcotic pain medication such as Oxycodone, or Dilaudid. ?????? Muscle relaxant such as Robaxin. Take thise as needed for muscle spasm. They will make you sleepy, so do not drive while taking these medications ?????? An over the counter stool softener for constipation (try Dulcolax, Milk of Magnesia or ?????? Correctal at first and Magnesium Citrate or Fleets enema if needed). Miscellaneous: * You have had a fusion, do not use non-steroidal anti-inflammatory drugs (NSAIDs) (e.g., aspirin; ibuprofen, Advil, Motrin, Nuprin; naproxen sodium, Aleve) for 6 months after surgery. NSAIDs may cause bleeding and interfere with bone healing. * Do not smoke. Smoking delays healing by increasing the risk of complications (e.g., infection) and inhibits the bones' ability to fuse. WHEN TO CALL THE DOCTOR ??????Call the doctor at ([**Telephone/Fax (1) 88**] if you have: ?????? A temperature of 101??????F or above ?????? Increased redness, soreness, swelling or foul-smelling drainage from the incision ?????? Clear drainage from the incision ?????? Inadequate pain relief ?????? Nausea or vomiting ?????? Shortness of breath ?????? Pain in your calf Important Instructions Regarding Emergencies and After-Hour Calls ?????? If you have what you feel is a true emergency at any time, please present immediately to your local emergency room, where a doctor there will evaluate you and contact us if needed. Due to the complexity of neurosurgical procedures and treatment of neurosurgical problems, effective advice regarding emergency situations cannot be given over the telephone. ?????? Should you have a situation which is not life-threatening, but you feel needs addressing before normal office hours or on the weekend, please present to the local emergency room, where the physician there will evaluate you and contact us if needed. Followup Instructions: Follow-Up Appointment Instructions ?????? Please return to the office in 10 days (from your date of surgery) for removal of your sutures and staples and a wound check. Although we try to be thorough, we may miss [**First Name (Titles) 2730**] [**Last Name (Titles) 109374**]s or staples. Be sure to point out any incisions, which may be covered by clothing at the time of suture removal. This appointment can be made with the Nurse Practitioner. Please call [**Telephone/Fax (1) 2731**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in 6 weeks. ?????? You will not need a CT scan of the spine, as this was done prior to you discahrge from the hospital. Completed by:[**2137-9-6**]

[ "805.2", "272.4", "E884.9", "997.4", "E878.1", "401.9", "V45.81", "780.62", "786.59", "737.19", "560.1", "493.90" ]

icd9cm

[ [ [] ] ]

[ "84.52", "03.53", "77.79", "00.94", "81.05", "81.63" ]

icd9pcs

[ [ [] ] ]

9559, 9565

6050, 8461

370, 424

9627, 9651

1107, 1112

15112, 15970

696, 714

8558, 9536

9586, 9606

8487, 8535

9675, 11514

729, 729

743, 1088

276, 332

11526, 15089

452, 552

1126, 6027

574, 628

644, 680

31,107

125,265

25320

Discharge summary

report

Admission Date: [**2170-7-13**] Discharge Date: [**2170-7-28**] Date of Birth: [**2127-9-16**] Sex: M Service: SURGERY Allergies: Morphine Attending:[**First Name3 (LF) 301**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: 1. Exploratory laparotomy. 2. Lysis of adhesions. 3. Gastrostomy tube placement, Witzel. 4. Primary repair of incisional hernia. History of Present Illness: Mr. [**Known lastname 18691**] is a 42 y/o male who had a laparoscopic Roux-en Y gastrix bypass at an outside hospital in 9/[**2166**]. Subsequently he developed internal hernias and a ventral hernia, and underwent exploratory laparotomy with lysis of adhesions and repair of hernias in [**5-28**]. Since then , he has experienced intermittent severe abdominal pain. The most recent episode began 3 days prior to admission after dinner, when he epxerienced cramping, worsening midabdominal pain. He went to [**Hospital **] Med Center [**Hospital1 189**] where he was admitted with nausea, pain, and obstipation, but no nausea. He had not had a bowel movement or flatus since 3 days ago. He had a KUB which showed dilated small bowel loops with stool and gas in the colon, and a CT scan from [**7-11**] that showed a large superficial fluid collection anterior to mesh, and dilated small bowel without a clear transition point. Past Medical History: 1. Obesity, s/p RNYGBP [**9-24**] 2. Internal hernia repair [**2-27**] 3. Ventral hernia repair [**5-28**] 4. HTN 5. Depression 6. s/p cholecystectomy Social History: Denies alcohol or tobacco use and works as a carpenter. Family History: Noncontributory Physical Exam: VS: 98.4 80 138/90 20 100% RA Gen: In pain, sitting on edge of bed, AAO CV: RRR, no M/G/R Lungs: CTA B/L Abd: Soft, well healed incisions, seroma with erethema and tenderness to palpation. No rebound or peritoneal signs. Ext: Warm, without edema Rectal: Guaiac negative. Pertinent Results: [**2170-7-13**] 09:47PM WBC-5.6 RBC-3.90* HGB-12.7* HCT-35.1* MCV-90 MCH-32.6* MCHC-36.2* RDW-12.8 [**2170-7-13**] 09:47PM GLUCOSE-101 UREA N-21* CREAT-0.7 SODIUM-138 POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-26 ANION GAP-16 [**2170-7-13**] 09:47PM ALT(SGPT)-453* AST(SGOT)-189* ALK PHOS-381* AMYLASE-91 TOT BILI-3.6* [**2170-7-13**] 09:47PM LIPASE-96* Brief Hospital Course: Because of his elevated LFTs, Mr. [**Known lastname 18691**] had a repeat CT done which showed small bowel obstruction with a transition point. The decision was made to take him to the OR, where an exploratory laparotomy was performed with lysis of adhesions, gastric tube placement, and repair of incisional hernia. See operative report dictated [**7-16**] for further details. During the operation he was noted to have feculent material from his NG tube and his oropharynx, and showed signs of [**Last Name (LF) **], [**First Name3 (LF) **] he remained intubated and was transferred to the SICU. He was started on Kefzol, Flagyl, and Zosyn, and levophed and propofol drips. TPN was started as well. On POD [**1-23**] he continued to spike fevers, so Vanco was started and Kefzol DCd for empiric coverage. Ventilator wean was attempted and failed on POD3. A tracheostomy was performed and trach tube inserted by Dr. [**Last Name (STitle) **] on POD5. Sputum cultures grew out Gram negative rods and enterococci, so Vanco was continued. His bowel function returned so he was started on a stage III bariatric diet. His repiratory function also improved gradually, so he was weaned to extubation on POD10. He was transfered to the floor on POD 12, where he continued to improve rapidly and tolerated his PO feeds. He received physical therapy and responded well. As he was taking good PO, urinating well, and his vital signs stable, the decision was made to discharge him to home on [**2170-7-28**]. Medications on Admission: 1. Paxil 2. Zestril 3. HCTZ 4. Multivitamin 5. B12 Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 2. Colace 100 mg Capsule Sig: One (1) Capsule PO BID PRN as needed for constipation. 3. Multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: 1. Small bowel obstruction. 2. Incisional hernia. 3. Acute respiratory distress syndrome. Discharge Condition: Stable, tolerating stage 5 diet, pain well controlled. Discharge Instructions: Please call your surgeon if you develop chest pain, shortness of breath, fever greater than 101.5, foul smelling or colorful drainage from your incisions, redness or swelling, severe abdominal pain or distention, persistent nausea or vomiting, inability to eat or drink, or any other symptoms which are concerning to you. No tub baths or swimming. You may shower. If there is clear drainage from your incisions, cover with a dry dressing. Leave white strips above your incisions in place, allow them to fall off on their own. Change your tracheostomy site dressing with the xeroform, gauze, and tape as needed every few days until the incision closes on its own. Keep your gastric tube capped, but vent it three times a day. Activity: No heavy lifting of items [**11-5**] pounds until the follow up appointment with your doctor. Medications: Resume your home medications. You will be given pain medication which may make you drowsy. No driving while taking pain medicine. You should take a multivitamin daily. Diet: You may resume your normal diet. Followup Instructions: Call Dr. [**Last Name (STitle) 15645**] office to schedule your follow-up appointment if you do not already have one. Completed by:[**2170-8-2**]

[ "E849.8", "599.7", "560.81", "867.0", "998.13", "507.0", "E870.0", "E878.8", "V45.86", "E849.7" ]

icd9cm

[ [ [] ] ]

[ "33.24", "96.71", "96.07", "54.59", "97.23", "43.19", "99.04", "99.15", "38.93", "96.04", "31.1" ]

icd9pcs

[ [ [] ] ]

4271, 4277

2351, 3863

282, 417

4414, 4471

1971, 2328

5576, 5724

1643, 1660

3964, 4248

4298, 4393

3889, 3941

4495, 5553

1675, 1952

228, 244

445, 1379

1401, 1553

1569, 1627

29,810

194,359

54535

Discharge summary

report

Admission Date: [**2103-7-20**] Discharge Date: [**2103-7-25**] Date of Birth: [**2041-8-24**] Sex: M Service: NEUROSURGERY Allergies: Sulfonamides / Wellbutrin / Tape Attending:[**Known firstname 2724**] Chief Complaint: This 62-year-old gentleman presented with low back pain. There were no radicular findings. Imaging included a CT which demonstrated a T8 lytic lesion with extensive bony destruction and epidural extension. An MRI could not be obtained due to the presence of the pacemaker. Major Surgical or Invasive Procedure: PROCEDURES: 1. T8 vertebrectomy, anterior. 2. T7-T8 and T8-T9 anterior arthrodesis. 3. Insertion of interbody device. 4. Anterior plating T7-T9. 5. Local autografts. History of Present Illness: 62 M presented with lower back pain, metestatic lesions from renal cell carcinoma. There were no radicular findings. Imaging included a CT which demonstrated a T8 lytic lesion with extensive bony destruction and epidural extension. An MRI could not be obtained due to the presence of the pacemaker. Past Medical History: Hypertension Pacer [**2091**], colonic polyps, thyroid, AF ablation Social History: 40 PPD smoker currently. Occ ETOH. Lives with wife and works in IT at [**Name (NI) 82882**] power plant Family History: Father had stroke in 70s. Mother had colitis. Sister has cardiac valvular disease. Physical Exam: On Admission: On examination, his motor strength is [**5-19**] in hip flexion, extension, quadriceps, hamstrings, dorsiflexion, and plantar flexion bilaterally. His sensory examination was intact with respect to modality of light touch. His reflexes were normal and symmetric. There was no clonus. There is no point tenderness of the thoracic spine. Pertinent Results: 1)TSpine INDICATION: 51-year-old male status post T8 fusion, to evaluate hardware and alignment. Frontal and lateral radiographs of the thoracic spine were performed on [**2103-7-23**] and compared to [**2103-7-20**]. Patient is status post corpectomy with fusion of T7 through T9. The placement of hardware appears unchanged from previous examination. No evidence of immediate complication is identified. There are several embolization coils located posterolaterally to the left of the hardware. A pacemaker device is partially visualized. IMPRESSION: Post-surgical changes as above status post fusion of T7 through T9. No radiographic evidence of immediate hardware related complication identified. 2) Two intraoperative radiographs of the spine were obtained without a radiologist present. These demonstrate localization of a thoracic vertebral body and subsequent spinal fusion. For additional details, please consult the operative report. [**2103-7-20**] 04:05PM GLUCOSE-136* UREA N-11 CREAT-0.8 SODIUM-137 POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-25 ANION GAP-12 [**2103-7-20**] 04:05PM estGFR-Using this [**2103-7-20**] 04:05PM CALCIUM-7.8* PHOSPHATE-4.0 MAGNESIUM-1.5* [**2103-7-20**] 04:05PM WBC-12.3*# RBC-3.54* HGB-11.5*# HCT-31.7* MCV-90 MCH-32.5* MCHC-36.3* RDW-13.8 [**2103-7-20**] 04:05PM PLT COUNT-189 [**2103-7-20**] 01:57PM TYPE-ART TEMP-37 PO2-184* PCO2-49* PH-7.39 TOTAL CO2-31* BASE XS-4 Brief Hospital Course: This 62-year-old gentleman presented with lowback pain. There were no radicular findings. Imaging includeda CT which demonstrated a T8 lytic lesion with extensive bonydestruction and epidural extension. An MRI could not beobtained due to the presence of the pacemaker. He was brought to the OR for multiple procedures including: PROCEDURES: 1. T8 vertebrectomy, anterior. 2. T7-T8 and T8-T9 anterior arthrodesis. 3. Insertion of interbody device. 4. Anterior plating T7-T9. 5. Local autografts. While in hospital post-operatively he was transferred to the SICU when he became hypoxic(94% sats on NRB) and tachycardic on [**7-21**]. CTA negative for PE. On [**7-23**] he was transferred back to floor, and weaned off oxygen. On [**7-24**] his chest tube was removed and changed to a drain to bulb suction. On [**7-24**] at 1pm he complained of chest pain, for which he was started on Oxygen, telemetry, cardiac enzymes were negative, an MI was ruled out. Pt was cleared for discharge to home by PT on [**7-25**]. Medications on Admission: Medications on Admission: Coumadin 2mg (on hold) Metoprolol 25mg [**Hospital1 **], Levothyroxine 75mg daily, lorazepam 1 QHS Keflex 500mg q6hr Albuterol .083% Neb Soln Discharge Medications: Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 4. Lorazepam 0.5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please resume your usual coumadin dosing: 10 mg (5 pills) on Wed/Fri/Sunday and 8 mg (4 pills) on all other days. Tablet(s) 7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Please apply at night and remove during the day, per your regimen in the hospital. Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0* 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain: Not to exceed 4 g daily. Disp:*100 Tablet(s)* Refills:*0* 9. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours): Do not drive or operate machinery while taking this medication. Disp:*10 Patch 72 hr(s)* Refills:*0* 10. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q3-4H (Every 3 to 4 Hours) as needed for pain: do not drive after taking this medication. Disp:*60 Tablet(s)* Refills:*0* 11. Methimazole 10 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Home Discharge Diagnosis: Metastatic renal cancer with T8 lesion Discharge Condition: Neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR SPINE CASES ??????Do not smoke ??????Keep wound(s) clean and dry / No tub baths or pools for two weeks from your date of surgery ??????If you have steri-strips in place ?????? keep dry x 72 hours. Do not pull them off. They will fall off on their own or be taken off in the office ??????No pulling up, lifting> 10 lbs., excessive bending or twisting ??????Limit your use of stairs to 2-3 times per day ??????Have a family member check your incision daily for signs of infection ??????If you are required to wear one, wear cervical collar or back brace as instructed ??????You may shower briefly without the collar / back brace unless instructed otherwise ??????Take pain medication as instructed; you may find it best if taken in the a.m. when you wake for morning stiffness and before bed for sleeping discomfort ??????Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc. unless directed by your doctor ??????Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ??????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: ??????Pain that is continually increasing or not relieved by pain medicine ??????Any weakness, numbness, tingling in your extremities ??????Any signs of infection at the wound site: redness, swelling, tenderness, drainage ??????Fever greater than or equal to 101?????? F ??????Any change in your bowel or bladder habits Followup Instructions: Have staples out [**Month (only) 205**] l6 in Dr[**Name (NI) 2845**] office between [**9-26**]. Follow up with Dr. [**Last Name (STitle) 548**] in 6 weeks with xrays. Call [**Telephone/Fax (1) 2992**] for appt. Follow up with Dr. [**Last Name (STitle) **].... Follow up with [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2103-7-31**] 4:00 Follow up with [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 28268**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2103-7-31**] 4:00

[ "189.0", "427.31", "401.9", "198.5", "799.02", "V45.01", "338.18" ]

icd9cm

[ [ [] ] ]

[ "33.24", "81.62", "81.04", "77.89", "84.51" ]

icd9pcs

[ [ [] ] ]

5988, 5994

3231, 4257

570, 743

6077, 6101

1777, 3208

7714, 8291

1302, 1386

4499, 5965

6015, 6056

4309, 4453

6125, 7691

1401, 1401

257, 532

771, 1073

1415, 1757

1095, 1164

1180, 1286

20,856

146,660

1248

Discharge summary

report

Admission Date: [**2197-3-12**] Discharge Date: [**2197-3-17**] Date of Birth: [**2126-3-16**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old male with multiple vascular risk factors including several prior strokes, who presents to the Emergency Department with a chief complaint of left sided weakness. Mr. [**Known lastname **] was in his usual state of health. Per wife, his doctor had given him a good checkup and felt that at about midnight, he was awoke and he noted the sudden onset of left sided weakness in his arm, leg, and face. He had no sensory changes at this time. His wife reports that he was able to see and respond to things on the left side of his face. Mr. [**Known lastname **] did not have a headache, and does not have one now. There was no change in his level of consciousness. His wife brought him into the Emergency Room for further evaluation of his left sided weakness. PAST MEDICAL HISTORY: 1. Hypertension. 2. Status post myocardial infarction. 3. Seizure disorder. 4. Right cerebellar hemorrhage in [**2195-9-9**]. 5. Peripheral vascular disease. 6. Abdominal aortic aneurysm repair in [**2191**]. 7. Hypercholesterolemia. 8. Congestive heart failure with ejection fraction of 30%. 9. Chronic renal insufficiency. MEDICATIONS ON ADMISSION: 1. Lipitor 10 mg po q day. 2. Captopril 25 mg po tid. 3. Plavix 75 mg po q day. 4. Dilantin 100 mg po tid. 5. Lopressor 12.5 mg po bid. 6. Celexa 40 mg po q day. 7. Colace 100 mg po q day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Lives at home with wife, 40 pack year history of smoking, quit 20 years ago, no alcohol use, former automechanic. FAMILY HISTORY: History of asthma and diabetes. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: He is afebrile. His blood pressure is 210/75, pulse is 48, breathing 18, and O2 sat is 99% on room air. In general, he is a well-developed and well-nourished comfortable appearing older man. HEENT shows no evidence of trauma. Mucous membranes are moist. Neck: No carotid bruits or thyromegaly. Pulmonary is clear to auscultation bilaterally. Cardiovascular: Bradycardic, no murmurs. Abdomen is soft and nontender, positive bowel sounds x4. Extremities weak peripheral pulses. Mental status: Awake, alert, and oriented times three. Language is dysarthric, but fluent with good comprehension and repetition. Months of years [**Month (only) 1096**] and then [**Month (only) 216**] and then he stopped. Extinguishes double simultaneous stimuli. Cranial nerves: Visual acuity is good. Visual fields are full. Extraocular muscles are intact. Pupils are 3-2 mm bilaterally. Facial sensation is intact. He has left facial droop. Hearing is intact to finger rub. Palatal elevation is symmetric. Tongue is midline. Motor examination: Normal tone and bulk throughout, no vesiculations. Left side deltoid 0, biceps 0, triceps 0. Wrist flexors, extensors, finger flexors and extensors are all 1. Quadriceps is 1. Hamstrings 0, dorsiflexion 0, plantar flexion 0, [**Last Name (un) 938**] 2, that was his left side. His right side is [**6-12**] throughout. Reflexes are brisk and symmetric. Toes go up bilaterally. Sensation intact to pain and light touch and impaired proprioception and feet bilaterally. Coordination and gait are not tested. LABORATORIES: White count is 8.0, hematocrit 38.4, platelets 225. Sodium 141, potassium 3.6, chloride 109, bicarb 25, BUN 29, creatinine 1.3, glucose 102. PT 13.4, INR 1.2, PTT 26.9. CT scan of the head shows a right internal capsular hemorrhage measuring about 1.5 cm in its largest dimension. HOSPITAL COURSE: The patient was admitted to Neurology service. He was started on Nipride drip to maintain systolic blood pressure between 140-160. While in the Intensive Care Unit, he had improvement in his neurological symptoms and regained strength in his right arm. He required multiple antihypertensives to control his blood pressure. Mr. [**Known lastname **] was called out to the regular Neurology floor on [**3-15**]. His examination at that time showed a left facial droop and left sided weakness. His deltoid was [**4-12**]. Biceps 4-/5, triceps 4-/5, wrist flexors 5-/5, wrist extensors 4+/5, finger flexors 4+/5, finger extensors 4+/5, iliopsoas [**5-13**], quadriceps 5-/5, hamstrings 4+/5, dorsiflexors [**5-13**], plantar flexors 5-/5 and extensor hallucis longus 4+/5. The proximal greater than distal weakness was felt to be consistent with a watershed infarction. Mr. [**Known lastname **] had a low grade temperature on [**3-15**]. Chest x-ray showed a left retrocardiac opacity. Urinalysis suggested a urinary tract infection. He was started on ceftriaxone and then transitioned to Levaquin. On [**3-16**], he had an episode of acute desaturations to the mid 80s. Chest x-ray suggested pulmonary edema. He received Lasix 20 mg IV x1 and improved. Electrocardiogram showed small ST elevations in V1 through V2. Troponin peaked at 3.5 and CKs were never elevated. Cardiology service was consulted. They recommended conservative treatment with a beta blocker, aspirin, and ACE inhibitor. He should receive a stress test, but not while in the post-stroke hospitalized setting. DISCHARGE DIAGNOSES: 1. Right internal capsule hemorrhage. 2. Pneumonia. 3. Small myocardial infarction. DISCHARGE MEDICATIONS: 1. Dilantin 100 mg po tid. 2. Colace 100 mg po bid. 3. Lipitor 10 mg po q day. 4. Celexa 40 mg po q day. 5. Tylenol prn. 6. Protonix 40 mg po q day. 7. Regular insulin-sliding scale. 8. Labetalol 200 mg po bid. 9. Lisinopril 5 mg po bid. 10. Levaquin 500 mg po q day to complete a seven day course. CONDITION ON DISCHARGE: The patient will be discharged in stable condition. He is going to rehabilitation. His left hemiparesis is improving. FOLLOW-UP INSTRUCTIONS: He will follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1206**] and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7790**] as an outpatient. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**], M.D. [**MD Number(1) 2107**] Dictated By:[**Last Name (NamePattern1) 5476**] MEDQUIST36 D: [**2197-3-17**] 16:48 T: [**2197-3-21**] 12:19 JOB#: [**Job Number 7791**]

[ "486", "593.9", "428.0", "401.0", "780.39", "342.90", "431", "410.91", "599.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

1700, 1754

5282, 5367

5390, 5690

1323, 1551

3667, 5261

156, 949

2557, 3649

1769, 2270

2286, 2540

5861, 6328

971, 1297

1568, 1683

5715, 5836

18,677

193,933

46210

Discharge summary

report

Admission Date: [**2169-4-14**] Discharge Date: [**2169-4-28**] Date of Birth: [**2088-7-18**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: palpitations, SOB Major Surgical or Invasive Procedure: [**4-18**] redo sternotomy/ AVR (#23 [**First Name8 (NamePattern2) **] [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 9041**]), CABG x 1 (SVG->PDA) History of Present Illness: Pt is an 80 y/o M hx MI s/p CABG, extensive cardiac history (read below in PMHx), severe AS (h/o syncope), DM, HTN, and Hyperlipidemia who presents today to ED with palpitations, CP and SOB and found to have Afib w/ RVR. . At baseline, patient is able to walk up 6 stairs and has to stop due to SOB. He has ? gastroenteritis for the last few days. Today, he was unable to climb any steps as he felt lousy intially. Then he developed severe [**10-25**] pounding chest pain which was associated with SOB and sweating. He did not have any dizziness or syncope with that. He called EMS and enroute, he was found to have AFib w/ RVR and was given bolus of Amio IVB without any effect. . Upon arrival in the ED, his HR was > 160, BP was 100-120/70-90, RR 30. He then received 10 mg IV Dilt -> BP dropped to 84/74 without any effect on the HR. He was then electrically cardioverted to sinus rhythm. Subsequently his vitals were stable at around 101, 127/80, 28, 100%/NRB. He also received 4.5 lts of NS. He also had some ST depressions in the inferolateral leads in the setting of tachycardia and so he was started on heparin. He also got 2.5 IV lopressor to which he dropped his SBP from 125 to 70 which reverted back to his baseline of around 120 within few minutes. He was also given Levaquin 500 mg IV for UTI. . Cath from [**2169-4-7**] -- Three vessel coronary artery disease with patent LIMA to LAD and occluded SVG to Ramus and jump segment to R PDA. -- Severe aortic stenosis. -- Moderate diastolic ventricular dysfunction -- severe AS w/ peak gradient of 55 mmHg, valve area of 0.65m3 -- EF of 60% without regional wall motion abnormalities Hemodynamics: -- moderately elevated R & L sided filling pressure with RVEDP of 15mmHg and LVEDP of 18mmHg -- moderate PAH with a PASP of 50mmHg -- CI depressed at 2 L/min/m2 Past Medical History: - CAD s/p CABG x 3 in [**2158**] (LIMA to LAD, SVG to OM, and SVG to RCA) - S/P stenting [**2164**] of mid RCA, PTCA of proximal RCA and PDA - DM - HTN - Hyperlipidemia - Left leg cellulitis - OA - Renal cell carcinoma (unchanged in 4 months) - Depression - Asbestos Lung - Spinal stenosis Social History: Lives with daughter in [**Name (NI) 2312**] Denies EtOH use Quit smoking in [**2104**] . Family History: Father - MI in his 60's Mother - died of unknown cancer Physical Exam: VS: 95.2, 100, 107/74, 21, 100%/NRB Gen: appears comfortable, mild conversational dyspnea HEENT: PERLA, EOMI, Dry MM Neck: distended neck veins, JVD ~ [**7-23**] cms Heart: tachycardia, regular rhythm, distant heart sounds, could not appreciate any murmur Lungs: mild expiratory wheezing, crackles at bases bilaterally Abd: distended, tympanic, bowel sounds normoactive, soft/NT Ext: 1+ edema bilaterally, changes from venous statis on right, resolving cellulitic changes on left Pulses: Right: Carotid 1+ Femoral 1+ Popliteal 1+ DP 1+ PT 1+ Left: Carotid 1+ Femoral 1+ Popliteal 1+ DP 1+ PT 1+ Pertinent Results: [**2169-4-14**] CArotid Duplex Ultrasound 1. Occluded left internal carotid artery. 2. No significant right ICA or CCA stenosis (right ICA stenosis is graded as less than 40%). [**2169-4-15**] ECHO Conclusions: The estimated right atrial pressure is 5-10 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild to moderate regional left ventricular systolic dysfunction with anterior and infero-lateral hypokinesis (?multi-vessel CAD?). Right ventricular systolic function is borderline normal. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are severely thickened/deformed. There is at least moderate aortic valve stenosis (area 0.8-1.19cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. The pulmonic valve leaflets are thickened. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2169-2-24**], there are new regional wall motion abnormalities c/w multi-vessel CAD. The degree of aortic stenosis (moderate to severe) is probably similar (currently lower gradient probably secondary to decreased cardiac output). [**2169-4-17**] Vein Mapping There is a patent right greater saphenous vein, however, there is reflux throughout and varicosities below the knee. There are patent bilateral lesser saphenous veins of small diameter and the left greater saphenous vein is only visualized at the saphenofemoral junction and not seen throughout the rest of the leg. Brief Hospital Course: Mr. [**Known lastname 97733**] was admitted to the [**Hospital1 18**] on [**2169-4-14**] for further evaluation of his aortic stenosis and coronary artery disease. He was evaluated by the cardiac surgical service given that a recent cardiac catheterization revealed occluded vein grafts from his prior CABG in [**2158**]. Mr. [**Known lastname 97733**] was worked up in the usual preoperative manner. A carotid duplex ultrasound was performed which revealed an occluded left internal carotid artery and mild plaque in the right internal carotid artery. Ciprofloxacin was started for a urinary tract infection. Vein mapping was performed which revealed a patent right saphenous vein with dimensions ranging between 3.7mm to 6.7mm. On [**2169-4-18**], Mr. [**Known lastname 97733**] was taken to the operating room where he underwent a redo sternotomy with coronary artery bypass grafting to one vessel and an aortic valve replacement using a 23mm [**Known lastname 9041**] Porcine Valve. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. Pressors were continued to maintain an acceptable blood pressure. Gentle diuresis was initiated. On postoperative day three, Mr. [**Known lastname 97733**] [**Last Name (Titles) **]e neurologically intact and was extubated. Amiodarone was started for atrial fibrillation. On postoperative day five, Mr. [**Known lastname 97733**] was transferred to the step down unit for further recovery. The physical therapy service was consulted for assistance with his postoperative strength and mobility. Haldol was used for periods of postoperative delirium. As his diet improved and advanced, his oral diabetes medications were resumed. Foley was reinserted for urinary retention on POD #7. Mental status much improved on POD #9 and haldol discontinued. C. diff. culture sent for diarrhea amd was negative twice. He was discharged to rehab on POD#10 in stable condition. Medications on Admission: ASA 325 mg daily Lipitor 80 mg daily Glyburide 5 mg daily Colace 100 mg [**Hospital1 **] Pantoprazole 40 mg daily Citalopram 20 mg daily Senna 8.6 mg prn 2 times a day Albuterol PRN Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*30 Capsule(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*0* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Tablet(s) 9. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disk with Device(s) 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Tablet(s) 11. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 10 days. 13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Four (4) Capsule, Sustained Release PO DAILY (Daily). Discharge Disposition: Extended Care Facility: TBD Discharge Diagnosis: AS AF CAD s/p CABG [**2158**], s/p stenting of mid RCA, PTCA of proximal RCA and PDA DM HTN hyperlipidemia LLE cellulitis OA RCC depresions asbestosis spinal stenosis decompression laminectomy arthroplasty of proximal phalanx 3rd digit left foot torn right medial and lateral meniscus and degenerative arthritis hernia repair Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds or driving until follow up with surgeon. Followup Instructions: Dr. [**Last Name (STitle) **] 1-2 weeks Dr. [**Last Name (STitle) 1911**] in [**2-18**] weeks Dr. [**Last Name (STitle) **] 4 weeks [**Telephone/Fax (1) 170**] Already scheduled appointments: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2169-4-28**] 10:20 Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2169-10-2**] 10:00 Completed by:[**2169-4-28**]

[ "427.31", "272.4", "433.10", "414.01", "410.71", "501", "424.1", "428.0", "414.02", "787.91", "250.00", "788.20", "401.9", "293.0", "599.0" ]

icd9cm

[ [ [] ] ]

[ "88.72", "99.62", "36.11", "39.61", "35.21" ]

icd9pcs

[ [ [] ] ]

8850, 8880

5241, 7182

339, 507

9251, 9259

3483, 5218

9558, 10036

2793, 2851

7415, 8827

8901, 9230

7208, 7392

9283, 9535

2866, 3464

282, 301

535, 2356

2378, 2670

2686, 2777

5,161

109,822

48211+59071

Discharge summary

report+addendum

Service: GENERAL Date: [**2125-5-22**] Surgeon: [**First Name8 (NamePattern2) **] [**Name8 (MD) 4174**], M.D. [**MD Number(1) 16133**] DATE OF DISCHARGE: To be determined. HISTORY OF THE PRESENT ILLNESS: This is a 77-year-old man with history of cerebral palsy, mild mental retardation, coronary artery disease, seizure disorder, and small-bowel obstruction, who presented from [**Hospital3 **] Center with diffuse lower abdominal pain with radiation to the back, fever, nausea, and vomiting for two days. The patient first noted this pain when his wheelchair struck another one, five days prior to admission. He was also complaining of a productive cough of yellow-to-brown sputum. Vital signs in the emergency room revealed temperature 100.3, pulse 118, blood pressure 91/54, respiratory rate 20, oxygen saturation 95% on 1.5 liters. The patient was given IV Ampicillin, Gentamicin, and Flagyl in the emergency room and he was admitted to the Surgery Service initially. Of note, Levofloxacin 500 mg p.o.q.d. had been started at the [**Hospital3 1761**] on [**5-7**]. Per report, he has a baseline congested cough. LABORATORY DATA: Admission labs are significant for an increased white blood cell count 34.1, ALT 242, AST 122, alkaline phosphatase 166, amylase [**2049**], lipase 750, total bilirubin 1.2. CT of the abdomen was consistent with pancreatitis with question of organizing collection inferior to the head of the pancreas, mild left intrahepatic duct dilation. MRCP was done consistent with acute pancreatitis, no filling defects in biliary tree and free fluid in abdomen and pelvis. He was treated with IV fluids, pain medications sternotomy and bowel rest. He was started on IV antibiotics. In addition, PICC line was placed. The patient continued to be febrile the first few days of hospitalization. TPN was started as he was NPO and on [**5-2**] because the LFTs, amylase, and lipase were all back to normal and the patient's test was resolving, he was transferred to the Medicine Service. Because his MRCP was inconclusive, ERCP was done on [**5-11**] with the finding of stone and sludge at the biliary tree. The stone was removed and sphincterotomy was done. Common bile duct was dilated to 12-mm. PAST MEDICAL HISTORY: 1. Cerebral palsy. 2. Mild mental retardation. 3. Coronary artery disease status post myocardial infarction, EF 35%. 4. Seizure disorder. 5. Asthma. 6. [**Doctor Last Name 15532**] esophagus with stricture. 7. Status post ileocecetomy in [**2122**]. 8. Status post Total hip replacement, right side. 9. Status post open reduction and internal fixation. 10. Small-bowel obstruction status post LOA [**2123-5-24**]. 11. History of cholecystectomy, open. MEDICATIONS ON ADMISSION: 1. Enteric coated aspirin 325 mg p.o.q.d. 2. Digoxin 0.25 mg p.o.q.d. 3. Diltiazem 30 mg p.o.q.i.d. 4. Lasix 20 mg p.o.q.d. 5. Neurontin 600 mg p.o.t.i.d. 6. Prevacid 30 mg p.o.q.d. 7. Cozaar 25 mg p.o.q.d. 8. Multivitamin, one tablet p.o.q.d. 9. Percocet t.i.d. 10. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o.q.d. 11. Primidone 250 mg p.o.q.h.s.; 125 mg p.o. q.a.m. 12. Ambien 5 mg p.o.q.h.s. 13. Combivent MDI. 14. Vanceril MDI. MEDICATIONS ON TRANSFER TO THE MEDICINE SERVICE: 1. IV fluids. 2. Protonix IV q.d. 3. TPN. 4. Flagyl 500 mg IV t.i.d. 5. Levofloxacin 500 mg IV q.d. 6. Lopressor 25 mg per NG tube t.i.d. 7. Hydromorphone 0.5 mg to 1 mg q.3h. to 4h.p.r.n. 8. Digoxin. 9. Diltiazem. 10. Gabapentin. 11. Losartan. 12. Ambien. 13. Albuterol nebulizers. 14. Beclovent MDI q.i.d. 15. Combivent MDI q.i.d. 16. Pneumoboots. 17. Droperidol 0.625 mg IV p.r.n. 18. Primidone ALLERGIES: The patient is allergic to DILANTIN, CAPOTEN, AND SHELLFISH. SOCIAL HISTORY: The patient lives at [**Hospital3 **] Center. He has a niece in [**Location (un) 8985**] [**State 3914**]. He transfers with assistance and self-propels himself in a wheelchair. He is independent with medications and needs assistance with toiletting. FAMILY HISTORY: Noncontributory. CODE STATUS: Full. PHYSICAL EXAMINATION: Examination revealed the following: On [**5-8**], vital signs revealed the following: Temperature 100.3, pulse 118, blood pressure 91/54, respiratory rate 20, oxygen saturation 91% on two liters. GENERAL: The patient was in no acute distress, conversant, poor historian, alert, and oriented times three. HEENT: Anicteric, pale skin. PULMONARY: Coarse breath sounds, crackles at the bilateral bases. CARDIAC: Regular rate and rhythm. ABDOMEN: Soft, diffusely tender, especially in the right upper quadrant greater than right lower quadrant; positive [**Doctor Last Name **] sign, positive voluntary guarding and rebound; negative tap shake; 3 x 2 incisional hernia; no incarcerated bowel; easily reducible contents, guaiac-negative; normal tone; decreased stool in vault. EXTREMITIES: Warm, spastic left upper extremity and bilateral lower extremities. LABORATORY DATA: Laboratory data revealed the following: WBC 34.1, hematocrit 41.1, MCV 98, differential 88% neutrophils, 3 bands, 3 lymphocytes, 6 monocytes, platelet count 153,000. Urinalysis: Yellow, clear, specific gravity 1.001, large blood, negative nitrite, negative protein, negative glucose, negative ketones, small bilirubin, 0.2 urobilirubin, 5.5 pH, trace leukocyte esterase, greater than 50 red blood cells, 5 white blood cells, few bacteria, no yeast. Sodium 144, potassium 4.4, chloride 105, bicarbonate 25, BUN 26, creatinine 1.3, glucose 103, anion gap 18, ALT 242, AST 122, alkaline phosphatase 166, amylase [**2049**], total bilirubin 1.2, lipase 750. C. difficile negative. Blood cultures revealed no growth. Urine culture revealed no growth. Portable AP chest x-ray revealed no evidence of pneumonia. Portable abdomen: Marked limited abdominal examination, no clear obstructive pattern identified. Abdominal ultrasound: The patient is status post cholecystectomy, common bile duct appears unremarkable, limited evaluation of the rest of the abdomen due to overlying gas. CT of the abdomen with contrast as well as pelvis: Pancreatitis with a probable organizing collection inferior to the head of the pancrease; mild left intrahepatic ductal dilatation. MR of the abdomen, [**5-10**], [**2125**]: No MR evidence of filling defects in the biliary tree and limited study; changes consistent with acute pancreatitis; prominent head of the pancreas; free fluid in the abdomen and pelvis. Chest AP, [**5-10**]: Successful placement of PICC, the tip of which is in the SVC ready for use. [**5-12**], [**2125**], portable abdominal film, dilated small bowel loops and earlier partial small-bowel obstruction suspected. [**5-12**], portal AP: Slight elevation of the left hemidiaphragm with subsegmental atelectasis at the left base, otherwise, no interval change. [**5-13**]: Portal AP: Worsened fluid status versus prior increased bibasilar atelectasis. [**5-13**]: Portal AP: Intraperitoneal free air on the upright projection. [**5-14**]: Portal AP: No evidence of pneumonia or CHF, atelectasis left base unchanged. [**5-14**]: CT with reconstruction of the abdomen and pelvis; interval progressive of peripancreatic inflammatory changes less than 30% of the pancreatic parenchyma demonstrating a lack of contrast enhancement; interval increase in size or probable organizing phlegmon in the region of the inferior pancreatic head; no drainable fluid collection; free air within the biliary tree presumably secondary to the recent ERCP; inadequate assessment of previously-described thickened loops of jejunum secondary to lack of distention with oral contrast; paraumbilical and right inguinal hernias; small bilateral pleural effusions. [**5-16**]: Portal AP: Film is rotated to the left. NG tube extends below diaphragm. Heart size is borderline, but difficult to assess. No definite CHF, pulmonary edema, or pulmonary consolidation, no pneumothorax. AP chest: [**5-17**]: NG tube in distal stomach with distal end not included on the film, heart size normal, low lung volume with bibasilar atelectasis, no pneumothorax, no evidence for CHF. Chest AP [**5-18**]: Status post right brachial vein, PICC line placement, line is ready for immediate use with tip in the distal SVC. HIT Antibody negative. EKG: [**5-8**], sinus tachycardia with ventricular ectopy, PR interval 0.2, leftward axis, rate of 140, grouping ST segments in leads 1, AVL and V5 through V6. IMPRESSION: This is a 77-year-old gentleman with history of gallstones who was admitted with gallstones pancreatitis, now status post ERCP with sphincterotomy. #1. GASTROINTESTINAL: The patient has gallstone pancreatitis, status post ERCP with sphincterotomy and stone removal. Initially, after the ERCP the patient did well and started to tolerate sips of fluid. The patient was afebrile on [**5-11**]. He was still on Levofloxacin and Flagyl at that time for possible fluid collection in the head of the pancreas. On the evening of [**5-11**], the patient's urine output began to decline, despite continuing IV fluid and the patient complained of increasing abdominal pain and was noted to have increasing abdominal distention. His pain was controlled with Dilaudid. He was given antiemetics p.r.n. The following morning on [**5-12**], these were more exaggerated and NG tube was placed with the return of large amounts of bilious fluid. The patient's abdomen decreased in size with this, however, because of his clinical status, he was transferred to the Intensive Care Unit for further management. In the Intensive Care Unit, the patient's antibiotic spectrum was widened. He was found to be hypotensive, probably secondary to third spacing his amylase, lipase, and LFTs all within normal limits at that time. He was not thought to be having post ERCP pancreatitis. The patient did continue to spike in the ICU. Antibiotics were widened to Ampicillin, Levofloxacin, and Flagyl. The patient's hypertension resolved with aggressive IV hydration. Repeat CT was done, which showed continuing fluid collection in the head of the pancreas, however, it was decided to discontinue antibiotics on [**5-15**] and watch him and his fever curve off antibiotics. The patient was though to be stable enough to transfer back to the floor on [**5-16**]. He was continued off antibiotics. He was NPO for two days, without nausea or vomiting. The patient was continued on TPN at that point with pain control and IV fluids. On [**5-18**], the patient removed his NG tube and it was kept out as he was having no nausea or vomiting. He began to pass gas and to have bowel movements, which became diarrhea. Stool cultures were sent for C difficile stool cultures and stool leukocytes, which are still pending to date. General Surgery, Gastrointestinal, and ERCP Team continued to follow the patient. His diet was slowly advanced to the point of a regular diet on [**5-22**] without decompensation. However, TPN was continued even when he began taking p.o. given his poor caloric intake. The patient should followup with Dr. [**Last Name (STitle) **], his surgeon, one month after discharge and he should have a repeat CT of the abdomen to evaluate the fluid collection the head of the pancreas six weeks after discharge. NG lavage was positive for coffee-ground and the patient was started on Protonix IV then p.o. b.i.d. #2. FLUIDS, ELECTROLYTES, AND NUTRITION: Upon transfer to the Medicine Team on [**5-11**], the patient was hypernatremic at 153. This may have contributed to his decompensation the following day with hypotension. The patient was placed on half normal saline. However, when his urine output dropped, he was bolused with normal saline. Urine output improved with IV hydration. Electrolytes were repleted, both in his IV fluid and through his TPN. He was able to advance his diet to regular on [**5-22**]. However, he was continued on TPN. #3. CARDIOVASCULAR: The patient had a history of cardiovascular disease with CHF. While the patient was in the Intensive Care Unit between [**5-12**] and [**5-16**], he was noted to have a troponin leak with no active chest pain or EKG changes. He was started on IV Lopressor because he was tachycardiac and this controlled the tachycardia well. Aspirin was held off given his occult blood in his NG lavage fluid. The patient continued to complain of intermittent chest pain each time without EKG changes he was ruled out two to three times during this admission for myocardial infarction. Tachycardia was also thought perhaps to be due to his pain. #4. PULMONARY: The patient has history of asthma, chronic obstructive pulmonary disease. The patient was continued on his MDIs and nebulizers while in house with good relief. Occasionally, he was felt to be fluid overloaded and responded well to Lasix. #5. HEMATOLOGY: The patient had a decrease in his hematocrit when he went to the unit and transfused two units of packed red blood cells. The hematocrit then stabilized. The patient also was noted to have a decrease in his platelet count to 100. HIT antibody was checked and found to be negative. Only for the first day three days of hospitalization was the patient receiving Heparin subcutaneously. This was then switched to pneumoboots for DVT prophylaxis. Platelets improved to normal. #6. NEUROLOGICAL: The patient has a history of seizure disorder and he is on Neurontin and Primidone at home. These were taken off when the patient was NPO and on the evening of [**5-19**], the patient reported to the nurse that he had had a brief seizure, which was normal for him. He was restarted. He did not have a postictal state. He was restarted on Neurontin and Primidone at that point. The following day all of his medications were switched to PO and he restarted on his old cardiac medications such as Digoxin and Cozaar. #7. PROPHYLAXIS: Protonix b.i.d. and Pneumoboots. Physical therapy was asked to see the patient prior to discharge as well. The Department of Nutrition followed the patient for his nutritional recommendations. This is a summary of the hospital course to [**2125-5-22**]. The rest of the [**Hospital 228**] hospital course will be dictated by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. He will do an addendum to this summary and add a condition of discharge, discharge status, discharge medications, and discharge diagnoses. DR.[**Last Name (STitle) **],[**First Name3 (LF) 177**] 12-972 Dictated By:[**Last Name (NamePattern1) 7069**] MEDQUIST36 D: [**2125-5-22**] 14:46 T: [**2125-5-22**] 15:00 JOB#: [**Job Number 99116**] Name: [**Known lastname 1585**], [**Known firstname 2794**] Unit No: [**Numeric Identifier 16366**] Admission Date: [**2125-5-8**] Discharge Date: [**2125-5-25**] Date of Birth: [**2047-9-14**] Sex: M Service: ACOVE DISCHARGE SUMMARY ADDENDUM: This is an addendum to the discharge summary dated [**2125-5-22**] to detail the events between [**2125-5-22**] and [**2125-5-25**]. New date of discharge [**2125-5-25**]. HOSPITAL COURSE: In the interim Mr. [**Known lastname **] was unable to keep up his po intake which had been monitored in order to prepare for discontinuance of TPN and transfer to the [**Hospital3 6278**] facility. His po intake was variable and inconsistent on a day to day basis and it was felt that the patient would be best served by being discharged to an alternative rehabilitation facility which could accommodate continued TPN. At this time the patient is being prepared for discharged to [**Hospital **] Rehabilitation facility which will continue TPN. In addition in the interim the patient experienced several episodes of atypical chest and abdominal pain all with normal EKGs and without any acutely concerning findings. It should be noted that the majority of these episodes responded to analgesia with Morphine Sulfate 1 milligram IV and this should be strongly considered should the patient experience any future atypical chest pain or abdominal pain without EKG changes. DISCHARGE MEDICATIONS: 1. Beclovent MDI two puffs qid inhaled. 2. Combivent MDI two puffs qid inhaled. 3. Combivent nebulizers q four hours prn. 4. Primidone 125 milligrams po q A.M. and 250 milligrams po q HS. 5. Neurontin 300 milligrams po tid. 6. Lopressor 25 milligrams po bid. 7. Protonix 40 milligrams po q day. 8. Cozaar 25 milligrams po q day. 9. Digoxin 0.25 milligrams po q day. 10. Tylenol 650 milligrams po q four hours prn. 11. Dilaudid 0.5 to 1 milligram IV q three to four hours prn. 12. Albuterol nebulizers q four hours prn. 13. Enteric coated aspirin 325 milligrams po q day. 14. TPN. DISCHARGE INSTRUCTIONS: Routine PIC line care with saline flushes, no Heparin flushes. The patient has question Heparin induced thrombocytopenia and should not receive any Heparinized products. FINAL DIAGNOSIS: 1. Gallstone pancreatitis. 2. Coronary artery disease. 3. Seizure disorder. 4. Asthma. 5. Esophageal reflux. 6. Hypotension. 7. Sepsis. 8. Question Heparin induced thrombocytopenia. DISCHARGE CONDITION: Stable. DISCHARGE FOLLOW UP: The patient should be followed by the rehabilitation facility doctor and then transferred to [**Hospital3 6278**] facility where he will be followed by the [**Hospital3 643**] facility physician. [**Name6 (MD) 33**] [**Name8 (MD) 635**], M.D. [**MD Number(1) 16367**] Dictated By:[**Name8 (MD) 292**] MEDQUIST36 D: [**2125-5-25**] 09:53 T: [**2125-5-25**] 10:13 JOB#: [**Job Number 3613**]

[ "276.5", "577.0", "780.39", "428.0", "574.51", "285.9", "997.4", "458.9", "560.1" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.15", "96.07", "51.85", "96.33" ]

icd9pcs

[ [ [] ] ]

17970, 17989

4198, 15941

16955, 17545

2889, 4181

15958, 16932

17757, 17948

17569, 17740

18000, 18430

2390, 2863

55,320

117,810

35468

Discharge summary

report

Admission Date: [**2164-3-22**] Discharge Date: [**2164-3-26**] Date of Birth: [**2118-8-18**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4691**] Chief Complaint: s/p Fall off truck Major Surgical or Invasive Procedure: Irrigation and suturing of forehead laceration History of Present Illness: 46 yo man s/p fall off top of truck onto head with large scalp hematoma, small left frontal ICH, C7 spinous process fracture and T3 anterior body fracture. Past Medical History: low back pain, anger management(on zoloft), cocaine use, smoking Social History: Married Family History: Noncontributory Physical Exam: Upon admission: T: 98.6F BP: 130-140 / 70-80 HR: 70 bpm R 16 100 % O2Sats in 2 l NC. Gen: WD/WN, comfortable, in mild distress (pain). On hard collar. 7 cm wound in his RIGHT mid-orbital line from his forehead back to motor areas. The epidural areas were intact. Pupils: PERLLA 2.5 to 1.5 mm EOMs Intact Neck: unable to assess. Lungs: Mild ronchi bl Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+. Surgical scars. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: Limited by pain. Legs are bl antigravity. His LEF arm is in pain (dislocation) Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: 1 + throughout. Toes downgoing bilaterally. Propioception intact Rectal exam normal sphincter control Pertinent Results: [**2164-3-22**] 02:19PM WBC-14.2*# RBC-4.45* HGB-15.3 HCT-42.5 MCV-95 MCH-34.2* MCHC-35.9* RDW-13.1 [**2164-3-22**] 02:19PM PLT COUNT-265 [**2164-3-22**] 08:20AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2164-3-22**] 08:16AM GLUCOSE-119* LACTATE-1.4 NA+-143 K+-4.2 CL--97* TCO2-28 [**2164-3-22**] 08:09AM UREA N-21* CREAT-1.0 [**2164-3-22**] 08:09AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG CT head [**2164-3-22**] IMPRESSION: 1. Small left frontal subarachnoid hemorrhage. 2. Large right frontal scalp laceration without evidence of underlying fracture. 3. Sinus disease. Clinical correlation recommended. CT c-spine 3//[**12-19**] IMPRESSION: 1. C7 spinous process fracture. 2. Prominence of the prevertebral soft tissue raising concern for ligamentous injury. MRI is recommended. Hand xray IMPRESSION: Perilunate dislocation. No fracture. MR Cervical spine IMPRESSION: 1. Prevertebral edema from C2 through C5, which could indicate anterior longitudinal ligamentous injury. 2. Edema around the posterior elements compatible with interspinous ligament injury. 3. C7 and T3 fractures grossly unchanged from prior CT, allowing for differences in modality. Brief Hospital Course: He was admitted to the Trauma Service. He suffered a significant scalp avulsion injury and was taken to the operating room for hemostasis of this wound. Neurosurgery was consulted due to his small subarachnoid hemorrhage and spine injuries; these were managed non operatively. He was maintained in a hard cervical collar and will continue with this for 3 months and will follow up with Neurosurgery at that time. His forehead laceration was irrigated and sutured by Plastic surgery and he will follow up within 4-5 days for suture removal. Orthopedics was also consulted for the left perilunate dislocation and this will be repaired operatively within the next several days as an outpatient. In the meantime the extremity was splinted and he will remain non weight bearing through the left hand. His pain was initially controlled with IV narcotics and he was later changed to oral pain medications which were effective. He was advanced to a regular diet for which he tolerated. He was able to ambulate independently. Social work was consulted and followed along with patient during his hospital stay. Medications on Admission: Percocet, zoloft Discharge Medications: 1. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*80 Tablet(s)* Refills:*0* 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**4-16**] hours as needed for pain. 7. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 6 days. Disp:*24 Capsule(s)* Refills:*0* 8. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's PO twice a day as needed for constipation. 9. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as needed for constipation. Discharge Disposition: Home Discharge Diagnosis: s/p Fall off truck Scalp hematoma and laceration Horizontal C7 spinous process fracture Left frontal intracranial T3 anterior body fracture Left perilunate dislocation Discharge Condition: Hemodynamically stable, tolerating a regular diet, pain adequate controlled. Discharge Instructions: You must continue to wear the hard cervical collar for at least the next 3 months. DO NOT bear any weight on your left hand because of the fracture. Continue with the antibiotics until they are done. Remain in the splint on your left hand until told to remove by Dr. [**Last Name (STitle) **], Orthopedics. Apply Bacitracin to your forehead laceration twice daily. Return to the Emergency room if you develop any fevers, chills, headache, increased weakness/numbness in any of your extremities, shortnes of breath, chest pain, nauseea, vomiting, diarrhea and/or any other sympotms that are concerning to you. Followup Instructions: 1)Follow-up this week with Dr.[**Last Name (STitle) 8689**], Orthopedics after discharge for surgical repair of your left hand fracture. Call [**Telephone/Fax (1) 1228**] for an appointment. 2)Follow up in 3 months with Dr. [**Last Name (STitle) 63264**], Neurosurgery for your spine fracture. Call [**Telephone/Fax (1) 1669**] for an appointment. Inform the office that you will need a repeat CT scan of your cervical spine for this appointment. 3) Follow up with Plastic Surgery this week for your forehaed laceration; call [**Telephone/Fax (1) 5343**] for an appointment. 4)Follow up with your primary care doctor within the next [**1-13**] weeks for a general physical. Completed by:[**2164-3-28**]

[ "805.07", "E884.9", "852.00", "833.09", "805.2", "873.42" ]

icd9cm

[ [ [] ] ]

[ "86.59", "79.73", "39.98" ]

icd9pcs

[ [ [] ] ]

4972, 4978

2908, 4015

333, 381

5190, 5268

1625, 2885

5930, 6638

698, 715

4082, 4949

4999, 5169

4041, 4059

5292, 5907

730, 732

275, 295

409, 568

747, 1197

1212, 1606

590, 657

673, 682

73,648

169,972

1619

Discharge summary

report

Admission Date: [**2123-8-19**] Discharge Date: [**2123-8-25**] Service: MEDICINE Allergies: Sulfonamides / Xanax / Tetracyclines / Erythromycin / Tetanus Antitoxin / Morphine / Isosorbide Attending:[**First Name3 (LF) 4071**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Cardiac Catheterization Mitral Valve Annuloplasty Intubation History of Present Illness: **As obtained from patient, patient's son and [**Name (NI) **] records** [**Age over 90 **] yo F with past history of aortic stenosis, CAD s/p CABG x3 (LIMA to LAD, SVG to RCA, SVG to OM) and s/p LMCA and PCxA stent, CHF, bronchiectasis, obstructive sleep apnea, HTN, hyperlipidemia, who presents with progressive dyspnea following discharge from this hospital on [**2123-8-14**]. She was on room air upon discharge and saturations were ~92%; however, she reports that she has been on oxygen "day and night" and presented to the ED with 3L nasal cannula for supplemental O2. Patient reports that she has been dyspneic with any movement in the last few days. Only [**Doctor Last Name **] she is perfectly still will she breath comfortably. Patient reports that her sputum production had changed from white sputum early in the week to dark brown sputum later in the week with some episodes of hemoptysis. Her son reports several days of low grade fevers. She reports being very fatigued currently as in such state has a hard time relaying the history in the past week. She feels that her memory has suffered during her recent illness. [**Name (NI) **] son states that during an office visit with Dr. [**Last Name (STitle) **] yesterday they had discussed valvuloplatsy and percutaneous aortic valves. When I asked the son about patient's weight gain since leaving the [**Last Name (STitle) **], she had only gained 0.4 pounds since discharge on [**2123-8-14**]. In the ED, the patient was afebrile with vitals prior to transfer of T 97.9, BP 121/63, HR 71, RR 18, O2sat 95% 3L NC. Had a chest xray in the ED that was consistent with pulmonary edema; however, underlying pneumonia could not be ruled out. Patient was subsequently given Levofloxacin 750 mg IV. Patient also received 20 mg IV lasix while in the ED, but there is no documentation of a response in urine output to that dose. Was guaiac negative in the ED. REVIEW OF SYSTEMS: General: (+)ve: cough, hemoptysis, fevers (-)ve: stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac: (+)ve: chest pain, dyspnea on exertion, orthopnea (sits up to sleep in hospital bed) (-)ve: paroxysmal nocturnal dyspnea, ankle edema, palpitations, syncope, presyncope Past Medical History: Cardiac History: CABG: [**2111-3-18**] LIMA to LAD, SVG to RCA, SVG to OM Percutaneous coronary intervention: [**2117-2-1**] Anatomy: Right dominant system. Native three vessel coronary artery disease. Widely patent SVG-OM, SVG-RCA, and LIMA-LAD. Intervention: Successful rotational atherectomy, PTCA, and stent of the LMCA and proximal circumflex artery was performed with a 1.75 mm Rotaburr and a 4.0 x 18 mm Bx Velocity Hepacoat postdilated to 4.5 mm Pacemaker/ICD: Generator change in [**2121-4-2**] [**Company 1543**] EnRhythm dual chamber pacemaker in DDI mode indicated for tachy-brady syndrome Other Past History: 1) Severe osteoarthritis s/p knee replacement 2) tachy-brady syndrome 3) Bronchectasis/COPD 4) TIAs 5) Duodenal ulcer 6) s/p TAH and BSO 7) Cholecystectomy in [**2111-9-25**] for crescendo biliary colic 8) Bilateral mastectomies 9) Cystocele 10) Rectocele repairs 11) Tonsillectomy as a child 12) History of peptic ulcer disease 13) Deep venous thrombosis in her right leg after childbirth 14) Bilateral cataract surgery Social History: Social history is significant for approximately a 10 pack-year smoking history with last use during World War II. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS: T 97.7, BP 134/73, HR 74, 22, 98% 3L Gen: Elderly female appears tachypneic. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. Pupils are unequal with OD aniscoria, but both pupils are reactive to light, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with indistinguishable JVP due to prominent carotid pulsation and accessory muscle use during respiration. CV: RR, normal S1, soft S2. III/VI SEM at RUSB radiation to carotids. No thrills, lifts. No S3 or S4. No delay in carotid upstroke. Chest: Pectus carinatum and kyphosis. Tachypneic with accessory muscle use in the neck. Patient has crackles [**12-27**] the way up both posterior lung fields. Minimal dullness to percussion at bases. Crackles clear slightly with cough. Abd: BS+, obese, soft. No abdominial bruits. Large territories of tender abdominal ecchymoses in distribution of heparin injections. Ext: Trace edema on the left. 1+ pitting edema on the right. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Superior to the left groin is an area of redness beneath the left pannus. Neuro: Patient names the months backwards with good fluidity and speed. Strength is equal bilaterally and [**3-29**] at shoulders, elbows, wrists, hands. [**2-27**] at hips and knees. Pulses: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: 2D-ECHOCARDIOGRAM ([**2123-8-11**]): [**Location (un) 109**] by plannimetry 0.7cm2. The left atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 40-45 %) with inferior akinesis. There is no ventricular septal defect. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is severe mitral annular calcification. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. LABORATORY DATA: Na 138, K 3.5, Cl 102, HCO3 23, BUN 26, Cr 1.3, Gluc 224 Ca: 7.8 Mg: 1.8 P: 6.1 D WBC 12.9, Hb 10.6, Hct 29.9, Plt 172 ---N:92.1 L:5.4 M:1.3 E:1.1 Bas:0.1 PT: 14.2 PTT: 28.8 INR: 1.2 ABG: pH 7.46, pCO2 39, pO2 186, HCO3 29 STUDIES: CATH [**2123-8-20**]: 1. Three vessel coronary artery disease. 2. Patient [**Name (NI) 9389**], SVG-OM, SVG-Acute marginal 3. Critical aortic stenosis treated with balloon valvotomy 4. Severe calcification and tortuosity of aorta. 5. Hypotension due to large groin bleed with likely vagal reaction superimposed successfully treated. TTE [**2123-8-23**]: The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with inferior akinesis. There is no ventricular septal defect. Right ventricular chamber size is normal. with borderline normal free wall function. The aortic arch is mildly dilated. The aortic valve leaflets are severely thickened/deformed. There is moderate to severe aortic valve stenosis (area 0.8-1.0cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is severe mitral annular calcification. An eccentric, posteriorly directed jet of moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2123-8-11**], the mean aortic valve gradient is lower, and the degree of MR and AR are less. Cardiac output has increased. Brief Hospital Course: #. Dyspnea: Attributed to acute on chronic systolic and diastolic heart failure in the setting of severe aortic stenosis and recent measured EF of 40-45% with inferior akinesis. Patient had crackles [**12-27**] the way up both posterior lung fields and a radiographic appearance of pulmonary edema. Her exam and CXR were both worse than upon [**2123-8-14**] discharge. BNP was measured at ~[**Numeric Identifier 3301**] in the ED. Less likely is a pneumonia developing in the setting of bronchiectasis and recent hospitalization; however, the patient was afebrile and without an elevated white count or convincing radiographic appearance of pneumonia. Received levofloxacin X1 in the ED. Was slowly diuresed and then went to cath lab for valvuloplasty. After sheath pulled had hypotensive episode requiring intubation and pressors. She was sent to the CCU. In the CCU patient was transfused 2 units of pRBCs and given fluids. She was slowly weaned off pressors and extubated. She was tranferred back to the floor where diuresis to euvolemia was acheived with chlorothiazide (500mg IV) and lasix (80mg IV). She continued to receive home pulmonary regimen of combivent, flovent, and guaifenisen and her dyspnea slowly resolved. By discharge she was no longer requiring O2 during the day and was on her home CPAP regimen at night. She will continue on home regimen of 60mg lasix orally daily. #. CAD: Extensive history of CAD with prior CABG and cardiac catheterization with coronary intervention in [**2116**]. No documented cardiac cath since that time. Chance that new ECHO finding of inferior akinesis at last hospitalzation could be attributed to coronary event. Repeat cath here showed no significant disease in CABG grafts and three vessel coronary disease. No interventions were performed. Patient was continued on asa, plavix, beta blocker, statin. #. Rhythm: Had VT in cath lab and had to be defibrillated. After this episode had no further events on tele. #. Anemia: Hct was low throughout admission likely [**12-26**] hematoma from heparin SC at OSH. She was transfused 2 units in setting of hypotension in CCU. A few days later her hct had continued to trend down and she was transfused another unit of pRBCs with hct to 27. Iron studies were not helpful as were taken after 2 units of pRBCs transfused. The hct was 27 and stable on discharge. She will have follow up hcts drawn at [**Hospital1 1501**] in [**11-25**] days to ensure no further decrease. . #. GERD: continued home pantoprazole 40 mg [**Hospital1 **] #. OSA: Continued home CPAP at night #. Osteoarthritis: Continued home Tylenol arthritis #. HTN: Patient's beta blocker was decreased in setting of hypotension post-cath. She was maintained on 25mg metoprolol [**Hospital1 **] while hospitalized. As outpatient she may need titration of this medication. #. FEN: - Follow and replete electrolytes in setting of active diuresis. - Cardiac diet. - No IVF at present. #. Access: - PIV #. PPx: - PO diet - Bowel regimen - Heparin subcutaneous #. Code: Extensive discussion with patient and her son, [**Name (NI) **], who is her health care proxy. [**Name (NI) **] desires to be DNR/DNI and understands the implications of that decision. Will document this in the medical record. This decision may be temporarily reversed for procedures. #. Communication: Son, [**Name (NI) **], is a pharmacist at [**Hospital1 18**] Medications on Admission: 1) Heparin (Porcine) 5,000 unit/mL TID 2) Simethicone 80 mg Tablet PO TID W/MEALS 3) Aspirin 81 mg PO DAILY 4) Ipratropium-Albuterol 18-103 mcg Two Puff Q6H 5) Pantoprazole 40 mg Tablet PO Q12H 6) Metoprolol Tartrate 50 mg [**Hospital1 **] 7) Calcium Carbonate 500 mg daily 8) Fluticasone 110 mcg Two Puff [**Hospital1 **] 9) Ascorbic Acid 500 mg daily 10) Loratadine 10 mg daily 11) Clopidogrel 75 mg daily 12) Ferrous Sulfate 325 mg PO daily 13) Folic Acid 1 mg daily 14) Nitroglycerin 0.2 mg/hr Patch Q24H 15) Multivitamin PO DAILY 16) Docusate Sodium 100 mg TID 17) Azelastine 137 mcg Aerosol [**Hospital1 **] 18) Tylenol Arthritis 650 mg Tablet SR PO BID 19) Lovastatin 40 mg QHS 20) Guaifenesin SR 600 mg [**Hospital1 **] 21) Furosemide 60 mg daily Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Lovastatin 20 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). Disp:*30 Tablet(s)* Refills:*2* 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. 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* 6. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Tablet, Chewable(s)* Refills:*2* 7. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Tylenol Arthritis Pain 650 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). Disp:*60 Tablet Sustained Release(s)* Refills:*2* 9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Loratadine 10 mg Tablet Sig: One (1) Tablet PO daily (). Disp:*30 Tablet(s)* Refills:*2* 11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 14. Azelastine 137 mcg Aerosol, Spray Sig: One (1) Nasal [**Hospital1 **] (2 times a day). Disp:*1 tube* Refills:*2* 15. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 16. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 20. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 21. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO once a day. Disp:*90 Tablet(s)* Refills:*2* 22. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for intertriginous rash. Discharge Disposition: Extended Care Facility: [**Location (un) 5481**] [**Hospital1 1501**] Discharge Diagnosis: Aortic stenosis Abdominal hematoma Hypotension Acute renal failure from heart failure Acute on chronic systolic heart failure Anemia Discharge Condition: The patient was afebrile, hemodynamically stable, with stable hematocrit before discharge. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 2L You were admitted to the hospital for worsening shortness of breath. This was because of your thickened valve in your heart. You had a surgery on this valve to fix it. During this procedure you had a low blood pressure and needed to have a tube put down your throat to help you breathe. You were given blood to help with your blood pressure and the tube was removed the next day. Your shortness of breath is better after the surgery. Medication Changes: STOP: Heparin START: Lactulose 30mL PO three times daily for constipation CHANGE: Metoprolol 25mg PO twice daily (instead of 50mg twice daily) STOP: Nitro patch CHANGE: Aspirin 81mg daily to Aspiring 325mg daily START: Senna 1 tab twice daily for constipation START: Bisacoydl 10mg by mouth or per rectum daily as needed for constipation START: Miconazole powder to intertrigonous areas twice daily as needed You should call your doctor or come back to the emergency room if you experience light-headedness, dizziness, fainting, blood in your stools or black tarry stools, chest pain, palpitations, nausea, vomiting, severe sweating, worsening shortness of breath, weight gain, or extreme fatigue. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 2450**] ([**Telephone/Fax (1) 1408**]) on [**2123-9-1**] at 11:30am. He should check your weight, blood counts, and kidney function. Please follow up with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 5068**] ) on Tuesday [**2123-8-31**] at 10:15. He should check your weight and heart function and make any change he feels necessary to your medications. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4074**] Completed by:[**2123-8-25**]

[ "584.9", "414.00", "424.1", "428.21", "530.81", "494.0", "272.4", "V45.81", "715.90", "428.0", "486", "401.9", "424.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

15068, 15140

8282, 11681

311, 373

15317, 15410

5608, 8259

16736, 17269

4110, 4192

12486, 15045

15161, 15296

11707, 12463

15434, 15992

4207, 5589

2340, 2823

16012, 16713

264, 273

401, 2321

2845, 3924

3940, 4094

852

133,664

45511+45512

Discharge summary

report+report

Admission Date: [**2156-4-2**] Discharge Date: [**2156-4-6**] Date of Birth: [**2108-5-5**] Sex: M Service: SURGERY Allergies: Percocet Attending:[**First Name3 (LF) 301**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: V-Q scan dopplers of lower extremities History of Present Illness: Pt is a 47y/o M who presents 10 days after his open Roux-en-Y gastric bypass with a complaint of chest pain. Pt was recovering at home when he put his abdominal binder back on and felt pain that started in his earlobes and migrated down to involve his arms, throat, and chest ending in his epigastrum. He noted he felt a little short of breath at the time and went to the ED. No fevers, chills, nausea, vomiting. Past Medical History: 1. Asthma 2. Bronchitis 2. HTN 3. Morbid obesity, s/p open Roux-en-y Gastric bypass Social History: quit tobacco [**2154**], 30 pack-year history social EtOH no other drug use Family History: NC Pertinent Results: [**2156-4-2**] 04:46PM LACTATE-2.6* [**2156-4-2**] 04:20PM GLUCOSE-123* UREA N-13 CREAT-1.0 SODIUM-137 POTASSIUM-4.4 CHLORIDE-96 TOTAL CO2-25 ANION GAP-20 [**2156-4-2**] 04:20PM CK(CPK)-164 [**2156-4-2**] 04:20PM cTropnT-<0.01 [**2156-4-2**] 04:20PM CK-MB-2 [**2156-4-2**] 04:20PM CALCIUM-9.3 PHOSPHATE-3.9 MAGNESIUM-2.0 [**2156-4-2**] 04:20PM WBC-15.2* RBC-4.92 HGB-15.1 HCT-44.3 MCV-90 MCH-30.8 MCHC-34.2 RDW-13.6 [**2156-4-2**] 04:20PM PLT COUNT-552*# [**2156-4-2**] 04:20PM PT-13.2* PTT-24.2 INR(PT)-1.1 Brief Hospital Course: Pt was admitted to the surgical service with a chief concern of MI, PE, or leak. Pt went from the ED into the SICU given his presentation with chest pain and his recent surgery. Due to his body habitus, a conventional GUI with flouroscopic visualization is impossible, as is a CTA to evaluate for PE. A VQ scan was performed which was read as low probability, but severely limited due to body habitus. A conventional CXR was also performed which revealed bibasilar atelectasis, but no evidence of pleural effusion, or pneumothorax. A modified UGI was performed using multiple CXRs to replace the video floroscopy and this showed no evidence of leak or obstruction. Pt's chest pain persisted in the ICU and an EKG revealed that there were significant ST segment elevations and pr segment depressions concerning for pericardial process. Due to the still high concern for pulmonary process, pulmonology was consulted, who recommended CPAP (which the pt had previously been supplied, but doesn't really use at home), and they suggested a 2D echo. An echo was performed which revealed a trivial to very small pericardial effusion, and a repeat ECG showed markedly less st and pr segment abnormalities. Given the pt's recent gastric surgery and the possibility of NSAID induced gastritis, the pt was discharged home on HD 5 with roxicet and tylenol to manage his now improved chest pain. Discharge Medications: 1. Ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) ml PO BID (2 times a day). Disp:*600 ml* Refills:*2* 2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. Disp:*150 ML(s)* Refills:*0* 3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Diazepam 5 mg Tablet Sig: One (1) Tablet PO q6h prn as needed for back spasm. Disp:*20 Tablet(s)* Refills:*0* 7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. Disp:*5 Tablet(s)* Refills:*0* 8. Chewable Multi Vitamin Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. Disp:*30 Tablet, Chewable(s)* Refills:*2* 9. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. Disp:*1 inhaler* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Post operative abdominal pain Atelectasis Discharge Condition: stable Discharge Instructions: If you experience clear drainage from your wounds, cover them with a clean dressing and stop showering until the drainage subsides for at least 2 days. No heavy lifting or exertion for at least 6 weeks. No driving while taking pain medications. Narcotics can cause constipation. Please take an over the counter stool softener such as Colace or a gentle laxative such as Milk of Magnesia if you experience constipation. You should continue your [**Month/Day/Year **] stage 4 diet. You may take showers (no baths) after your dressings have been removed from your wounds. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in a week. His office number is: [**Telephone/Fax (1) 9000**]. You should see him in a week. Admission Date: [**2156-4-8**] Discharge Date: [**2156-4-10**] Date of Birth: [**2108-5-5**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 301**] Chief Complaint: nausea and vomiting Major Surgical or Invasive Procedure: none History of Present Illness: 47M POD 19 from open roux en y gastric bypass surgery with CCY now presents with nausea and vomiting. He was recently discharged with a diagnosis of pericarditis after presenting with chest pain. He was discharged [**4-6**] from that admission and states that since getting home he has been taking in only liquids with a very small amount of oatmeal. He began to have emesis [**4-7**] and has been dry heaving since that time. Past Medical History: 1. Asthma 2. Bronchitis 2. HTN 3. Morbid obesity Social History: quit tobacco [**2154**], 30 pack-year history social EtOH no other drug use Family History: NC Physical Exam: 97.8 89 152/73 20 96%RA Alert, oriented, no acute distress Anicteric Lungs clear to auscultation bilaterally Regular rate/rhythm, no rub, S1 S2 Abdomen obese, soft, non-tender, +bowel sounds Wound edges approximated, healin well, mild spotting on gauze, no significant erythema Normal rectal tone, guiaic neg No extremity edema, pedal pulses present Pertinent Results: [**2156-4-7**] 08:25PM BLOOD WBC-13.2* RBC-5.07 Hgb-16.0# Hct-45.4 MCV-90 MCH-31.6 MCHC-35.3* RDW-13.4 Plt Ct-614* [**2156-4-7**] 08:25PM BLOOD Neuts-83.9* Lymphs-11.2* Monos-2.8 Eos-1.3 Baso-0.8 [**2156-4-7**] 08:25PM BLOOD Glucose-123* UreaN-14 Creat-1.1 Na-138 K-4.4 Cl-97 HCO3-26 AnGap-19 [**2156-4-7**] 08:25PM BLOOD ALT-30 AST-27 CK(CPK)-93 AlkPhos-116 Amylase-17 TotBili-0.5 [**2156-4-7**] 08:25PM BLOOD CK-MB-2 cTropnT-<0.01 [**2156-4-7**] 08:25PM BLOOD Albumin-4.3 Calcium-9.8 Phos-3.5 Mg-2.0 RADIOLOGY ABDOMEN (SUPINE & ERECT) [**2156-4-7**] 10:22 PM INDICATION: 47-year-old man with known pericarditis, 14 days post-op from open Roux-en-Y gastric bypass. Eval nausea and vomiting. SUPINE AND ERECT RADIOGRAPHS OF THE ABDOMEN: There is normal abdominal bowel gas pattern. No definite evidence for bowel dilatation is seen. There are no air-fluid levels. The osseous structures appear unremarkable. IMPRESSION: No evidence of bowel obstruction. CHEST (PA & LAT) [**2156-4-7**] 10:22 PM IMPRESSION: No acute cardiopulmonary process. SMALL BOWEL ONLY (BARIUM) [**2156-4-9**] 4:43 PM REASON FOR THIS EXAMINATION: pt too large for fluro swallow study but needs swallow with serial abd x-rays to eval for UGI obstruction. HISTORY: 47-year-old man with known pericardidis 14 days postop from Roux-en-Y gastric bypass, now with nausea. Seven abdominal radiographs including AP, lateral and oblique projections were obtained. The initial radiographs were taken after the administration of oral gastrografin and demonstrate free passage of contrast through the esophagus and into the gastric remnant without evidence of anastomotic leak. Subsequent images were obtained after the administration of thin barium showing normal caliber small and large bowel with rapid transit of barium through to the descending colon in approximately 20 minutes. There is no evidence of obstruction. Surgical clips are noted over the right upper quadrant. Osseous structures are unremarkable. IMPRESSION: No evidence of anastomotic leak or obstruction. Brief Hospital Course: Pt was admitted to the MIS surgical service where he was conservatively managed with IV hydration, stage II diet, prn anzemet and compazine. His levo was changed to IV, and he ws observed. On the night of HD1 he had one episode of dryheaves, but his frequency of vomitting (with the antiemetic regimen) was noted to be dramatically less than the 12 times in one day that he noted on admission. None the less we made him NPO in an attempt to avoid all nausea/wreching on staple lines. A UGI was performed which showed no mechanical abnormality to explain his recurrent nausea. Pt was slowly advanced to a stage III diet (which he was able to tolerate) and was discharged home on HD4. Medications on Admission: Ranitidine 150", Roxicet, montelukast 10', HCTZ 25', Lisinopril 20', diazepam 5q6prn, levo 500' (from prev admission), MVI, Advair inh. Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. 2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 5. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 2 days. Discharge Disposition: Home Discharge Diagnosis: dehydration morbid obesity hypertension obstructive sleep apnea GERD asthma gout bronchitis dyslipidemia Discharge Condition: Good Discharge Instructions: Call your surgeon or go the ER if you experience: -chest pain or shortness of breath -fevers greater than 101.5 degrees, chills -persistent nausea and vomiting -severe abdominal pain -inability to pass gas or stool -redness or foul-smelling drainage at wound Medications: Resume your usual home medications. Complete the antibiotic course (levofloxacin) by taking it through [**4-11**]. Take the Roxicet (oxycodone/acetaminophen liquid) as prescribed for pain. In addition, you will need to take liquid Zantac (acid-reducer) for 2-3more weeks and a chewable multivitamin every day. Diet: Stay on a Stage III diet until follow-up. Do not self-advance your diet. Do not chew gum or drink out of a straw. Activity: You may resume your usual activities. However, you should not lift anything heavier than [**10-17**] lbs for the next 4 weeks. Wound Care: You may shower as you normally would, but no swimming or bathing until after follow-up. Followup Instructions: You have these previously scheduled appointments: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 28351**] Date/Time:[**2156-4-14**] 12:45 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 97101**], MA, RN, LDN Phone:[**Telephone/Fax (1) 28351**] Date/Time:[**2156-4-14**] 1:30 Completed by:[**2156-4-19**]

[ "278.01", "518.0", "535.40", "789.07", "493.90", "780.57", "786.52", "401.9", "530.81", "E935.9", "423.9", "V45.3" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9735, 9741

8326, 9016

5213, 5220

9890, 9897

6253, 7354

10890, 11285

5860, 5864

9202, 9712

9762, 9869

9042, 9179

9921, 10766

5879, 6234

5154, 5175

7383, 8303

10778, 10867

5248, 5678

5700, 5750

5766, 5844

518

120,954

44014

Discharge summary

report

Admission Date: [**2109-3-26**] Discharge Date: [**2109-3-29**] Date of Birth: [**2062-9-18**] Sex: M Service: MEDICINE Allergies: Clindamycin Attending:[**First Name3 (LF) 2186**] Chief Complaint: Shortness of breath and HTN Major Surgical or Invasive Procedure: none History of Present Illness: 46 y/o Ethiopian male with a h/o T1DM, HIV, ESRD, and peripheral neuropathy who presented to the ED with SOB, cough, and pleuritic chest pain. Pt states that he was in his usual state of health until he developed a fever (temp to 102 at home), pleuritic chest pain, and SOB the night prior to admission. He reports URI symptoms over the past 6 days. His last HD session was the day prior to admission with removal of over 2L of fluid. Pt was evaluated in the ED. Of note, he had not taken his medications prior to admission. . Upon arrival to the ED, vitals were T 99.7 HR 70 BP 227/104 RR 16 and 98%RA. He was given Metoprolol 5 mg IV x 1 and hydralazine 10 mg IV x 1. He was also given cefepime 2 grams IV and vancomycin 1 g IV. He was started on a Nipride gtt for BP control and transferred to the MICU hemodynamically stable. . In ICU, he was monitored and continued on nipride gtt for BP control. Renal was consulted and he had HD with 3.5 UF. He was also found to have a multifocal pneumonia by CT scan and Abx changed to vanco/levo. ID was consulted. When off nipride, he was then transferred to medical floor. . On the floor, he currently has no complaints except that cough may be worsening. He denies any fevers, chills, nausea, vomiting, pain. Pt in middle of changing dwell for PD and wished to defer further discussion. Past Medical History: - Type 1 diabetes - HIV (boosted atazanavir, lamivudine, stavudine), dx'd [**2096**] - ESRD on HD, planned change to peritoneal dialysis in near future, on transplant list (clinical study for HIV/solid organ transplant) - Recent hospitalizations for Serratia bacteremia (presumed source AV graft) most recently treated with 6 week course meropenem - History of schistosomiasis - Restless leg syndrome - Peripheral neuropathy on gabapentin - S/p cholecystectomy Social History: Moved from [**Country 4812**] in [**2091**]. Lives with wife in [**Location (un) 538**]. Works in support services for a law firm. Denies any alcohol or IV drug use. Quit smoking last year; previous 30 pack-year history. Family History: Non-contributory. Physical Exam: T 98.9 HR 82 BP 197/98 RR 12 98% 2L NC General: WD/WN 46 y/o male in NAD. HEENT: NC/AT. PERRLA. EOMI. MMM. OP clear. Neck: No LAD or JVD. CV: Normal S1, S2 without m/r/g. Pulm: CTAB without wheezes or crackles. Abd: Soft, ND, mild diffuse tenderness. Normoactive BS. Ext: No c/c/e. Neuro: CNs II-XII grossly intact. A/O x 3. Skin: No rash Pertinent Results: CT Chest: IMPRESSION: 1. No pulmonary embolism is seen. 2. Diffuse peribronchiolar opacities within both lungs that suggest infectious etiology. 3. Small bilateral pleural effusion which is associated with left lower lobe atelectatic changes. . Labs on discharge: [**2109-3-29**] WBC-6.2 RBC-3.56* Hgb-12.8* Hct-37.1* MCV-104* MCH-35.8* MCHC-34.4 RDW-15.3 Plt Ct-241 Glucose-115* UreaN-45* Creat-9.4*# Na-137 K-4.2 Cl-95* HCO3-30 Brief Hospital Course: # SOB/PNA: Etiology most likely [**1-11**] to PNA and possible volume overload due to missing HD; his SOB has improved after removing 2L from HD. On CT chest, he was noted to have diffuse bronchial opacities concerning for infection. In ED, he was started on vanc and cefepime. In MICU, continued vanc (dose based on level and re-dose at HD) and started levofloxacin to cover for CAP and possible HAP given recent admission in [**1-16**]. ID was consulted and felt this was reasonable and low suspicion for other infectious etiologies. Rapid resp panel was negative. He was discharged on a course of PO levofloxacin (10 day course) . # HTN: Pt admitted with HTN urgency requiring nipride gtt likely [**1-11**] to not taking BP meds for 2 doses prior to admission. Once in MICU, he was weanned off nipride gtt and transitioned back to home HTN meds. For the remainder of hosp course, he was normotensive. . # HIV: Followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] as outpatient. Recent viral load and CD4 count 393 (and in this range in 1/[**2107**]). He continued his outpatient antiretroviral regimen. On discharge, he will have close follow-up with Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 9404**]. . # ESRD: Currently attempting to transition pt to PD but pt has been noncompliant with teaching. he continuied on his home HD schedule with outpatient plans to transition to PD. . # T1DM: No active issues. He re-started home insulin regimen and covered with RISS (on regular at home) . # FEN - renal, diabetic, cardiac healthy diet - monitor lytes . # Access - Right HD catheter - PIV . # Code - full code Medications on Admission: Gabapentin 100 mg tid Atenolol 50 mg PO daily Compazine PRN Insulin (NPH 10 U [**Hospital1 **] and Regular 5 U QAM) Lamivudine 250 mg PO after HD on HD days Atazanavir 300 mg PO QD Ritonavir 100 mg PO DAILY Stavudine 20 mg PO QHD DAYS after HD Ativan PRN Tenofovir 300 mg PO QSAT Discharge Medications: 1. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO QSATURDAY (). 3. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 10 days. Disp:*5 Tablet(s)* Refills:*0* 4. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for Insomnia. 7. Lamivudine 10 mg/mL Solution Sig: One (1) PO DAILY (Daily). 8. Stavudine 20 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 9. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 10. Atenolol 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Lanthanum 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 12. Insulin Please continue your home insulin regimen Discharge Disposition: Home Discharge Diagnosis: Primary: pneumonia HIV hypertensive urgency Discharge Condition: stable, normotensive, afebrile Discharge Instructions: You had very high blood pressures and also a pneumonia, which is being treated with antibiotics. . Please call 911 or go to the emergency room if you have any fevers greater than 100.4, chills, nausea, vomiting, shortness of breath, chest pain, or any other concerning symptoms. . Please take all medications as prescribed and attend all follow-up appointments. Followup Instructions: Please attend your appointment with Dr. [**First Name (STitle) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2109-4-1**] 10:10AM in the [**Hospital Ward Name 23**] Building [**Location (un) 453**]. . You also have an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**] on [**4-23**] at 10 AM. The location is [**Last Name (NamePattern1) 439**]. Please call [**Telephone/Fax (1) 457**] if you have any questions. . Please go to your regular dialysis center on Monday for dialysis. You will receive your peritoneal dialysis equiptment from home. . Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2109-5-14**] 9:10 Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name 9406**] Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2109-5-14**] 10:00 Provider:

[ "042", "250.01", "285.9", "585.6", "356.9", "486", "V15.82", "333.94", "V15.81", "403.91" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

6236, 6242

3259, 4914

300, 307

6330, 6363

2804, 3049

6773, 7714

2410, 2429

5245, 6213

6263, 6309

4940, 5222

6387, 6750

2444, 2785

233, 262

3068, 3236

335, 1670

1692, 2155

2171, 2394

13,508

129,323

45316+45317

Discharge summary

report+report

Admission Date: [**2143-6-19**] Discharge Date: [**2143-6-24**] Date of Birth: [**2079-2-22**] Sex: M Service: MEDICAL ICU REASON FOR ADMISSION: Acute on chronic hypercarbic respiratory failure. HISTORY OF PRESENT ILLNESS: This is a 64-year-old male with longstanding obstructive sleep apnea who presents with hypoxemia and acute on chronic hypercarbic respiratory failure. The patient was discharged from [**Hospital6 1760**] on [**2142-12-22**] for chest pain. He was ruled out at that time for myocardial infarction and PE by chest CTA. His oxygen saturations were noted to be 96% on room air. Since being discharged, he has become progressively somnolent. He was referred to have an overnight sleep study two days prior to admission for work-up of his somnolence. At the sleep clinic, he was found to have a resting oxygen saturation of 60-70% on room air, which corrected to the high 90s with a 100% nonrebreather mask. The sleep study was significant for apnea and persistent desaturations. He was referred to the Emergency Room the next morning. In the Emergency Room, he was found to be somnolent with oxygen saturations in the 70s on room air and 80s on six liters nasal cannula. Respiratory rate of 21. He was placed on 100% nonrebreather and arterial blood gas revealed the following: 7.20/109/106. The patient was then set to be admitted to the Medicine Floor for further work-up when he became more somnolent and more difficult to arouse. An arterial blood gas on 1.5 liters nasal cannula revealed the following: 7.17/117/65. Oxygen saturations were 85%. The Medical Intensive Care Unit Team was called to evaluate the patient. Trial of BiPAP was unsuccessful on improving the patient's ventilation, pCO2 improved only marginally after being on BiPAP. Arterial blood gas 7.21/115/82. He was then intubated to further improve his ventilation. REVIEW OF SYSTEMS: No fever, chills, no cough, shortness of breath, chest pain, weight loss, hemoptysis, melena, maroon stools, diarrhea, constipation, dysuria. PAST MEDICAL HISTORY: 1. Obstructive sleep apnea on CPAP 12 years ago. Unclear of intubations in the past. 2. Hypertension. 3. Anxiety. 4. Osteoarthritis - cervical. MEDICATIONS: 1. Multivitamin. 2. Vitamin C. ALLERGIES: No known drug allergies. FAMILY HISTORY: Diabetes, coronary artery disease, no history of cancer. SOCIAL HISTORY: Lives alone in [**Location (un) **] and drinks three to four beers per day. Denies tobacco use. He is a retired police officer. PHYSICAL EXAMINATION: Afebrile. Pulse 68. Respiratory rate 15. Blood pressure 112/58. Oxygen saturations 100% on respirator. In general, he is morbidly obese, thick neck, intubated and sedated. Head, eyes, ears, nose and throat: Sclerae are anicteric. Cannot assess jugular venous pressure due to neck fat. Cardiovascular: Regular rate and rhythm, distant [**Doctor Last Name **] sounds, question split S2,P2. Respiratory: Few crackles in left base, no wheezing. Abdomen: Obese, soft, nontender, no hepatosplenomegaly. Extremities: Trace lower extremity edema, no clubbing. LABORATORIES: Significant for a hematocrit of 56.2, INR of 1.9. All other laboratories were normal. The patient had a chest CT on [**6-19**] which demonstrated 2.4 cm left apical low density nodule that was associated post obstructive collapse which is suspicious for lung cancer. A CT head demonstrated no evidence of intracranial metastases. Chest x-ray showed cardiomegaly, left base atelectasis and pleural effusion. Electrocardiogram was normal sinus rhythm at 80, right bundle branch block with secondary T wave changes. This was new from [**2142-12-22**]. HOSPITAL COURSE: 1. Respiratory failure: The patient only remained intubated over the first night of admission. At first the patient was hyperventilated, but the pCO2 eventually corrected to approximately 65 to 70 which was likely the patient's baseline based on his bicarbonate. His sedation was lightened on the day following intubation and he was extubated with BiPAP support. The patient remained extubated over the rest of his admission and was using BiPAP at night during the rest of his admission. His BiPAP was titrated up over the course of his admission and his BiPAP was at 16 and 10 with O2 of two per liters. The patient was requiring O2 during his entire day which was new from previous. 2. Obstructive sleep apnea: The patient was started on BiPAP as mentioned above 60 and 10. The patient will need further outpatient sleep study following discharge as his previous study was very poor due to his desaturations and marked decompensation. Repeatedly, it was discussed with the patient that weight loss as well as decreased alcohol use would improve his quality of life and probably require him to use less BiPAP and possibly home O2. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] will provide follow-up of his OSA in Sleep Unit at [**Hospital1 18**]. 3. Lung nodule: The patient was found to have an incidental small 2.4 cm lung nodule and was to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 57475**] as an outpatient for further evaluation to determine whether this was a malignancy. 4. Depression and anxiety: In discussion with the patient he appeared to be somewhat depressed during this admission and prior to the admission, he was started on Celexa while in the hospital. 5. Cardiac: The patient had a very small troponin leak of.02. He was ruled out for myocardial infarction by CKs and this was likely secondary to elevated PA pressure and right heart strain for his severe obstructive sleep apnea. To prevent progression of this, the patient needs outpatient treatment for his obstructive sleep apnea. 6. Polycythemia: The patient's hematocrit was quite elevated likely secondary to his hypoxia. On discharge from the Medical Intensive Care Unit, the patient's condition was good. DISCHARGE STATUS: To home with home O2 therapy and BiPAP at night. DISCHARGE FOLLOW-UP PLANS: 1. Lung clinic: [**2143-6-27**] with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Doctor Last Name **] and CT prior to this, as well as breathing test. 2. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 96797**] [**Location (un) 1683**], primary care physician, [**Name10 (NameIs) **] to two weeks. 3. Dr. [**First Name (STitle) **] Normal in Sleep Clinic for another sleep study within one to two weeks. DISCHARGE MEDICATIONS: 1. Celexa 20 mg 1 po q.d. 2. Oxygen 2 liters nasal continuous used during the daytime. 3. BiPAP, EPAP 16, IPAP 10, back up rate 12, titrate O2. Use overnight. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D. [**MD Number(1) 3091**] Dictated By:[**Last Name (NamePattern1) 8141**] MEDQUIST36 D: [**2143-10-15**] 03:36 T: [**2143-10-16**] 15:25 JOB#: [**2165**] Admission Date: [**2143-6-19**] Discharge Date: [**2143-6-24**] Date of Birth: [**2079-2-22**] Sex: M Service: MEDICAL ICU REASON FOR ADMISSION: Acute on chronic hypercarbic respiratory failure. HISTORY OF PRESENT ILLNESS: This is a 64-year-old male with longstanding obstructive sleep apnea who presents with hypoxemia and acute on chronic hypercarbic respiratory failure. The patient was discharged from [**Hospital6 1760**] on [**2142-12-22**] for chest pain. He was ruled out at that time for myocardial infarction and PE by chest CTA. His oxygen saturations were noted to be 96% on room air. Since being discharged, he has become progressively somnolent. He was referred to have an overnight sleep study two days prior to admission for work-up of his somnolence. At the sleep clinic, he was found to have a resting oxygen saturation of 60-70% on room air, which corrected to the high 90s with a 100% nonrebreather mask. The sleep study was significant for apnea and persistent desaturations. He was referred to the Emergency Room the next morning. In the Emergency Room, he was found to be somnolent with oxygen saturations in the 70s on room air and 80s on six liters nasal cannula. Respiratory rate of 21. He was placed on 100% nonrebreather and arterial blood gas revealed the following: 7.20/109/106. The patient was then set to be admitted to the Medicine Floor for further work-up when he became more somnolent and more difficult to arouse. An arterial blood gas on 1.5 liters nasal cannula revealed the following: 7.17/117/65. Oxygen saturations were 85%. The Medical Intensive Care Unit Team was called to evaluate the patient. Trial of BiPAP was unsuccessful on improving the patient's ventilation, pCO2 improved only marginally after being on BiPAP. Arterial blood gas 7.21/115/82. He was then intubated to further improve his ventilation. REVIEW OF SYSTEMS: No fever, chills, no cough, shortness of breath, chest pain, weight loss, hemoptysis, melena, maroon stools, diarrhea, constipation, dysuria. PAST MEDICAL HISTORY: 1. Obstructive sleep apnea on CPAP 12 years ago. Unclear of intubations in the past. 2. Hypertension. 3. Anxiety. 4. Osteoarthritis - cervical. MEDICATIONS: 1. Multivitamin. 2. Vitamin C. ALLERGIES: No known drug allergies. FAMILY HISTORY: Diabetes, coronary artery disease, no history of cancer. SOCIAL HISTORY: Lives alone in [**Location (un) **] and drinks three to four beers per day. Denies tobacco use. He is a retired police officer. PHYSICAL EXAMINATION: Afebrile. Pulse 68. Respiratory rate 15. Blood pressure 112/58. Oxygen saturations 100% on respirator. In general, he is morbidly obese, thick neck, intubated and sedated. Head, eyes, ears, nose and throat: Sclerae are anicteric. Cannot assess jugular venous pressure due to neck fat. Cardiovascular: Regular rate and rhythm, distant [**Doctor Last Name **] sounds, question split S2,P2. Respiratory: Few crackles in left base, no wheezing. Abdomen: Obese, soft, nontender, no hepatosplenomegaly. Extremities: Trace lower extremity edema, no clubbing. LABORATORIES: Significant for a hematocrit of 56.2, INR of 1.9. All other laboratories were normal. The patient had a chest CT on [**6-19**] which demonstrated 2.4 cm left apical low density nodule that was associated post obstructive collapse which is suspicious for lung cancer. A CT head demonstrated no evidence of intracranial metastases. Chest x-ray showed cardiomegaly, left base atelectasis and pleural effusion. Electrocardiogram was normal sinus rhythm at 80, right bundle branch block with secondary T wave changes. This was new from [**2142-12-22**]. HOSPITAL COURSE: 1. Respiratory failure: The patient only remained intubated over the first night of admission. At first the patient was hyperventilated, but the pCO2 eventually corrected to approximately 65 to 70 which was likely the patient's baseline based on his bicarbonate. His sedation was lightened on the day following intubation and he was extubated with BiPAP support. The patient remained extubated over the rest of his admission and was using BiPAP at night during the rest of his admission. His BiPAP was titrated up over the course of his admission and his BiPAP was at 16 and 10 with O2 of two per liters. The patient was requiring O2 during his entire day which was new from previous. 2. Obstructive sleep apnea: The patient was started on BiPAP as mentioned above 60 and 10. The patient will need further outpatient sleep study following discharge as his previous study was very poor due to his desaturations and marked decompensation. Repeatedly, it was discussed with the patient that weight loss as well as decreased alcohol use would improve his quality of life and probably require him to use less BiPAP and possibly home O2. 3. Lung nodule: The patient was found to have an incidental small 2.4 cm lung nodule and was to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] as an outpatient for further CT to evaluate whether this was a growing lung nodule. 4. Depression and anxiety: In discussion with the patient he appeared to be somewhat depressed during this admission and prior to the admission, he was started on Celexa while in the hospital. 5. Cardiac: The patient had a very small troponin leak of.02. He was ruled out for myocardial infarction by CKs and this was likely secondary to elevated PA pressure and right heart strain for his severe obstructive sleep apnea. To prevent progression of this, the patient needs outpatient treatment for his obstructive sleep apnea. 6. Polycythemia: The patient's hematocrit was quite elevated likely secondary to his hypoxia. On discharge from the Medical Intensive Care Unit, the patient's condition was good. DISCHARGE STATUS: To home with home O2 therapy and BiPAP at night. DISCHARGE FOLLOW-UP PLANS: 1. Lung clinic: [**2143-6-27**] with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Doctor Last Name **] and CT prior to this, as well as breathing test. 2. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 96797**] [**Location (un) 1683**], primary care physician, [**Name10 (NameIs) **] to two weeks. 3. Dr. [**First Name (STitle) **] Normal in Sleep Clinic for another sleep study within one to two weeks. DISCHARGE MEDICATIONS: 1. Celexa 20 mg 1 po q.d. 2. Oxygen 2 liters nasal continuous used during the daytime. 3. BiPAP, EPAP 16, IPAP 10, back up rate 12, titrate O2. Use overnight. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D. [**MD Number(1) 3091**] Dictated By:[**Last Name (NamePattern1) 8141**] MEDQUIST36 D: [**2143-10-15**] 03:36 T: [**2143-10-16**] 15:25 JOB#: [**2165**]

[ "518.89", "278.00", "300.00", "780.57", "305.00", "286.9", "416.8", "401.9", "518.84" ]

icd9cm

[ [ [] ] ]

[ "96.71", "93.90", "96.04" ]

icd9pcs

[ [ [] ] ]

9313, 9371

13386, 13817

10699, 12897

9542, 10681

12914, 13363

8896, 9039

7225, 8876

9061, 9296

9388, 9519

9,001

196,303

274+275+55201

Discharge summary

report+report+addendum

Admission Date: [**2147-9-8**] Discharge Date: Service: ADDENDUM: Remove Captopril from the discharge medication list and add Prinivil 40 mg by mouth every day. For the medication Diflucan, change the strength from 400 mg to 100 mg by mouth every day times two more days. Add to follow-up instructions, the patient is to follow-up with Dr. [**Last Name (STitle) **] as an outpatient and she is to follow-up with the [**Hospital1 69**] [**Hospital 2663**] Clinic for an endometrial biopsy. This clinic can be reached at area code [**Telephone/Fax (1) 2664**]. Dictated By:[**Name8 (MD) 2665**] MEDQUIST36 D: [**2147-9-20**] 13:06 T: [**2147-9-20**] 14:48 JOB#: [**Job Number 2666**] Admission Date: [**2147-9-8**] Discharge Date: [**2147-9-20**] HISTORY OF PRESENT ILLNESS: The patient is an 88 year old female with coronary artery disease, congestive heart failure and diabetes mellitus who presented with fever, abdominal pain after being found down at her nursing home. Her history patient is a resident at [**Hospital3 2558**] who was found status post questionable fall the morning of admission and was noted to have a left-sided weakness without head trauma or loss of consciousness. The fall was unwitnessed. Subsequently the patient had a large occult blood positive stool and was also found to have complaints of abdominal pain. At the nursing home the temperature was 102.1 with a pulse of 126, blood in by ambulance to [**Hospital6 256**] Emergency Department for evaluation with a temperature of 103.2, pulse 120, blood pressure 108/40 and respiratory rate of 30 with an oxygen saturation of 94%. In the Emergency Department the patient was found to have an increased respiratory rate. She denied cough, chest pain, shortness of breath, nausea and vomiting or dysuria. She did complain of abdominal pain and diarrhea. The patient is demented at baseline. The patient denied any fevers or chills prior though it is unclear but it is possibly p.o. intake had been decreased for several days. PAST MEDICAL HISTORY: Coronary artery disease, status post congestive heart failure with last admission in [**2144-4-5**] for diastolic heart failure, Type 2 diabetes, dementia, benign positional vertigo, status post cholecystectomy, status post femoral neck fracture on the right with a hemiarthroplasty, chronic anemia with hematocrit of 29 and B12 deficiency. ALLERGIES: Benzodiazepine which causes severe agitation. ADMISSION MEDICATIONS: 1. Multivitamin 2. Enteric coated Aspirin 325 mg p.o. q.d. 3. Lasix 40 mg p.o. q.d. 4. Prinivil 30 mg p.o. q.d. 5. Megace 400 mg p.o. b.i.d. 6. Lopressor 25 mg p.o. b.i.d. 7. Isordil 30 mg p.o. t.i.d. 8. Neurontin 100 mg p.o. q. 6 9. Colace 100 mg p.o. b.i.d. PHYSICAL EXAMINATION: Physical examination revealed a temperature of 103.2, pulse 120, blood pressure 108/40 and respiratory rate of 30 and oxygen saturation of 94%. The patient was an awake, alert, tachypneic elderly white female in mild distress. Pupils were left, surgical, minimally reactive, right reactive. Extraocular muscles grossly intact. Oropharynx, mucous membranes were dry, edentulous. Neck was supple with jugulovenous distension of 10 cm, no lymphadenopathy. Cardiovascular examination, tachycardiac, normal S1 and S2. Lungs with decreased breath sounds bilaterally anteriorly at the bases, otherwise clear to auscultation. Abdomen was diffusely tender with bowel sounds, no masses, no organomegaly and mild distention. Occult blood positive brown stool per the Emergency Department. Back examination, positive costovertebral angle tenderness bilaterally per Emergency Department. Extremities with 1+ pitting bilaterally with no edema. Left hip with 5 cm erythematous abrasion, no pelvic instability, no pain to passive range of motion of the left hip. No abrasions on the upper extremity. Neurological examination, per the Emergency Department, alert answering questions in Russian. Cranial nerves III through XII grossly intact. Left arm, flaccid, no response to pain. Left leg withdraws to pain but also flaccid. LABORATORY DATA: Admission laboratory data revealed a white blood cell count 17.1, hemoglobin 10.0, hematocrit 30.0, platelets 346,000. PT was 12.2, PTT 19.1, INR 1.0. 100 white blood cells on urinalysis. Glucose was 308, BUN 74, creatinine 2.1, sodium 148, potassium 5.8, chloride 113, bicarbonate 12, ALT 54, AST 125, CK 6,163, alkaline phosphatase 53, total bilirubin 0.5, CK MB 84. Albumin 3.8, calcium 9.1, phosphorus 6.3, magnesium 2.7. Cardiac troponin greater than 50. Base x-ray on [**9-8**] revealed a right lower lobe opacity with atelectasis and probable pneumonia. Computerized tomography scan on [**9-8**] revealed no evidence of acute intracranial hemorrhage. Computerized tomography scan of the abdomen on [**9-8**] revealed a small right pleural effusion with bibasilar atelectasis right greater than left with dense vascular calcification. There was a large hiatal hernia, nonspecific large bowel wall thickening without stranding or pneumatosis which could not exclude bowel ischemia, probable sacral myelocele was there as well. Computerized tomography scan of the cervical spine on [**9-8**] revealed degenerative joint disease without evidence of acute fracture. HOSPITAL COURSE: The patient was admitted to the Medicine Intensive Care Unit. Given her high troponin levels, Cardiology was seen in consultation and they felt that it was not appropriate to cardiac catheterize the patient at that time. Given her history of large bloody stool, the patient was not deemed a candidate for heparinization either. She was maintained on Aspirin, Beta blocker and as lytes improved an ACE inhibitor was added as well. During her course in the hospital the patient did continue to have transient chest pain which was often relieved by Nitroglycerin but no electrocardiogram changes were found. Some episodes of chest pain did have to be treated with 1 mg of intravenous morphine. The patient was placed on Nitropaste to provide longterm pain relief and the patient's episodes of chest pain subsided. Infectious Disease - The patient was seen to have probable sepsis with several possible etiologies including the possibility of ischemic bowel as indicated by the computerized tomography scan as above, infectious colitis and urosepsis. The patient was treated with antibiotics and a Surgery consultation was obtained. The patient was taken to the Operating Room on [**9-9**] for an exploratory laparotomy to rule out ischemic bowel and it was ruled out by this procedure. Please see the operative note dictation for further details of this procedure. To continue the workup of her diarrhea, the patient received stool cultures which were all negative and Clostridium difficile cultures which were negative times three. The patient's diarrhea continued and ultimately it was felt that possibly the diarrhea was caused by her antibiotics. After an acceptable course of antibiotic therapy for her urosepsis and pneumonia these were discontinued and the diarrhea did resolve. The patient did receive a transfusion of 4 units of packed red blood cells over her stay in the hospital due to a low hematocrit and her history of coronary artery disease and recent myocardial infarction. Renal - The patient did have acid based abnormalities with a respiratory alkalosis and metabolic acidosis likely lactic acidosis secondary to sepsis with an anion gap. There was no evidence of ketones. Electrolytes and bicarbonate were administered to adjust the patient's electrolyte status. The patient's renal failure was attributed to prerenal azotemia and she was hydrated to relieve this. Electrolyte adjustment continued throughout her stay in the Medicine Intensive Care Unit as well as her stay on the floor. Neurologic - The patient was considered as possibly having had a cerebrovascular accident. Computerized tomography scan in the Emergency Department was negative for any new ischemia. It was felt that sepsis and/or ischemia may be unmasking left-sided weakness. The patient was followed with a repeat computerized tomography scan and was seen by the Neurology Consult Service. The patient's weakness did resolve. No further workup ensued at this point. Gastrointestinal - The patient was admitted with bloody diarrhea as described above. The workup above was undertaken and in addition further computerized tomography scans were obtained after the patient was transferred from the Medicine Intensive Care Unit to the General Medical Floor because of ongoing diarrhea. One of these abdominal computerized tomography scans revealed a small well circumscribed lesion in the pancreas. The patient's lipase was elevated. The question was raised as to whether or not the patient may be experiencing pancreatitis and the patient was maintained on a BRAT diet, lipase levels declined. It was felt that this may be contributing to the patient's abdominal complaint. An abdominal ultrasound on [**9-19**] revealed no additional changes in this lesion. Eventually the patient's diarrhea declined. Genitourinary - One of the aforementioned computerized tomography scans also revealed a fluid-filled uterus. To workup this discovery a transvaginal ultrasound was undertaken which revealed a uterine stripe of 0.45 cm. This was reviewed with the Gynecology Consult Service and they recommended the patient have an outpatient uterine biopsy. They felt that there were no urgency to working up this problem at this time. With respect to the above issues, the patient's status gradually improved. CKs continued to trend down. Lipase trended down. Electrolytes improved. Diarrhea subsided. The patient was also seen by the Speech and Swallow Service who felt that the patient could tolerate ground food given her swallowing problems. The patient also developed a urinary tract infection with yeast. This was treated with Diflucan. On [**2147-9-20**], the patient was deemed stable for discharge back to the [**Hospital3 2558**] Nursing Home. DISCHARGE INSTRUCTIONS: The patient should continue a ground diet with thick liquids to resume physical therapy as tolerated. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q.d. 2. Multivitamin 1 tablet p.o. q.d. 3. Protonix 40 mg p.o. q.d. 4. Nystatin Swish and Swallow 46 ml p.o. q.i.d. 5. Lopressor 100 mg p.o. t.i.d. 6. Captopril 37.5 mg p.o. t.i.d. 7. Diflucan 400 mg p.o. q.d. to complete a four day course FINAL DIAGNOSIS: 1. Myocardial infarction 2. Left-sided weakness 3. Lactic acidosis 4. Pancreatitis 5. Pneumonia 6. Urosepsis 7. Diarrhea, unknown origin [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2667**], M.D. [**MD Number(1) 2668**] Dictated By:[**Name8 (MD) 2665**] MEDQUIST36 D: [**2147-9-19**] 14:04 T: [**2147-9-19**] 16:17 JOB#: [**Job Number 2669**] Name: [**Known lastname 286**], [**Known firstname 287**] Unit No: [**Numeric Identifier 288**] Admission Date: [**2147-9-8**] Discharge Date: Date of Birth: [**2059-9-6**] Sex: F Service: ADDENDUM: MEDICATIONS: Isordil 30 mg po tid and Regular Insulin sliding scale fingersticks to be done four times daily; if blood sugar less than 60 give [**Location (un) 289**] juice, if blood sugar 61-150 give 0 units of regular insulin subcu, if 151-200 give 1 unit of regular insulin subcu, if 201-250 give 2 units of regular insulin subcu, if 251-300 give 3 units of regular insulin subcu, if 301-350 give 5 units of regular insulin subcu, if 351-400 give 6 units of regular insulin subcu. DISCHARGE INSTRUCTIONS: Flush PICC line daily with 2 cc of Heparin 100 units per cc and 10 cc of normal saline. Change PICC line dressing q Saturday. [**First Name11 (Name Pattern1) 126**] [**Last Name (NamePattern4) 290**], M.D. [**MD Number(1) 291**] Dictated By:[**Name8 (MD) 292**] MEDQUIST36 D: [**2147-9-20**] 13:16 T: [**2147-9-20**] 14:51 JOB#: [**Job Number 293**]

[ "553.00", "577.0", "584.9", "599.0", "486", "428.0", "410.11", "041.4", "276.2" ]

icd9cm

[ [ [] ] ]

[ "54.11", "54.21" ]

icd9pcs

[ [ [] ] ]

10254, 10525

5328, 10103

10542, 11672

11697, 12087

2494, 2764

2787, 5310

809, 2047

2070, 2471

5,772

112,403

49691

Discharge summary

report

Admission Date: [**2168-2-11**] Discharge Date: [**2168-3-5**] Date of Birth: [**2106-1-30**] Sex: F Service: MEDICINE Allergies: Zestril / Coumadin Attending:[**First Name3 (LF) 2145**] Chief Complaint: Dyspnea on exertion and lower extremity edema Major Surgical or Invasive Procedure: medical intensive care unit (MICU) monitoring History of Present Illness: This is a 62 year old female with history of pulmonary embolus in [**2160**] treated with heparin/coumadin complicated by large retroperitoneal bleed from a supratherapeutic INR, diastolic congestive heart failure, diabetes [**Year (4 digits) **], obstructive sleep apnea on Bipap who presents with increased dyspnea on exertion. One day prior to admission, she had increase in weight of 2 lbs and increasing lower extremity edema to mid leg bilaterally. On day of admission she had a 10 lb increase in weight and today her dypsnea on exertion became severe, her balance was off, she felt lightheaded/dizzy with standing. Patient denies chest pain or fever. She admits to a chronic cough with increased sputum production and phlegm over the past several weeks. She also notes right scapula pain with inspiration over the past several weeks. She sleeps with bed elevated and has cpap machine at home. She has urinary incontinence and thinks she has had worsened symptoms recently. Past Medical History: 1. Pulmonary emboli ([**2160**]) status post IVC filter secondary to retroperitoneal bleed on coumadin; Sadddle embolus ([**2168**]) 2. Thoracic osteomyelitis status post 6 week treatment with vancomycin. Also concern for underlying tumor that is being worked up. 3. Insulin dependent diabtes complicated by neuropathy and retinopathy. 4. Congestive heart failure recently diagnosed per patient. Echocardiagram during this admission does not demonstrate any heart failure. 5. Chronic lower extremity edema 6. Obesity 7. Right foot ulcers 8. Fibromyalgia 9. Osteoarthritis, left knee status post "injection" and prior knee surgery [**72**]. multiple surgeries: appendectomy, cholecystectomy (ex lap), partial hysterectomy 11. Obstructive sleep apnea on BIPAP at night 13. L4-5 herniated disc, status post steroid injections Social History: She quit smoking 23 years ago - she started at age 13 with 1 pack per day and then increased to 2-3 packs per day until she quit. She denies alcohol. She lives at home with a [**Doctor Last Name **] child who is 20 years old. She has cleaning lady. She walks independantly. Family History: Her brother had a stroke at age 65. There is a family history of diabetes, hypertension, and Multiple sclerosis. Physical Exam: Vitals: Temperature:98.9 Pulse:79 Blood pressure:107/53 Respiratory rate:18 Oxygen Saturation:95% on room air. GENERAL: pleasant morbidly obese female in no acute distress, breathing comfortably HEENT: Extraoccular movements intact, pupils equal and reactive, moist mucous membranes. NECK: unable to appreciate JVP given body habitus, no bruits. CARDIAC: distant heart sounds, regular rate and rhythm, no appreciable murmurs, rubs, or gallops. PULMONARY: Clear to ausculatation bilaterally, no respiratory distress, no accessory muscle use. BACK: midline lower surgical scar appreciated ABDOMEN: obese, soft, normoactive bowel sounds, nontender, nondistended surgical scar transverse from left lower costal edge towards right hepatic area, right lower quadrant surgical scar at McBurney's point. EXTREMITIES: Edema, trace-1+ pitting to knee bilaterally, Dorsalis pedis 1+ bilaterally, ulcer on dorsal surface of right first digit NEURO: alert and oriented times 3. Gait not observed. Cranial nerves II-XII grossly intact. Pertinent Results: Hematology: WBC-9.3 HGB-13.6 HCT-39.9 PLT COUNT-193 NEUTS-69.2 BANDS-0 LYMPHS-22.0 MONOS-3.8 EOS-3.5 BASOS-1.5 . Chemistries: SODIUM-143 POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-29 UREA N-36 CREAT-1.0 GLUCOSE-163 CALCIUM-9.2 PHOSPHATE-2.3 MAGNESIUM-2.2 . Cardiac: CK(CPK)-42 CK-MB-NotDone cTropnT-0.06 proBNP-50 . Coagulation: PT-11.5 PTT-18.5 INR(PT)-0.9 D-DIMER-4006 . Urinalysis: negative. . EKG: sinus tachycardia, normal intervals, no ST changes. . Imaging: 1. Chest x-ray: No radiographic evidence of failure. 2. Chest CTA: Large saddle embolus involving the right and left main pulmonary arteries extending to the middle and lower lobes bilaterally. The CT obstruction index is about 50%. Stable appearance of right upper lobe lung nodule. Brief Hospital Course: This is a 62 year-old female who presented with dyspnea on exertion and lower extremity edema who was found to have saddle pulmonary emboli. . 1. Pulmonary emboli: Her CTA was notable for a saddle embolus involving the right and left main pulmonary arteries extending to the middle and lower lobes bilaterally with an obstruction index of about 50%. She was started on heparin as a bridge to Coumadin. Her Coumadin dose was increased until a therapeutic level was achieved. This is her second pulmonary emboli and therefore she will likely need anticoagulation for life. She will need a hypercoagulable work-up as an outpatient. She was discharged on 7.5 mg daily of Coumadin. . 2. Hematomas: While on anticoagulation, she developed 2 hematomas in her left flank and left groin. She had no evidence of compartment syndrome. Her pain was controlled with Tylenol and oxycodone. She did require red cell transfusions for blood loss anemia. . 3. Hypotension: Early on during this admission, she developed hypotension to 85/41. Her blood pressure responded to a fluid challenge. An EKG had no signs of ischemia and a echocardiogram had no sign of right ventricular dysfunction. Her hematocrit at that time was stable and there was no sign of acute bleed. She appeared intravascularly dry with an low Fe Urea. Therefore, her hypotension was attributed to overdiuresis. Her blood pressure improved with hydration. . 4. Lower extremity edema: On admission, she had increased lower extremity edema above her baseline. There was no evidence of heart failure on echocardiogram. She was initially overdiuresed resulting in hypotension, as above. Once her blood pressure had stabilized, she was restarted on her outpatient Lasix dose with decrease in lower extremity edema. She appeared to be overdiuresed on her previous outpatient dose of Lasix; therefore, she was discharged on a lower dose (20 mg daily). . 5. Urinary tract infection: She was noted to have cloudy urine and a urine culture was positive for klebsiella. She was treated with a 7-day course of ceftriaxone. . 6. Diabetes: She had been on 36 units of Lantus as an outpatient. Her sugars were under poor control (A1c = 9.3), so her Lantus was increased to 42 units. This regimen yielded good glucose control. . 7. Obstructive sleep apnea: She was maintained on CPAP at night. . 8. Right toe ulcer: She had been seen by [**Doctor Last Name **] for debridement of her ulcer. She was maintained on wet-to-dry saline dressing changes daily. . 9. Back pain: She was maintained on her outpatient gabapentin and baclofen. . 10. FEN: Low sodium cardiac diabetic diet. She had hyperkalemia on admission that was treated. She had no further episodes of hyperkalemia. . 11. Prophylaxis: Anticoagulation with heparin/Coumadin, Colace/senna, PPI, ambulation. . 12. Access: Peripheral IV . 13. FULL CODE . 14. DISPO: She was discharged to home once she was therapeutic on Coumadin for 48 hours. She will follow-up in clinic 4 days post-discharge for an INR and hematocrit check. Medications on Admission: 1. spectravite 2. gabapentin 800mg qid 3. baclofen 10mg ([**2082-11-1**]) 4. spironolactone 25mg' 5. diovan 40mg' 6. lasix 80mg' 7. protonix 40mg' 8. mirapex 0.5mg' 9. ranitidine 300mg' 10. aspirin 81mg' 11. lipitor 10mg' 12. citalopram 40mg' 13. bethenachol 25mg qid 14. tramadol 100mg qid Discharge Medications: 1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO QID (4 times a day). 4. Baclofen 10 mg Tablet Sig: ASDIR Tablet PO TID (3 times a day): Take 10 mg (1 tablet) in the morning, 10 mg in the afternoon, and 20 mg (2 tablets) at bedtime. 5. Pramipexole 0.25 mg Tablet Sig: Two (2) Tablet PO QD (). 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Tramadol 50 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 10. Bethanechol Chloride 25 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Take while still taking oxycodone. Disp:*60 Capsule(s)* Refills:*2* 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation: Continue while taking oxycodone. Disp:*30 Tablet(s)* Refills:*0* 13. Warfarin 5 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 14. Oxycodone 5 mg Tablet Sig: 1-3 Tablets PO Q3-4H (Every 3 to 4 Hours) as needed: Take until leg pain resolves. Disp:*45 Tablet(s)* Refills:*0* 15. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 16. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours): until left leg pain resolves. Disp:*100 Tablet(s)* Refills:*2* 17. Insulin Glargine 100 unit/mL Solution Sig: Forty Two (42) units Subcutaneous at bedtime. 18. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 3894**] Health VNA Discharge Diagnosis: saddle pulmonary embolism Discharge Condition: Stable. She has large left medial thigh hematoma that is stable in size. Her left leg pain is stable if not slightly improved. her respiratory status is stable. Discharge Instructions: Please take all medications as prescribed and keep all follow-up appointments. . Call your doctor or go to emergency room if you develop sudden worsening shortness of breath, fever/chills, lightheadedness, chest pain, palpitations, bleeding that doesn't stop or anything else that you find worrisome. Followup Instructions: You have the following appointment to have your INR checked: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2967**], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 5808**] Date/Time:[**2168-3-9**] 1:40 . You also have the following appointments: Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2168-4-4**] 10:00 Provider: [**Name10 (NameIs) 5005**] [**Last Name (NamePattern4) 5342**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2168-4-4**] 11:00 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**] Completed by:[**2168-3-7**]

[ "V58.67", "E934.2", "276.7", "924.00", "357.2", "724.5", "707.15", "276.52", "327.23", "041.3", "599.0", "287.5", "285.1", "278.01", "250.60", "415.19", "922.2", "428.30" ]

icd9cm

[ [ [] ] ]

[ "93.90", "99.04", "38.93" ]

icd9pcs

[ [ [] ] ]

9711, 9773

4489, 7533

324, 372

9843, 10008

3720, 4466

10358, 11003

2547, 2662

7875, 9688

9794, 9822

7559, 7852

10032, 10335

2677, 3701

239, 286

400, 1386

1408, 2235

2251, 2531

26,756

103,790

48579

Discharge summary

report

Admission Date: [**2152-6-29**] Discharge Date: [**2152-7-7**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: hypertensive emergency with AMS Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 96278**] is a [**Age over 90 **] year old female with history of poorly controlled hypertension (reported baseline SBP of 170), dementia; admit with HTN emergency and mental status changes. Patient had emesis x3, blood-tinged with last episode, at [**Hospital1 1501**] this morning. She was hypertensive to SBP 190-240/70-90 there without significant improvement after her morning meds. In the ED, SBP 270/80, HR 76, afebrile. Had emesis x1; NGL done with some guaiac positive return (coffee ground appearing). NGT kept in place, 200 cc total returned to suction. GI consulted, felt likely [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear; would EGD only if continued hematemesis and BP more stable. BP wise, brought down to goal ~190 with labetalol gtt. EKG with isolated TWI in V6, 1st set enzymes negative. There was concern for mental status changes (at baseline "pleasantly confused", per last d/c summary vaguely oriented to time/place); in ED patient oriented to self and agitated requiring restraints to keep patient from pulling out NGT. Had head CT with no brain pathology but concern for intraocular hemorrhage on initial read. Other workup included lactate 2.2, CXR and U/A unremarkable. Past Medical History: PAST MEDICAL HISTORY - Hypertension, difficult to control per PCP; baseline reportedly 170s - Congestive heart failure, EF unknown - Borderline DM2 - Chronic kidney disease stage IV (baseline Cre 1.6-1.8) - Osteoarthritis s/p L THR - Dementia - Hypothyroidism, recently started on levothyroxine (last month) Social History: Lives at [**Hospital3 2558**]. Power of Attorney is brother [**Name (NI) **] [**Name (NI) 102210**]. Denies tobacco, EtOH. Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T 97.8F, BP 151/50 (range 131/46 - 179/63 since arrival to ICU) P 75, RR 19, 98% SaO2 on 2 L NC General: NAD, well nourished elderly female HEENT: NC/AT, sclerae anicteric, MMM, no exudates in oropharynx Neck: supple, no nuchal rigidity, bilateral carotid bruits Lungs: clear to auscultation CV: regular rate and rhythm, no MRG Abdomen: soft, non-tender, non-distended, bowel sounds present Ext: warm, no edema, pedal pulses appreciated Skin: no rashes Neurologic Examination: Mental Status: Awake and alert, but poor attention; follows simple commands only intermittently Oriented to person but cannot/will not state time or place. Language: perseverative; to question of name, answered "[**Known firstname 102211**] [**Last Name (NamePattern1) 102212**]..." and when asked to repeat, "No ifs ands or buts," said, "No and ifs and ifs and buts and buts and..." Calculation: not tested Fund of knowledge: unable to assess Memory: registration: [**2-7**] items, recall [**2-7**] items at 3 minutes No evidence of apraxia or neglect Cranial Nerves: Blinks to threat. Pupils equally round and reactive to light, 4 to 3 mm bilaterally. Extraocular movements intact, no nystagmus. Facial sensation intact bilaterally. Facial movement normal and symmetric. Hearing intact to finger rub bilaterally. Palate elevates midline. Tongue protrudes midline, no fasciculations. Trapezii full strength bilaterally. Motor: Normal bulk and tone throughout. No tremor or asterixis. Able to lift all extremities off the bed but unable to cooperate with detailed testing. According to nursing staff, she was pulling at tubes overnight with full strength in both arms. Sensation: No deficits to light touch and pin-prick. Reflexes: B T Br Pa Pl Right 2 2 2 2 1 Left 2 2 2 2 1 Toes were downgoing bilaterally. Coordination: No intention tremor. Gait: Unable to assess Pertinent Results: ADMISSION LABS: [**2152-6-29**] 11:51AM BLOOD WBC-15.9*# RBC-5.26 Hgb-14.7 Hct-43.2 MCV-82 MCH-27.9 MCHC-34.0 RDW-13.1 Plt Ct-272 [**2152-6-29**] 11:51AM BLOOD Neuts-94.2* Bands-0 Lymphs-3.9* Monos-1.2* Eos-0.3 Baso-0.5 [**2152-6-29**] 11:51AM BLOOD Glucose-223* UreaN-26* Creat-1.3* Na-138 K-4.0 Cl-101 HCO3-22 AnGap-19 [**2152-6-29**] 11:51AM BLOOD cTropnT-<0.01 [**2152-6-29**] 11:51AM BLOOD ALT-10 AST-15 CK(CPK)-43 AlkPhos-76 TotBili-0.6 [**2152-6-29**] 08:32PM BLOOD TSH-0.29 [**2152-6-29**] 08:32PM BLOOD Free T4-2.3* [**2152-6-29**] 12:11PM BLOOD Lactate-2.2* [**2152-6-29**] 10:17PM BLOOD Lactate-3.8* [**2152-6-30**] 04:31AM BLOOD Lactate-2.0 NOTABLE DISCHARGE LABS: Cr 1.2, BUN 19 WBC 14.1 HCT 38.8 INR 1.6 MICROBIOLOGY: [**6-29**], [**2152-7-2**] Urine Cultures: negative [**2152-7-7**] Urine Cultures: NGTD [**2152-7-2**] Urine Legionella: negative [**6-29**], [**7-2**], [**2152-7-6**] Blood Cultures: negative [**2152-7-6**] Stool C. diff toxins A & B: negative CT HEAD W/O CONTRAST Study Date of [**2152-6-29**] 11:56 AM HISTORY: Altered mental status, systolic blood pressure 200's, nausea and vomiting. Rule out intracranial bleed. COMPARISON: None. TECHNIQUE: Non-contrast head CT. CT OF THE HEAD WITHOUT CONTRAST: There is no evidence of masses, hydrocephalus, shift of normally midline structures, infarction, or hemorrhage. Bilateral basal ganglia calcifications are seen. The ventricles and sulci are prominent consistent with age-related atrophy. Vascular calcifications are seen. Confluent hypodensities within the periventricular white matter likely represent chronic microvascular ischemia. The osseous structures demonstrate hyperostosis frontalis interna. The surrounding soft tissues are unremarkable. The visualized paranasal sinuses are clear. Partial opacification of the mastoid air cells bilaterally is noted. A right scleral band is seen around the right globe. IMPRESSION: No intracranial hemorrhage. CT ABDOMEN W/CONTRAST Study Date of [**2152-6-29**] 2:53 PM INDICATION: [**Age over 90 **]-year-old female with vomiting and abdominal pain. COMPARISON: Abdominal radiographs from same day. TECHNIQUE: MDCT-acquired axial imaging of the abdomen and pelvis was performed following administration of oral and intravenous contrast. Multiplanar reformatted images were obtained and reviewed. CT ABDOMEN: There is mild dependent bibasilar atelectasis. Liver is unremarkable. There is a thin crescent of hyperdensity layering in the gallbladder fundus, which may represent a tiny amount of [**Doctor Last Name 5691**] versus a small focus of adenomyomatosis. Gallbladder is otherwise unremarkable. Pancreas is atrophic and fatty replaced. Spleen is unremarkable. Adrenal glands and kidneys are unremarkable. There is no hydronephrosis. Stomach and intra-abdominal loops of bowel are unremarkable. Nasogastric tube is in place, tip in the gastric body. There is a moderate axial hiatal hernia and a small fat-containing ventral hernia. There is no free air, free fluid, or abnormal intra- abdominal lymphadenopathy. There is mild atherosclerotic calcified and noncalcified plaque throughout the abdominal vasculature. CT PELVIS: Pelvic loops of large and small bowel are unremarkable, except to note sigmoid diverticulosis. Evaluation of the deep pelvic structures is limited by streak artifact from bilateral hip replacements. There is no definite free pelvic fluid. There is no abnormal pelvic or inguinal lymphadenopathy. OSSEOUS STRUCTURES: There is no osseous lesion suspicious for malignancy. Multilevel degenerative changes in the thoracolumbar spine are noted, with moderate dextroconvex thoracolumbar scoliosis. IMPRESSION: 1. No specific CT finding to explain hematemesis and abdominal pain. 2. Moderate axial hiatal hernia. 3. Diverticulosis, without evidence of diverticulitis. 4. Small fat-containing ventral hernia. ECHO [**2152-6-30**] The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF 70-80%). A mild apical intracavitary gradient is identified. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: hypertrophic, hyperdynamic left ventricle Chest X-ray, PA and Laterl [**2152-7-2**]: The lungs are hyperinflated and the diaphragms are flattened, consistent with COPD. There are low inspiratory volumes. Allowing for this, there is probable moderate cardiomegaly and mild unfolding of the aorta. The ascending aorta is prominent, consistent with chronic hypertension. There is upper zone re-distribution, but I doubt overt CHF. There is a small right pleural effusion posteriorly. There is also minimal blunting of both costophrenic angles. No focal infiltrate is identified. Sinus rhythm with supraventricular premature depolarizations. Marked lateral ST segment depressions. Compared to the previous tracing sinus rhythm is now present with overall reduced ventricular rate and diminished ischemic ST segment depression. Intervals Axes Rate PR QRS QT/QTc P QRS T 71 142 96 444/463 86 64 169 ECG - [**2152-7-4**] - Ectopic atrial rhythm with ventricular premature depolarizations. Inferior myocardial infarction. Short P-R interval with abnormal P wave axis raising consideration of ectopic atrial rhythm. Diffuse non-diagnostic repolarization abnormalities. Compared to the previous tracing of [**2152-7-3**] an ectopic atrial rhythm is now present with inferior myocardial infarction pattern. Shoulder XR [**2152-7-4**] - IMPRESSION: No acute fracture detected involving the proximal humerus or shoulder girdle. Possible old healed proximal humeral fracture. Probable chronic rotator cuff tear. Superior and anterior subluxation of humeral head with respect to glenoid, but no frank dislocation. CXR [**2152-7-4**] - Lung volumes are low, particularly elevation of the left lung base, new. Some of this may be due to left lower lobe atelectasis. Heart size top normal, unchanged. No pulmonary edema or vascular redistribution to suggest heart failure. No appreciable pleural effusion. This examination is not designed for detection of rib fractures which are easily missed. ECG - [**2152-7-6**] - 7AM - Atrial fibrillation, mean ventricular rate 128. Compared to the previous tracing no major change.Rate PR QRS QT/QTc P QRS T 128 0.86 312/431 0 -9 -155 Brief Hospital Course: HYPERTENSION, HYPERTENSIVE EMERGENCY, ALTERED MENTAL STATUS: Ms. [**Known lastname 96278**] was initially admitted to the MICU after coming from the ED on a labetolol drip for her hypertension. Once in the MICU, neurology was consulted for altered mental status, non-fluent aphasia and possible left-sided neglect. Neurology ultimately felt her presentation was consistent with transient worsening of her dementia from relative hypotension/hypoperfusion in the setting of aggressive blood pressure reduction. SBP was at one point 110 - 120 while on the beta-blocker drip. Neurology recommended maintaining SBP within the 160 - 180 range, which was attained off medicines. After 24 hours of blood pressures in this range, mental status and speech returned to baseline. She had no residual deficits and was at her baseline dementia. Head CT showed no evidence of bleed. Since she recovered to baseline, further MRI studies were not deemed necessary. At discharge she was conversant, pleasant and was able to follow multistep commands. She had registration but significantly impaired recall at 5 minutes, with no improvement with prompting or lists. Two days after being called out to the floor from the MICU, her blood pressure began to increase and she was restarted on lisinopril 40mg, HCTZ 25m, with PRN hydralazine. On [**2152-7-2**], she then dropped her systolic BP to the 70's when her rhythm changed from sinus to atrial fibrillation with RVR. She was noted to have ST segment depressions in I, II, AVL, V3, V4, V5, V6 and ST elevation in III, AVR, VI. She did not respond to IV metoprolol, and as pacer pads were being placed she developed ventricular fibrillation. She became pulseless for which chest compressions were initiated and the patient was given 1 shock. NSR was reattained and patient regained consciousness. Repeat EKG showed NSR, but continued, however to show lessened ST changes as above. A right femoral central line placed, heparin bolus and gtt initiated for a STEMI. She was transferred to the CCU conversant and, on [**7-3**], was started on 20 mg LISINOPRIL, 25 mg METOPROLOL [**Hospital1 **], and NORVASC 5 mg daily for a low SBP goal of 160 based on the patient's longstanding hypertension in the 170's. Her IV heparin was discontinued, and SC heparin started due to the risk of bleeding. Her troponins were elevated (max 5.3) and trended down with medical managment of her ischemia, thought to be [**1-8**] demand during the afib episodes. She was started on ASA, continued on beta blocker, ACEI and high dose statin. She was continued on these medications throughout the hospitalization. GIbIIa inhibitor was not started due to concern for acute bleeding. ATRIAL FIBRILLATION: Once patient was hemodynamically stable, she was transferred back to the floor on [**7-4**], where she continued to have episodes of atrial fibrillation with RVR. She was difficult to controll with IV beta blockade and responded transiently to cardizem IV. She was started on cardizem PO 60mg qid, with marginal control of HR (90s - 100s) with frequent reversions to fibrillation. On [**7-5**], patient was started on amoiodarone loading dose of 400mg QD. She converted to sinus rhythm of ~ 50 - 60. She had occasional reversions to atrial fibrillation on [**7-5**] - [**7-6**], which were converted to sinus rhythm with 20mg IV doses of cardizem. Her rhythm was controlled for over 24 hours prior to discharge. Patient was also noted to have 2 asymptomatic pauses of 3 - 5 seconds each. She was evaluated by EP and ordered a 30 day heart monitor to be triggered for HR < 40 or > 100. She has a follow up appointment with Dr. [**Last Name (STitle) **] regarding atrial fibrillation control and suspected tachy-brady syndrome. Because of frequent conversions from atrial fibrillatin to sinus rhythm, her age and her history of hypertension and diabetes, patient was deemed a candidate for anticoagulation. She was started on coumadin 2mg PO daily on [**2152-7-5**], which was increased subsequently to 4mg PO daily on [**2152-7-6**]. Her INR on [**2152-7-7**] was 1.6. She should have her INR measured daily and warfarin dosing adjusted to goal of INR 2 - 3. LEUKOCYTOSIS: She was noted to have leukocytosis on admission. The workup for this has remained negative throughout hospitalization, and may have been a stress response although blood cultures were pending at discharge (multiple earlier sets were negative). Her urine cultures, C.diff and legionella were negative. She was afebrile throughout and was never on antibiotics while in-house. UPPER GI BLEED: The day of admission, Ms. [**Known lastname 96278**] has several episodes of emesis thought to be from GI upset in the setting of the severe hypertension. The last episode of emesis was coffee-grounds and guaiac positive. The GI service was consulted and felt this was due to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] tear, and she was never scoped. Her bleeding appeared to resolve as her Hct was stable throughout the admission and she had no further episodes of emesis. She was placed on PO protonix. She did test positive for H.Pylori by EIA, but was not treated due to no signs of acute bleeding and the risks associated with long term antibiotic treatment in a geriatric patient. On [**7-4**] patient was noted to have right sided abdominal pain on deep palpation. Negative [**Doctor Last Name **], no signs of acute abdomen were noted on exam. Pt. has a ventral hernia on CT from [**6-29**], but no other abdominal process to explain the pain. Her lactate was 1.3. LFTs normalized by [**2152-7-6**]. Pain was well controlled with APAP. She should be reevaluated with serial abdominal exams for follow up. LEFT SHOULDER PAIN: Left shoulder and chest wall pain were also noted on [**7-4**]. These were reproducible w/ palpation, and with shoulder ROM manipulation. Patient also had supraspinatus tenderness, no apprehension sign. Given recent chest compressions when she was coded, there was concern for fractures. X-ray did not show fractures of the ribs or shoulder/humerus. Shoulder x-ray showed probable rotator cuff tear. She was treated by physical therapy and acetaminophen around the clock. HYPOTHYROIDISM: The patient has a history of hypothyroidism and her synthroid had been recently increased from 50 to 225 mcg in the course of 1 month, and while at [**Hospital1 18**], she has been given 50 mg given concern for overmedication causing AFib. CHRONIC KIDNEY DISEASE: At baseline, patient has CKD with likely etiology being HTN. Baseline reportedly 1.6-1.8. Cr improved to 1.2 with 250 - 500 NS boluses daily and remained stable stable [**7-4**] - [**7-7**]. Patient will require renal dosing of medications. SCLERAL BUCKLE: Opthalmology also consulted for a possible intraocular hemorrhage that was seen on CT on admission. Ophthalmology thought the scleral buckle was secondary to prior repair of retinal detachment. CODE STATUS, COMMUNICATION: The patient is a poor candidate for invasive procedures given her age and baseline dementia. Her brother, [**Name (NI) **] [**Name (NI) 102210**] is her health care proxy and her current status is DNR/DNI. He can be reached at ([**Telephone/Fax (1) 102213**] or [**Telephone/Fax (1) 102214**]. PENDING ISSUES FOR FOLLOW-UP: 1. Patient is on coumadin and will require daily measurements of PT/INR and adjustment of her coumadin dose to achieve goal INR of 2 - 3. 2. Patient was started on amiodarone for atrial fibrillation with rapid ventricular response. She should be continued on this medication at a dose of 400mg daily for another 10 days, then on 200mg daily for another 14 days, followed by maintenance dose. Her liver and kidney function tests should be checked weekly and electrolytes every other day until stabilized. 3. Heart failure - patient has documented heart failure of likely diastolic dysfunction. EF ~ 70%. She is on metoprolol and lisinopril. Her diet is restricted as below and she has no fluid restriction. Activity level is as per PT recommendations. Patient should be weighed daily and monitored for symptoms of heart failure: shortness of breath, leg edema, orthopnea. She will be follow up by cardiology and primary care physician. Medications on Admission: MEDICATIONS AT HOME Norvasc 5 mg daily (increased yesterday) Synthroid 225 mcg daily (appears recent increase) Lisinopril 20 mg daily Atenolol 50 mg daily Colace 100 mg [**Hospital1 **] APAP 650 TID bisacodyl prn MOM prn [**Name2 (NI) **] senna [**Hospital1 **] 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. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day) as needed for constipation. 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. Insulin Lispro 100 unit/mL Solution Sig: sliding scale Subcutaneous ASDIR (AS DIRECTED): As per [**Hospital1 18**] inpatient sliding scale. 8. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 10 days: Then can be changed to 200mg daily for additional 14 days, followed by maintenance dose. 12. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day: Q 1700. 14. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Primary: Myocardial infarction, Hypertensive emergency Secondary: Hypertension, Atrial fibrillation, Diabetes mellitus, Chronic kidney disease Discharge Condition: Hemodynamically stable At discharge she was conversant, pleasant and was able to follow multistep commands. She had registration but significantly impaired recall at 5 minutes, with no improvement with prompting or lists. Discharge Instructions: You were admitted to [**Hospital1 18**] with significantly elevated blood pressure. As you were treated for this, you had changes in your mental state. You then developed a new arrhythmia, following which you had a heart attack. These were thought to be due to elevated thyroid hormones. . You were treated for all these complications and required intensive care unit management. You were able to recover to your mental state baseline. Your arrhythmias were finally controlled with medications (see medication list below). Finally, because of your arrhythmia (atrial fibrillation) you were started on a medication (coumadin) to help prevent a stroke. You were discharged to your nursing facility in a hemodynamically stable condition, with your heart rate controlled. During your hospitalization, through discussion with your health care proxy and the medical staff, you resuscitation status was changed to Do not resuscitate, do not intubate. Should you experience new chest pain, shorness of breath, difficulty speaking, dizzyness, palpitations, fever, cough, new pain or any other symptom concerning to you, please contact your health care provider at the rehabilitation facility or go to the nearest emergency room. Followup Instructions: Please follow up with the following appointments: You will be seen at your facility by your primary care doctor: Dr. [**First Name (STitle) 807**]. . Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], [**Hospital1 18**], [**Hospital Ward Name 23**] 7, on [**2152-8-4**] at 2pm. [**Telephone/Fax (1) 102215**]. Provider: [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) 15351**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2152-7-17**] 9:00 Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2152-8-4**] 2:00 [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "250.00", "427.31", "427.41", "530.7", "403.90", "553.21", "585.4", "041.86", "294.8", "428.30", "244.9", "V43.64", "428.0", "410.91" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

20755, 20825

10776, 10822

292, 298

21012, 21238

4002, 4002

22514, 23265

2063, 2081

19412, 20732

20846, 20991

19121, 19389

21262, 22491

4680, 10753

2121, 2584

221, 254

326, 1574

3178, 3983

4018, 4664

10837, 19095

2608, 2608

1596, 1907

1923, 2047

27,661

126,459

31450

Discharge summary

report

Admission Date: [**2129-9-16**] Discharge Date: [**2129-10-11**] Date of Birth: [**2050-1-29**] Sex: M Service: MEDICINE Allergies: Haldol / Heparin Agents Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Fever from Facility Major Surgical or Invasive Procedure: PICC placement History of Present Illness: Mr. [**Known lastname **] is a 79 year-old male with a history of diabetes, coronary artery disease, recent AVR who presents from rehab with fevers and acute renal failure. . Recent long-term admission ([**7-9**] - [**8-25**]) with volume overload and hypotension in the setting of severe aortic stenosis. The hospitalization was complicated by a slow GI bleed with notable black tarry stools; an EGD showed evidence of gastritis and duodenotis and a colonoscopy showed evidence of diverticulosis but no evidence of active bleeding. Also during the admission, his trach was changed three times secondary to persistent leak; tracheomalacia extending to both mainstem bronchi was noted. On [**2129-8-12**] he was taken to the operating room where he underwent AVR. . In speaking with staff from rehab, patient spiked on [**9-6**]; was started on vancomycin an ceftazidime for MRSA in the sputum and ESBL in the urine. Tip from PICC line grew staph on [**9-9**]. Zosyn was added on that day. The creatinine was noted to increase on [**9-11**] and the vancomycin was stopped. Transfused one unit of pRBC on [**9-13**]. . On the morning of admission, spiked to 101.8. Blood cultures were sent and he was transferred to [**Hospital1 18**] for further care. Past Medical History: 1. Coronary artery disease: - Left heart cath done at [**University/College **] revealed non-obstructive CAD, 2. Diabetes mellitus 3. Atrial fibrillation 4. s/p AVR, [**8-5**] 5. Anemia 6. s/p MVC with multiple traumas in [**2-2**] with prolonged 4 month hospital stay at [**University/College **], with trach placed [**2129-5-25**] after several intubations for hypercarbic respiratory failure 7. Chronically depressed mental status 8. Chronic b/l pleural effusions 9. Chronic, severe generalized myopathy with mild membrane instability, and evidence for a moderate peroneal neuropathy at the right fibular neck seen on EMG on [**5-/2129**] . INFECTIOUS HISTORY: 1. MRSA PNA: Grown on sputum sample from [**2129-6-26**]. 2. Pseudomonal PNA: Has grown pseudomonas in [**6-5**] sputum samples from [**6-11**] - [**8-13**]. Possible colonization. 3. VRE UTI: Grown on urine culture from [**2129-8-19**]. Treated with linezolid. Social History: Non-smoker. Currently at [**Hospital 100**] rehab. Has several children. Daughter [**First Name8 (NamePattern2) **] [**Name2 (NI) 74057**] is a nurse and makes many of his health decisions. Family History: non-contributory Physical Exam: vitals - T 97.3, BP 165/85, HR 83. AC 500/12, PEEP 5, Fi02 0.4 gen - Trached. Does not respond to verbal cues (did not squeeze hand) and does not make eye contact. In no apparent distress but grimaces often during physical. heent - Trach in place. Difficult to assess JVP. cv - Hard to hear heart sounds over vent. Irregular. Systolic murmur. Sternal wound healing without dehiscence. pulm - Clear anteriorly without wheeze or rales. abd - Soft and mildly distended. Non-tender. ext - Cool. RUE with edema > LUE. Minimal lower extremity edema. Bronze coloration of anterior shins R>L. neuro - Does not follow commands. Pertinent Results: LABS: . ---ADMIT--- 138 104 66 ============ 141 4.0 26 1.7 . Ca: 8.9 Mg: 2.3 P: 3.2 ALT: 68 AP: 263 Tbili: 0.8 Alb: 2.2 AST: 65 LDH: 221 . WBC: 13.9 PLT: 182 HCT: 24.4 PT: 16.7 PTT: 39.9 INR: 1.5 . RUE ULTRASOUND ([**2129-8-6**]): . ECHO ([**2129-9-28**]): Increased pressure gradient across the replaced AV valve. Outflow tract obstruction due to decreased ventricular filling. Otherwise normal echo. . Renal US ([**2129-9-19**]): 1. No evidence of hydronephrosis. 2. Moderate amount of free pelvic fluid. . Discharge Labs: 138 93 79 AGap=5 ------------ 52 4.0 44 1.9 Ca: 9.5 Mg: 2.4 P: 3.6 \7.7/ 10.6 ---- 200 /23.3\ Brief Hospital Course: ASSESSMENT/PLAN [**9-17**]: 79 year-old male with a history of [**Month/Year (2) 8751**] and eventual trach, coronary artery disease, AVR, diabetes who presents with fevers. . 1. Fever and leukocytosis: Transfered from rehab with culture data positive for ESBl E.Coli UTI ([**Last Name (un) 36**]:zosyn, gent, imi, tetracyclin; resis: augmentin, amp, ceftriaxone, aztreonam, cefepime. He was sent from rehab on vanc (History of MRSA in sputum) and zosyn, and on admission was switched to vanc and meropenem. Pt had a pseudomonas culture from his sputum which was initially thought to be contamination, but given signs of PNA on CXR, was treated as a real infection. There were no signs of MRSA infection on cultures so vanc was discontinued (pt had been on a >10 day course starting in rehab). His old PICC line was replaced with a new IR guided picc line early in his admission. Given that pt had a ESBL UTI, it was decided to give him a 14 day course of meropenem, which would cover the organisms isolated from sputum culture as well. Pt defervesed well on meropenem therapy. There were occassional isolated fever and WBC spikes which had negative workups (sputum cultures continued to show pseudomonas contamination). Later in his hospital course, urine appeared cloudy and cultures indicated yeast. Foley was changed without resolution of findings, so pt was given a 5 day course of fluconazole for bladder candidiasis and had the foley changed after that course. . 2. Acute renal failure: Baseline creatinine of 1.0-1.1 at the time of prior discharge. Pt came in with elevated Cr in the 1.8 range. Pt was volume overloaded from rehab along with fliud resucitation from admission, so it was initially felt that volume overload in the setting of history of CHF was causing poor forward flow and decreased renal perfusion. Pt was agressively diuresed on admission, but Cr did not improve (though urine output was appropriate). A course of low dose captopril (6.25mg tid) was attempted to reduce afterload and increase forward flow, but this caused pt to become hypotensive, so it was stopped after 1 day. TTE was performed which showed EF of 70% without wall motion abnormalities, but did show outflow tract obstruction likely from intravascular depletion. Renal US showed no abnormalities. During diuresis, Cr varied from 1.7 to 2.0, and it was assessed that this was likely a new chronic problem in this patient. Will recommend checking BUN/Creatinine atleast twice a week unless his clinical picture changes. . 3. Respiratory Failure - Pt had been chronically ventilated since his automobile accident earlier this year. He had some success with weaning in the past, but his respiratory status would eventually fail and he would need to be intubated again, and thus necessitated a tracheostomy. Ventilator weaning was attempted during admission, and pt did show some evidence of being able to be weaned. While initially unsuccessful at being taking off of AC for more than 30 minutes, but by the time of transfer he was able to stay on pressure support of 15/5 for over 24 hours at a time, but then would tire and require higher PS settings for rest. It was noted that the pt was requiring higher cuff pressures to prevent tracheostomy leaking. IP was consulted who stated that pt has a known history of tracheomalicia, and that the pt's trachea is fairly large and the current hardware available is a less than perfect fit. Their recomendation is to accept higher cuff pressures with some leak and that as long as the pt is being adqeuately ventilated, there is little acute intervention that needs to be done at this time. . 4.Volume Overload: Pt was volume overloaded from rehab and from fluid resucitation on admission. Diuresis was started with lasix IVP, and at one point necessitating a lasix drip (Adjusted between 2-7mg/h) to which he diuresed appropriately. Lasix dose needed to be adjusted frequently for hypotension. Potassium was repleted as needed while on drip. Lasix was switched to 40mg IV bid. As the patient became closer to his euvolemic state, hypotension was more difficult to control and at times needed fliud boluses to maintain BP. Lasix was discontinued on [**10-7**] when pt looked clinically euvolemic and lab values were starting to indicate increasing contraction alkalosis and rising BUN/creatinine. Need to consider adding lasix if his clinical condition changes. . 5. Anemia: Normocytic anemia, which was stable for the first 2 weeks of pt's admission. Iron studies were performed which confirmed the diagnosis of anemia of chronic disease. Around the 3rd week, HCT slowly drifted down from ~25 to closer to 20. Stool guiacs were negative and there was no other obvious source of bleeding noted. Pt had been on SQH for DVT prophylaxis but it was felt that this dosing shouldn't cause such serious bleeding. Pt was transfused 2 units of PRBC over 2 days and hct stabilized around 23. Likely multifactorial with some component of chronic blood loss given the history of GI bleed (from gastritis and diverticulitis). . 6. Oral bleeding: Noted by the team on the day of discharge, pt has apparently been having some mild oral bleeding from irritated oral mucosa. Exam showed no obvious source of bleeding, but it is likely coming from the roof of the mouth. Pt is unable to open his mouth very wide, and it is thought that the agressive mouth cleaning force required to get swabs and suction into his mouth may have caused some mucosal damage, and has been chronically oozing since then. Pt's crit has been stable. Recomend gental oral hygiene to prevent exacerbation of oral bleeding and consider dental evaluation if bleeding persists. . 7. LFT abnormalities: Unclear etiology, but altered LFTs were stable during admission. Pt would occassionally complain of abdominal pain, but it was difficult to ascertain the course of these symptoms. The pt's mental status during admission was withdrawn, and he would often choose to not communicate with the medical team. In discussion with prior attending physicians who had cared for the pt, they report that the pt has had a history of chronic abdominal pain with a negative workup. . 8. Coronary artery disease/ recent AVR: It is uncertain as to where this diagnosis came from, given that pt has had a normal cardiac cath within the last year, and his TTE shows normal EF without wall motion abnormalities and normal ventricular size and function. Pt did complain of chest pain on one occassion which was reproducable on palpation and associated with breathing (possibly exacerbated by agressive ventilator weaning). He ruled out for ACS by cardiac enzymes. TTE findings were reviewed with Cardiac surgery team and no acute interventions were planned by them. . 9. Diabetes mellitus: Pt's blood sugar was stable on insulin. SSI was increased to begin dosing with NPH at FS of 150 for tighter control. . 10. Atrial fibrillation: Pt was kept on beta blockers, but was reduced to lower dosing due to his recurrent hypotension. He was continued on ASA for anticoagulation, but was not started on warfarin given his history of GI bleed. . 11. Mental Status: Waxing/[**Doctor Last Name 688**] participation but patient would nod y/n to questions on occassion. Pt appeared to understand questions, and would follow commands on occassion. It was uncertain whether there was an aspect of depression involved in his mental status presentation. . 12. Actinic Purpua: Dermatolgy consult and biopsy were performed. No acute intervention needed per them. . ---FEN: G-tube 70ml/hr (Probalance) and 30ml [**Hospital1 **] (Prostat) ---PPx: Suq Q heparin (SRA negative), PPI. ---Access: PICC. ---Code: DNR with continuing tracheal ventilation, as discussed with pt's daughter [**Name (NI) **] [**Name (NI) 74057**]. ---Contact: Daughter [**First Name8 (NamePattern2) **] [**Name (NI) 74057**] ([**Telephone/Fax (1) 74059**]) Medications on Admission: 1. Metoprolol 25mg TID 2. Simvastatin 20mg daily 3. Albuterol/Ipraprotrium combivent 4. Omeprazole 40mg [**Hospital1 **] 5. Citalopram 40 mg daily 6. RISS with 7 units of lantus QHS 7. Vitamin D 1000 units daily 8. Docusate Sodium 50 mg [**Hospital1 **] 9. Cyanocobalamin 50 mcg daily 10. Folic Acid 1 mg daily 11. Thiamine HCl 100 mg daily 12. Acetaminophen 325 mg PRN 13. Chlorhexadine mouthwash 14. Zosyn 3.375g Q8H (started [**9-14**]) 15. Flagyl 500mg PO TID 16. Nystatin topical Discharge Medications: 1. Simvastatin 20mg po qday 2. Citalopram 40mg po qday 3. Vitamin D 1000 units po qday 4. Docusate (liquid) 50mg po bid 5. Cyanocobalamin 50 ??????g po qday 6. Folic Acid 1mg po qday 7. Thiamine 100mg po qday 8. Chlorhexidine Gluconate Oral Rinse 0.12% 15ml oral [**Hospital1 **] swish and spit 9. ASA 81 po qday 10. Heparin 5000 units SC tid 11. Lansoprazole disintegrating tab 30mg po qday 12. Miconazole powder 2% topical tid. 13. Metoprolol 12.5mg po tid 14. Albuterol-Iprotropium 6 puffs inhaled q6h prn SOB 15. Nystatin-Triamcinolone Ointment topical [**Hospital1 **]. 16. Glargine 7 units qhs 17. Humalog SS (2U for BS 151-200, 4U for BS 201-250, 6U for BS 251-300, 8U for BS 301-350, 10U for BS 351-400). 18. Acetaminophen 650mg po q6h. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary: Acute on chronic renal failure Persistent ventilator dependence Secondary: Anemia of chronic disease acute on chronic diastolic congestive heart failure Bioprosthetic aortic valve replacement actinic purpura atrial fibrillation Pseudomonas PNA [**Female First Name (un) 564**] UTI Discharge Condition: stable vital signs with current ventilator settings. Discharge Instructions: You have been evaluated and treated for acute on chronic renal failure and persistent ventilator requirements. You have been evaluated and treated for acute on chronic renal failure and persistent ventilator requirements. For your respiratory issues, the staff at the rehabilitation facility will work with you to increase your ability to breath on your own with decreased ventilator support. This process may take a long time, and it may not be possible to take you off the ventilator even after all this work. The staff at the facility will make this assessment as they track your progress. Followup Instructions: You will be re-evaluated by the doctors at the rehab facility. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "518.83", "311", "585.9", "789.00", "V46.11", "482.1", "250.00", "428.0", "294.8", "999.9", "428.33", "285.29", "458.29", "782.1", "427.31", "338.29", "519.19", "584.9", "112.2" ]

icd9cm

[ [ [] ] ]

[ "99.04", "86.11", "96.6", "96.72", "38.93", "99.15" ]

icd9pcs

[ [ [] ] ]

13382, 13454

4146, 11299

312, 328

13788, 13843

3476, 3993

14488, 14690

2793, 2811

12613, 13359

13475, 13767

12104, 12590

13867, 14465

4009, 4123

2826, 3457

253, 274

356, 1616

11314, 12078

1638, 2570

2586, 2777

29,614

108,872

16577

Discharge summary

report

Admission Date: [**2164-7-20**] Discharge Date: [**2164-8-3**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2387**] Chief Complaint: Transfer from [**Hospital6 **] for cardiac cath Major Surgical or Invasive Procedure: Cardiac cath with stenting Endotracheal intubation Cardioversion Central Line placement History of Present Illness: [**Age over 90 **] year old woman with h/o anemia [**2-25**] angiodysplagia-related GI bleed, h/o colon cancer, CAD s/p anterior MI [**2164-6-19**], resulting in depressed EF (35%) who was transferred from [**Hospital1 **] Hosp for cardiac catherization. . Recent relevant history: Pt had an anterior MI on [**2164-6-19**] and was treated medically at NEBH. She did not undergo cardiac catherization at that time. TTE showed LVEF=35% with severe hypokinesis of the apex infero-apically to antero-apically. There was akinesis of the distal septum, about halfway to the apex, including the apex. There was no AR, 2+ MR, 2+ TR, with PA pressures between 70 and 75mmHg. . Pt was d/c'd to a cardiac rehab where she had persistant chest discomfort, SOB, palpitations with nausea, and was re-admitted to [**Hospital1 **] for evaluation on [**2164-6-28**]. There, MI was ruled out by cardiac enzymes and pt's symptoms were determined to be likely related to mild CHF along with anxiety. Pt was diuresed, then sent back to rehab with medication adjustments. Back at the rehab, patient continued to have vomitting, chest tightness, and LUQ pain, and pt was admitted to [**Hospital3 7872**] on [**2164-7-3**]. Again, she was ruled out for MI by EKG and cardiac enzymes. Persantine stress test, which did not reproduce her pain, showed mostly fixed anterior infarct with mild lateral peri-infarct edema, no ischemia. She was D/C'd to rehab with a diagnosis of non-cardiac chest pain likely d/t GERD. . About one week later, on [**7-19**], she experienced similar symptoms, partially relieved by SL Nitro. She went to her scheduled follow up appointments with Dr. [**Last Name (STitle) 11679**] and Dr. [**Last Name (STitle) **] (GI), and during it she was found to have a her hct=26, and troponin=0.62 with equivocal EKG changes. She was admitted to [**Hospital3 **] for transfusion, but after 1 unit of pRBCs, she developed acute congestive heart failure. She was diuresed with Lasix 80 IV, given Nitro paste, and, after these treatments, became hypotensive to 79/33. Dopamine was started. Cardiac enzymes revealed trop 2.96 and CK 170 (MB not done). Decision was made to transfer patient to [**Hospital1 18**] for further management/ catherization. Of note, her WBC also increased to 15.2, and started on empiric Levaquin. . On arrival to [**Hospital1 18**], pt admitted to CCU team. [**Name (NI) 47025**], pt was without complaints. She was taken to cath lab, where a near total occlusion of proximal/ostial LAD was found along with a Lcx 90% lesion (Lcx dominant vessel). The LCx lesion was approached first. While intervening on the LCx lesion, the patient became hypotensive--likely from occluding the dominant LCx, causing decreased flow to LAD. WIth the hypotension, she also became nauseous and vomitted (?aspirated). She then became asystolic. CPR was initiated as the procedure continued. The LAD lesion was stented with good resultant flow and the LCx lesion was angioplastied (with resultant dissection). During this, the patient was intubated and started on levophed and dopamine. She went into a wide complex tachycardia--VT vs. SVT/sinus tach w/ incomplete RBBB. She was started on lidocaine gtt and given 300mg Amio bolus. At the time of transfer to the CCU, the patient's ABG was 7.04/36/436 and lactate 6. . On arrival to the CCU, the patient was still vented. Her blood pressure dropped into the 50s shortly after her arrival. After getting 2amps of bicarb, BP improved to SBP 90-100s. A-line placement was attempted unsuccessfully (with doppler in b/l radial vessels). A right femoral venous catheter was placed. Of note, pt had bloody NGT drainage. . *** Cardiac review of systems is notable for current absence of dyspnea on exertion, ankle edema, syncope or presyncope. (Prior to cath) Past Medical History: HTN, Hyperlipidemia GERD CAD - NSTEMI [**5-/2164**]; P-MIBI w/ fixed anterior defect CHF mild aymptomatic, noncritical carotid stenosis mild aortic stenosis h/o colon cancer, s/p colon resection iron deficiency anemia chronic low-grade GI bleed secondary to angiodysplasia of small bowel ? COPD s/p cholecystectomy, appendectomy Social History: Patient had been living independently and doing her own ADLs until her MI in [**2164-5-24**]. Since her MI, she has been in rehab. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: Day of Discharge VS: T 97, BP 119-152/39-55, HR 57-81, RR 18-20, 98 O2 % 1L Gen: thin, in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with no appreciable JVD. CV: RRR normal s1/s2, III/VI SEM heard best at LUSB, no rubs or gallops Chest: Kyphosis, barrel chest. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: Soft, + bruising, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP Pertinent Results: [**2164-7-20**] 07:38PM BLOOD WBC-13.6*# RBC-2.80* Hgb-8.4* Hct-27.1*# MCV-97# MCH-30.0 MCHC-31.0 RDW-16.3* Plt Ct-453* [**2164-7-20**] 06:30PM BLOOD Glucose-589* UreaN-28* Creat-1.2* Na-125* K-3.2* Cl-100 HCO3-8* AnGap-20 [**2164-7-20**] 07:38PM BLOOD Calcium-7.7* Phos-4.8* Mg-1.4* [**2164-7-20**] 07:38PM BLOOD PT-18.3* PTT-150* INR(PT)-1.7* [**2164-8-3**] 07:20AM BLOOD WBC-14.9* RBC-3.69* Hgb-11.1* Hct-34.4* MCV-93 MCH-30.0 MCHC-32.2 RDW-18.8* Plt Ct-486* [**2164-8-3**] 07:20AM BLOOD Glucose-106* UreaN-26* Creat-1.2* Na-142 K-3.8 Cl-102 HCO3-29 AnGap-15 [**2164-8-2**] 07:45AM BLOOD Calcium-9.1 Phos-3.6 Mg-1.7 . [**2164-7-20**] 07:38PM BLOOD CK(CPK)-153* [**2164-7-21**] 03:48AM BLOOD CK(CPK)-353* [**2164-7-22**] 04:51AM BLOOD CK(CPK)-219* [**2164-7-20**] 07:38PM BLOOD CK-MB-14* MB Indx-9.2* [**2164-7-21**] 03:48AM BLOOD CK-MB-28* MB Indx-7.9* cTropnT-2.31* [**2164-7-22**] 04:51AM BLOOD CK-MB-8 cTropnT-1.88* . [**2164-8-1**] 06:55AM BLOOD proBNP-[**Numeric Identifier 47026**]* . [**2164-7-21**] 03:48AM BLOOD ALT-390* AST-407* LD(LDH)-509* CK(CPK)-353* AlkPhos-122* Amylase-208* TotBili-0.3 [**2164-7-31**] 06:45AM BLOOD ALT-38 AST-24 AlkPhos-85 TotBili-0.3 . ECHOCARDIOGRAM [**2164-7-23**] The left atrium and right atrium are normal in cavity size. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the mid inferolateral wall and distal inferio wall. The remaining segments contract normally (LVEF = 55 %). The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is mild-moderate aortic valve stenosis (area 1.2cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. There is at least mild pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. IMPRESSION: Normal left ventricular cavity size with mild regional systolic dysfunction suggestive of CAD. Mild-moderate aortic valve stenosis. At least mild pulmonary artery systolic hypertension. Brief Hospital Course: [**Age over 90 **] year old woman with h/o CAD, s/p anterior MI [**2164-6-19**], resulting in depressed EF (35%) and anemia [**2-25**] angiodysplagia-related GI bleed who was transferred from [**Hospital1 15204**] Hosp for cardiac catherization and is s/p LCx stent with dissection leading to cardiac arrest requiring resuscitation and intubation. Clinical status gradually improved but course complicated by multiple episodes of acute on chronic congestive heart failure (although present EF wnl), stable at discharge on diuretics. . 1.) CAD/Ischemia: S/p cardiac cath, which showed dominant Lcx with 90% lesion & ostial LAD lesion. The LAD lesion was stented and the Lcx lesion was angioplastied. This was complicated by dissection of LCx, with subsequent cardiac arrest in cath lab that resolved with CPR and pressors. The patient was medically managed with ASA, plavix, statin, and metoprolol. She would benefit from starting an ACE I once her creatinine has stabilized. . 2.) Dysrrhythmia: Pt went into wide-complex tacycardia (VT vs. SVT/sinus tach with partial RBBB) after her cardiac arrest, converting to NSR on lidocaine drip & amiodarone. Pt subsequently developed A fib with RVR in the 130s, which resulted in a hypotensive episode requiring cardioversion x 7 before stabilizing. Throughout the rest of her hospital course, patient remained in normal sinus rhythm. The amiodarone and digoxin was discontinued prior to discharge as the Afib only occurred in the setting of recent MI/cardiac arrest. . 3.) Acute on chronic systolic heart failure: Prior echo showed an EF of 35%, improved to 55% on [**2164-7-23**] echo. During her hospital course, pt had multiple episodes of acute respiratory distress secondary to the development of pulmonary edema in the setting of hypertension, likely due to a stiff LV. She was acutely managed with Lasix, morphine, nitropaste and nebs prn with good response. She received afterload reduction with hydralazine. She also received a short course of prednisone in light of her COPD. CXR on [**7-31**] showed improvement in mild pulmonary edema with bilateral pleural effusions present which partially layer and occupy the fissure. Pt stable on discharge dose of Lasix 40 mg po daily, to be sent to rehab with O2 for dyspnea on exertion. . 4.) R/o infection: Differential dx of acute respiratory distress included pneumonia. CXR [**7-26**] with poor inspiratory effort and thus was difficult to interpret. Endotracheal tube culture was MRSA +, and vancomycin was started empirically in the setting of acute respiratory distress although pt was afebrile with nl wbc. However, CXR [**7-28**] was consistent with mod pulm edema with no opacities suggestive of PNA, so vancomycin was discontinued. Since then, patient has been afebrile, although WBC increased to peak of 17.3 but trending down at 14.3 on discharge in context of recent prednisone course. Low suspicion for active infection as pt continued to be afebrile without cough/sputum, UA neg, Ucx with normal flora, C. diff neg. . 5.) Delirium: Pt experience several episodes of delirium (sundowning) in the setting of complicated hospital course in intensive care unit. She responded well to Haldol. Since her transfer to the floor, her mental status is much improved without further incidences. . 6.) Acute renal failure: Pt with baseline Cr of 1.2. On discharge, creatinine is stabilizing at 1.2, down from a creatinine max of 1.7. We suspected this was due to contrast nephropathy, shock, or possibly prerenal volume depletion. . 7.) Anemia: Pt has h/o anemia due to chronic GI bleeding related to angiodysplasia of small bowel, s/p 1 unit pRBC transfusion at OSH on [**2164-7-19**]. She had bloody NGT drainage post-cath. On [**2164-7-27**] she had clear bloody fluid per rectum. She had a guiac + black stool on [**2164-7-31**] and subsequently. However, she had a normal colonoscopy within the past year. In addition, Hct was stable (ranging from 31 to 35) and in light of her complicated hospital course, it was determined by the attending and with family that further intervention with endoscopy would not offer any therapeutic benefit. She will continue enteric-coated ASA 81mg PO daily and Plavix 75 mg PO daily for her stent. She is on Lansoprazole 30 daily. . 8.) Elevated LFTs were noted post-hypotension. We suspected this was secondary to shock liver as they normalized when re-checked on [**2164-7-31**]. . 9.) FEN/GI: Speech and Swallow evaluated the patient several times post-extubation and in her most recent eval they did not find clinical evidence of aspiration and she was advanced to liquids and soft solids. Clinical nutrition saw the patient on [**2164-8-1**] and recommended that she be on a low salt diet with supplemental high calorie, high protein shakes. She should have regular calorie intake monitoring to ensure adequate nutrional support. Medications on Admission: Advair Diskus 150 mcg 1 puff b.i.d. Spiriva 1 capsule inhaled daily Aldactone 25 mg p.o. daily Avapro 75 mg p.o. daily Crestor 10 mg p.o. daily Desyrel 50 p.o. at bedtime iron sulfate 325 mg a day Lasix 20 mg Monday, Wednesday, and Friday Plavix 75 mg a day Pletal 50 mg a day Protonix 40 mg b.i.d. Tenormin 25 mg Zetia 10 mg a day Carafate 1 g liquid four times daily. Discharge Medications: 1. Clopidogrel 75 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 2. Rosuvastatin 5 mg Tablet [**Date Range **]: Two (2) Tablet PO DAILY (Daily). 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Date Range **]: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [**Hospital1 **]: One (1) Cap Inhalation DAILY (Daily). 5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Hospital1 **]: One (1) Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 6. Hydralazine 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H (every 6 hours). 7. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 8. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1) Tablet, Delayed Release (E.C.) PO once a day. 9. Trazodone 50 mg Tablet [**Hospital1 **]: 0.5 Tablet PO HS (at bedtime) as needed. 10. Furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 11. Aspirin 81 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 12. Prevacid SoluTab 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day. 13. Colace 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO twice a day. 14. Sodium Chloride 0.65 % Aerosol, Spray [**Last Name (STitle) **]: [**1-25**] Sprays Nasal QID (4 times a day) as needed. 15. Acetaminophen 325 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 16. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day. 17. Senna 8.6 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO twice a day as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary: Coronary Artery Disease s/p stenting Ventricular Fibrillation s/p cardioversion Aspiration Pneumonia COPD exacerbation . Secondary: Hypertension Mental Status Changes Chronic Kidney Failure Discharge Condition: Stable. ambulating with minimal supplemental oxygen with 1 person assist for transfers. Discharge Instructions: You were admitted for cardiac cath and underwent stenting of your coronary arteries. However, the procedure was complicated by a ventricular arrhythmia that required cardioversion. You were intubated emergently and transferred to the cardiac intensive care unit. Your heart muscle appears to have preserved function and you will follow up with your cardiologist for a follow up ECHO in [**4-29**] weeks. . We have made some changes to your medications as seen below: We have discontinued your Aldactone, Avapro, Pletal, Protonix, Zetia, Carafate, Atenolol. We have changed your Lasix to 40mg by mouth daily and Trazodone to 25mg PO qHS. We have added the following medications: Hydralazine 10mg, two tabs by mouth every 6 hours. Metoprolol 50mg by mouth twice a day. ASA 81mg PO daily Lansoprazole 30mg PO daily. . If you develop any new chest pain, shortness of breath or any other general worsening of condition, please call your PCP or come directly to the ED. Followup Instructions: Dr. [**Last Name (STitle) 11679**] follow up appointment on Tuesday [**8-7**] at 2pm Dr. [**Last Name (STitle) **] follow up appointment Wednesday [**8-15**] at 10am Completed by:[**2164-8-3**]

[ "997.1", "403.90", "428.0", "570", "584.9", "425.4", "518.81", "411.81", "410.72", "414.01", "427.5", "507.0", "280.0", "293.0", "427.31", "537.83", "414.12", "998.2", "491.21", "428.23" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.6", "37.78", "99.62", "99.60", "00.41", "38.93", "00.45", "36.07", "00.66", "37.23" ]

icd9pcs

[ [ [] ] ]

15177, 15249

7962, 12863

309, 399

15492, 15582

5654, 7939

16600, 16797

4745, 4827

13284, 15154

15270, 15471

12889, 13261

15606, 16577

4842, 5635

222, 271

427, 4227

4249, 4580

4596, 4729

42,555

151,483

50186

Discharge summary

report

Admission Date: [**2192-12-27**] Discharge Date: [**2192-12-30**] Date of Birth: [**2130-6-18**] Sex: F Service: MEDICINE Allergies: Iodine; Iodine Containing / Adhesive Tape Attending:[**First Name3 (LF) 2279**] Chief Complaint: GIB Major Surgical or Invasive Procedure: EGD History of Present Illness: 62F with PMH of HTN, renal cell CA s/p nephrectomy [**Numeric Identifier 389**], who presents after syncopizing today at work. She acutely began to feel diaphoretic and lightheaded, so she sat down. Per others' reports she then briefly syncopized and came to immediately afterwards, with no confusion, speech slurring, toic/clonic movements. Endorses associated N/V, but no CP or SOB. No recent F/C. She does note that she has been taking motrin once or twice daily ever since her total hip replacement in [**2192-4-19**]. She also reports that her stools have been darker but not frnakly black for the last few days . In the ED, VS were 97.9 95 113/77 16 100%RA. NAD. 2/6 SEM. benign belly. Had 1 epidose of coffee ground episodes. EKG showed 1st degree block, non ischemic. HCT of 29.3, baseline 40. T+C x 4 units, no blood given. NG lavage returned coffee grounds, no bright red blood. Self d/c'ed NGT. GI was consulted, will scope tomorrow. Last VS 100 34/74 16 99%RA. Access was obtained with 2 18g PIVs. Got 2L NS and admitted to ICU for monitoring. . Currently feels weak and tired but no other complaints. Past Medical History: HTN RCC s/p partial left nephrectomy [**2183**] - disease free since. high cholesterol s/p total hip replacement [**4-26**] Social History: Works as head of lead prevention program. Denies EtOH/tobacco/drug use. . Family History: non-contributory Physical Exam: VS: afeb 103 135-153/80-90s 21 98%RA Gen: middle aged female in NAD HEENT: conjunctival pallor Cor: RRR, 2/6 systolic murmur LSB Resp: CTAB Abd: obese, S/nt/nd +BS ext: WWP, no c/c/e Pertinent Results: [**2192-12-27**] 02:15PM BLOOD WBC-10.5 RBC-3.29* Hgb-9.9* Hct-29.3* MCV-89 MCH-30.2 MCHC-33.9 RDW-13.5 Plt Ct-246 [**2192-12-27**] 07:37PM BLOOD Hct-29.0* [**2192-12-28**] 03:31AM BLOOD WBC-9.2 RBC-3.08* Hgb-9.6* Hct-26.4* MCV-86 MCH-31.1 MCHC-36.2* RDW-13.5 Plt Ct-293 [**2192-12-27**] 07:37PM BLOOD PT-13.6* PTT-20.3* INR(PT)-1.2* [**2192-12-27**] 02:15PM BLOOD Glucose-131* UreaN-33* Creat-0.6 Na-141 K-5.2* Cl-107 HCO3-25 AnGap-14 [**2192-12-28**] 03:31AM BLOOD Glucose-94 UreaN-23* Creat-0.7 Na-141 K-3.8 Cl-108 HCO3-27 AnGap-10 ECG Study Date of [**2192-12-27**] 1:37:24 PM Sinus tachycardia. The P-R interval is short without evidence of pre-excitation. There is an RSR' pattern in lead V1 which is probably normal. Compared to the previous tracing the rate is faster and the P-R interval is shorter. Intervals Axes Rate PR QRS QT/QTc P QRS T 103 102 80 342/417 50 38 56 EGD Report: [**Last Name (LF) 2974**], [**2192-12-28**] Impression: Granularity, friability, erythema, congestion and nodularity in the duodenal bulb compatible with duodenitis Granularity, friability, erythema, congestion and erosion in the antrum and stomach body compatible with erosive gastritis Ulcer in the stomach body (injection, endoclip) Otherwise normal EGD to third part of the duodenum Discharge: [**2192-12-30**] 12:35PM BLOOD Hct-27.4* Brief Hospital Course: 62F with a history of chronic hip pain/NSAID, s/p right hip replacement this in [**4-26**] who presents with an apparent upper GI bleed. # Upper Gastrointestinal Bleed: The patient presented with syncopy and subsequent Coffee-groud emesis. She was initially admitted to the MICU for monitoring and while her HCT dropped from 29-->26, the patient had no evidence of hemodynamic compromise. The patient was started on an IV proton pump inhibior and the gastroenterology service was contact[**Name (NI) **]. The the patient underwent endoscopy which showed erosive gastritis and deuodenitis. Given the patient's history of chronic pain, NSAID induced gastropathy was the suscepted underlying cause. Because of the friability of the patient's stomach mucosa, no biopsy was obtained. At the time of discharge, Anti-H.pylori IgG pending. Over the course of hospitalization, the patient recieved 1 unit of blood. She continued to have dark stools, but had no further episodes of hematemesis. She was discharged with plans to continue a twice daily proton pump inhibior and a repeat endoscopy in [**1-22**] months. She was to have a repeat hematocrit check in 1 week. She was strictly instructed to avoid NSAIDs for pain control. # HTN: Home dose of lisinopril was initially held due to her gastrointestinal bleed. Throughout her stay, she was normotensive. She was instructed to restart her lisinopril upon discharge at the discretion of her primary care physician. . # Hyperliipidemia: The patient was continued on her home dose on niacin. Medications on Admission: lisinopril 20mg daily niacin 500 [**Hospital1 **] flaxseed oil MVI motrin 400mg [**Hospital1 **] prn Discharge Medications: 1. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed: Do not exceed 4g per day. . 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day: Please do not restart this medication until instructed by your primary care doctor. 5. Flaxseed Oil Oral 6. Niacin Flush Free Oral 7. Outpatient Lab Work Please Draw: Hematocrit Please ensure results are sent to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Office Fax: ([**Telephone/Fax (1) 104698**] Discharge Disposition: Home Discharge Diagnosis: Erosive Gastritis Deuodenitis Upper GI bleed Discharge Condition: The patient was hemodynamically stable, afebrile and without pain at the time of discharge. Discharge Instructions: You were admitted for evaluation and treatment of lightheadedness. It was felt that your symptoms were due to blood loss from bleeding in your stomach. During this hospitalization, you underwent an esophagogastroduodenoscopy (EGD) which showed an ulcer and stomach irriation. From your history, this was most likely caused by your daily use of ibuprofen. . Because of this irriation, you will need to take a medication (Omeprazole) twice a day for at least 8 weeks-- this will allow your stomach to heal. It is highly recommended that you undergo a repeat EGD in [**1-22**] months and that you no longer use ibuprofen or other types of medications known as NSAIDS. You may take Tylenol as needed for pain but you should let your doctor know if you need to take this on a regular basis. . Because of your bleeding, we also recommend that you follow-up with your PCP as soon as possible for a repeat check of your red blood count (Hematocrit) to make sure you have no further evidence of bleeding. . Your blood pressure was normal this hospitalization, we recommend that you do not continue to take your blood pressure medication (Lisinopril) until you see your primary care physician. . Please call your doctor or seek immediate medical attention if you develop more lightheadednedd, shortness of breath, chest pain, abdominal pain, increased darkened stools, black or tarry stools or any other symptom of concern. Followup Instructions: Please call your Primary care physician (Dr. [**Last Name (STitle) **] for an appointment in the next week to 10 days: [**Telephone/Fax (1) 608**] . Please call the [**Hospital **] clinic (Dr. [**First Name (STitle) 452**] to arrange for a repeat endoscopy in [**1-22**] months: ([**Telephone/Fax (1) 2233**] Appointments prior to this hospitalization: Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2193-1-17**] 7:40 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6781**], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2193-1-17**] 9:00 Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2193-8-2**] 7:35 [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**] Completed by:[**2193-1-1**]

[ "531.40", "535.41", "401.9", "535.61", "V10.52", "285.9", "272.0", "V43.64", "338.29", "V58.64", "E935.9" ]

icd9cm

[ [ [] ] ]

[ "99.04", "44.43" ]

icd9pcs

[ [ [] ] ]

5776, 5782

3311, 4863

308, 313

5870, 5964

1950, 3288

7430, 8328

1713, 1731

5015, 5753

5803, 5849

4889, 4992

5988, 7407

1746, 1931

265, 270

341, 1457

1479, 1605

1621, 1697

12,077

127,126

18386

Discharge summary

report

Admission Date: [**2156-3-22**] Discharge Date: [**2156-3-30**] Date of Birth: [**2101-1-11**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Sulfa (Sulfonamides) / Morphine / Lactose-Free Food Attending:[**Last Name (NamePattern1) 1561**] Chief Complaint: Recurrent tracheobronchomalacia after tracheoplasty and re-do. Major Surgical or Invasive Procedure: flex. bronch, thoracotomy, tracheoplasty, removal of posterior mesh @trachea, tracheobronchoplasty [**3-22**], takeback for R. hemothorax [**3-24**] History of Present Illness: The patient is a delightful 55-year-old woman who has had a right thoracotomy with tracheobronchoplasty with mesh. She had an excellent result for several years until she began developing a recurrent, intractable cough. This progressed and associated dyspnea on exertion developed. A bronchoscopy confirmed the presence of recurrent distal tracheomalacia, proximal left main tracheomalacia and the right main and bronchus intermedius malacia. There was also the development of cervical malacia. She recently underwent a cervical tracheal resection and reconstruction with a tightening of the posterior membranous wall. She had a reasonably good result with improvement in both cough and dyspnea. However, she does continue to have an intractable cough and dyspnea on exertion. Past Medical History: 1- tracheobronchomalacia 2- Diabetes Mellitus (controlled) 3- Hypertension 4- Hyperlipidemia 5- H/o Staphylococcal and pseudomonal PNA 6- Depression/Anxiety 7- Obstructive Sleep Apnea 8- Migraines 9- Asthma/Bronchitis Social History: Denies tobacco, +occasional EtOH, married, lives in [**State 12000**] Family History: Non-contributory (no malignancy/tracheomalacia/Collagen Vascular Disease) Physical Exam: General: well appearing female w/ chronic cough. HEENT: unremarkable. chest: CTA bilat. COR: RRR S1, S2 abd: soft, NT, ND, +BS Extrem: no C/c/E neuro: intact Pertinent Results: [**2156-3-22**] 05:20PM BLOOD WBC-12.2* RBC-3.89* Hgb-10.2* Hct-30.2* MCV-78* MCH-26.2* MCHC-33.8 RDW-14.9 Plt Ct-250 [**2156-3-22**] 05:20PM BLOOD Glucose-162* UreaN-19 Creat-0.9 Na-138 K-4.3 Cl-103 HCO3-27 AnGap-12 RADIOLOGY: [**3-22**] CXR: The cardiomediastinal silhouette is unremarkable. Two right-sided chest tubes are in place. A tiny right basilar pneumothorax is suspected, which is unsurprising given the recent postoperative context. Adjacent subcutaneous emphysema is also present and expected. The patient is status post prior costotomies at the level of the fifth and sixth right ribs (posterior archs). A small amount of pleural fluid is suspected at the right apex. Trace atelectases are seen bilaterally. [**3-23**] CXR: Interval partial pullback of one chest tube, with its tip now at the right lung base. Worsening bilateral atelectasis, especially on the right. Increasing right pleural effusion adjacent to the lung apex [**3-24**] CXR: Two chest tubes are present in the right hemithorax terminating at the right apex. Previously present large right pleural effusion has nearly resolved, and there is a new small-to-moderate basilar pneumothorax present. Widening of right mediastinal contour is present and may reflect medially loculated pleural fluid or mediastinal hematoma. This has improved compared to the preoperative radiograph. Improved aeration of the right lung is noted with residual atelectasis, predominantly in the right middle and lower lobes and to a lesser degree centrally in the right upper lobe. New hazy opacities have developed in the left perihilar region and may reflect asymmetric edema or aspiration. [**3-25**] CXR: Since the recent radiograph of several hours earlier, there has been no substantial change in a loculated hydropneumothorax with two chest tubes in place. Multifocal alveolar opacities involving the left upper, bilateral mid and right lower lung region have progressed in may be due to multifocal asymmetrical edema given waxing and [**Doctor Last Name 688**] present on recent serial radiographs. Aspiration is an additional consideration. Widening of right mediastinal contour is without change compared to recent postoperative radiographs. [**3-26**] CXR: Comparison with [**2156-3-25**]. The two right chest tubes are unchanged in position. There appears to be a mild increase in the right hydropneumothorax, which was known to be loculated. There is now more fluid component. The multifocal alveolar opacities involving the left upper lobe, bilateral mid and right lower lung zones, had increased slightly, and likely due to multifocal asymmetric edema, given the time course of change. Aspiration is also a consideration. There is stable widening of the mediastinal contour in this postoperative patient. [**3-28**] CXR: PA and lateral chest compared to moderate loculated right pleural abnormality along the lateral, upper mediastinal and posterior pleural surfaces has remained unchanged since [**3-27**] following removal of previous right pleural drains. There is no pneumothorax. Appreciable atelectasis at the right base is unchanged causing elevation of the right hemidiaphragm. The left lung shows linear atelectasis and vascular engorgement. The heart is normal size. There is no pneumothorax. Colonic distension is noted in the right upper abdominal quadrant, but there is no peritoneal free air. Brief Hospital Course: Ms. [**Known lastname 5514**] was admitted and taken to the OR for : 1. Flexible bronchoscopy. 2. Right redo thoracotomy with removal of Marlex mesh and redo tracheoplasty. 3. Redo right main bronchoplasty. 4. Redo proximal left main bronchoplasty. 5. Adjacent pleural flap to airway Please see operative notes for details of procedure. An epidural was placed for pain control and a PCA. She was extubated immediately post-operatively. She was admitted to the ICU for monitoring and aggressive pulmonary care. Two right chest tubes were in place and to suction with a moderate amount bloody drainage. She was maintained on IV clinda for mesh. She underwent a bronchoscopy on POD#1 for assessment of the repair and for clean out of secretions. Her post-operative course was complicated by development of a right hemothorax requiring transfusions and return to the OR on POD# 2 for evacuation of the hemothorax. Chest tube drainage was minimal and her Hematocrit remained stable. Chest tubes were removed on [**3-27**]. She progressed well with rehabilitation and was cleared for discharge home with continued oxygen. Medications on Admission: metformin 1'', bupropion 300', lansoprazole 30', citalopram 10', fexofenadine 180QPM, montelukast 10QPM, simvastatin 20', trazodone 50 QPM, advair 250/50'', spiriva 18', astelin'', flonase' Discharge Medications: 1. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*75 Tablet(s)* Refills:*0* 10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). Disp:*600 ML(s)* Refills:*2* 11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 12. Oxygen-Air Delivery Systems Device Sig: One (1) Miscellaneous continous. Disp:*1 * Refills:*2* 13. Neurontin 100 mg Capsule Sig: Two (2) Capsule PO once a day. Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: redo-redo tracheoplasty asthma/bronchitis, HTN. DM2 well-controlled, OSA, hypercholesterol, tracheobronchomalacia s/p tracheobronchoplasty/stenting [**2152**] (c/b S. aureus infection/PNA), re-do tracheoplasty with mesh [**12/2155**] Discharge Condition: good Discharge Instructions: Call Dr.[**Name (NI) 1816**] office [**Telephone/Fax (1) 170**] if you develop chest pain, shortness of breath, fever, chills, redness or drainage from your chest incisions. check your finger stick before meals and at bedtime- increase your metformin back to your home dose if you are eating fulls meals and your finger sticks are within range. Followup Instructions: You have a bronchoscopy tuesday [**2156-4-6**] in interventional pulmonology. Please report to daycare in the [**Hospital Ward Name 121**] building [**Location (un) 19201**] at 7:30am. Do not eat anything after midnight on monday.

[ "401.9", "272.0", "327.23", "250.00", "300.4", "493.90", "285.1", "519.19", "998.11", "E878.8", "518.0" ]

icd9cm

[ [ [] ] ]

[ "33.22", "34.03", "33.48", "99.04", "31.79" ]

icd9pcs

[ [ [] ] ]

8036, 8042

5387, 6518

404, 555

8320, 8327

1975, 5364

8720, 8954

1707, 1782

6758, 8013

8063, 8299

6544, 6735

8351, 8697

1797, 1956

301, 366

584, 1362

1384, 1603

1619, 1691

31,030

126,060

19205

Discharge summary

report

Admission Date: [**2168-2-22**] Discharge Date: [**2168-3-22**] Date of Birth: [**2136-8-11**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillin G Potassium Attending:[**First Name3 (LF) 492**] Chief Complaint: SOB Major Surgical or Invasive Procedure: -Intubated -L femoral line placed -L Arterial line placed History of Present Illness: 31yoM w/ ESLD EtOH cirrhosis, removed from Tx waiting list since [**2167-8-13**] transferred from OSH c/o dyspnea, L pleuritic CP x 6 days. Pt was somnolent, w/ desaturation despite being on NRB. . OSH COURSE: Initially presented to OSH with increasing SOB, rusty colored sputum diagnosed with LLL pna. treated with vanco and aztreonam due to PCN allergy. Transferred to [**Hospital1 18**] for further management. . ED COURSE: Initial VS 100.0 BP 109/60 HR 133 24-28% 93% 10L, Hypoxic with o2 sat of 90 on NRB. Intubated in ED, with etomidate 20mg, succ 120mg, fent 50, versed 2, followed by fent 100, vecuronium 8mg IVx1 . R IJ cvl was being placed under US when pt bucked. The needle was in, and the wire was being advanced at the time. The access was lost, and R neck hematoma was noted over the next 5 min. Manual pressure was held for 20 min. [x] ffp-2U; [X] plt 1 bags; [x] vascular c/s ; access 3PIV, not hypotensive, tachy 140s getting IVF bolus, received 1LNS. Intially placed on AC Vt 450-480s, PiP 50-55, Paralyzed w/vecuronium, switched to PCV, PEEP 20 -->PiP 45, 2 recruitment maneuvers, O2 sats improved. Received Levoflox as pt had received Aztreonma/Vanc prior to transfer. Received 4LNS. Past Medical History: -ESLD from EtOH Cirrhosis, extensive ETOH abuse -- encephalopathy [**4-26**] -- esophageal varices grade II [**6-26**] -- no HepB/HepC/HIV -internal hemorrhoids -insominia -anxiety -depression Social History: -Lives with partner, [**Name (NI) 9875**] -Significant ETOH hx-drank 1 gallon Vodka per day, off transplant list since [**7-/2167**] due to med non-compliance, continued drinking, lost to follow up. -denies IVDU Family History: NC Physical Exam: VS: 99.2 BP 101/47-->81/30 HR 138 ST RR30 99% PCV 22/18 FiO2 0.9 Vt 530 RR 32 GEN: Intubated, paralyzed/sedated HEENT: OGT w/coffee ground material guaiac +, anicteric sclera RESP: diminished BS L upper lung fields, no crackles, minimal wheezing CV: Reg tachycardic, Nml S1, S2, no M/R/G ABD: Soft, obese, ND/NT +BS, No organomegaly, no fluid wave EXT: no peripheral edema, no petechia noted, no rashes, 1+DP pulses b/l NEURO: sedated, paralyzed Pertinent Results: OSH LABS: -Lactate 7.6, Ammonia 213.6, tylenol level 37, alcohol level <10 INR 2.9 PTT 37.9 PT 21.8 WBC 1.3 HCT 26.9 PLT 11 40%Bands, 36%neutrophils , 18%lymphs BUN/CR 21/1.52 ALB 2.5 BILI 6.1 CPK 141 CK MB 8.0 MBI 5.7 Tn-I <0.01 . IMAGING: [**2168-2-22**] UE U/S: -Subcu swelling but no discrete hematoma. RIJ and R carotid are patent without evidence of pseudoaneurysm or AV fistula. . [**2168-2-22**] CXR: IMPRESSION: Large left lung consolidation consistent with pneumonia with likely superimposed pleural effusion. Possible small right effusion/consolidation. . EKG: Sinus tachycardia HR 139, non specific STD inf . Liver U/S [**2168-2-23**]: 1. Patent and dramatically enlarged 2 cm umbilical vein, which runs the entire length of the abdominal wall from the liver into the pelvis. Flow in all of the portal veins is towards this enlarged patent umbilical vein. 2. Splenomegaly. 3. No liver masses are identified. 4. No ascites identified. . Chest CT [**2168-2-26**]: 1. Severe, rapidly progressing, multifocal, necrotizing pneumonia. 2. No pleural effusion. 3. Cirrhotic liver, portal hypertension, ascites, anasarca. 4. Cholelithiasis. Gallbladder distension may be related to n.p.o. status; ultrasound indicated if there is clinical concern for cholecystitis. Brief Hospital Course: 31 yo M with ESLD, ETOH cirrhosis p/w LLL PNA to OSH, tx here with septic shock, respiratory failure requiring intubation ([**2168-2-22**]), found to have strep pneumo PNA and empyema (s/p chest tube), ARDS, pancytopenia and ARF who subsequently developed VAP, MRSE bacteremia, and overwhelming hypotension with hypothermia. Given his overwhelming organ failure, septic shock, and poor long-term prognosis, taken with Mr. [**Known lastname 34858**] wishes, his co-HCP'[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1692**] [**Last Name (NamePattern1) 52348**] and [**First Name8 (NamePattern2) 2808**] [**Last Name (NamePattern1) 52349**] decided to make goals of care comfort measures only. He was extubated at 1730 on [**2168-3-22**] and passed away at 1845 that same day with his family at his bedside. 1. Respiratory Failure: Intubated since [**2168-2-22**]. Resp failure initially strep pneumo PNA with L empyema s/p chest tube placement ([**2168-2-23**]), decreased MS, pulmonary edema, ARDS. Stopped vancomycin/levofloxacin on [**3-6**] (though should have been 4 wk course given empyema). Developed recurrent VAP [**3-17**], on vanco/zosyn, mini-BAL with only yeast. Less secretions, afebrile. Vancomycin/Pip-Tazo ([**Date range (1) 52350**]), though will need 4 wk course for pan-sensitive strep pneumo (could use vanco [**Date range (1) 52351**] vs. consider switching to ctx or pcn). Diureses attempted with Lasix 20 IV q6H (I/O goal -0.5 to -1L). 2. Bacteremia: Developed [**1-26**] blood cx [**3-17**] MRSE, [**3-18**] NG. He was on vanco planned for 2 weeks treatment from neg. cx. He was considered for resiting lines (try for picc, d/c right picc and cvc), consider resite art.line 3. Hypotension: Briefly hypotensive [**3-21**], fluid responsive, thought related to diuresis as improved with ivf and he was net negative. However, he developed severe hypotension as described above on [**3-22**] prompting a discussion with both HCP's and family re goals of care and was made CMO. 4. ARF/ATN: Likely ATN, seems to be waxing and [**Doctor Last Name 688**]. Stopped octreotide/midodrine since unlikely to be HRS. 5. Anemia/Pancytopenia: Secondary to bleeding in mouth (suction trauma and coagulopathy) and through OG tube (portal gastropathy on EGD) and underlying liver disease. Blood products were used to reverse coagulopathy throughout his hospital course. 6. Empyema: Noted on admission with strep pneumo from pleural fluid. He had a chest tube placed. Per thoracic [**Doctor First Name **] chest tube placed [**2-23**] for difficulty ventilating, significant air space loss. Initial WBC of pleural fluid >1000. This was continued with chest tube to water seal. 7. ESLD: Secondary to alcohol use, off transplant list. Pt with significant alcohol abuse, med non-compliance, lost to follow up. Tylenol level was not above Rumack-[**Doctor First Name **] nomogram. Liver service recommended supportive care and his liver continued to fail throughout his hospital course. He was continued on lactulose and rifaximin. 8. Ileus: Continued attempts at low dose trophic tube feeds failed and caused bleeding. Decreasing narcotic sedation did not help. PO naloxone, erythromcyin and reglan also did not help. 9. FEN: TF as above, TPN since [**2-29**], (no calcium, no heparin). Hypernatremia resolved with free water repletion, will monitor. 10. PPX: Pneumoboots, PPI 11. Communication: [**First Name4 (NamePattern1) 1692**] [**Last Name (NamePattern1) 52348**]: Partner, HCP is shared with sister [**Name (NI) 2808**]. 12. ACCESS: L fem line discontinued [**2-29**], L IJ placed [**2-29**]. R A-line on [**2-29**], R PICC on [**3-10**] Medications on Admission: MEDS Per last OMR note, unclear if taking: -amiloride 15 mg once a day -Protonix 40 once a day -multivitamins -nadolol 40 once a day -folic acid -trazodone 150 q.h.s. -oxycodone p.r.n. -Celexa 30 mg once a day -Remeron 15 mg once a day -Lasix 60 mg once a day -Lactulose 15 cc once a day -Seroquel 200 mg q.h.s. Discharge Medications: None. Discharge Disposition: Expired Discharge Diagnosis: Septic shock, respiratory failure, bacteremia, pneumonia, end stage liver disease. Discharge Condition: Deceased. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]

[ "276.2", "995.92", "873.64", "998.12", "456.21", "E879.8", "780.52", "348.39", "574.20", "584.5", "E928.3", "510.9", "038.9", "481", "789.59", "275.41", "284.1", "572.3", "785.52", "285.1", "455.0", "873.65", "038.19", "276.0", "458.29", "305.00", "999.9", "537.89", "571.2", "560.1", "300.00", "518.81" ]

icd9cm

[ [ [] ] ]

[ "99.15", "34.04", "96.04", "45.13", "96.6", "33.24", "96.72", "38.91", "38.93" ]

icd9pcs

[ [ [] ] ]

7895, 7904

3830, 7503

292, 352

8030, 8154

2533, 3807

2047, 2051

7865, 7872

7925, 8009

7529, 7842

2066, 2514

249, 254

380, 1586

1608, 1802

1818, 2031

83,062

129,076

50800

Discharge summary

report

Admission Date: [**2190-11-24**] Discharge Date: [**2190-12-15**] Date of Birth: [**2113-12-4**] Sex: M Service: MEDICINE Allergies: Zestril Attending:[**First Name8 (NamePattern2) 812**] Chief Complaint: Upper GI Bleed Major Surgical or Invasive Procedure: Endotracheal intubation, Central line placement History of Present Illness: 76 yo male with hx of GERD and DMII, was found by friend poorly responsive and covered in coffee ground emesis. [**Name (NI) 1094**] friend who is internist, was visiting him as he sounded ill over the phone, with symptoms of congestion, rhinorrhea, and SOB. Pt had complained of non specific symptoms over the last couple days, including cough and congestion. Unknown if he was febrile, or had sick contact. . Review of systems obtained from friend and includes no hx of [**Name (NI) 105649**], BRBPR, but chronic abdominal discomfort over the last several months. . In the emergency department, pt was found to be hypoxic. initial VS: HR 134 BP 192/105 RR 25 O2 85% NRB. Pt was intubated, and some gastric content was suctioned from ET tube. Gastric lavage significant for black/coffee ground content which cleared after 500cc. Past Medical History: 1. DMII on oral meds 2. Stroke/ TIA - [**2180**] 4. HTN 5. GERD - reflux esophagitis 6. Depression 7. Prostate Ca s/p surgery [**94**] years ago 8. Dyslipidemia 9. Diverticulitis 10. CAD - hypokinesis on ECHO, non symptomatic 11. osteopenia 12. last outpt Cr - 1.4 Social History: lives alone, retired, no smoking, no drinking Family History: noncontributory Physical Exam: T= 96.9 BP= 142/78 HR= 84 RR= 18 O2= 94% on 3L NC GENERAL: well appearing, conversant HEENT: dry mucous membranes, OP clear. Neck: Supple, No LAD CARDIAC: RRR. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. EXTREMITIES: No edema or calf pain, 2+ distal pulses SKIN: No rashes/lesions, ecchymoses. NEURO: CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: Labs on admission: WBC 19.2 N77.7 L16 M5.4 E0.9 B 0.3 Hct 41.3 MCV 92 Plts 312 PT 11.5 PTT 17.8 INR 1.0 ESR 25 Na 136 94 20 / Glucose 271 ------------------- K 3.6 25 1.2 \ ALT/AST 20/37 LDH 238 CK 1126 AlkP 61 Tbili 0.5 Lipase 43, 77 Cardiac enzymes negative x2 TIBC 170 Ferritin 341 Tranferrin 131 TSH 1.7 CRP 135.1 ABG 7.37/52/51/31 lactate 2.8 --> 0.7 Acetylcholine receptor antibodies negative Acetylcholine receptor modulating antibodies pending Plasma metanephrines normal See OMR for all Cx's. Pertinents: Legionalla Ag negative Influenza A/B negative CMV negative UCx negative x8 Blood Culture 2/2 bottles, Routine (Final [**2190-12-7**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL SENSITIVITIES. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. 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. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SECOND MORPHOLOGY. FINAL SENSITIVITIES. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. 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 _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | STAPHYLOCOCCUS, COAGULASE NEGATIVE | | CLINDAMYCIN----------- =>8 R =>8 R ERYTHROMYCIN---------- =>8 R =>8 R GENTAMICIN------------ 4 S 4 S LEVOFLOXACIN---------- 4 R 4 R OXACILLIN------------- =>4 R =>4 R RIFAMPIN-------------- 2 I 2 I TETRACYCLINE---------- <=1 S <=1 S VANCOMYCIN------------ 2 S <=1 S Anaerobic Bottle Gram Stain (Final [**2190-12-2**]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. REPORTED BY PHONE TO [**Doctor Last Name **] [**Doctor Last Name **] AT 1712 ON [**2190-12-2**]. Since these cultures, pt has been BCx negative x7 Cdiff negative, Urine cx neg ********Labs on discharge: IMAGING, significant, for full imaging see OMR: [**11-24**] EKG Baseline artifact. Regular and narrow complex rhythm. Probable sinus tachycardia. Left axis deviation. Late R wave progression. ST-T wave abnormalities. Since the previous tracing of [**2185-3-18**] the rate has increased. ST-T wave abnormalities are more prominent. [**2190-11-24**] CXR CHEST, SINGLE AP VIEW: Heart is mildly enlarged, with a mildly tortuous aorta. The lungs are clear without conosolidation or edema. There is no pleural effusion or pneumothorax. A large hiatal hernia is similar in appearance to the prior study. No free air is identified. IMPRESSION: 1. No free air identified. 2. Stable mild cardiomegaly. 3. Large hiatal hernia. [**11-25**] Echo The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Doppler parameters are most consistent with Grade I (mild) left ventricular diastolic dysfunction. The right ventricular free wall is hypertrophied. The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**2-5**]+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. Compared with the report of the prior study (images unavailable for review) of [**2184-11-1**], the right ventricle is mildly dilated, hypertrophic and moderate pulmonary artery systolic hypertension is detected. [**12-1**] CT neck IMPRESSION: 1. The presence of endotracheal and endogastric tubes limits the evaluation of the retropharyngeal and prevertebral soft tissue spaces; however, there is no definite effusion, phlegmon or collection at these sites. 1. Small, 9-mm apparent rim-enhancing fluid collection located roughly at the level of the left tonsillar pillar, which may represent liquefactive necrosis and early abscess formation; this should be correlated with findings on direct physical examination. 2. Extensive fluid opacification of all visualized paranasal sinuses, left more than right mastoid air cells and middle ear cavities and the nasal cavity and nasopharynx, likely related to protracted intubation and supine positioning. While concurrent infection cannot be excluded by imaging, there is no evidence of bone destruction. 3. Scattered patchy ground glass opacities in a peribronchovascular distribution in the lung apices; please see separately-dictated report of concurrent chest CT for further details. 4. Grossly patent cervical tracheal airway, with endotracheal tube in situ. [**12-1**] CT chest IMPRESSION: 1. Left greater than right bibasilar consolidations, the appearance is nonspecific, and can be attributed to atelectasis, aspiration or infection, however, in review of the time course of multiple prior radiographs, the findings are in favor of improving atelectasis or aspiration and less likely infectious pneumonia. 2. Ground glass opacities in the right upper lobe, the time course cannot be reliably established rendering these concerning for aspiration or pneumonia. 3. Probably reactive borderline lymph nodes. 4. Large hiatal hernia. [**12-5**] CT head IMPRESSION: 1. No acute intracranial process. 2. Diffuse the opacification of the paranasal sinuses, which may be attributed to intubation. Infection cannot be excluded. [**12-8**] Repeat neck CT IMPRESSION: 1. The previously noted small rim-enhancing fluid collection at the level of the left tonsillar pillar is not as well seen on the current study, but likely similar-to-slightly smaller in size. No new collections are identified. 2. Progressive opacification of the paranasal sinuses. New fluid in the mastoid air cells. This is likely related to protracted intubation. As on the prior study, infection cannot be excluded by imaging. 3. Unchanged patchy ground-glass opacities at the lung apices. [**12-10**] video swallow study: IMPRESSION: Aspiration of thin barium. Penetration with nectar barium. Moderate amount of residual in the valleculae. [**12-14**] video swallow study: IMPRESSION: Penetration with thin and nectar-thick liquids and aspiration with thin liquids. For details, please see separate report by the speech and swallow division on OMR. [**12-12**] Xray L hand and wrist: FINDINGS: An oxygen saturation measurement device is positioned over the left index. There is no evidence of localized soft tissue swelling. The bone mineralization appears normal. No evidence of cortical disruptions suspicious for fracture. The distal interphalangeal joints show moderate to high-grade arthritic changes, mild moderate arthritic changes are also seen at the bases joint of the first digit. No evidence of osteoporosis. Brief Hospital Course: MICU COURSE: # Respiratory Failure: Initially thought to be aspiration pneumonitis vs viral URI/PNA. Arrived to the ICU intubated for aiwary protection and was quickly extubated. He tolerated extubation overnight, however the following day had some diffculty swallowing with lunch and difficulty with thick secretions. He then had elevated BP, he became more tachypnic and had increased work of breathing and the decision was made to re-intubate. Etiology for respiratoy distress likely aspiration vs CHF flash vs infection. He was started on antibiotics, however sputum cultures were continually negative. Pt remained intubated for over a week and had a difficult time with weaning because he had generalized weakness, also persistantly febrile over that time and concern for infection contributing to difficulty weaning, however he began to improve and eventually tolerated extubation. . # Persistent fevers: Had several rounds of negative cultures but eventually with positive blood cultures for GPC treated with vancomycin. Also concern for sinusitis on CT head treated with augmentin and evaluated by ENT for small 9mm fluid collection near tonsillar pillar, concern for small phlegmon vs abscess. ENT evaluated, drainage attempted however no fluid aspirated. Pt continued to have low grade fevers and c/o neck pain. Repeat neck CT scan obtained showed decrease in size of L fluid collection, did show persistent sinusitis, pt continued on Augmentin. . # Weakness: Developed generalized weakness and was evaluated by neuro who felt likely due to critical illness myopathy. Weakness improved somewhat when sedation weaned off and eventually improved leading to extubation. Continued to gain strength and will need further PT and OT. Neuro had also been considering doing EMG. . # Dysphagia: Had h/o of dysphagia before admission and seen to have difficulty swallowing, mouth breathing, difficulty handling secretions, and copious coughing. Neuro re-consulted who did not feel this could be related to stroke. Neuro recommended video swallow study that recommended pt get nutrition through Dobhoff, stay NPO. Pt currently NPO and receiving nutrition through NGT. Had broached the subject of PEG tube with pt who was amenable if necessary. . # Atrial fibrillation w RVR ?????? Had one episode of a fib with RVR, likely precipitants fluid overload and HTN. No prior hx of afib. Now rate controlled with diltiazem. Will likely require anti-coagulation given high CHADS score, holding off for now given recent GI bleed. . # Coffee ground emesis: Initially with coffee ground emesis but negative upper endoscopy and NG lavage negative x2, trace guiac positive. Hematocrit stable. Will need colonoscopy as outpatient. . # L wrist gout and L foot podagra: Just before leaving MICU pt c/o L wrist pain and first wrist then foot seen to be swollen, erythematous, and tender. LUE u/s did not show DVT. Consulted Rheum who did not feel tap to be necessary, started on Prednisone with some improvement. Recommended repeat urate level in 4 wks. . # Hypertension: BP continued to rise and hypertension meds were added back and uptitrated as necessary, currently on Methyldopa, Metoprolol and Losartan. . . . . . . . . . . . . . . . . . ................................................................ MEDICINE FLOOR COURSE: Pt is a 77 yo male who was admitted for hypoxia in the setting of coffee ground emesis and URI now with weakness/dysphagia and deconditioning after a prolonged MICU course. . # Gout: Symptoms improved on steroids. LUE U/S on [**12-11**] was negative for DVT. Hand films were normal except for degenerative changes. Pt finished 3d of Prednisone 20 mg PO daily, now on taper of 10mg daily x 2d then stop. Uric acid was nl, however should recheck in 4 weeks as this can be falsely normal in acute gout. . # Fever/Leukocytosis: pt remained afebrile with resolved leukocytosis. The leukocytosis is thought to be [**3-8**] steroids. Pt completed 7 days of vancomycin for two bottles of coag negative staph prior to transfer to floor. Pt was continued on fluticasone nasal spray for ?sinusitis seen on CT. Pt also completed a 14d course of either augmentin or unasyn (depending if tolerating PO or not) for possible peritonsillar abscess per ENT recs. . # Weakness/respiratory difficulty: Likely [**3-8**] critical care myopathy. Neurology was following who suggested an EMG, however can be done as outpatient as pt was improving clinically. Pt has a F/U with outpt Neurology. A repeat video swallow showed imrpovement and pt was started on diet per speech & swalloe recs. The Dobhoff tube was taken out as pt was tolerating diet. . # Hypertension: Reasonably controlled on current regimen (SBP 140-160). Pt was continued on Losartan 100mg daily, Methydopa 500mg [**Hospital1 **]. Pt was switched to long-acting beta-blocker, Toprol 200mg daily. Since BPs are above ideal range, adding home HCTZ or titrating up the Toprol can be considered. . # S/P atrial fibrillation w RVR: Pt had one episode of Afib in the setting of fluid overload, has since been in sinus rhythm. Pt does not require anticoagulation at this time. Pt was continued on Metoprolol. . # S/P coffee ground emesis: Pt had no other episodes of GI bleed and Hct has been stable. Upper endoscopy and NG lavage were negative. Pt could benefit from colonoscopy as outpatient. Pt was continued on PO PPI [**Hospital1 **]. Home Aggrenox was initially held due to GI bleed, however since the benefits seem to outweigh the risks at this point, pt was restarted on it. Pt should be monitored for any new signs of Gi bleed and periodically check Hct. . # DMII: Pt was mostly maintained on long-acting insulin and sliding scale during hosptial stay, but was switched back to home Metformin prior to discharge. Fingersticks were in reasonable range 100-200. . # Pt was NPO and on tube feeds through Dobhoff due to dysphagia, however subsequently switched to diabetic diet- ground (dysphagia) solids, nectar prethickened liquids, pills crushed and chin tucked with swallowing once video swallow study showed functional improvement. Pt was on a good bowel regimen and on Heparin SC for DVT ppx. Pt was full code. Medications on Admission: Aggrenox [**Hospital1 **] Simvastatin 20mg qhs Metformin 1000mg [**Hospital1 **] Folic Acid 1mg qday Buproprion 75mg daily, [**2-5**] daily Calcium+ Vit D Cozaar 100mg daily HCTZ 25mg daily Fluoxetine 20mg daily Prevacid 15mg daily Alpha - Methyldopa 500mg tabs [**Hospital1 **] (anti hypertensives) Naprosyn - few months ago 225mg 2 [**Hospital1 **] Discharge Medications: 1. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr [**Hospital1 **]: One (1) Cap PO BID (2 times a day). 2. Metformin 500 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times a day). 3. Prednisone 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily) for 2 days. 4. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr [**Hospital1 **]: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 5. Simvastatin 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO at bedtime. 6. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 7. Methyldopa 250 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q12H (every 12 hours). 8. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Hospital1 **]: [**2-5**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 10. Losartan 50 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). 11. Fluoxetine 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 12. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2 times a day). 13. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 14. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Four (4) Puff Inhalation QID (4 times a day) as needed for shortness of breath or wheezing. 15. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Last Name (STitle) **]: Four (4) Puff Inhalation Q6H (every 6 hours) as needed for sob/wheezing. 16. Calcium Carbonate-Vitamin D3 400-133.3 mg-unit Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 17. Fluticasone 50 mcg/Actuation Spray, Suspension [**Last Name (STitle) **]: Two (2) Spray Nasal DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary Diagnosis: UGIB Critical care myopathy Peritonsillar abscess Secondary Diagnosis: GERD DMII h/o CVA Discharge Condition: good, OOB with assistance, tolerating ground solids and nectar liquids Discharge Instructions: You were admitted to [**Hospital1 18**] because you vomited blood and were found unresponsive. A ventilator was used to help your lungs breathe and you stayed in the Intensive Care Unit until you improved clinically. You were eventually taken off the ventilator, and did very well breahting on your own. In the meantime, you developed an infection in your throat and also possibly your blood, both of which were treated with antibiotics. You also had a gout flare, which was treated with steroids. Because of the long period of time you spent i nthe ICU, you had weakness and trouble swallowing, which required you to be feed through a feeding tube. However, you eventually regained some strength and you started tolerating a diet. You still need physical therapy to help you to continue to improve. Please make the following changes to your medications: 1. START Prednisone 10mg PO daily x 2days 2. START Toprol XL 200mg daily 3. START artificial tears to both eyes as needed for dry eyes 4. START Lansoprazole 30mg daily 5. STOP Lansoprazole 15mg daily 6. STOP HCTZ until further notice 7. START Flonase nasal spray daily 7. START Ipratropium and Albuteral inhalers as needed for shortness of breath or wheezing Please seek immediate medical attention if you expreience extreme weakness in your limbs, high fevers, chest pain, shortness of breath or any other concerning symptoms. Followup Instructions: Follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**] in [**Hospital 878**] Clinic on [**1-10**] at 10:00 AM in the [**Hospital Ward Name 23**] Bldg, [**Location (un) **]. Ph# [**Telephone/Fax (1) 2928**]. A follow-up appt with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] will be made at time of discharge from the rehab facility. [**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **] MD, DMD [**MD Number(2) 821**] Completed by:[**2190-12-15**]

[ "518.81", "274.9", "585.9", "461.9", "276.0", "250.00", "578.0", "584.9", "475", "403.90", "427.31", "359.9", "790.7", "V10.46", "041.19" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.72", "38.93", "96.6", "96.04", "45.13" ]

icd9pcs

[ [ [] ] ]

18339, 18405

9819, 16012

294, 343

18558, 18631

2158, 2163

20071, 20623

1569, 1586

16415, 18316

18426, 18426

16038, 16392

18655, 19489

1601, 2139

19518, 20048

240, 256

4672, 9796

371, 1202

18517, 18537

18445, 18496

2177, 4652

1224, 1490

1506, 1553

73,686

120,933

47468

Discharge summary

report

Admission Date: [**2121-9-5**] Discharge Date: [**2121-9-15**] Date of Birth: [**2056-2-21**] Sex: F Service: MEDICINE Allergies: Penicillins / Codeine Attending:[**Known firstname 2195**] Chief Complaint: Afib with RVR complicated by flash pulmonary edema and hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: 65F with PMHx significant for recently diagnosed atrial fibrillation (discharged [**2121-8-26**], not anticoagulated), CVA with residual R facial droop/dysphagia s/p G-tube, and CAD s/p PCI of RCA in [**2114**], who presents to the ED from [**Hospital 100**] Rehab with palpitations, suprapubic pressure, and feeling generally unwell. Per report she was hypotensive at [**Hospital 100**] Rehab, however, she was not hypotensive at any point in our ED. Non-contrast head CT showed no acute intracranial process. Labs were significant for lactate 2.1, AST 161, ALT 241, normal WBC with slight left shift, troponin <0.01, Hgb/Hct 11.6/35.3 (stable), and urinalysis suggestive of infection (0 epis, mod leuk, mod bacteria, WBC 13). CXR showed worsening CHF with moderate to severe pulmonary edema, increased size of bilateral pleural effusions (R>L), and bibasilar airspace opacities. Patient received clindamycin 600mg IV and levofloxacin 500mg IV to cover for possible pneumonia (has penicillin allergy). She was ordered for vancomycin but did not receive it. An EKG checked prior to transfer to the ICU showed afib with RVR @ 115. VS on transfer were 99% 4L NC, 138/100, HR 120. On arrival to the MICU, patient is sleepy, but states that her symptoms have improved. Review of systems: (+) Per HPI, sweats, lower abdominal pain, shortness of breath x 2 days, palpitations x weeks (worse x 1 day), sputum production (-) Denies fever, chills, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough or wheezing. Denies chest pain, chest pressure, or weakness. Denies nausea, vomiting, diarrhea, constipation, or changes in bowel habits. Denies dysuria, frequency, or urgency. Past Medical History: Left upper pole renal mass, concerning for malignancy ([**2121-4-15**]) Ductal carcinoma in situ bilaterally, status post bilateral mastectomies Thoracic aortic aneurysm Hypertension Hyperlipidemia s/p CVA secondary to basilar artery rupture in [**2099**]. CAD, status post PCI of her RCA in [**2114**] Urinary incontinence Depression PUD s/p tubal ligation Subarachnoid hemmorhage Right distal clavicle fracture Dysphagia s/p g-tube Necrotizing PNA [**12/2119**] Hematuria Compression fx t11 Chronic aspiration, strict NPO s/p procedure at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**Month (only) **]/[**2120-1-16**] related to swallowing s/p duodenal AVM bleed [**10/2120**] (hospitalized at [**Hospital3 26615**] with Hct 10, s/p argon coagulation) Social History: She has been living at [**Hospital 100**] Rehab. She has a daughter, [**Name (NI) **], who lives in [**Name (NI) **], and a son, [**Name (NI) **], who lives locally. Retired waitress. She has smoked since the age of 13. The most she has smoked is 1 pack per day. She denies alcohol. She denies any IV drug use or the use of any other illicit drugs. Family History: She has a sister with breast cancer. Her father died at the age of 51 of a heart attack. She has 3 brothers who have had heart attacks, 1 at the age of 58, 1 at the age of 64, and 1 at the age of 60. Physical Exam: Admission Exam: T: 96.2, BP: 123/105, P: 106, R: 26, O2: 96% 4L NC General: sleepy, oriented x 3 (person, [**Hospital3 **], [**2121-8-16**], Friday), no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: irregularly irregular, normal S1 + S2, no murmurs, rubs, gallops Lungs: Bilateral crackles throughout, decreased breath sounds at RLL, no wheezes or rhonchi Abdomen: soft, non-tender although pt endorses a sensation of "pressure" upon palpation, non-distended, bowel sounds present, no organomegaly GU: foley catheter in place Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema Neuro: R sided facial droop (baseline), gait not observed, exam limited [**1-16**] pt falling asleep Discharge Exam: Vitals: Tm: 98.1 102/60 75 18 94% on RA General: alert, laying in bed, no acute distress HEENT: MMM, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: irregularly irregular, normal S1 + S2, no murmurs, rubs, gallops Lungs: normal respiratory effort, CTAB, no w/r/r Abdomen: soft, non-tender, non-distended, bowel sounds present, G-tube in place, site is c/d/i Ext: warm, well perfused, 1+ pulses, no edema Neuro: R sided facial droop (baseline) Pertinent Results: [**2121-9-5**] 10:15PM PT-12.7* PTT-26.8 INR(PT)-1.2* [**2121-9-5**] 10:15PM PLT COUNT-237 [**2121-9-5**] 10:15PM NEUTS-80.7* LYMPHS-12.6* MONOS-6.6 EOS-0.1 BASOS-0.1 [**2121-9-5**] 10:15PM WBC-9.3 RBC-3.67* HGB-11.6* HCT-35.3* MCV-96 MCH-31.7 MCHC-33.0 RDW-14.2 [**2121-9-5**] 10:15PM ALBUMIN-3.2* CALCIUM-8.0* PHOSPHATE-3.3 MAGNESIUM-2.7* [**2121-9-5**] 10:15PM cTropnT-<0.01 [**2121-9-5**] 10:15PM LIPASE-57 [**2121-9-5**] 10:15PM ALT(SGPT)-241* AST(SGOT)-161* ALK PHOS-172* TOT BILI-0.2 [**2121-9-5**] 10:15PM GLUCOSE-165* UREA N-55* CREAT-0.7 SODIUM-138 POTASSIUM-4.4 CHLORIDE-96 TOTAL CO2-34* ANION GAP-12 [**2121-9-5**] 10:29PM LACTATE-2.1* [**2121-9-5**] 11:20PM URINE HYALINE-10* [**2121-9-5**] 11:20PM URINE RBC-1 WBC-13* BACTERIA-MOD YEAST-NONE EPI-0 [**2121-9-5**] 11:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5 LEUK-MOD [**2121-9-5**] 11:20PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.022 [**2121-9-5**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] [**2121-9-5**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] [**2121-9-5**] URINE URINE CULTURE-PENDING INPATIENT [**2121-9-6**] 01:06PM BLOOD calTIBC-313 Ferritn-57 TRF-241 [**2121-9-7**] 06:45AM BLOOD VitB12-1378* Folate-GREATER TH [**2121-9-6**] 04:53AM BLOOD T4-5.0 T3-71* Free T4-1.0 [**2121-9-6**] 01:06PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2121-9-6**] 01:06PM BLOOD HCV Ab-NEGATIVE [**2121-9-12**] 06:00AM BLOOD ALT-58* AST-30 LD(LDH)-182 AlkPhos-90 TotBili-0.3 Drug monitoring [**2121-9-10**] 06:00AM BLOOD Digoxin-<0.2* [**2121-9-12**] 06:00AM BLOOD Digoxin-1.6 [**2121-9-15**] 06:00AM BLOOD Digoxin-0.7* IMAGING CT HEAD [**2121-9-5**] HISTORY: 55-year-old female with history of CVA, now with altered mental status. STUDY: CT of the head without contrast; images were acquired in soft tissue and bone algorithms. Coronal and sagittal reformatted images were also generated. COMPARISON: [**2119-4-20**]. FINDINGS: There is no intracranial hemorrhage, edema, or mass effect. Bilateral basal ganglia infarcts are unchanged from prior exam. Metallic streak artifact from basilar tip aneurysm clip is present. Post-right temporal craniotomy changes are present along with encephalomalacia of the right temporal lobe. The ventricles and sulci are prominent compatible with age-related involutional changes. The visualized paranasal sinuses demonstrate moderate mucosal thickening in the left sphenoid sinus. Mastoid air cells are clear. IMPRESSION: 1. No acute intracranial process. 2. Old infarct and encephalomalacia as described above. 3. Left sphenoid sinus disease. CXR PA/Lateral [**9-5**] HISTORY: Chest pain. TECHNIQUE: Upright AP and lateral views of the chest. COMPARISON: [**2121-8-22**] chest radiograph and chest CTA. FINDINGS: Lung volumes are low. Evaluation of the right lung apex is obscured due to the patient's chin projecting over this region. The heart size remains moderate to severely enlarged. The aorta is tortuous and aneurysmally dilated, better seen on the prior CT. In the interval, there is worsening pulmonary edema which is now moderate to severe in extent, with increased size of bilateral pleural effusions which are small to moderate on the right and trace on the left. Ill-defined airspace opacities within the lung bases could reflect atelectasis though aspiration or infection cannot be excluded. No large pneumothorax is detected, but again the right lung apex is obscured. Mild compression deformity of a lower thoracic vertebral body is again noted as well as within an upper lumbar vertebral body. IMPRESSION: Worsening congestive heart failure with moderate to severe pulmonary edema, increased size of bilateral pleural effusions, right greater than left, and bibasilar airspace opacities which could reflect atelectasis though aspiration or infection cannot be excluded. CXR portable [**9-6**] Final Report REASON FOR EXAMINATION: Evaluation of the patient with coronary artery disease, CVA, hypertension and atrial fibrillation. Portable AP radiograph of the chest was reviewed in comparison to [**9-5**]. There is substantial interval improvement in pulmonary edema which is still present, mild to moderate, associated with bilateral pleural effusions and bibasal atelectasis. Cardiomegaly is severe. Brief Hospital Course: Assessment and Plan: 65F with PMHx significant for recently diagnosed atrial fibrillation (discharged [**2121-8-26**]), CVA with residual R facial droop/dysphagia s/p G-tube, and CAD s/p PCI of RCA in [**2114**], who presents to the ED from [**Hospital 100**] Rehab with palpitations and suprapubic pressure, and was found to have a UTI and afib with rapid ventricular response. ACTIVES ISSUES: # Atrial fribrillation w/RVR: Patient reports intermittent palpitations since her discharge on [**8-26**] and states that they were worse on the day of admission. Also reports increased shortness of breath for the 2 days prior to admission; CXR in the ED shows worsening CHF with moderate to severe pulmonary edema and increased size of bilateral pleural effusions (R>L). She had a TTE on [**2121-8-25**] that showed new dilated cardiomyopathy with an EF of 30%. Possible that her RVR has led to worsening pulmonary edema and symptoms. Etiology of afib thought to be hyperthyroidism which is now being treated; she currently has evidence of a UTI, which could be cause of RVR. HR 100s-140s since presentation. Of note, she is not anticoagulated given history of multiple extensive intracranial hemorrhages as well as history severe GI bleed; cardioversion was deferred as well. Dual nodal [**Doctor Last Name 360**] control with metoprolol and diltiazem was initiated, but pt continued to be tachycardic. Regimen was changed to metoprolol tartrate 100mg TID and digoxin with more effective HR control. After loading dose of digoxin, tachycardia resolved to HR in 60-90s, however, loading digoxin was elevated level (1.6, goal is 0.8), thus digoxin was stopped until digoxin levels were therapeutic (digoxin level 0.7 on [**2121-9-15**]). She was re-started on digoxin 0.0625 mg PO daily (half of prior dose). She was treated for a urinary tract infection would could have been the trigger in addition to her dilated cardiomyopathy. She continues on aspirin 325 mg PO qD for stroke prophylaxis despite her CHADS2-VASC score, which indicates that she should be on coumadin. However, coumadin was not initiated given recent prior GIB from AVMs. The risks/benefits of coumadin therapy should be discussed as an outpatient. # Urinary tract infection: Patient reports developing suprapubic pressure/lower abdominal discomfort on the afternoon of presentation. Denies any dysuria or frequency, but does endorse sweats and is mildly diaphoretic on exam. No rebound or guarding. Urinalysis suggestive of infection with 0 epis, moderate leuk, negative nitrite, moderate bacteria, WBC 13, RBC 1. She received a dose of levofloxacin 500mg in the ED. Pt grew enterococcus and pan-sensitive E.coli in urine in [**2117**]. Pt was treated with 7d of levofloxacin. Follow up urine culture showed alpha-hemolytic organisms c/w lactobacillus and strep >100,000. PT completed 7d course of levofloxacin prior to culture data. # Acute on chronic systolic CHF: Patient has recently diagnosed dilated cardiomyopathy with global hypokinesis and EF 30% on [**2121-8-25**] TTE. Currently has evidence of volume overload with worsening pulmonary edema on CXR and hypoxia (92% 4L NC); likely related to afib with RVR. Got lasix diuresis with good urine output and improvement in respiratory symptoms. DC-ed lisinopril due to insufficient systolic BP room in the setting of metoprolol uptitrate and dilt for afib. . # Questionable pneumonia: CXR with RLL infiltrate; atelectasis vs. pleural effusion vs. pneumonia. Patient has no clinical signs of PNA -- no cough, fever, or elevated WBC, however, she does have known chronic aspiration and is at increased risk for aspiration pneumonia. She was covered with levofloxacin both urinary tract infection and ? pneumonia, which seems doubtful. # Transaminitis: Patient has elevated AST/ALT. No RUQ pain to suggest biliary pathology. Given lack of clinical symptoms, LFTS were trended. It is thought that this elevation may be due to hepatic congestion in the context of pulmonary edema vs methimazole. LFTs have been downtrending and have now normalized at discharge. # Hyperthyroidism: Diagnosed during admission earlier this month; thought to be a contributor to her new atrial fibrillation. Continued methimazole 10mg daily. Endocrinology was consulted and suggested decreasing methimazole to 7.5 mg PO qD. TFTs were TSH, T3, T4, free T4 were WNL TSH 0.56 T4 5.0 T3 71 Free T4 1.0. She is scheduled for endocrinology follow-up, and will need repeat testing including thyroid function tests, spot urine iodine/Cr, and serum metanephrines for adrenal incidentaloma. CHRONIC ISSUES: # CAD: S/p PCI to LAD [**2114**]. Denies chest pain. Troponin wnl x 2 . Continued aspirin, metoprolol. Statin was deferred due to transamnitis. # H/o CVA w/chronic aspiration: Strict NPO, all meds through g-tube, gets tube feeds. Tube feeds initially held, restarted. TRANSITIONAL ISSUES: - Follow-up with endocrinology regarding thyroid and incidental adrenal mass from prior CT abdomen - The patient should undergo lab testing in 2 weeks for the following: [ ] TFTs [ ] spot urine iodine/cr [ ] consider blood work for adrenal incidentaloma such as pheochromocytoma screening at the same time [ ] follow-up digoxin levels on [**9-17**] or 4th [**2120**] for goal of 0.8 blood dig levels - consider anticoagulation with coumadin as outpatient for atrial fibrillation after risk/benefits discussion - consider addition of statin and ACEi for systolic CHF if liver function remains normal and BP room for lisinopril - repeat CXR in [**3-21**] weeks to establish clearance of pulmonary edema and any possible pneumonia Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain 2. Aspirin 325 mg PO DAILY 3. Clobetasol Propionate 0.05% Cream 1 Appl TP [**Hospital1 **] 4. Lisinopril 10 mg PO DAILY 5. Polyethylene Glycol 17 g PO DAILY:PRN constipation 6. Sertraline 25 mg PO DAILY 7. Loratadine *NF* 10 mg PO/NG daily 8. Omeprazole *NF* 20 mg PO/NG DAILY 9. Methimazole 10 mg PO DAILY 10. Metoprolol Tartrate 75 mg PO TID Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain or fever 2. Methimazole 7.5 mg PO DAILY 3. Clobetasol Propionate 0.05% Cream 1 Appl TP [**Hospital1 **] 4. Metoprolol Tartrate 100 mg PO Q8H Hold for SBP < 100 or HR < 60 5. Polyethylene Glycol 17 g PO DAILY:PRN constipation 6. Sertraline 25 mg PO DAILY 7. Docusate Sodium (Liquid) 100 mg PO BID constipation 8. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 9. Senna 1 TAB PO HS 10. Aspirin 325 mg PO DAILY 11. Loratadine *NF* 10 mg PO/NG daily 12. Digoxin 0.0625 mg PO DAILY recheck digoxin in [**1-17**] days ([**2121-9-17**] - [**2121-9-18**]) 13. Outpatient Lab Work On [**2121-9-17**] or [**2121-9-18**], please check digoxin level. Goal level is ~ 0.8. 14. Outpatient Lab Work On [**9-28**], please check TSH, T4, T, spot urine iodine/creatine, and plasma free metanephrines ICD-9: 242.9, Thyrotoxicosis Please fax results to: MALA [**Last Name (NamePattern4) 16956**], MD Phone: [**Telephone/Fax (1) 1803**] Fax:([**Telephone/Fax (1) 86540**] Patient has appointment on MONDAY [**2121-10-6**] at 9:30 AM to follow-up results Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - LTC Discharge Diagnosis: Primary Diagnoses: Atrial Fibrillation with Rapid ventricular rate, and Pulmonary edema Secondary Diagnoses: Hyperthyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 27785**], It was a pleasure taking care of you while you were admitted to [**Hospital1 18**]. You were admitted with palpitations and were found to have a rapid heart rate with an abnormal heart rhythm called atrial fibrillation. This heart rhythm also called some fluid to build up in your lungs. For these issues, you received medications to decrease your heart rate and help remove the fluid from your lungs. You tolerated this well. You were also found to have a urinary tract infection which we treated with an oral antibiotic. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Please make an appointment to see your primary care doctor, Dr. [**Last Name (STitle) **], withint 3-5 days of your discharge. Department: CARDIAC SERVICES When: FRIDAY [**2121-9-19**] at 3:40 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: MEDICAL SPECIALTIES When: MONDAY [**2121-10-6**] at 9:30 AM With: MALA [**Last Name (NamePattern4) 16956**], MD [**Telephone/Fax (1) 1803**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage ** Your [**9-16**] appt with Dr. [**Last Name (STitle) **] has been replaced with the appt above. Completed by:[**2121-9-16**]

[ "401.9", "V15.82", "428.23", "V44.1", "438.83", "441.2", "425.4", "242.90", "272.4", "599.0", "V45.82", "311", "427.31", "424.0", "787.20", "V49.86", "414.01", "428.0", "593.9", "438.82", "790.4" ]

icd9cm

[ [ [] ] ]

[ "96.6" ]

icd9pcs

[ [ [] ] ]

16444, 16509

9176, 13763

343, 349

16678, 16678

4739, 9153

17509, 18355

3286, 3487

15340, 16421

16530, 16618

14825, 15317

16829, 17486

3502, 4252

16639, 16657

4268, 4720

14070, 14799

1664, 2100

241, 305

377, 1645

16693, 16805

13779, 14049

2122, 2903

2919, 3270

11,618

197,247

24231

Discharge summary

report

Admission Date: [**2161-4-23**] Discharge Date: [**2161-5-1**] Date of Birth: [**2096-2-23**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Status post myocardial infarction. Major Surgical or Invasive Procedure: CABGx2(LIMA->LAD, SVG->OM) [**2161-4-24**] History of Present Illness: Ms. [**Known lastname 6483**] is a splendid 65 year old female who was admitted to [**Hospital 1474**] Hospital on [**2161-4-9**] increased dsypnea. She ruled in for a myocardial infarction and was managed medically. A cardiac catheterization was peformed which revealed severe 2 vessel coronary artery disease and she was subsequently transferred to the [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for further management. Past Medical History: Smoking Pneumonia Ventricular tachycardia Hyperlipidemia Non ST elevation MI Right toe amputation Social History: Smoked 2 packs daily for 50 years. No alcohol. Lives with husband. Family History: Mother with coronary artery disease. Physical Exam: Temp: 97.9 Pulse: 66 BP: 137/74 GEN: No acute distress HEENT: NCAT, anicteric sclera, PERRL, EOMI, oropharynx benign NECK: No lymphadenopathym no JVD, 2+ carotids without bruit LUNGS: Bibasilar crackles HEART: RRR, no murmur ABD: Soft, nontender, nondistended, normoactive bowel sounds PULSES: 2+ throughout NEURO: Cranial nerves II-XII intact Pertinent Results: [**2161-4-23**] 06:20PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2161-4-23**] 05:33PM WBC-13.7* RBC-4.51 HGB-12.8 HCT-37.3 MCV-83 MCH-28.3 MCHC-34.2 RDW-14.6 [**2161-4-23**] 05:33PM ALT(SGPT)-25 AST(SGOT)-16 LD(LDH)-228 ALK PHOS-112 TOT BILI-0.7 [**2161-4-23**] 05:33PM GLUCOSE-98 UREA N-19 CREAT-0.9 SODIUM-140 POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-22 ANION GAP-17 [**2161-5-1**] 05:45AM BLOOD WBC-10.0 RBC-3.50* Hgb-10.1* Hct-30.6* MCV-87 MCH-29.0 MCHC-33.2 RDW-14.4 Plt Ct-283 [**2161-5-1**] 05:45AM BLOOD Plt Ct-283 [**2161-5-1**] 05:45AM BLOOD Glucose-89 UreaN-23* Creat-0.9 Na-138 K-4.8 Cl-98 HCO3-31* AnGap-14 [**2161-5-1**] 05:45AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.2 [**2161-4-29**] CNIS: Less than 40% stenosis bilateral internal carotid and extracranial internal carotid arteries. [**2161-4-23**] CXR: No acute cardiopulmonary process. [**2161-4-23**] ECHO: There is moderate global left ventricular hypokinesis. No masses or thrombi are seen in the left ventricle. There is mild global right ventricular free wall hypokinesis. There is no aortic valve stenosis. No mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. [**2161-4-23**] EKG: Sinus rhythm with PACs. Prolonged QT interval Lateral ST-T changes are nonspecific No previous tracing Brief Hospital Course: Ms. [**Known lastname 6483**] was admitted to the [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] Medical Center on [**2161-4-23**] for further management of her coronary artery disease. The cardiac surgery service was consulted for surgical revascularization and Ms. [**Known lastname 6483**] was worked-up in the usual preoperative manner including a carotid duplex ultrasound which revealed a less then 40% stenosis of the bilateral internal carotid arteries. An echocardiogram was performed which revealed mild mitral regurgitation and an ejection fraction of 15-20%. On [**2161-4-24**], Ms. [**Known lastname 6483**] was taken to the operating room where she underwent coronary artery bypass grafting to two vessels. Postoperatively she was taken to the cardiac surgical intensive care unit for monitoring. Amiodarone was started prophylactically for prevention of a ventricular arrythmia given her low ejection fraction and past history. On postoperative day one, Ms. [**Known lastname 6483**] [**Last Name (Titles) 5058**] neurologically intact and was extubated. The electrophysiology service was consulted in regards to placing a prophylactic internal cardiac defibrillator given her low ejection fraction and past run on non sustained ventricular tachycardia however elected to not treat her for ventricular tachycardia given her preoperative run of ventricular tachycardia was likely ischemia related. Beta blockade and an Ace inhibitor were started and her amiodarone was discontinued. Plavix was started for anticoagulation. She developed atrial fibrillation on postoperative day two and her amiodarone was restarted which converted her back to a normal sinus rhythm. The congestive heart failure service was consulted for assistance in her care. Gentle diuresis was continued. On postoperative day four, she was transferred to the cardiac surgical step down unit for further recovery. The physical therapy service was consulted for assistance with her postoperative strength and recovery. The diabetes service from [**Last Name (un) **] was consulted for assistance with her diabetes medication management. Ms. [**Known lastname 6483**] continued to make steady progress and was discharged to her home on postoperative day seven. She will follow-up with Dr. [**Last Name (STitle) **], her cardiologist and her primary care physician as an outpatient. Medications on Admission: None until 2 weeks prior to admission: Imdur 30mg daily Lopressor 25mg twice daily Lisinopril 5mg daily Lasix 20mg daily Spirinolactone 25mg daily Plavix 75mg daily Lipitor 80mg daily Discharge Medications: 1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7 days. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. 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* 4. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 5 days: Then decrease to 400 mg PO daily for 1 week, then decrease to 200 mg PO daily. Disp:*50 Tablet(s)* Refills:*0* 6. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 9. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* 10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Coronary artery disease. Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. You may not drive for 4 weeks. You may not lift more than 10 lbs. for 3 months. You should shower, let water flow over wounds, pat dry with a towel. Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) 17887**] for 1-2 weeks. Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks. Completed by:[**2161-5-1**]

[ "272.0", "440.20", "305.1", "V17.3", "V58.67", "427.31", "410.72", "414.01", "428.20", "428.0", "440.0", "V49.72", "250.00" ]

icd9cm

[ [ [] ] ]

[ "99.04", "36.15", "34.04", "88.72", "38.91", "89.68", "89.64", "36.11", "39.61" ]

icd9pcs

[ [ [] ] ]

6970, 7025

3000, 5422

355, 400

7094, 7101

1607, 2977

7344, 7517

1187, 1225

5656, 6947

7046, 7073

5448, 5633

7125, 7321

1240, 1588

281, 317

428, 966

988, 1087

1103, 1171

29,495

182,822

23427

Discharge summary

report

Admission Date: [**2126-1-22**] Discharge Date: [**2126-1-30**] Date of Birth: [**2062-4-14**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2160**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: lithotripsy and ureteral stent change central line placement PICC line placement History of Present Illness: Ms. [**Known lastname **] is a 63 yo F with hx of renal caliculi and s/p lithotripsy with subsequent urosepsis and ICU admission in [**Month (only) **] [**2124**]. She re-presents with a similar episode from the PACU s/p lithotripsy with hypotension of sys bp to 50's in recovery. Two days prior to the procedure, the patient had a urine cx showing ESBL E. coli. She was started on nitrofurantoin that day and on the day of her surgery 2 days later she received a pre-operative dose of gentamicin 250mg in addition to the nitrofurantion she was on. The procedure was unremarkable and the patient was stable and extubated when she left the OR. In the PACU, the patient c/o chills and subsequently her systolic bp dropped to the 50's and spike a fever to 102. She was fluid bolused with a total of 3L and received levofed 0.06mg/min. She was also given 1 dose of Zosyn 2.25g IV before coming to the unit. She arrived in the unit and was bolused an additional 2L and the levafed dose was increased to 0.6mg/min. The patient c/o back pain and headache on arrival and denied chest pain or SOB. The patient had a similar episode in [**2125-10-25**] when she underwent the same procedure for renal calculi. At that time, she became hypotensive post-operatively and was admitted to the ICU for suspected urosepsis. While in the unit, she developed moderate pulmonary edema following aggressive fluid recusitation. Past Medical History: HTN Renal caliculi Unknown conduction abnormality resulting in bradycardia, s/p pacemaker placement [**2119**] in [**Country 651**] Unknown liver disease in her 30's that was treated and cured with injections Cardiologist: Dr [**Last Name (STitle) **] Social History: From [**Country 651**], speaks only Mandarin, son available to translate. Non-smoker, rare Et-OH Family History: Mother had MI in old age. Brother and sister have some type of heart disease Two brothers died of heart disease in their 60s and 70s. Physical Exam: VS: 102.5 89/42 77 14 97% 2Lnc Gen: A/O x3, in mild distress, mentating clearly HEENT: Dry MM, anicteric CV: rrr, s1/s2, no mrg Pulm: CTAB, no wheezes or crackles hear, good air movement throughout GI: +BS, soft, non distended, mild TTP of RLQ, no rebound/guarding GU: Foley in place draining bright red urine Ext: UE/LE warm, 2+ pulses, no edema, right A-line in place Pertinent Results: CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN Reason: 3 [**Hospital 93**] MEDICAL CONDITION: 63 year old woman with REASON FOR THIS EXAMINATION: line placement PROCEDURE: Chest portable for line placement on [**2126-1-22**], at 21:31. COMPARISON: [**2126-1-22**], at 19:14. HISTORY: Evaluate for line placement. FINDINGS: In the interim, a new right subclavian central line has been placed with distal tip projected over the proximal SVC. Mild cardiomegaly with clear lungs. No pleural effusion. IMPRESSION: 1. Status post placement of a right subclavian central line with distal tip projected over the proximal SVC. No acute cardiopulmonary process is seen. Chest portable AP on [**2126-1-23**] at 5:23. COMPARISON: [**2126-1-22**] at 21:20. HISTORY: 63-year-old female with hypotension likely sepsis, evaluate for edema, infiltrate, effusion. FINDINGS: In the interim, there is a newly developing left retrocardiac opacity and right lower lobe opacity likely atelectasis and/or aspiration. In addition, there is increase in haziness around the left perihilar region indicating a newly developing atelectasis and/or aspiration. There is slight indistinctness and thickening of the interstitial and intervascular pulmonary tree indicating coexistent pulmonary edema and/or pneumonia. There is no change in the status of the right subclavian line which terminates in the proximal SVC. No change in the status of the pacemaker. IMPRESSION: 1) Newly developing bibasilar atelectasis and lingular atelectasis likely aspiration. 2) Acute interstitial edema which could either be secondary to underlying [**Last Name **] problem or an infectious process. Clinical correlation is recommended. ECHO: Conclusions The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) There is no ventricular septal defect. 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. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2125-11-7**], the RV chamber size may be slightly smaller (not as well visualized as in the prior study). The degree of TR and pulmonary hypertension detected are slightly less. CT OF THE CHEST WITH INTRAVENOUS CONTRAST: There are large bilateral pleural effusions and atelectasis in the lower lobes and right middle lobe. A calcified granuloma is seen in the right upper lobe (2:36). The heart and pericardium appear within normal limits. A pacemaker with dual electrodes is present. The central airways appear patent. The esophagus is mildly distended. CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: Multiple subcentimeter hypodensities are seen in the right and left lobes of the liver measuring up to 9 mm in diameter and too small to accurately characterize. An irregular hypodensity adjacent to the falciform ligament is in a location typical for focal fatty infiltration. The portal vein is patent. The gallbladder is nondistended. There is no biliary dilation. The pancreas, spleen, and adrenal glands appear unremarkable. An internal ureteral stent is present on the right with its proximal pigtail coiled in the renal pelvis and distal loop coiled within the bladder. There is urothelial enhancement and thickening within the right renal pelvis and proximal ureter (2:72), and periureteral stranding. Heterogeneity of the nephrogram is present on the right with multiple cortical areas of hypoenhancement. There is additional cortical thinning in the upper pole. No definite calcified stones are identified in the proximal right ureter although a few calcified-appearing foci in interpolar region calix (2:71), nonspecific due to the presence of excreted contrast, could represent stone fragments. The left kidney shows parapelvic cysts and a couple of tiny hypodense lesions, too small to characterize, but appears otherwise unremarkable. The large and small bowel loops are normal in caliber. Moderate amount of ascites is present. CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The bladder contains a Foley catheter and the distal end of the right ureteral stent. A punctate calcification at the ureteral orifice on the right within the coil of the stent (2:114) likely represents a stone fragment. The distal left ureter, uterus and adnexa, rectum and sigmoid colon appear unremarkable. There is a moderate amount of ascites in the pelvis. There are no pathologically enlarged [**Year (4 digits) **] or inguinal lymph nodes. Diffuse stranding is seen throughout the subcutaneous tissues consistent with anasarca. An unusual paired linear density located around the greater curvature of the stomach (2:83) suggests a track of a previously present catheter or other manmade structure, and is of uncertain significance. Alternatively, this could represent paired venous structures with an unusual appearance. BONE WINDOWS: No lesions worrisome for osseous metastatic disease are identified. A sclerotic focus in the T12 vertebra could represent a bone island. IMPRESSION: 1. Findings consistent with right-sided pyelonephritis with ureteral stent in place. Small stone fragments in the collecting system and distal right ureter.Proximal ureter inflammation indicated by wall thickenng and enhancement. 2. Large bilateral pleural effusions, ascites, anasarca. 3. Hypodense hepatic and renal lesions (in addition to findings of pyelonephritis), too small to characterize. TWO VIEW CHEST [**2126-1-30**] COMPARISON: [**2126-1-26**]. INDICATION: CHF. Assess pleural effusions. The heart is mildly enlarged, and the aorta is tortuous, unchanged. Bilateral pleural effusions are again demonstrated, with interval decrease in size. Effusions are currently small to moderate in size, with apparent subpulmonic component of the left effusion. Improving aeration at the lung bases is also demonstrated with minor residual atelectasis. Indwelling pacing leads remain in standard position. New right PICC line is present with tip terminating within the proximal superior vena cava. IMPRESSION: Improving pleural effusions and adjacent basilar atelectasis. [**2126-1-29**] 05:50AM BLOOD WBC-8.5 RBC-3.44* Hgb-10.1* Hct-30.6* MCV-89 MCH-29.5 MCHC-33.1 RDW-12.6 Plt Ct-164 [**2126-1-25**] 05:32AM BLOOD WBC-25.8* RBC-3.25* Hgb-9.8* Hct-29.2* MCV-90 MCH-30.0 MCHC-33.4 RDW-12.9 Plt Ct-110* [**2126-1-22**] 06:34PM BLOOD WBC-0.6*# RBC-3.86* Hgb-11.4* Hct-34.4* MCV-89 MCH-29.6 MCHC-33.2 RDW-13.0 Plt Ct-180 [**2126-1-26**] 03:58AM BLOOD Neuts-85.3* Bands-0 Lymphs-12.2* Monos-2.3 Eos-0.1 Baso-0.1 [**2126-1-27**] 07:36AM BLOOD PT-11.0 PTT-28.2 INR(PT)-0.9 [**2126-1-29**] 05:50AM BLOOD UreaN-9 Creat-0.6 Na-141 K-3.5 Cl-104 HCO3-33* AnGap-8 [**2126-1-22**] 06:34PM BLOOD Glucose-92 UreaN-14 Creat-0.7 Na-140 K-5.1 Cl-109* HCO3-21* AnGap-15 [**2126-1-29**] 05:50AM BLOOD ALT-7 AST-11 AlkPhos-66 TotBili-0.3 [**2126-1-24**] 04:15AM BLOOD ALT-14 AST-44* LD(LDH)-524* AlkPhos-61 TotBili-0.4 [**2126-1-22**] 06:34PM BLOOD ALT-12 AST-42* LD(LDH)-603* CK(CPK)-122 AlkPhos-68 Amylase-61 TotBili-0.7 [**2126-1-24**] 04:15AM BLOOD proBNP-5992* [**2126-1-23**] 02:15AM BLOOD CK-MB-3 cTropnT-<0.01 [**2126-1-22**] 08:01PM BLOOD CK-MB-2 cTropnT-<0.01 [**2126-1-22**] 06:34PM BLOOD CK-MB-2 cTropnT-<0.01 [**2126-1-28**] 07:00AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.8 [**2126-1-24**] 04:15AM BLOOD TSH-1.0 [**2126-1-23**] 10:56AM BLOOD Cortsol-38.1* [**2126-1-23**] 10:29AM BLOOD Cortsol-34.3* [**2126-1-23**] 07:31AM BLOOD Cortsol-31.8* [**2126-1-23**] 02:33AM BLOOD Lactate-2.2* [**2126-1-22**] 10:47PM BLOOD Lactate-6.0* [**2126-1-22**] 10:43PM BLOOD Lactate-4.6* [**2126-1-25**] 12:54PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.016 [**2126-1-25**] 12:54PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG [**2126-1-25**] 12:54PM URINE RBC-183* WBC-8* Bacteri-FEW Yeast-NONE Epi-0 [**2126-1-25**] 12:54PM URINE Mucous-RARE [**2126-1-22**] 06:34PM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.030 [**2126-1-22**] 06:34PM URINE Blood-LG Nitrite-NEG Protein-100 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD [**2126-1-22**] 06:34PM URINE RBC->1000* WBC-0 Bacteri-NONE Yeast-NONE Epi-4 Blood and urine cultures negative at time of discharge. Brief Hospital Course: 1. Septic shock: The patient likely became bacteremic due to instrumentation of her GU tract when she had the UTI. Pre-procedure antibiotics may account for the absence of organisms on post-operative cultures. She was intially treated with aggressive fluid resuscitation and broad spectrum antibiotics. She required levophed and vasopressin for blood pressure support initially. She did well and was able to wean off pressors quickly. Her white count at admission to the ICU was quite low but subsequently rebounded to nearly 25. While the source of her sepsis was thought most likely to be the E. coli isolated from her urine pre-operatively, a CT torso was performed to rule out other causes of sepsis and explanations for persistent elevated leukocytosis and was normal. Her white count normalized by day of transfer. On floor ID was consulted and they recommended ertapenam for the possible ESBL organism till the ureteral stent is removed on [**2-13**]. They will follo wup with up on that day as well as GU. Weekly labs to be faxed to [**Hospital **] clinic. 2. Atrial Fibrillation: She developed atrial fibrillation in the ICU following fluid resuscitation. She was treated with lopressor and subsequently amiodarone. She will need to take an aspirin for stroke prevention per cardiology recommendations. A TTE was performed which showed preserved pump function and 1+MR and [**12-26**]+ TR. Ep cpnsulted and they interrogated the pacemaker. Device clinic follow up is recommended. She will follow up with cardiology clinic for further management. Amiodarone taper is also advised. 3. h/o cardiac conduction disorder, type unknown with pacer: The EP service was consulted as it was unclear if the patient's pacer was pacing appropriately. Ms. [**Known lastname **] will follow up in device clinic for further management of her pacer. 4. h/o nephrolithiasis: s/p lithotripsy and ureteral stent placement. She will need to follow up with Dr. [**Last Name (STitle) 770**] as an outpatient in urology clinic for stent removal. 5. She developed HSV orolabialis and was treated with a 7 day course of acyclovir. 6. She also developed a chalazion on left eye and warm compresses were recommended. Medications on Admission: Isosorbide mononitrate lopressor Discharge Medications: 1. PICC line care Per protocol 2. Heparin Flush PICC (100 units/ml) 2 mL IV DAILY:PRN 10 ml NS followed by 2 mL of 100 Units/mL heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 3. Ertapenem 1 gram Recon Soln Sig: One (1) Recon Soln Injection once a day for 14 days: Continue till [**2126-2-13**] till ureteral stent is removed. Further course to be determined by Infectious disese team. . Disp:*14 Recon Soln(s)* Refills:*0* 4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*0* 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 6. Amiodarone 100 mg Tablet Sig: One (1) Tablet PO once a day: Start after completion of the 200 mg twice daily for 2 weeks regimen is complete. . Disp:*30 Tablet(s)* Refills:*0* 7. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours) for 5 days. Disp:*30 Capsule(s)* Refills:*0* 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* (patient was prescribed pantoprazole. A call from pharmacy after discharge was received. Apparantly, prilosec OTC was covered by patients insurance and pantoprazole was not. Hence switched to prilosec OTC. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Urinary tract infection/ sepsis HSV orolabialis Thrombocytopenia atial fibrillation Liver and renal lesion on CT Chalazion left eye Discharge Condition: Stable Discharge Instructions: You will be treated with IV antibiotics. These should be continued till your ureteral stent is removed by the urologist. You will also require weekly labs that should be faxed to the infectious disease doctor - Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. You also have an appointment with him as below. Your heart was noted to be irregular and the cardiologist have recommended a new medicine called amiodarone. take it as prescribed and follow up with the cardiologist also. You also have a herpes infection of the lips. Complete the course of acyclovir as prescribed. For the chalazion on the left eye - used warm compresses as needed upto 3-4 times daily till resolution. discuss with your primary doctor about this also. Incidentally, some spots were seen on your liver and kidney that will require further follow up. Discuss this with your primary care doctor. Followup Instructions: EP - [**2126-2-8**] at 9AM. PCP [**Name Initial (PRE) **] [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 8236**] on Friday [**2126-2-1**] at 1345 hours Provider: [**Name10 (NameIs) 9909**] FLOOR UNIT Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2126-2-13**] 10:00 Provider: [**Name10 (NameIs) 12082**] CARE ID Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2126-2-13**] 1:30P Cardiology; Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2126-3-25**] 1:00

[ "041.4", "592.0", "789.59", "287.5", "054.9", "288.00", "995.92", "038.42", "591", "373.2", "427.31", "785.52", "V45.01", "793.6", "E849.7", "793.5", "590.80", "511.9", "514", "416.8", "998.59", "255.41", "276.6", "E878.1" ]

icd9cm

[ [ [] ] ]

[ "38.93", "38.91", "97.62", "56.0", "89.45", "59.8" ]

icd9pcs

[ [ [] ] ]

15329, 15387

11569, 13772

327, 410

15563, 15571

2809, 2871

16517, 17090

2260, 2395

13855, 15306

2908, 2931

15408, 15542

13798, 13832

15595, 16494

2410, 2790

276, 289

2960, 11546

438, 1854

1876, 2129

2145, 2244

56,287

100,774

9027

Discharge summary

report

Admission Date: [**2124-6-26**] Discharge Date: [**2124-6-29**] Date of Birth: [**2061-9-22**] Sex: F Service: [**Year (4 digits) 662**] Allergies: Codeine / Morphine / Rifaximin / Linezolid / Vancomycin / Dilaudid Attending:[**First Name3 (LF) 8388**] Chief Complaint: Lower GI Bleed Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy (EGD) History of Present Illness: 62yoF with alcoholic cirrhosis, varices, s/p TIPS in [**2123**], ischemic bowel [**2120**] s/p R colectomy, and ileostomy reversal who presents from [**Location (un) 620**] with LGIB. Pt has a 15 year hx of alcohol abuse, and relapsed with alcohol 1 month ago. 3 days ago, pt developed black bloody stools with 4 large bloody bowel movements last night. Pt had 3 more this morning filling the toilet bowl w/ BRBB + black stool which improved this morning. Pt has had some nausea, but no vomiting or hematemesis. At [**Name (NI) 31237**], pt had dark red blood on rectal exam. NG lavage was negative but there was poor return of fluid. HCT 20 down from her baseline of 31. She was started on pantroprazole, octreotide and given 1 unit of blood prior to transfer. Vitals were stable on transfer. On arrival to [**Hospital1 18**], patient reported feeling nauseous and anxious, and was afraid of withdrawing from EtOH. She did have 1 more large bloody BM in the ED. Her initial VS were 99.8 95 108/76 18 98%. She was given 4mg IV zofran. She was receiving 2nd unit pRBC. Hepatology recommended transfer to MICU for emergent EGD for suspicion of UGIB. On arrival to the MICU, pt was stable and received a 2nd unit of blood. Vitals 99.8 97 107/74 18 99%. In MICU, pt received emergent EGD which showed a 1 cm non-bleeding ulcer with fresh clot in the stomach at the gastro-jejunal anastomosis and grade 1 distal esophageal varices. Past Medical History: 1. EtOH abuse x15 yrs: last drink was [**2122-6-23**] 2. Cirrhosis: c/b ascites, esophageal varices w/o hemorrhage 3. Last EGD [**2122-5-6**] - showed 1 cord of Grade II varicies 4. Exploratory laparotomy for SBO with lysis of adhesions ([**8-/2122**]), right colectomy, end ileostomy ([**2122-7-10**]) 5. Asthma 6. Gastric ulcers 7. Hypothyroidism 8. Loose ostomy output - has been treated with mesalamine in past without relief 9. Depression 10. h.o. Gastric bypass 14 years ago 11. s/p hysterectomy for endometriosis and "abnormal looking cells" 12. Malnutrition on tube feeds 13. Multiple incisional hernia operations complicated by exposed mesh from prior ventral hernia repair 14. h.o. SBP on Ciprofloxacin - patient states she thinks she had VRE Social History: Quit smoking [**2105**]. Denies illicit drug use. 15 year history of alcohol abuse, recent relapse 1 month ago. Lives with husband (who is s/p renal transplant from daughter) and her daughter and 1 [**Name2 (NI) 12496**]. (1 year old is now with father) Currently unemployed and has not seen a social worker/counselor for depression. Pt worked in billing and collections for a surgeon in the past. Family History: Father, brother and uncle have [**Name (NI) 3729**]. Father died of lung CA. Mother died of brain CA. Sister died of MS. Brother with [**Name (NI) 4522**] disease. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 99.8 BP:107/74 P:97 R:18 18 O2: 99% on RA General: Alert, oriented, in mild distress, very anxious with tremors of upper extremities HEENT: Sclera anicteric, MMM, oropharynx clear 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, no bulging flanks, negative fluid wave, several serpigenous erythematous escoriating lesions with central clearing across lower abdomen and lower extremities Rectal: Deferred. GI only noted skin tags and minor external hemorrhoids with not active source of bleeding or fissures. GU: no foley Ext: warm, well perfused, 2+ pulses, no edema Neuro: no focal deficits Physical exam on discharge: hemodynamically stable, afebrile no abd pain excoriating rash on LEs, chest wall Pertinent Results: Admission: [**2124-6-26**] 11:58PM HCT-21.0* [**2124-6-26**] 07:00PM GLUCOSE-100 UREA N-23* CREAT-0.9 SODIUM-142 POTASSIUM-4.7 CHLORIDE-109* TOTAL CO2-17* ANION GAP-21* [**2124-6-26**] 07:00PM ALT(SGPT)-30 AST(SGOT)-100* ALK PHOS-75 TOT BILI-2.6* [**2124-6-26**] 07:00PM ALBUMIN-3.1* CALCIUM-7.6* PHOSPHATE-3.6 [**Month/Day/Year 31238**]-1.4* [**2124-6-26**] 07:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2124-6-26**] 07:00PM WBC-7.4 RBC-2.67* HGB-7.7* HCT-23.2* MCV-87 MCH-28.7 MCHC-33.0 RDW-16.2* [**2124-6-26**] 07:00PM PLT SMR-LOW PLT COUNT-92* [**2124-6-26**] 07:00PM PT-15.5* PTT-37.5* INR(PT)-1.5* LIVER/GALLBLADDER US WITH DOPPLERS ([**2124-6-27**]): 1. Patent TIPS. No ascites. 2. Borderline splenomegaly. 3. Limited assessment of the liver, but it is coarsened in echotexture compatible with known cirrhosis. EGD ([**2124-6-26**], prelim): -Esophagus: 2 cords of grade I varices were seen in the lower third of the esophagus. The varices were not bleeding. -Stomach: A marginal ulcer was seen on the jejunal side of the gastro-jejunal anastamosis. The ulcer was 1cm in diameter. There was some exudate that was washed off. There were a few pigmented spots but no visible vessel or clot. There was some minimal contact bleeding from the tissue at the edge of the ulcer, but no active bleeding noted from the ulcer and no blood seen in the stomach pouch or intestine. -Duodenum: Normal duodenum. -Other findings: Normal Roux-en-Y gastric bypass anatomy noted consistent with known history -IMPRESSION: Varices at the lower third of the esophagus. A marginal ulcer was seen on the jejunal side of the gastro-jejunal anastamosis. The ulcer was 1cm in diameter. There was some exudate that was washed off. There were a few pigmented spots but no visible vessel or clot. There was some minimal contact bleeding from the tissue at the edge of the ulcer, but no active bleeding noted from the ulcer and no blood seen in the stomach pouch or intestine. Normal Roux-en-Y gastric bypass anatomy noted consistent with known history. Otherwise normal EGD to third part of the duodenum -RECOMMENDATIONS: Prilosec 40mg [**Hospital1 **]. Check H. pylori antibody. Take Carafate suspension 2 grams twice a day. The source of bleeding was from the marginal ulcer. Given its endoscopic appearance it is a low risk to re-bleed. Avoid alcohol and smoking. RUQ u/s [**6-27**]: 1. Patent TIPS. No ascites. 2. Borderline splenomegaly. 3. Limited assessment of the liver, but it is coarsened in echotexture compatible with known cirrhosis. Labs on Discharge: [**2124-6-29**] 01:05PM BLOOD WBC-7.9# RBC-3.50* Hgb-10.3* Hct-31.4* MCV-90 MCH-29.6 MCHC-33.0 RDW-17.4* Plt Ct-119* [**2124-6-29**] 06:05AM BLOOD Glucose-105* UreaN-20 Creat-0.9 Na-138 K-3.6 Cl-107 HCO3-25 AnGap-10 [**2124-6-29**] 06:05AM BLOOD ALT-28 AST-73* AlkPhos-96 TotBili-1.5 [**2124-6-29**] 06:05AM BLOOD Albumin-3.2* Calcium-8.7 Phos-3.0 Mg-1.8 Brief Hospital Course: 62 yo F with h/o EtOH cirrhosis c/b portal HTN and bleeding varices, s/p TIPS ([**2123**]) and h/o ischemic bowel s/p right colectomy and ileostomy reversal ([**2120**]), who recently relapsed with drinking who presented with upper GI bleed. #GI BLEED: Ms. [**Known lastname 2643**] was admitted to the MICU where she had an emergent EGD for suspicion of upper GI bleed. EGD showed a 1cm non-bleeding marginal ulcer at the site of the gastro-jejunal anastomasis from her prior Roux-en-Y gastric bypass as the most likely cause of her GI bleed. Given h/o portal hypertensive gastropathy and variceal bleeds, she had RUQ abdominal ultrasound which showed that TIPS was patent with no ascites/splenomegaly. She received 4 units of blood total, and her HCT bumped from 20 to 26 following transfusion. She had one more episode of black stool and large BRBPR while in the MICU on HD #2, no further episodes after this. She initially received Octreotide on admission, this was DC'd once lower suspicion for variceal bleed. EGD showed nonbleeding ulcer at GJ anastomosis which was likely source of bleed. She was initially on pantoprazole gtt, later switched to pantoprazole 40mg IV BID and Carafate susp 2gm [**Hospital1 **]. She also received 3-day course of Ceftriaxone for SBP prophylaxis. Her home spironolactone and Lasix were held in MICU in setting of GI bleed. Heparin prophylaxis was held in MICU given recent GI bleed. Patient was then transferred to the floor where her hct remained stable. On discharge, she will take 3 days of Cipro 500mg [**Hospital1 **] for SBP prophylaxis, will continue carafate, increase her home PPI dose from qd to [**Hospital1 **]. She will have labs re-checked and faxed to liver clinic on [**2124-7-3**] to assure her hct remains stable. . # ALCOHOLIC CIRRHOSIS: The patient's home furosemide, spironolactone were held in setting of GI bleed. Her lactulose was held in MICU per her preference. . #ALCOHOL WITHDRAWAL: At admission to the MICU, the patient reported a fear of going into alcohol withdrawal even though her last drink was just on the morning of her admission. The patient did not score per CIWA while in MICU, so it was discontinued. She received her home folate, multivitamins, and thiamine. Patient was interested in outpt program to stop drinking. Spoke with social work. . #THROMBOCYTOPENIA: The patient's platelet count at admission was 92 and decreased to 58 on [**2124-6-28**]. The thrombocytopenia could be secondary to decreased production by a hypocellular bone marrow as seen in cirrhosis, but is most likely dilutional given the patient's transfusion with several units of pRBCs. . #ACID-BASE DISTURBANCE: The patient had an initial AG of 21. Her AG metabolic acidosis could be secondary to alcoholic or starvation ketoacidosis. Based on her initial blood gas, the patient also had a primary respiratory alkalosis, likely secondary to hyperventilation from her anxiety. She also had a primary metabolic alkalosis, likely secondary to volume contraction alkalosis given her GI bleed. Her AG closed over the course of her hospitalization. . #ANXIETY: Ms. [**Known lastname 2643**] received Lorazepam prn for her anxiety. . #RASH: The patient's rash was serpiginous in appearance, most c/w tinea corporis (with many overlying excoriations). She received Clotrimazole cream and oral fluconazole for treatment of her rash. Will need outpatient derm follow up given severity and chronicity of rash. Wanted to see derm in clinic in [**Location (un) 55**], provided contact information. . #DEPRESSION: The patient was continued on her home gabapentin. . #HYPOTHYROIDISM: The patient was continued on her home levothyroxine sodium. . TRANSITIONS OF CARE: -will have cbc/chem10/coags/LFTs checked on [**7-3**] and faxed to liver clinic -wil be seen in liver clinic as outpt -will take Cipro 500mg PO bid x3 days -changed PPI dosing from qd to [**Hospital1 **], will need to be changed back to qd as outpt -started carafate, may need to be d/c'ed as outpatient Medications on Admission: Levothyroxine 50 mcg PO QD Lansoprazole 30 mg DR [**Last Name (STitle) **] oxide 400 mg PO QD Furosemide 40 mg PO QD Spironolactone 25 mg 2 tablets PO QD Folic acid 1 mg PO QD B complex vitamin 1 cap PO QD Senna 8.6 mg 1 tab PO BID Docusate sodium 100 mg PO BID Gabapentin 300 mg cap PO TID Oxycodone 5 mg 1-2 tablets PO Q3H Lactulose 10 gm/15 ml syrup, 30 ml PO QID Discharge Medications: 1. Levothyroxine Sodium 50 mcg PO DAILY 2. Senna 1 TAB PO BID:PRN constipation 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Gabapentin 300 mg PO Q8H 5. Sucralfate 1 gm PO BID Please give separately from other meds so do not affect absorption RX *Carafate 1 gram twice a day Disp #*30 Tablet Refills:*0 6. Thiamine 100 mg PO DAILY RX *thiamine HCl 100 mg once a day Disp #*30 Tablet Refills:*2 7. FoLIC Acid 1 mg PO DAILY 8. Bacitracin Ointment 1 Appl TP QID RX *bacitracin zinc 500 unit/gram four times a day Disp #*1 Tube Refills:*2 9. Clotrimazole Cream 1 Appl TP [**Hospital1 **] RX *Antifungal (clotrimazole) 1 % twice a day Disp #*1 Tube Refills:*2 10. Lansoprazole Oral Disintegrating Tab 30 mg PO BID RX *lansoprazole 30 mg twice a day Disp #*60 Tablet Refills:*2 11. [**Hospital1 **] Oxide 400 mg PO DAILY 12. Furosemide 40 mg PO DAILY 13. Spironolactone 50 mg PO DAILY 14. OxycoDONE (Immediate Release) 5 mg PO Q3H:PRN pain take 1-2 tabs for pain as needed 15. Vitamin B Complex 1 CAP PO DAILY 16. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days RX *Cipro 500 mg twice a day Disp #*6 Tablet Refills:*0 17. Outpatient Lab Work Please check CBC, Chem10, LFTs, coags on [**2124-7-3**] and fax results to: Liver clinic Fax: [**Telephone/Fax (1) 24156**] Discharge Disposition: Home Discharge Diagnosis: Gastrointestinal bleed Discharge Condition: Patient's physical examination is unchanged at time of transfer to floor. Discharge Instructions: Dear Mrs. [**Known lastname 2643**], It was a pleasure participating in your care at [**Hospital1 771**]. You were admitted on [**2124-6-26**] because you had several bloody bowel movements suggesting that you had bleeding of your gastrointestinal tract. You received an esophagogastroduodenoscopy which showed a small ulcer in your stomach as the most likely source of your bleed. You were treated with several units of blood, and your red blood cell count has increased in response to your transfusion. We also treated your chronic rash, most likely ringworm, with an antifungal cream, Clotrimazole. As we discussed, please call the dermatology clinic in [**Location (un) 55**], information is below. . Please attend the follow up appointments listed below. . We have made the following changes to your medications: START -Ciprofloxacin 500mg twice per day for 3 days -Sulfacrate 1g twice per day until your doctor tels you to stop -Thiamine 100mg daily -Clotrimazole cream twice per day, apply to rash -Bacitracin cream 4 times per day, apply to scratches on legs until healed CHANGE Lansoprazole from 30mg daily to twice per day; take at this frequency until your doctor tells you to stop. Please have your labs checked this [**Last Name (LF) 766**], [**7-3**] and the results will be faxed to the transplant clinic. Followup Instructions: Department: Liver Center With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] When: [**7-14**] at 12:20pm Phone: [**Telephone/Fax (1) 24157**] Department: DERMATOLOGY [**Country **] Dermatology and Laser Center [**Location (un) **] # 104 [**Location (un) 55**] ([**Telephone/Fax (1) 31239**] Please call to schedule an appointment Department: DERMATOLOGY When: WEDNESDAY [**2124-8-2**] at 10:30 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11937**], PA [**Telephone/Fax (1) 3965**] Building: None [**Location (un) **] Campus: OFF CAMPUS Best Parking: Parking on Site Department: ORTHOPEDICS When: FRIDAY [**2124-8-25**] at 9:40 AM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: SPINE CENTER When: FRIDAY [**2124-8-25**] at 10:00 AM With: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 8603**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2124-6-29**]

[ "311", "300.00", "534.40", "287.5", "110.5", "263.9", "V45.86", "493.90", "303.92", "276.2", "571.1", "285.1", "244.9", "572.3" ]

icd9cm

[ [ [] ] ]

[ "45.13", "96.6" ]

icd9pcs

[ [ [] ] ]

12932, 12938

7200, 10893

359, 393

13004, 13079

4218, 6801

14457, 15696

3068, 3235

11637, 12909

12959, 12983

11245, 11614

13103, 13899

3275, 4089

4117, 4199

13928, 14434

305, 321

6821, 7177

421, 1859

10914, 11219

1881, 2636

2652, 3052

17,384

118,828

9790

Discharge summary

report

Admission Date: [**2136-8-1**] Discharge Date: [**2136-9-4**] Date of Birth: [**2099-9-10**] Sex: F Service: SURGERY Allergies: Penicillins / Tetracyclines / Succinylcholine / Clozaril / Calcium Channel Blocking Agents-Benzothiazepines / Beta-Adrenergic Blocking Agents Attending:[**First Name3 (LF) 1384**] Chief Complaint: ESRD with superior and inferior vena cava obstruction Major Surgical or Invasive Procedure: [**2136-8-2**] brachial artery to atrium graft [**2136-8-3**] thrombectomy of RUE graft Trache [**2136-8-13**] exploration of RUE graft History of Present Illness: 36F with ESRD [**3-9**] IgA nephropathy w transhepatic HD catheter, last admission for exposed cuff. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] assessed access options. She has had multiple failed accesses in the past, last time with tunneled femoral line sepsis (MRSA) with removal of line and I+D right groin. Has b/l iliac thrombosis. She was recently d/c'd on warfarin and Vanco IV through [**8-10**]. Currently dialyzing through the recently replaced transhepatic catheter. Following extensive testing of vessels, it has been determined to attempted construction of a graft from the brachial vein to the right atrium as the short segment of IVC from the hepatic arteries to the right atrium appears widely patent, this will be performed on [**8-2**]. Last hemodialysis Tuesday [**7-31**], states treatment cut short due to clotting of the dialysis machine. . Past Medical History: PAST MEDICAL HISTORY: 1. ESRD due to IgA nephropathy 2. Schizoaffective disorder 3. Depression 4. Anemia 5. GERD 6. Cardiomyopathy 7. Hypothyroidism 8. GI bleed 9. Coagulase negative staph infection 10. RLE DVT PAST SURGICAL HISTORY: s/p L upper & lower AV fistula - failed s/p R AV fisula basilic v transposition - failed s/p R forearm AV graft - failed s/p PD catheter '[**27**] - failed central venous stenosis - R brachiocephalic v. occlusion of inominate v. s/p R arm brachial->axilla AV graft ([**2133-10-9**]) s/p thrombectomy & angioplasty of outflow stenosis ([**2133-10-11**]) s/p thrombectomy ([**2133-10-23**]) s/p thrombectomy and revision of R arm AV graft ([**2133-11-12**]) s/p thrombectomy of R arm AV graft ([**2133-11-16**], [**2133-12-15**]) s/p excision of infected R arm AV graft ([**2133-12-25**]) [**2136-8-2**] right brachial artery to right atrium graft [**2136-8-3**] rue graft thrombectomy 7/-/07 Trache [**2136-8-13**] RUE exploration -seroma [**2136-8-31**] UTI, pseudomonas Social History: Lives at [**Location (un) **] Health and Rehab center, unemployed, no tobacco, alcohol, or recreational drug use. Estranged from mother [**Name (NI) **] ([**Telephone/Fax (1) 32972**]) Family History: Non-contributory. Physical Exam: VS: 99.4, 93, 128/86, 24, 97%RA, wt 74.5 kg Gen: pale female, lying in bed, NAD, slow to respond to questions but alert/oriented Lungs: scattered coarse crackles throughout Heart: RRR, no M/R/G noted Abdomen: soft, round, non-tender, non-distended, hemodialysis catheter in place mid/left abdomen, dressing C/D/I Extr: no C/C/E Skin: dry, warm . Pertinent Results: [**2136-8-1**] 05:05PM PT-16.2* PTT-27.1 INR(PT)-1.5* [**2136-8-1**] 05:05PM PLT COUNT-230 [**2136-8-1**] 05:05PM WBC-4.2 RBC-2.86* HGB-9.2* HCT-29.1* MCV-102* MCH-32.1* MCHC-31.6 RDW-19.6* [**2136-8-1**] 05:05PM ALBUMIN-3.1* CALCIUM-8.3* PHOSPHATE-2.5* MAGNESIUM-2.3 [**2136-8-1**] 05:05PM ALT(SGPT)-9 AST(SGOT)-18 ALK PHOS-142* TOT BILI-0.2 [**2136-8-1**] 05:05PM GLUCOSE-94 UREA N-21* CREAT-6.0*# SODIUM-136 POTASSIUM-4.2 CHLORIDE-96 TOTAL CO2-30 ANION GAP-14 Brief Hospital Course: On [**2136-8-2**] she underwent superior vena cava bypass with an 8-mm ringed [**Name (NI) 4726**] PTFE graft. Creation of a right axillary artery to right atrial bypass/fistula using a 6-mm [**Doctor Last Name 4726**]-Tex graft to the 8-mm [**Doctor Last Name 4726**]-Tex graft mentioned above and had Arteriovenous fistulogram. Sugeon was Dr.[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 914**]. Please see operative report for details. She was sent to the SICU postop intubated and sedated. She remained on iv vanco and flagyl via a right foot iv that was placed in the OR. On pod 1, she was started on IV Heparin. Dialysis was done using the transhepatic catheter. Due to a low SBPs (80-90's)UF was targeted to minimum. A neo drip was used. On [**9-2**] the graft was found to be clotted. Hypercoagulable labs were sent prior to starting heparin. Hematology was consulted for w/[**Location 32973**]. Factor V Leiden, PT gene mutation , AT III, protein C, and protein S were sent. Anticardiolipin antibodies were negative. Dr. [**First Name (STitle) **] noted that the likeliest etiology of her thrombotic disorder was an underlying inflammatory condition aggravated by foreign bodies (dialysis catheters). She was taken back to the OR by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] for thrombectomy with revision and reposition of AV graft and intraoperative fistulogram. Postop the graft had a bruit/thrill. She was extubated, but required re-intubation for respiratory distress. Vocal cords appeared abnormal with airway edema. Levaquin was added to her antibiotic regimen. On pod [**3-8**], CVVHD was initiated for low BP. She was unable to be extubated with RR to 40-50s. Neo drip continued to keep sbp >90. HR was in high 90s. IV lopressor was given. She had a right femoral line in place. Propofol was weaned off. The CVVHD catheter clooted on [**8-5**], but resolved to TPA. ENT evaluated and found displaced arytenoid proximal to cords possibly fractured vs supraglottic edema. She remained intubated and was given IV decadron. Re-intubation was required. CT of the neck demonstrated no evidence of arytenoid subluxation or dislocation. Fracture was difficult to evaluate given mostly cartilaginous makeup of the arytenoids. A right apical pneumothorax and subcutaneous anasarca were noted. The study and the report were reviewed ENT recommended extubation in OR with anesthesia present. Chest tubes were removed on pod 4. She required reinstitution of neo for low bp and 2 units of PRBC were transfused for hct of 23. On pod 5 ([**8-7**])she underwent direct laryngoscopy with tracheotomy. Surgeon was Dr. [**First Name11 (Name Pattern1) 10827**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]. Findings: Extensive supraglottic edema. #6 trach placed. Postop, CVVHD was resumed given low bp's. She was eventually weaned off pressors and cvvhd was changed to HD. Antibiotics were stopped on [**8-11**]. Heparin continued until inr became therapeutic with coumadin. On [**8-13**] a fistulogram was performed for RUE swelling and erythema. Complete occlusion of the right forearm graft and patent right upper arm graft was found. A 12 x 12 cm complex fluid collection was noted within the right upper arm suggestive of complex seroma/hematoma or abscess. On [**8-13**], ENT performed a fiberoptic exam noting significant edema of arytenoids bilaterally with floppy left arytenoid. The #6 cuff trache was removed and replaced with a # 6 cuffless nonfenestrated trache. Stay suture was removed. Passymuir valve was not recommended given airway obstruction above trache. F/u with Dr. [**First Name (STitle) **] as outpatient was recommended. She developed a temp of 101. antibiotics (linezolid and levaquin)were started. Flagyl continued. Blood cultures were drawn. ID was involved. On [**8-14**], she was taken back to the OR for exploration of graft for tense seroma. The graft was still open. Gram stain and culture were negative. Blood cultures were negative. The graft bruit was found to be diminished on pod 1. It was felt that she would require repeat thrombectomy. HD continued via the transhepatic catheter. She passed a bedside swallow eval. Diet was advanced to thin liquids and soft consistency solids. She tolerated this well. A nasoduodenal tube was placed and feedings were started for nutrition support given low kcal intake. This was subsequently removed when she was taking in ~1100kcal. A Passy-Muir valve was well tolerated although, ENT preferred to wait on using the PM valve given degree of edema. She was well maintained on 40%Trache collar. She remained in the hospital this last week for possible thrombectomy of the graft. This was to be done on [**8-29**], but this was cancelled due to patient having a seizure while on hemodialysis on [**8-28**]. She experienced a 30sec witnessed tonic-clonic sz with foaming of mouth and biting of tongue. She did not require Ativan. Vitals were stable. O2 remained 100% and glucose was 113. Lytes were acceptable. Given that she was on coumadin with inr of 2.5, a head CT was done. This was negative for bleed/shift or mass. Ventricles were wnl. A neuro consult was obtained. It was felt that in combination with uremia and multiple potential seizure threshold lowering medications that she had a seizure possibly from dis-equilibrium during dialysis. Cessation of reglan was encouraged and no anti-sz medication was felt to be needed at this time. An EEG was done without seizure activity noted. Neuro did not want to start anti-seizure medications unless she seized again. Trazodone and reglan were stopped. Thorazine was decreased and prolixin lunch dose was increased in conjunction with her outpatient psychiatrist. On the day prior to discharge, she complained of right foot and calf pain. She had a edematous R>L leg. Calf was tight without cord. No erythema was noted. An ultrasound revealed thrombosis within the right common femoral vein and a complex fluid collection within the right calf medially likely representing a hematoma. An abscess could not be excluded. A CT showed multiple discrete fluid collections, most consistent with hematomas within the calf musculature bilaterally, predominantly involving the soleus muscles. While these collections appear consistent with hematomas, superimposed infection cannot be excluded.There was evidence of chronic degeneration/injury of the right posterior tibial tendon and subcutaneous edema, greater on the right was noted. Leg elevation was ordered. Coumadin was supra-therapeutic with an inr (3.8) on [**8-31**]. Coumadin was held then resumed. Last coumadin was 3mg on [**9-3**]. INR was 2.1 on [**9-4**]. She should have an INR qd and adjust until stable. Goal inr was [**3-10**]. Hemodialysis should continue on Mon-Wed-Thursday via the transhepatic catheter. On [**8-31**], she spiked a temp to 101. She was pan cultured with a positive urine culture for >100,000 col of pseudomonas sensitive to meropenum. She was started on Meropenum on [**9-2**]. A u/a and urine culture should be sent once the meropenum finishes. Linezolid was stopped on [**9-4**] as blood cultures have been negative to date. Flagyl should continue for 2 weeks after meropenum is complete. She has limited iv access and currently has a saline lock in the dorsum of the left foot. She will follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] in the outpatient clinic. Future RUE thrombectomy will be discussed during this visit. An appointment with Dr. [**First Name4 (NamePattern1) 9317**] [**Last Name (NamePattern1) **] ENT [**Telephone/Fax (1) 2349**] is scheduled in 2 weeks. An appointment with her outpatient psychiatrist should be scheduled. She is discharged now to [**Hospital **] Rehab in stable condition. She is afebrile. SBP runs in the low 100s. She was ambulatory with PT. Medications on Admission: Colace 100 [**Hospital1 **], Tiotropium Bromide 18 mcg IH QD, Metoclopramide 5 PO TID, Folic Acid 1 mg [**Hospital1 **], Levothyroxine 150 mcg QD, Epoetin Alfa 22,000 units SC 3x/week during HD, Prilosec 20 mg PO BID, Ropinirole 1.5 qhs, Metronidazole 500 mg [**Hospital1 **], Fluphenazine 5mg QD + 10 mg hs + 2.5 mg 12noon, Trazodone 100mg hs, Mirtazapine 37.5 mg hs, Clonazepam 0.75 mg [**Hospital1 **], Metoprolol Tartrate 12.5 mg TID, hold sbp <110 or HR <55, Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H PRN, Cinacalcet 150 mcg QD, please give with supper, Heparin 5,000 unit/mL [**Hospital1 **], Warfarin 2 mg QD, Thorazine 100 mg HS, Vanco 500 mg q HD treatment T-TH,S, Nephrocap 1 QD . Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Levothyroxine 100 mcg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 4. Ropinirole 1 mg Tablet Sig: 1.5 Tablets PO QPM (once a day (in the evening)). 5. Fluphenazine HCl 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Fluphenazine HCl 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Fluphenazine HCl 2.5 mg Tablet Sig: Two (2) Tablet PO LUNCH (Lunch): please give at lunch. 8. Mirtazapine 15 mg Tablet Sig: 2.5 Tablets PO HS (at bedtime). 9. Clonazepam 0.5 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): continue for 2 weeks after meropenum discontinued. 11. Insulin Regular Human 100 unit/mL Solution Sig: follow sliding scale Injection four times a day. 12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 13. Chlorpromazine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 17. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed: for pruritus. 18. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): hold for sbp <110 or HR <60. 19. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day): to peri area/groin. 20. Transhepatic Catheter Care Dialysis to flush catheter with heparin/saline q HD 21. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day. 22. meropenum Sig: Five Hundred (500) mg once a day for 3 days: give IV . Due 4pm [**9-4**].send u/a and urine culture after last meropenum dose. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: esrd VRE MRSA bacteremia Left arytenoid fracture(tracheal injury) thrombosis of RUE av graft, s/p thrombectomy Seizure, generalized [**2136-8-28**] Discharge Condition: good Discharge Instructions: Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] [**Telephone/Fax (1) 673**] if fever, chills, absence of bruit/thrill of Right upper extremity AV graft, bleeding at graft site, increased RUE swelling or redness, malfunction of Transhepatic catheter or excessive bruising. Continue Hemodialysis every Mon-Wed-Friday via transhepatic catheter Followup Instructions: Please schedule a follow up appointment with her outpatient psychiatrist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (ENT)Otolaryngology [**Telephone/Fax (1) 32974**] Tuesday [**9-18**] at 3:45. 1244 [**Location (un) **] Stree, [**Location (un) 55**] Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2136-9-13**] 9:00 Completed by:[**2136-9-4**]

[ "295.70", "790.92", "998.13", "459.2", "V12.51", "996.73", "599.0", "478.6", "518.5", "244.9", "998.12", "V09.0", "V09.80", "780.39", "585.6" ]

icd9cm

[ [ [] ] ]

[ "99.04", "31.42", "00.14", "39.95", "86.04", "88.44", "96.04", "96.72", "31.1", "96.6", "39.23", "39.49" ]

icd9pcs

[ [ [] ] ]

14290, 14369

3688, 11633

453, 599

14561, 14568

3189, 3665

14994, 15456

2787, 2807

12388, 14267

14390, 14540

11659, 12365

14592, 14971

1796, 2568

2822, 3170

360, 415

627, 1523

1567, 1773

2584, 2771

78,966

127,489

53374

Discharge summary

report

Admission Date: [**2200-5-26**] Discharge Date: [**2200-6-3**] Date of Birth: [**2117-12-10**] Sex: F Service: MEDICINE Allergies: Aspirin / Nitroglycerin Attending:[**First Name3 (LF) 30**] Chief Complaint: Abdominal pain, vaginal bleeding Major Surgical or Invasive Procedure: Intubation RIJ placement History of Present Illness: 82 yo F with a past medical history of DM, CAD, CHF, CKD and Parkinson's presents with 2 weeks of vaginal bleeding. At time of initial assessment husband reported that patient was experiencing intermittent episodes of vaginal bleeding vs hematuria over the last 2 weeks, as well as headaches and chills. In the ER patient was reported having 1 tablespoon per day of vaginal bleeding, but was not wearing pads. Also reported generalized weakness and intermittent chest pain/dyspnea over the last 3 days, with occasional headaches. Denies recent cough, diarrhea, and hemoptysis. Does report chronic urinary frequency of about 10-15 times per day, which is unchanged from baseline. In the ED patient was noted to be wheezing at the bases and was guaiac positive. Vaginal exam was noteable for gross blood without masses and a normal cervix. Patient was TTP in the RLQ, but could not further classify this pain. CXR showed an enlarged cardiac silhouete, but no obvious consolidation. EKG was noted to be at baseline. Pelvic u/s was negative. CT abdomomen and pelvis was unremarkable. Cardiac enzymes were negative. FS was noted to be 33 with the patient relatively asymptomatic, and patient was given an amp of D50 x1. FS improved to 65. Mental status started to worsen as patient became progressive more agitation. Patient received another amp of D50 but mental status appeared to worsen. Head CT was ordered and patient was given ativan 1 mg IV x1 for this procedure. She was also given Zofran 4 mg IV x1 and Morphine 4 mg IV x1. CT head was unremarkable. Thereafter she was lethargic but arousable. She was started on a D10 W drip at 125 cc/hr and transferred to the ICU. Patient was transferred to the MICU, VS were 90, 13, 162/78, 100% RA. In the ICU, patient remained lethargic and became disoriented. On [**5-27**] mental status deteriation, deemed secondary to morphine and ativan adminstration/component of hypoglycemia, continued to deteriate and patient became hypercapneic and was intubated. On [**5-28**] patient was started on CTX and azithromycin due to concern for PNA, sputum positive for gram possitive cocci, culture grew rare Asperigillos; Urine culture + for Garnderella and patient started on Flagyl. On [**5-29**] patient self extubated and was transitioned with bipap. saturting in the high 90s. Passed speech and swallow eval. Mental status continued to improve and patient was transferred to the floor. On the floor patient feeling much better. Continues to report pelvic pain and vaginal bleeding. Reports occassional chills, SOB and cough productive of clear sputum. Denies chest pain. Past Medical History: 1. Diabetes mellitus, type 2, poorly controlled, last HbA1c 9.0 [**1-15**] 2. Atrial fibrillation, on coumadin 3. Coronary artery disease s/p stent to the RCA 09/[**2191**]. 4. Congestive heart failure, EF 70% [**12/2198**] 5. Hypertension. 6. Hypercholesterolemia. 7. Seizures 8. Parkinson's disease 9. Hx. PUD and gastritis 10. Hx. abnormal pap smears 11. Status post bilateral total knee replacement. 12. Low back pain 13. Chronic kidney disease with baseline creatinine 1.3-1.9 Social History: Patient lives with her husband in [**Location (un) 686**], daughter lives nearby. Patient is a former smoker, but none in recent years. No alcohol. She walks with the aid of a cane. She was born in [**Male First Name (un) 1056**]. She is spanish speaking only. Grandson, [**Name (NI) **], is primary communicator for the family. Family History: Brother with DM. No CAD or COPD. Physical Exam: On admission - Vitals: T: 98.0 BP: 134/78 P: 91 R: 24 O2: 96% RA General: Lethargic, arousable to sternal rub and loud verbal stimuli, nonverbal HEENT: Sclera anicteric, MMM, oropharynx clear, pupils minimally reactive Neck: supple, JVP not elevated, no LAD Lungs: Loud bilateral expiratory wheeze, with I:E ratio less than 1:2 CV: distant HS, irregular, 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 Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema On discharge Vitals: T: 98.9 BP: 132/92 P: 65 R: 23 O2: 93% 4L General: Alert, pleasant, spanish speaking only HEENT: Sclera anicteric, MMM, oropharynx clear, pupils minimally reactive Neck: supple, JVP not elevated, no LAD Lungs: soft b/l expiratory wheeze, no crackles no rhonchi CV: irregular, irregular, no murmurs, rubs, gallops, trace b/l edema on feet Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis Pertinent Results: Admission Labs [**2200-5-26**] WBC-11.7* RBC-4.59 Hgb-10.3* Hct-35.7* MCV-78* MCH-22.5*# MCHC-28.9* RDW-19.4* Plt Ct-291 Neuts-75.6* Lymphs-17.2* Monos-5.0 Eos-1.6 Baso-0.5 PT-16.6* PTT-24.7 INR(PT)-1.5* BLOOD Glucose-82 UreaN-15 Creat-1.3* Na-139 K-5.0 Cl-101 HCO3-29 AnGap-14 Lipase-64* Calcium-9.3 Phos-3.1 Mg-2.0 ART pO2-34* pCO2-79* pH-7.21* calTCO2-33* Base XS-0 Lactate-1.7 K-4.3 CT Head W/O Contrast -- No acute process identified. . Pelvis, Non-Obstetric -- Thickened endometrial stripe (5mm) on transabdominal US only. No gross abnornmality of the myometrium is seen. Endovaginal US was not performed at this time due to lack of a language translator for consent. The decision for TV US will be made following a CT examination. . CT Abdomen W/Contrast -- Preliminary Result+ Dictated ([**1-/8773**]) CT Pelvis W/Contrast -- Preliminary Result+ Dictated ([**1-/8773**]) Normal appendix. No bowel obstruction. Indetermin left adrenal nodule, stable since [**2190**]. No acute CT findings to explain pain. Transvaginal US ([**5-30**]) Endometrial stripe appears to be thickened up to 0.7 cm with a small fluid collection in the fundus. Endometrial stripe appears to be irregular without evidence of flow within. Adnexa are not identified. There is no evidence of free fluid within the pelvis. There is no evidence of focal abnormality within the myometrium. CXR: PA and Lateral ([**5-31**]) Compared with [**2200-5-28**], the ET tube and NG tubes have been removed. There is an abnormal appearance to the right upper zone. Differential diagnosis includes parenchymal opacity, unusual prominence of vessels, or assymetric pulmonary edema. There is a small right pleural effusion. Compared with [**2200-5-28**], the cardiomediastinal silhouette is stable. Changes in the right upper zone and right base and atelectasis at the left base is similar, allowing for technique. Brief Hospital Course: 82 yo F with a past medical history of DM, CAD, CHF, CKD and Parkinson's presents with 2 weeks of vaginal bleeding, and noted to have ED course complicated by hypoglycemia and altered mental status. . #. Altered mental status: Unclear etiology but presumably related to morphine and ativan received in the ER as well as infectious process. [**Month (only) 116**] have been related to hypoglycemia, but appears unlikely that patient would be asymptomatic at FS of 33, but then become progressively more agitated as FS improved. CT head unremarkable. Patient did not improved with narcan, and was not given flumzenil trial. Patient was intubated for poor mental status and hypercapnia, and once extubated on [**5-29**], mental status rapidly improved to "baseline" according to the family. According the family, patient has dementia at baseline, and is not oriented to year secondary to illiteracy. RPR was negative. TSH and B12 were normal. When called out to the medicine floor, mental status remained stable and was consistent with baseline per family members. . #. Hypoglycemia: Unclear precipitant as no dramatic changes to her sulfonylurea or insulin regimen. Transiently required D10 drip in the ER, but was rapidly weaned off while in the ICU. Cr at baseline making changes in sulfonylurea pharacokinetics less likely. Insulin regimen unchanged. [**Month (only) 116**] be related to poor med compliance at home. Patient also on a betablocker which might mean she has asymptomatic hypoglycemia at baseline. Additionally, ACS or sepsis could precipitate hypoglycemia but seems less likely as ROMI was negative and blood cultures were negative. Long acting insulin was held in MICU. On the floor fingersticks were checked as per protocal. Insulin sliding scale was initiated. Oral medications were held until patient taking in adequate POs. Discharged on on standing NPH and ISS with plan to restart oral regimen in rehab once taking in adequate PO. . # Garnerella UTI: Asymptomatic UTI. Treated with flagyl 500mg PO BID for planned 7 day course, end date [**6-6**]. . #. Vaginal bleeding: Given endometrial stripe on ultrasound, and age, there is concern for endometrial cancer. Patient continued to have bloody spotting while in house. HCT stable. Vaginal ultrasound showed thickened endometrial stripe to 0.7cm. Spoke with GYN, no further work-up to be done in house and will follow patient as outpatient with plan for biopsy. . # Afib: Rate controlled and anticoagulated. Coumadin was continued despite vaginal bleeding. While on floor continued receiving coumadin with INR at time of discharge: 2.8. Plan to recheck INR at rehab. . # Diastolic CHF: Initially euvolemic however diuretics were held after creatinine elevation in the ICU. On the floor patient was hypervolumic. Patient diuresed well on combination of PO and IV lasix. Home lasix 40mg PO BID was uptitrated to 60mg PO BID prior to discharge. Patienty minimally volume up at time of discharge however symptoms of shortness of breathe resolved with no elevated JVP and trace edema in bilateral feet. Weight at time of discharge was 94.5kg. Per PCP dry weight is 200lbs. Statin, ace-i, and betablocker were continued. . # Hypertension: On the floor patient was hypertensive with systolic blood pressures in the 180s. Home dose of metoprolol was uptitrated and transitioned to 150mg Toprol XL with good result, lisinopril was increased from 20mg to 40mg. Creatinine at time of discharge was 1.3 which is consistent with patient's baseline. Clonidine was continued at home dose. . # Seizure d/o: Continued Keppra . # Chronic kidney disease - Kidney function worsened after receiving contrast and while in the ICU diuresis was stopped. On the floor, diuresis was reinstituted. Creatinine improved and at time of discharge creatinine was 1.3. Plan to monitor renal fucntion with creatinine check at rehab. . # Code: DNR/DNI. After discussion with both patient and family members decision was made to change code status to DNI/DNR (documented in ICU notes) Medications on Admission: # Psyllium Oral Powder - 1 teaspoon daily # Keppra 500 mg po BID # Tylenol #3 Q8H Prn # Novolin 20 U QHS, 50 U QAM # Clonidine 0.2 mg TID # Atenolol 50 mg daily # Proair 1-2 puffs Q4-6H prn # Furosemide 40 mg [**Hospital1 **] # Lisinopril 20 mg dalu # Simvastatin 40 mg daily # Glyburide 10 mg Q am, 5 mg Q pm # Clotrimazole 1 % Topical Cream apply to affected areas twice a day # Colace 100 mg [**Hospital1 **] # Ferrous Sulfate 325 mg daily # Warfarin 5 mg Tab QMoWeSatSu, 2.5 mg QTuThFr # Sinemet 25 mg-100 mg Tab - 1 tab TID # Asmanex Twisthaler 110 mcg (30 doses)1 puff daily # Ranitidine 150 mg [**Hospital1 **] Discharge Medications: 1. Warfarin 5 mg Tablet Sig: One (1) Tablet PO 6X/WEEK (MO,TU,WE,TH,FR,SA). 2. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO 1X/WEEK ([**Doctor First Name **]). 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q4H (every 4 hours). 5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for wheeze. 6. Clonidine 0.1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig: One (1) PO DAILY (Daily). 11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever, pain. 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 14. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day) as needed for CHF. 15. Outpatient Lab Work Please check Creatinine and INR at rehab facility. 16. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). 18. Outpatient Speech/Swallowing Therapy Please have outpatient speech and swallow evaluation. Continue nectar thick liquid diet. Patient is to eat with assistance. Discharge Disposition: Extended Care Facility: [**Hospital3 537**]- [**Location (un) 538**] Discharge Diagnosis: Primary diagnosis: Vaginal bleeding Congestive Heart Failure Secondary: Atrial Fibrillation Diabetes Mellitus Dementia Discharge Condition: Mental Status: Clear and coherent, baseline dementia. Level of Consciousness: Alert and interactive, spanish speaking only. Activity Status: Ambulates with assistance. Discharge Instructions: You presented to the Emergency Department with pelvic pain and vaginal bleeding. You were given pain and anxiety medications to relieve your anxiety. Unfortunately, you became extremely sedated from these medications. You required transfer to the intensive care unit (ICU) and intubation to help you breath. After you were extubated you were transferred to the medicine floor. On the floor your mental status continued to improved. We reinstituted your home medications and monitored your volume status, blood pressure and blood sugars. You were seen by physical therapy who recommend discharge to a rehabiliation center. . The following changes were made to your home medications: STOPPED Glyburide 10 mg Q am, 5 mg Q pm. Please resume taking when taking in adequate food and drink at rehab. STARTED on Metronidazole 500mg tablets to be taken by mouth once in the morning and once at night. Continue this medication through [**6-6**]. (7day treatment course) BEGIN taking Metoprolol XL 150mg by mouth daily INCREASED Lasix by mouth from 40mg twice a day to 60mg twice a day INCREASED Lisinopril from 20mg to be taken by mouth daily to 40mg to be taken by mouth daily. . Followup Instructions: It is very important that you keep your follow up appointments as listed below: Department: [**Hospital3 249**] When: WEDNESDAY [**2200-6-4**] at 11:10 AM With: [**First Name8 (NamePattern2) 11136**] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: OBSTETRICS AND GYNECOLOGY When: MONDAY [**2200-6-23**] at 4:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 71322**], MD [**Telephone/Fax (1) 2664**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 1935**] CENTER When: WEDNESDAY [**2200-8-20**] at 10:10 AM With: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. [**Telephone/Fax (1) 253**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2200-6-4**]

[ "V85.4", "585.9", "250.80", "E939.4", "584.9", "332.0", "V58.61", "428.0", "182.0", "427.31", "276.2", "486", "403.90", "345.90", "414.01", "E947.8", "599.0", "V45.82", "518.81", "E935.2", "278.01", "276.0", "292.81", "428.33", "041.89" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

13322, 13393

6962, 7174

315, 342

13557, 13557

5056, 6939

14949, 16066

3850, 3884

11654, 13299

13414, 13414

11011, 11631

13751, 14418

3899, 5037

14436, 14926

243, 277

370, 2983

13433, 13536

13572, 13727

3005, 3488

3504, 3834

9,249

125,396

8062

Discharge summary

report

Admission Date: [**2169-8-1**] Discharge Date: [**2169-8-18**] Date of Birth: [**2099-2-19**] Sex: M Service: [**Doctor First Name 147**] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7760**] Chief Complaint: RUQ abdominal pain Major Surgical or Invasive Procedure: 1. L hepatic artery embolization by Interventional Radiol. ([**8-1**]) 2. Exploratory laparotomy decompression w/ washout ([**8-1**]) 3. Abdominal closure ([**8-4**]) History of Present Illness: Mr [**Known lastname 11257**] is a 70 year old male with a history of prostate cancer and hepatitis B, who presented to the hospital with a several hour history of acute onset right upper quadrant abdominal pain. He was initially hypotensive, requiring blood products. While stable, a CT scan was obtained that demonstrated two large liver lesions; one in the fourth segment of the liver and a second in the sixth segment. One had an obvious blush with evidence of free intraperitoneal blood throughout the abdomen. He was aggressively fluid resuscitated with blood products, transferred to the [**Hospital1 69**] from the [**Hospital 620**] Campus. Past Medical History: Prostate Ca Chronic Hep B Cirrhosis Social History: -(+) EtOH/Tobacco in past; not anymore -military (Korean/[**Country 3992**]) -Lives with 2 supportive sisters and GF from [**Name (NI) 2784**] Physical Exam: On admission: VS 94.8, HR 90, 134/70, RR 19, 99%(RA) GEN: distressed HEENT: PERRL, EOMI, OP pink, mmm CV: sinus bradycardia RESP: air moving bilaterally, Decreased BS on Left ABD: rigid, tender EXT: no c/c/e, 2+ pulses (DP/PT/femoral) NEURO: grossly intact Pertinent Results: [**2169-8-1**] 07:15PM WBC-12.9*# RBC-3.76* HGB-11.8* HCT-33.6* MCV-90 MCH-31.4 MCHC-35.0 RDW-13.7 [**2169-8-1**] 07:15PM NEUTS-72* BANDS-9* LYMPHS-17* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2169-8-1**] 07:15PM PT-16.0* PTT-33.5 INR(PT)-1.6 [**2169-8-1**] 07:15PM ALT(SGPT)-19 AST(SGOT)-20 ALK PHOS-39 AMYLASE-35 TOT BILI-0.8 [**2169-8-1**] 07:15PM LIPASE-32 [**2169-8-1**] 07:15PM GLUCOSE-190* UREA N-15 CREAT-0.9 SODIUM-141 POTASSIUM-3.6 CHLORIDE-113* TOTAL CO2-18* ANION GAP-14 [**2169-8-1**] 07:15PM CALCIUM-6.2* PHOSPHATE-4.7* MAGNESIUM-1.4* DIAGNOSIS: 1. Liver tumor (A,B): a. Extensive necrosis and hemorrhage. b. Rare foci of atypical hepatic cells, suspicious for hepatoma. 2. Liver tumor (C-F): a. Foci of hepatocellular carcinoma, mainly well-differentiated. b. Marked necrosis. 3. Liver tumor (G-K): a. Foci of hepatocellular carcinoma, mainly well-differentiated. b. Marked necrosis. 4. Liver tumor (L): a. Necrotic tissue. b. No tumor identified. 5. Wedge biopsy of anterior liver (M): a. Minimal portal mononuclear cell inflammation (grade 0-1). b. Trichrome stain: Cirrhosis (stage 4). c. Iron stain: No stainable iron. d. No tumor. e. The features are consistent with chronic viral hepatitis B. Brief Hospital Course: Upon admission, a chest tube was placed in Mr [**Known lastname 11257**] for a possible left pneumothorax that occurred after placement of subclavian cordis line. On HD2, He underwent angiography which revealed evidence of active extravasation from a small branch off the left hepatic artery. This was coil embolized by interventional radiology successfully. After the interventional procedure, it was noted that his abdomen was extremely tense, consistent with an abdominal compartment syndrome. Because of this, decompression was indicated. He was taken to the OR on [**8-1**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6633**] for Exploratory laparotomy, Evacuation of abdominal compartment syndrome and hematoma, and Irrigation and abdominal silo placement. On [**8-2**], he was intubated. He was transferred to the SICU. On [**8-3**], continued on the vent; fentanyl was increased and propofol decreased, Fio2 decreased. He returned to the OR on [**8-4**] for abdominal washout and wall closure performed by Dr. [**Last Name (STitle) 6633**]. On [**8-5**] fentanyl drip was dc'ed. He was on CPAP. Propofol was increased d/t increased agitation. His Hct, Plt, Cr, INR remained stable, but his ALT/AST/BUN was slightly increased. He was extubated on [**8-6**] with O2 sats of 93-95%. He was agitated and was given Haldol for short effect and Fentanyl q1hour. After suffering poor oxygenation, he was intubated; propofol was resumed. On [**8-7**], he remained on AC and he failed propofol weaning. Chest CT was done and ruled out metastasis. On [**8-8**], ICU team continued to diurese with Lasix and continued to attempt weaning off vent. After noting reddening of abdominal wound with serosanguinous discharge, staples were removed from wound. On [**8-9**], a vac dressing was placed on his abdominal wound. On [**8-10**], diuresis with lasix continued. He was also started on tube feeds. On [**8-11**], the chest tube was removed. He tolerated clear liquids and began diuresing on his own. He was provided a 1:1 sitter at bedside. He was extubated on [**8-12**], and he was transferred to FA9. On [**8-13**], he was started on regular diet, and TPN was tapered; foley was removed. Overnight, he became agitated and was given Haldol and Ativan. On [**8-14**], the CVC was dc'ed, and peripheral IV access was obtained. His IV was hep-locked, and he was placed on 1.5L fluid restriction. His vac dressing was removed and fascia was assessed and intact. He was placed back on the vac on [**8-15**] after draining ascitic fluid continued to soak the dressing. On [**8-16**], he was seen by Hepatology for evaluation for possible liver transplant. He was deemed not suitable for liver transplantation due to prior hx/o prostate ca and Hep B cirrhosis and size of liver lesions. He was subsequently placed on Aldactone 50mg and Lasix 20mg. Medications on Admission: None Discharge Medications: 1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). Disp:*60 injections* Refills:*2* 2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-16**] Puffs Inhalation Q4H (every 4 hours) as needed. Disp:*1 inhaler* Refills:*0* 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 6. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2* 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 8. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO QD (once a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: 1. Liver hematoma 2. Abdominal compartment syndrome 3. Cirrhosis 4. status post interventional radiology hepatic artery embolization 5. status post exploratory laparatomy and decompression 6. Celiac sprue 7. Hepatitis B 8. hepatocellular carcinoma Discharge Condition: stable Discharge Instructions: Please [**Name8 (MD) 138**] MD with any changes in your wound site including increasing erythema, increased discolored or thick discharge, or foul smelling discharge. Also call with spiking fevers, jaundice, inability to tolerate food, intractable nausea or vomiting. You should resume taking any medications you were taking prior to admission. You can continue to eat a regular diet. You should not lift any heavy objects for 2 months. (greater than 10 pounds). Followup Instructions: You should follow up with Dr. [**Last Name (STitle) 6633**] in [**12-16**] weeks. you can call her office [**Telephone/Fax (1) 2998**] for an appointment. you can see her in the [**Location (un) 620**] office or in the [**Location (un) **] office located on the [**Location (un) 10043**] of the [**Hospital Ward Name **] building, [**Location (un) **] in [**Location (un) 86**]. you should follow up with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] Urology in [**12-16**] weeks, call [**Telephone/Fax (1) 2998**] for an appointment for a voiding study. You have a follow up appointment with Dr. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] of oncology on monday [**8-28**] at 9:30 am. The office is in the [**Hospital Ward Name **] building on the [**Location (un) **].

[ "518.81", "572.2", "285.1", "155.0", "573.8", "428.0", "070.32", "512.1", "789.5" ]

icd9cm

[ [ [] ] ]

[ "93.56", "96.72", "88.47", "50.12", "99.07", "54.19", "99.06", "54.62", "99.05", "99.29", "99.04", "96.04" ]

icd9pcs

[ [ [] ] ]

7154, 7251

3116, 5982

352, 521

7551, 7559

1714, 3093

8075, 8878

6037, 7131

7272, 7530

6008, 6014

7583, 8052

1437, 1437

294, 314

549, 1202

1451, 1695

1224, 1261

1277, 1422

58,649

115,589

36941

Discharge summary

report

Admission Date: [**2159-7-29**] Discharge Date: [**2159-7-31**] Date of Birth: [**2076-10-31**] Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 425**] Chief Complaint: s/p PEA arrest/cardiac arrest Major Surgical or Invasive Procedure: cooling protocol History of Present Illness: 82M with h/o CABG 7 yrs ago, s/p ICD ([**Hospital3 **]) for ?CHF (5yrs ago), afib on coumadin, COPD with baseline SOB, presented with acute dyspnea and found to be in respiratory distress overnight on Am on [**7-29**] around 1-1:30am with syncope/collapse onto soft couch. CPR started within 5-10 minutes of patient being found down. First rhythm was PEA, was in agonal breathing, regained pulse s/p epi, atropine, and intubation. Sent to OSH (arrived 2:55am), per OSH, had pulse but lost pulse around 3:15am, patient given epi, atropine, heparin bolus and gtt, then regained pulse with v-pacing so cooling protocol started (patient down to 30 degrees). Possible report that ICD fired twice - then was V-paced, got bolus/gtt of amiodarone, 20mcg of dopa, 2L IVF, CK and trop flat, INR therapeutic, sent to [**Hospital1 18**]. . Arrived at [**Hospital1 18**] ED around 5:20am, initial 31.4 R, 66, 80/37, 22, 88% of FiO2 100, PEEP 5, PiP 44. ECG showing wide right bundle with possible complete heart block. Found to have small R apical pneumothorax s/p R chest tube but not large enough to be culprit for causing . RIJ, PIVs placed. Bedside ECHO showed no pericardial effusion, ventricles beating. On cooling protocol. Kept on amio gtt, started max dopa (20mcg), levophed (0.12). K was high, given calcium, bicarb. Vitals on transfer were T30.8 (getting 1L warm saline fluid, warming blankets), 72, 132/56, 95% FiO2 60, RR18 - 60, PEEP 6, peak P 36, TV 400. CVP 17. ABG on transfer was 7/15/64/555 . On arrival to CCU, patient was unresponsive, not withdrawing to any noxious stimulation. Patient was transferred on amiodarone gtt at 1, levophed at 0.14, and dopamine at 20 weaned down to 10. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: 3V disease, CABG [**2152**] -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: (5 years prior) placed in [**2154**] 3. OTHER PAST MEDICAL HISTORY: Asthma, hyperlipidemia, hypertension Social History: SOCIAL HISTORY: No tobacco use, rare alcohol socially. Lives with wife, continues to be quite active golfing several times per week. Family History: non-contributory Physical Exam: VS: T= 88.7 BP= 129/45 HR=71 RR= 20 O2 sat= 100% Vt 550 /PEEP 8 GENERAL: WDWN, nonresponsive to verbal stimuli or sternal rub. HEENT: NCAT. Sclera anicteric, pupils fixed and dilated bilaterally. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. ET tube in place NECK: Supple CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Ventilated. CTAB anteriorly without no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM. EXTREMITIES: No c/c/e. Cool. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. NEURO: Minimal withdrawal to painful stimuli in LLE, no other purposeful movement, pupils nonreactive Pertinent Results: [**2159-7-29**] 05:40AM WBC-12.2* RBC-4.09* HGB-13.4* HCT-41.7 MCV-102* MCH-32.7* MCHC-32.1 RDW-13.6 [**2159-7-29**] 05:40AM PLT COUNT-185 [**2159-7-29**] 05:40AM CK-MB-12* MB INDX-4.3 cTropnT-0.10* [**2159-7-29**] 05:40AM CK(CPK)-277* [**2159-7-29**] 05:40AM GLUCOSE-406* UREA N-31* CREAT-1.6* SODIUM-134 POTASSIUM-8.8* CHLORIDE-106 TOTAL CO2-18* ANION GAP-19 [**2159-7-29**] 05:43AM GLUCOSE-376* LACTATE-3.3* NA+-135 K+-8.0* CL--103 TCO2-21 [**2159-7-29**] 05:55AM PT-28.9* PTT-150* INR(PT)-2.9* [**2159-7-29**] 06:21AM TYPE-ART TEMP-30 TIDAL VOL-370 PO2-555* PCO2-64* PH-7.15* TOTAL CO2-24 BASE XS--7 -ASSIST/CON INTUBATED-INTUBATED Brief Hospital Course: # s/p cardiac arrest: Unclear etiology which prompted initial PEA arrest. No anticedent illness. No e/o ischemia on EKG. Anticoagulated so unlikely to be PE & no e/o EKG. Small R-sided pneumothorax with no e/o tension prior to arrival. No e/o hypovolemia. With profound acidosis. Thus, unclear but potentially primary cardiac vs pulmonary source. Patient underwent cooling protocol. The cardiac arrest team, including neuro, was involved. Patient was monitored on continuous 48hr bedside EEG per protocol. EEG on [**2159-7-30**] showed some higher amplitude spikes, but since early morning of [**2159-7-31**], EEG was flatline. Neuro felt that there was very little hope of significant recovery of brain function. Patient also continued to require moderately high doses of levophed and dopamine to maintain blood pressure. Family meeting was held [**2159-7-31**] with CCU team, neurology consult, SW. Family agreed that CMO would be in line with patient's wishes. Patient was extubated and all medications stopped. Patient received morphine prn for comfort. . # Respiratory failure: s/p intubation initially difficult to ventilate with high auto PEEP, PIP. Patient with h/o asthma and concern for bronchospasm on exam. No h/o COPD per available records. Patient received Albuterol / Ipratroprium nebs prn, daily CXR were followed. . # CORONARIES: h/o CAD s/p CABG. No localized ischemia on ECGs, no elevation in enzymes. # PUMP: No prior records in our system, family cannot relay any clear details. . # RHYTHM: V-paced, pacer interrogated showing oversensitivity leading to 2 episodes of inappropriate ICD firing at OSH, none since. Patient therapeutic on prior coumadin. Patient was monitored on telemetry. . Medications on Admission: MEDICATIONS: Coumadin 2.5mg / 5mg alternating daily Carvedilol 12.5mg [**Hospital1 **] Spironolactone 12.5 mg QHS Simvastatin 40mg QHS Aspirin 81 mg daily Albuterol inhaler PRN wheezing Aricept 5mg QHS Discharge Disposition: Expired Discharge Diagnosis: Patient passed on [**2159-7-31**]. Discharge Condition: Patient passed on [**2159-7-31**]. Discharge Instructions: Patient passed on [**2159-7-31**]. Followup Instructions: Patient passed on [**2159-7-31**].

[ "518.81", "427.31", "414.00", "428.0", "584.5", "E878.1", "276.7", "276.4", "V12.53", "427.1", "996.04", "997.31", "427.5", "V58.61", "426.0", "272.4", "512.8", "493.20", "403.90", "785.51", "V45.81", "578.0", "585.9" ]

icd9cm

[ [ [] ] ]

[ "34.04", "96.04", "96.71", "38.93", "99.81", "89.49" ]

icd9pcs

[ [ [] ] ]

5978, 5987

4011, 5726

326, 344

6065, 6101

3335, 3988

6184, 6221

2518, 2536

6008, 6044

5752, 5955

6125, 6161

2551, 3316

2160, 2283

257, 288

372, 2066

2314, 2352

2088, 2140

2384, 2502

9,291

188,577

23825

Discharge summary

report

Admission Date: [**2190-3-24**] Discharge Date: [**2190-4-19**] Date of Birth: [**2136-2-23**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2024**] Chief Complaint: planned for chemotherapy (Gemzar/cisplatin) Major Surgical or Invasive Procedure: Nasogastric tube placement and removal. History of Present Illness: 54 yo female with hx of metastatic breast cancer who presents for cycle #4 of gemcitabine and cisplatin. She is [**Location 7972**] speaking and interviewed with her daughther, who translated. Last cycle was [**2190-3-10**] which was well tolerated. Currently she as three concerns: abdominal pain, blurry vision, and low-back pain. She notes abdominal pain over the past 4 months which she has taken morphine for with some relief though the pain returns and is not well controlled. She has associated nausea, vomitting and constipation (last BM today but has required enema in the past) but no diarrhea. She further c/o 'blurry vision' which has been present since XRT 2 months ago and has been stable over that time. She is not able to state if the blurry vision is whole-field, peripheral or central. She further notes photophobia. She describes a tension of her skin around her eyes, worse on the right than the left, which also has been present since XRT requiring her to close her eyes. This is associated with a frontal headache. She is not able to say if anything makes this worse and says tylenol makes it better. Her third complaint is low back pain which localizes to the right flank region which she states has been present for 4 months also. This pain is not relieved by morphine, unlike her abdominal pain. On ROS she notes occasional chills, and tingling in her fingertips since starting chemo, and 57 pound weight loss over the past 4-5 months, denies fevers, nasal congestion, sore throat, cough, SOB, CP, arm or leg pain, rashes, dysuria. Past Medical History: Onc Hx: Stage II left breast cancer (estrogen neg, progesterone low positive, her2/neu neg) s/p mastectomy (0/9 lymph nodes) in [**7-21**]. This was followed by chest wall XRT and adjuvant chemotherapy. Has recurrent disease with mets to the brain, small bowel and extensive lymphadenopathy. She has undergone whole brain XRT which was completed in [**1-20**]. She is now receiving gemcitabine and cisplatin. . PMH: metastatic breast cancer as above HTN . Social History: [**Location 7972**], has five children. Retired since diagnosis of breast cancer two years ago. Patient independent with ADLs, lives alone but has very supportive family. The patient has five children. Family History: maternal aunt - breast ca in 50s Physical Exam: Vitals: 96.1 129/65 58 18 99%RA GEN: lying in bed, thin and ill-appearing, speaks only [**Location 12187**] [**Location 4459**]: NC/AT, + temporal wasting, OP clear but mm dry NECK: no palpable LAD, TTP right side of neck which she relates to the port-a-cath CHEST: CTAB, no rales/wheezes/rhonchi, port-a-cath in chest, site c/d/i CV: RRR, no murmurs, rubs, gallops, s1 s2 present ABD: loose skin folds, diffusely TTP EXT: 2+ pitting edema to knees (per her slightly increased) NEURO: EOMI, PERRL, face symmetric, full strength thoughout Pertinent Results: [**2190-3-24**] 02:00PM BLOOD WBC-6.7 RBC-3.08* Hgb-8.8* Hct-26.8* MCV-87 MCH-28.4 MCHC-32.7 RDW-22.4* Plt Ct-254# [**2190-4-16**] 12:00AM BLOOD WBC-6.2 RBC-3.55* Hgb-11.2* Hct-32.4* MCV-91 MCH-31.7 MCHC-34.7 RDW-19.2* Plt Ct-370 [**2190-3-26**] 07:31PM BLOOD PT-14.4* PTT-40.3* INR(PT)-1.3* [**2190-4-16**] 12:00AM BLOOD PT-15.3* PTT-30.7 INR(PT)-1.4* [**2190-3-28**] 12:00AM BLOOD Gran Ct-750* [**2190-4-6**] 12:00AM BLOOD Gran Ct-1340* [**2190-3-24**] 02:00PM BLOOD Glucose-110* UreaN-10 Creat-0.4 Na-132* K-3.6 Cl-99 HCO3-28 AnGap-9 [**2190-4-16**] 12:00AM BLOOD Glucose-75 UreaN-7 Creat-0.4 Na-133 K-3.6 Cl-103 HCO3-26 AnGap-8 [**2190-3-24**] 02:00PM BLOOD ALT-43* AST-24 AlkPhos-75 TotBili-0.4 [**2190-4-15**] 03:42AM BLOOD ALT-24 AST-29 AlkPhos-82 TotBili-0.6 [**2190-3-30**] 12:50PM BLOOD Lipase-9 [**2190-4-12**] 12:00AM BLOOD Lipase-17 [**2190-3-24**] 02:00PM BLOOD Calcium-8.1* Phos-2.8 Mg-2.1 [**2190-4-16**] 12:00AM BLOOD Calcium-7.6* Phos-3.7 Mg-1.9 [**2190-4-15**] 03:42AM BLOOD Albumin-1.6* Calcium-7.7* Phos-3.9 Mg-2.0 [**2190-3-24**] 02:00PM BLOOD CA27.29-298* [**2190-4-13**] 12:00AM BLOOD CA27.29-616* [**2190-3-26**] 08:21PM BLOOD Lactate-0.8 [**2190-3-30**] 01:06PM BLOOD Lactate-1.3 . [**3-24**] CT Head w/o contrast: CT HEAD WITH CONTRAST: Compared to [**2190-2-1**], there has been significant improvement in the degree of metastatic disease burden with most of the previously identified enhancing lesions no longer seen. A persistent focus of enhancement in the right frontal lobe (3:11) measures approximately 5 mm compared to 6 mm on [**2-1**]. An approximately 2 mm focus of enhancement adjacent to the frontal [**Doctor Last Name 534**] of the right lateral ventricle (3:14) is significantly smaller compared to [**2-1**] when it measured approximately 8 mm. No new lesions are identified and there is no shift of normally midline structures or evidence of acute minor or major vascular territorial infarct. Surrounding osseous structures are unremarkable. A small mucus polyp is noted within the left maxillary sinus. IMPRESSION: Marked improvement in the degree of metastatic disease burden with most of the previously identified enhancing metastases no longer identified. Small persistent foci of enhancement likely represent residual metastatic disease. . [**4-12**] Pa/Lat IMPRESSION: PA and lateral chest compared to [**2190-3-25**]: Small left pleural effusion or pleural scarring is unchanged since [**2190-3-10**]. Lung volumes are lower exaggerating heart size, which is mildly enlarged. Lungs are clear, with no evidence of pneumonia. Tip of the right subclavian line projects over the superior cavoatrial junction. No pneumothorax. . [**3-26**] Central airways are patent to the segmental levels, bilaterally. Small bilateral pleural effusions. Moderate pericardial effusion is noted. The lungs demonstrate airspace opacity in the lateral aspect of the lingular lobe consistent with post-radiation changes. The heart and great vessels are unchanged. The patient is status post left mastectomy. Interval decrease in size of the left supraclavicular and mediastinal lymphadenopathy. CT OF THE ABDOMEN WITH IV CONTRAST: Portal venous air is seen. The liver demonstrates homogeneous enhancement without evidence of focal lesion. The spleen, adrenal glands, and pancreas are normal. The gallbladder is normal. No evidence of intra- or extra-hepatic biliary ductal dilatation. Small amount of ascites is noted. The stomach demonstrates air within the posterior wall, not seen in the prior study. No evidence of free air within the abdomen. The remaining loops of small and large bowel are unchanged. Interval decrease in size of the multiple periaortic lymphadenopathy. CT OF THE PELVIS WITH ORAL AND IV CONTRAST: The bladder, rectum, sigmoid are unchanged. Free fluid within the pelvis is noted. No evidence of free air. BONE WINDOWS: No suspicious lytic or sclerotic lesions are identified. IMPRESSION: 1. Portal venous air as well as air within the posterior gastric wall. Cannot differentiate emphysematous gastritis from gastric emphysema. Clinical correlation is recommended. 2. Interval decrease in size of the left supraclavicular, mediastinal, and periaortic lymphadenopathy. 3. Bilateral pleural and pericardial effusions. 4. Postsurgical changes in the lingular lobe. . [**3-27**] RLE U/S IMPRESSION: No evidence of DVT in the right lower extremity. . [**3-29**] Ct abd/pelvis TECHNIQUE: Non-contrast multidetector CT acquired axial images of the abdomen and pelvis from the lung bases to the pubic symphysis. Multiplanar reformatted images were obtained. CT OF THE ABDOMEN: Lung bases are clear. Again seen are small bilateral pleural effusions and moderate pericardial effusion, unchanged. Stable pleural parenchymal scarring is noted within the lingular lobe likely representing post-radiation changes. Patient is status post left mastectomy. Within the limitations of a non-contrast exam, no focal lesion is identified within the liver. Previously identified portal venous gas is not appreciated on today's exam. The gallbladder, spleen, adrenal glands, pancrease, kidneys are unremarkable. Compared to the prior exam from [**2190-3-26**], there is a marked to complete resolution of the previously described intramural gas within the stomach wall. The intra-abdominal loops of large and small bowel are unremarkable. Small umbilical hernia is identified. No intra-abdominal free air is detected. Small amount of abdominal ascites is present. Small stable retroperitoneal lymphnodes are present, which do not meet CT criteria for pathologic enlargement. CT OF THE PELVIS WITHOUT INTRAVENOUS CONTRAST: The rectum, bladder, sigmoid colon are within normal limits. No pelvic lymphadenopathy is appreciated. Again seen is fluid within the pelvis, unchanged. BONE WINDOWS: No suspicious lytic or sclerotic lesion is identified. Degenerative changes are noted at L5-S1. IMPRESSION: 1. Compared to prior CT from [**2190-3-26**], there is a marked to almost complete resolution of the previously described intramural gas within the stomach wall. No portal venous air is detected on today's exam. 2. Stable bilateral pleural and pericardial effusions. . [**4-2**] IMPRESSION: No evidence of DVT in both lower extremities . [**4-7**] FINDINGS: Upright and left lateral decubitus abdominal radiograph demonstrate residual contrast within the large bowel, predominantly within the descending colon. No dilated loops of small bowel or intra-abdominal free air is identified. IMPRESSION: No evidence of obstruction. [**4-8**] CT head w/o contrast: FINDINGS: The small focus of residual enhancement in the right frontal lobe medially (3:11) is unchanged. The smaller focus adjacent to the [**Doctor Last Name 534**] of the right lateral ventricle is no longer visualized. No new enhancing lesions are seen. There is no mass effect, shift of normally midline structures, or hydrocephalus noted. No intra- or extra-axial hemorrhage is seen. The sinuses are clear. The soft tissues appear unremarkable. IMPRESSION: Small enhancing focus in the right frontal lobe is unchanged from the prior study, and a smaller enhancing focus has resolved. No new mass lesions, hemorrhage, or hydrocephalus. Brief Hospital Course: A/P: 54 yo woman w/ metastatic beast cancer here for cycle #4 of Gemzar/cisplatin with abdominal pain and flank pain. Ultimately, she decided that she wished for her goals of care to be comfort only given her poor prognosis so she was taken home by her family w/ home hospice. Hospital course complicated by: . # GI bleed: pt w/ lg hematemesis several nights prior to so was transfused 1 U PRBC and kept overnight in the [**Hospital Unit Name 153**] but hct and BP stable so sent back to the floor. GI aware but no plan for further work-up given prognosis. . # Vomiting: This has gotten worse, seems to have minimal nausea but projectile vomitting with and without PO suggesting mechanical trigger for reflexive vomitting. KUB negative [**4-7**] for obstruction. Head CT for increased masses/elevated intracranial pressure negative (stable disease) so likely not contributing to vomitting ([**4-8**]). For symptom management her dexamethasone was increased to 5mg iv bid from 3mg qd to improve appetite/nausea. She was tried on scheduled antiemetics with no relief and some lethargy so currently just scheduled compazine. PRN zofran, ativan, zyprexa and phenergan also ordered with minimal relief. Ultimately, it was thought to be [**12-18**] outlet obstruction from her cancer and as nothing surgical can be done for this at this point symptomatic management was continued w/ antiemetics. An NGT was placed at one point [**12-18**] hematemasis but she states that she was more comfortable with it out. . # LE edema: Left > right, US LLE negative for DVT [**4-11**], she has had this in the past, especially with steroids which were increased [**4-10**]. Also has been on aggressive ivf with low urine output/poor po/vomitting. . # Abdominal pain: Improved, also with fever [**2-25**], now improved off abx. No clear source, likely related to abdominal process. Blood cultures pedning NGTD. CT torso done and concerning for air in stomach wall and portal vein but f/u CT showed resolution. PPI increased to [**Hospital1 **]. GI and surgery both consulted but reluctant to intervene given very high risk of any procedure. Cultures negative. Abdominal pain seems improved. - now on fentanyl patch and prn morphine . # Metastatic breast CA: Admitted for cycle 4 gemcitabine/cisplatin with pre-hydration and anti-emetics; s/p dexamethasone taper for brain mets. CT head and torso demonstarte interval improvement of metastatic disease. Not likely to tolerate further chemo currently given poor nutritional status and poor functional status. CA 27.29 noted to rise [**4-7**] despite chemo: 350->518. As of family meeting [**4-9**] Ms. [**Known lastname **] does not feel strong enough for further chemo. Agrees to home with hospice and family slowing accepting this option. . # Luekopenia: Improved. started on GCSF [**2-26**] with good response, d/c'd [**2-28**] as WBC 10.2, WBC then dropped to nadir 1.9. . # Oral Thrush: nystatin swish and swallow qid. . # Hyponatremia: Improved. She has had in the past, thought to be hypovolemic, responded to IVF. . # Low-back pain: Unclear etiology, not likely related to bony mets as no point-tenderness on spine. Possibly related to RP mets given abdominal CT [**2190-1-16**] showed enhancement adjacent to the right adrenal, which if larger could be causing this pain though no comment on this on CT [**2190-2-24**]. . # Blurred vision: Intermittent. Likely related to XRT given time course and lack of progression but can not rule out progression of brain mets. CT head with contrast noteable for decrease in mets from [**2190-2-1**] with no new lesions, no edema or mass effect. [**Month (only) 116**] benefit from outpatient opthalmology consult. . # Anemia: Likely chemo-related, not significantly off recent baseline but with slow recovery, would transfuse hct<25 (s/p 2 uPRBC's on this admit). . # PPx: ppi [**Hospital1 **], heparin, BR. . # Access: Port. . # Code: DNR/DNI . # Contact: Daughter, [**First Name8 (NamePattern2) **] [**Name (NI) **]: [**Telephone/Fax (1) 60800**]. . Medications on Admission: Docusate Sodium 100 mg [**Hospital1 **] Senna 8.6 mg PO BID Pantoprazole 40 mg PO Q24H Hexavitamin PO DAILY Dexamethasone 2mg po every other day for 4 days->completed taper Morphine 30 mg SR PO Q8H Morphine 15 mg PO Q4-6H as needed bactrim 160-800 [**Hospital1 **] for 1 week (completed) ferrous sulfate 325mg po daily Discharge Medications: 1. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:*10 Patch 72 hr(s)* Refills:*2* 2. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO BID (2 times a day) as needed for nausea. Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*2* 3. Morphine Concentrate 20 mg/mL Solution Sig: 5-10 mg PO every 1-2 hours as needed for pain/sob. Disp:*120 mL* Refills:*1* 4. Prochlorperazine 25 mg Suppository Sig: One (1) Suppository Rectal Q12H (every 12 hours). Disp:*60 Suppository(s)* Refills:*2* 5. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for nausea or shortness of breath. Disp:*60 Tablet(s)* Refills:*2* 6. Roxanol Concentrate 20 mg/mL Solution Sig: Two (2) mL PO every 1-2 hours as needed for pain or shortness of breath: For emergency kit. Disp:*10 mL* Refills:*0* 7. Please see paper prescription for Dexamethasone Discharge Disposition: Home With Service Facility: VistaCare Discharge Diagnosis: Metastatic breast cancer Intractable nausea and vomiting Upper gastrointestinal bleeding Multifactorial anemia (blood loss, chronic disease) Discharge Condition: Patient discharged to home with hospice in fair condition. Discharge Instructions: You were admitted to the hospital with nausea and vomiting, and progression of your metastatic cancer. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] as needed.

[ "560.89", "578.9", "197.6", "197.4", "536.2", "338.3", "285.1", "V15.3", "V10.3", "198.3", "276.1", "V16.3", "112.0", "V58.11" ]

icd9cm

[ [ [] ] ]

[ "96.07", "99.25", "99.04" ]

icd9pcs

[ [ [] ] ]

15920, 15960

10576, 14610

359, 401

16145, 16206

3313, 10553

16358, 16424

2705, 2739

14979, 15897

15981, 16124

14636, 14956

16230, 16335

2754, 3294

276, 321

429, 1988

2010, 2468

2484, 2689

19,894

124,247

30821

Discharge summary

report

Admission Date: [**2200-5-24**] Discharge Date: [**2200-5-28**] Date of Birth: [**2121-11-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor First Name 1402**] Chief Complaint: atrial fibrillation with RVR Major Surgical or Invasive Procedure: None History of Present Illness: 78M w hx of PE, lupus anticoagulant, GERD, GI bleed, recent d/c from [**Hospital1 18**] for eval of CP (s/p stents to OM1 and D1) p/w Atrial fibrillation with RVR and CP. Pt was d/c'd yesterday to rehab. Did well overnight. This morning, awoke to bathroom then acutely became SOB with 8/10 CP. substerna, heavy, nonradiating. c/o nausea, diaphoresis, dizziness. BP 89/50 HR 120s. Given ntg x3 with some relief. Went to [**Hospital **] Hosp. Found to be in afib with RVR to 150s with old RBBB. Received dilt 20mg IV x1 then dilt gtt up to 10.h. given amio 150 x1 then 1mg/m. Remained in afib but rate improved to 100-110. Transferred to [**Hospital1 18**]. en route, converted to sinus. . Currently, c/o [**6-1**] CP. no SOB. c/o stable lower back pain. no edema, cough, fever, neck pain, dizziness, confusion. denies any palpitaitons at all today. Past Medical History: -CAD: recent ST elevations in inferior leads and s/p c cath at the [**Hospital1 18**] [**2200-5-23**]: Multiple balloon inflations and deployment of 4 stents were performed: two to the OM1 branch of the LAD, and two to the D1 branch of the LCx. -GERD -R thigh hematoma from lovenox -R CEA--[**2190**], pt had presented with "forgetfulness", and underwent CEA at [**Hospital1 112**] -Anemia -Back surgery -Lupus anticoagulant -Femur fracture [**2196**], surgical repair -GIB, pt does not recall in past. Never had EGD/Colonoscopy per him -TB, lung surgery x3 ([**2152**], R and L resections at [**Hospital 912**] hospital) -Recurrent DVT/PE, on lovenox, has IVC filter--history of DVT on coumadin Cardiac Risk Factors: Dyslipidemia Social History: Retired custodian. Former heavy smoker (2PPD x 30+ years), quit in [**2152**]. Former heavy ETOH, quit in [**2177**]. Limited activity by back pain. lives at rehab s/p discharge. Family History: NC Physical Exam: VS - 99.3 83 NSR 17 105/51 Gen: Elderly man in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with no appreciable JVD. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. lung fields CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: EKG OSH: Afib with rate of 150 RBBB (Old) EKG admit: NSR, delayed AV conduction 1st degree, normal axis, RBBB, TWI V1-V2, Q waves II, III . Admit labs: 144 107 13 --------------< 95 3.7 25 0.7 CK: 38 MB: Notdone Trop-T: 0.24 Ca: 8.4 Mg: 1.8 P: 3.4 TSH:2.1 PT: 13.8 PTT: 31.7 INR: 1.2 . 9.9 11.2 >---< 317 28 N:78.1 Band:0 L:16.4 M:4.5 E:0.8 Bas:0.1 . Trends/micro: C Diff positive CK: 24 - 38 - 25 Trop: 0.24 - 0.24 Discharge: Hct 26.5, INR 1.2m Creatinine 0.6, Na 142, K 4, HCO3 30 . Rads: [**5-25**]: CXR: Patient has had right upper thoracoplasty. Pleural thickening and scarring is present in the apex of the post resection right upper lung. Opacification in the infrahilar right lower lung could be scarring but acute infection cannot be excluded. There is no good evidence for pneumonia in the left lung. Heart is normal size. Pleural calcification or linear atelectasis is present at the right base, there also appears to be a small amount of fibrosis, but no appreciable pleural effusion is present nor is there evidence of pneumothorax . Recent data: [**5-20**] C Cath LMCA--no sign disease LAD--Diffuse calcific disease, serial 50% lesion and mid vessel 80% lesion LCX--TO distally with LPDA filling via RCA collaterals. Mid vessel 80% lesion proximal vessel 60% lesion RCA--Diffuse disease with serial 60% lesions (small vessel) PCI--Overlapping stents in distal OM with normal flow, mild thrombus, and no residual stenosis, absent collateral flow . [**5-22**] C Cath Driver stents overlapping in D1 . [**5-21**] ECHO: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricular cavity is mildly dilated with focal basal free wall hypokinesis. The aortic valve leaflets appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. IMPRESSION: Right ventricular cavity enlargement with basal hypokinesis and pulmonary artery systolic hypertension suggestive of primary pulmonary process (pulmonary embolism, COPD, etc.) though cannot exclude RV ischemia/myopathy. Mild mitral regurgitation. Brief Hospital Course: 78 yo man recently discharged after stents placed in the OM1 and D1 who presented with new onset Afib with RVR in setting of CP and SOB. Hospital course by problem: . # Chest/back pain: His presentation was atypical and longstanding. At best, his chest pain was [**5-1**]. It worsened up to [**8-1**] intermittently. We evaluated his cardiac status as below. As it appeared to be noncardiac in origin we searched for other causes. He has a history of GERD as well as spinal stenosis and atypical back pain. We increased his prilosec to treat for GERD. We also increased his gabapentin to treat for neuropathic pain. He tolerated these interventions well. Initially he required IV dilaudid for pain relief but with these measures and intermittent oxycodone/APAP he had good control of pain. . # SOB: This was concerning initially for cardiac ischemia. It was at the rehab in the setting of Afib with RVR. Thereafter, he only reported subjective complaints of SOB intermittently. Evaluation with a bedside O2 monitor showed sats >91%. We treated with MDIs based on exam findings of wheezing and history of smoking. This improved his symptoms. . # Cards rhythm: pt received dilt gtt and amio gtt at OSH then spontaneously converted to sinus prior to arrival in the CCU. We discontinued these interventions. We uptitrated his home metoprolol and he was in sinus throughout his hospital stay. We also continued lovenox for anticoagulation. TSH was normal. We did not suspect PE as the source of his afib as he had been properly anticoagulated and this would not have changed our management. . # Cards ischemic: no evidence of acute ischemia on these EKGs. Recently revascularized in the OM1 and D1. We cycled his enzymes and he did have a troponin leak (neg CKs) which ruled him in for an NSTEMI. We believe this was demand ischemia from his AFib with RVR and he was not having active ischemia once this was corrected. We continued his ASA, plavix, BB, and statin. His intermittent episodes of chest pain during his hospitalization were not felt to be cardiac ischemia. . # Cards pump: recent echo with no evidence of failure. No evidence of failure on exam. . # CP/Back pain: atypical and longstanding. He required IV dilaudid prn initially. We uptitrated his gabapentin and treated with percocet with good control. . # C Diff: Patient had complaints of epigastric pain and loose stools. We checked C Diff toxin which was positive. Flagyl was started. He has 12d left to complete a 14 day course. . # hx DVT/PE: lovenox as outpt regimen. . # Anemia: Hct was 26-30 per his known baseline. He had no episodes of melena or BRBPR. . # FC discussed on admit . # Dispo: to rehab. He has intermittent episodes of chest pain but serial EKGs did not suggest ischemia. His pain is improved with percocet and/or gabapentin. He was in NSR during his entire stay. . # Contact: HCP is brother in law: [**Telephone/Fax (1) 72955**] Medications on Admission: ALLERGIES: NKDA . CURRENT MEDICATIONS atorvastatin 80 daily imdur 30 daily senna [**Hospital1 **] tylenol prn lovenox 80 [**Hospital1 **] ambien 5 qhs percoect prn MOM dulcolax [**Name2 (NI) 72956**] XL 75 daily plavix 75 daily prilosec 20 daily asa 325 daily colace 100 [**Hospital1 **] neurontin 300 [**Hospital1 **] then 900 qhs Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain or temp>101. 2. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation Q6H (every 6 hours) as needed. 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) mg Subcutaneous Q12H (every 12 hours). 9. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO HS (at bedtime). 10. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 13. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 16. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation QID (4 times a day). 17. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO twice a day. 18. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 12 days. 19. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. Discharge Disposition: Extended Care Facility: [**Doctor First Name 391**] Bay - [**Hospital1 392**] Discharge Diagnosis: Primary: - chest pain NOS: noncardiac. thought to be GERD, MSK, or neuropathic - neuropathic back pain - c diff colitis - COPD Secondary: - CAD s/p recent stents to the OM1 and D1 - Anemia, baseline hct 28-32 - s/p back surgery - lupus anticoag - hx recurrent DVT/PE on lovenox - dyslipidemia Atrial Fibrillation with rapid ventricular response. Discharge Condition: Vital signs stable. Pain well managed. Cardiac rhythm is normal sinus. Discharge Instructions: You came in with shortness of breath, chest pain, and a rapid heart rate. Your heart rate improved and your symptoms improved. Your chest pain was evaluated and determined to be NONCARDIAC in origin. It is likely reflux disease, musculoskeletal disease, or neuropathic pain. . We continued your medications as previously prescribed except for the following adjustments: 1. increased your neurontin to 600, 600, 900 2. started flagyl 500mg TID for c diff colitis x14 total days 3. Started albuterol and atrovent inhalers 4. Increased prilosec to [**Hospital1 **] 5. Increased your Toprol XL . Please follow up with your [**Hospital1 4314**] as detailed below. . Please return to the hospital if you develop chest pain or shortness of breath or any other concerning symptoms. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 39288**] and Dr. [**First Name (STitle) 6164**] in the next two weeks. Dr. [**Last Name (STitle) 15321**] number is ([**Telephone/Fax (1) 24747**] Dr.[**Name (NI) 32618**] number is ([**Telephone/Fax (1) 24747**] . Please call to make a follow up appointment with the pulmonary clinic. ([**Telephone/Fax (1) 513**]

[ "285.9", "414.01", "V58.61", "530.81", "V45.82", "008.45", "V12.51", "496", "427.31", "355.9", "724.5" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10434, 10514

5354, 5492

346, 353

10904, 10979

2912, 5331

11809, 12175

2199, 2203

8684, 10411

10535, 10883

8327, 8661

11003, 11786

2218, 2893

278, 308

5520, 8301

381, 1231

1253, 1987

2003, 2183

5,871

148,458

10709+56170

Discharge summary

report+addendum

Admission Date: [**2155-6-30**] Discharge Date: Date of Birth: [**2094-12-9**] Sex: M Service: ADMITTING DIAGNOSIS: Status post Ivor-[**Doctor Last Name **] esophagogastrectomy complicated by anastomotic leak. CHIEF COMPLAINT: Anastomotic leak. HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old male who underwent Ivor-[**Doctor Last Name **] esophagogastrectomy at [**Hospital3 **] on [**2155-6-20**] for a Barrett's esophagus transformed into adenocarcinoma. He underwent an uncomplicated procedure and was noted to have a cirrhotic liver in the OR. He was transferred to the floor and continued to do well. He had a normal barium swallow on postoperative day #5 and was begun on po. On postoperative day #6 he developed a fever to 101.4 and subsequent respiratory distress requiring intubation. At this point he was started on Vancomycin/Cipro/Flagyl. Chest CT with Methylene Blue via chest tube showed a mediastinal leak. On postoperative day #7 he was hypotensive, a right PA catheter was placed and he was ruled out for MI. He had a sputum positive for MRSA. On postoperative day #10 repeat CT scan showed gross extravasation of contrast with apparent anastomotic collection and a large right pleural effusion. The patient was transferred to [**Hospital1 188**] for further care. PAST MEDICAL HISTORY: Diabetes mellitus, Barrett's esophagus, esophageal adenocarcinoma, villous pemphigoid, history of GI bleed, iron deficiency anemia, history of urinary incontinence. ALLERGIES: None known. MEDICATIONS: On admission Heparin subcu, Protonix 40 mg q d, Combivent MDI, Morphine 2-4 mg q 6 hours prn, Ativan .5 mg q 6 hours prn, Lisinopril 20 mg q d, Ciprofloxacin 200 mg q 12 hours, Vancomycin 1 gm q 18 hours, Flagyl 500 mg q 8 hours, Regular insulin sliding scale. The patient was transferred intubated and sedated. LABORATORY DATA: On admission, white cell count 10.9, hematocrit 25.8, platelet count 230,000, sodium 144, potassium 4.6, chloride 109, CO2 25, BUN 44, creatinine 1.7. HOSPITAL COURSE: The patient was transferred to [**Hospital1 346**] intubated and sedated for further management of this complication. He underwent a CT of the chest and a CT fluoroscopy guided NG tube placement. On CT chest the findings were a right lower lobe collapse, two small anastomotic leaks decompressed by chest tube. At this point Fluconazole was added to his antibiotic coverage. He also underwent a bronchoscopy which showed mucus plugs and was otherwise normal. He was noted to have elevated LFTs on the initial lab work with a total bilirubin of 11.9 and also raised BUN and creatinine. He continued to be ventilated. On [**7-2**] he was weaned from assist control ventilation to C-PAP. His sedation was slowly weaned off. Tube feeding was started. He also underwent a right upper quadrant ultrasound which showed minimal edema in the gallbladder wall and a small amount of fluid around the gallbladder consistent with ascites. There was no evidence of gallstones, biliary dilation or hepatic parenchymal abnormality. He continued to be stable over the next couple of days. On [**7-3**] he was noted to have increased respiratory secretions requiring Ambu bagging, lavage and suctioning. He was tachypneic and hypotensive. On [**7-4**] it was noted that he spiked a fever to 101.6. He was pancultured. At this point he was switched back to pressure support ventilation and his antibiotics were changed to Vancomycin, Piperacillin and Fluconazole. His central line was changed. He underwent another chest CT at this time which showed a small amount of fluid at the area of the previously seen anastomotic leak. There was no abscess noted. The CT also showed persistent ground glass opacities scattered throughout both lungs. The right lower lobe remained opacified. Underlying pneumonia could not be excluded. His bilateral effusions had improved somewhat on the CT. Over the course of [**7-4**] and [**7-5**] he was weaned slowly to C-PAP, his low grade temperature continued. His total bilirubin had gone down to 10 and the creatinine was 1.4 and urea 27. He continued to improve over the day. On [**7-6**] he was extubated. Post extubation he was noted to be tachypneic with a respiratory rate between 28 and 45. He had a weak cough and he was wheezing which improved with treatment. He was also noted to have diarrhea. On [**7-7**] his right chest tube was accidentally pulled and it was replaced under sterile condition. He tolerated it well. He continued to have diarrhea and his fluid was sent for C. diff. Flagyl was started at this point and he continued to progressively improve over the course of the next few days. He required intensive respiratory care with chest PT and suctioning. On [**7-10**] due to persistent tachypnea and difficulty handling secretions, a pulmonary consult was obtained. It was noted by them that he had many reasons for tachypnea, mainly his pain, stomach and right chest, thoracotomy, right lower lobe consolidation. He was clinically improving though, and the advice from the pulmonary team was to continue antibiotics and adequate hydration. He was deemed ready to transfer to the regular floor on [**7-10**]. On the early morning of [**7-11**] he had an episode of tachypnea and he was agitated. He was treated with nebulizers and he improved slightly. He continued to be stable during the day but had high nursing requirements with frequent respiratory care requirements. On early morning of [**7-12**] he was noted to be again tachycardic and hypotensive. At this point he received Ativan, Haldol, Morphine. On the morning of [**7-12**] it was noted that he was somnolent and his chest exam showed he was wheezing. At this point he was transferred to the SICU for more intensive nursing management. He also underwent a CT angiogram to rule out PE and contrast was given to evaluate for a leak. There was no evidence of PE, there was no evidence of leak from the esophagus. The CT also showed small bilateral pleural effusions with a loculated component at the right upper lobe posteriorly. There was no evidence of pneumothorax. There was a probable post inflammatory nodule at the left apex and there was a right lower lobe collapse. After the CT, his NG tube was discontinued. He continued to be stable though he had episodes of respiratory distress which improved with treatment. On [**7-14**] an ENT consult was obtained for possibility of tracheomalacia or upper airway obstruction. A laryngoscopy at this time revealed no evidence of upper airway obstruction. His chest tube was placed on water seal. On [**7-15**] the right chest tube was removed. As he continued to be clinically stable he was transferred to the floor. On the floor his requirements have been mainly chest PT. He has been ambulating. His Foley was discontinued on [**7-17**] and he had no difficulty voiding urine. Rehabilitation services have been solicited and he is awaiting transfer to a rehab unit. Microbiology on this admission: [**6-30**]: Urine culture, no growth. Blood culture, aerobic and anaerobic bottle, no growth. [**7-1**]: Bronchial washings, gram stain 3+, polymorphonuclear leukocytes, 4+ gram positive cocci in pairs and clusters. Culture showed staph aureus coag positive, Oxacillin resistant, also sparse growth of pseudomonas aeruginosa. [**7-3**]: Urine culture negative. Sputum [**7-3**], gram stain more than 25 PMN's, 3+ gram positive cocci in pairs and clusters. Culture positive for staph aureus coagulase positive. Blood culture [**7-3**], no growth. [**7-4**] blood culture, no growth. [**7-4**] catheter tip IV, no growth. [**7-8**], Clostridium difficile negative. [**7-9**], Clostridium difficile negative. [**7-10**], Clostridium difficile negative. DISCHARGE MEDICATIONS: Lopressor 100 mg po bid, Lisinopril 20 mg po q d, NPH insulin 36 units subcu [**Hospital1 **], Heparin 5,000 units subcu [**Hospital1 **], Ativan 1 mg po q h.s. and q 6 hours prn, Impact with fiber 75 cc per hour via J tube, Glutamine 5 mg per G tube [**Hospital1 **], Vitamin E 500 units per J tube [**Hospital1 **], Regular insulin sliding scale, Albuterol 2-4 puffs q 4 hours prn, Combivent MDI 2-4 puffs prn. DISCHARGE DISPOSITION: To rehabilitation center. DIET: Impact with fiber via J tube. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6066**] Dictated By:[**Last Name (NamePattern1) 2209**] MEDQUIST36 D: [**2155-7-18**] 08:45 T: [**2155-7-18**] 10:30 JOB#: [**Job Number 35059**] Name: [**Known lastname 6237**], [**Known firstname 6238**] Unit No: [**Numeric Identifier 6239**] Admission Date: [**2155-6-30**] Discharge Date: Date of Birth: [**2094-12-9**] Sex: M Service: ADDENDUM: The patient continued to be stable for the last few days. On [**2155-7-19**] it was noted that BUN had risen to 50 and creatinine had risen to 1.7. A renal consult was obtained. Impression was likely prerenal azotemia, BUN increasing out of proportion to creatinine, decreased . Sediment showed no RBCs, no WBC, occasional granular casts. Urine osms were checked and were 513 supporting this. Renal consult advised gentle hydration with normal saline to follow and suggested an ultrasound. It was not deemed necessary during this admission to do. He has continued to do fine. His tube feeds were switched from Impact to ProMod. He is ready for discharge. MEDICATIONS: Lisinopril to be held until BUN and creatinine are down to baseline values. Diet: ProMod with fiber 75 cc per hour via G tube, free water 250 cc qid via G tube. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 206**], M.D. [**MD Number(1) 207**] Dictated By:[**Last Name (NamePattern1) 5028**] MEDQUIST36 D: [**2155-7-21**] 11:40 T: [**2155-7-21**] 13:00 JOB#: [**Job Number 6240**]

[ "593.9", "997.4", "997.3", "250.00", "150.9", "518.0", "482.41", "571.5", "280.9" ]

icd9cm

[ [ [] ] ]

[ "97.29", "96.71", "93.90", "88.44", "96.07", "38.93", "96.05", "31.42", "96.6" ]

icd9pcs

[ [ [] ] ]

8300, 10012

7862, 8276

2057, 7838

249, 268

297, 1327

136, 231

1350, 2039

43,503

166,807

36807

Discharge summary

report

Admission Date: [**2118-7-24**] Discharge Date: [**2118-7-27**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2817**] Chief Complaint: R femoral intertrochanter fracture Major Surgical or Invasive Procedure: ORIF History of Present Illness: The Pt. is a [**Age over 90 **]y/o M with PMH of Dementia, AF, DVT admitted with R trochanteric fracture after falling out of his wheelchair. Per report, the patient was admitted to an OSH for behavioral disturbance thought secondary to Alzheimers and was found this am after falling out of his wheelchair at 0730, he walked back to bed with assistance. At 1330 he began complaining of R hip pain and was noted to have a shortened and rotated leg. He was taken to an OSH where he was found to have a R femoral trochanteric fracture with minimal displacement. At OSH HR 140s-150s with SBP in 90s. He was transferred to [**Hospital1 18**] for further management. . In the ED, initial vitals: T 97.4, HR 79 BP 116/77 RR 18 O2 97 on 3L NC. Labs demonstrated CK 219 Trop 0.03. Cr 1.3. Lactate 4.0, improved to 2.8 after 3L NS. WBC 12.4. Hip xray demonstrated R femoral intertrochanteric fracture with minimal displacement. CTA Chest prelim read without evidence of large PE. He was given Vancomycin 1gm IV and Zosyn. Morphine 2mg IV X4. Diltiazem 10mg IV X2. Haldol 5mg IV X1. Orthopedics evaluated the patient in the ED and plan for repair in am. Vitals prior to transfer to ICU HR 119. BP 120/94, RR 25, 100% 3L Past Medical History: Hypertension DVT Dementia Atrial Fibrillation Inguinal Hernia Ataxia . Social History: Has lived in [**Hospital1 1501**]; recently moved to Radius for dementia unit Family History: Unlikely to be contributory in this [**Age over 90 **] year old man Physical Exam: Vitals: T 97, HR 135, BP 154/78, RR 17, O2 100% 2L Gen: alert, not oriented, responds to questions by yelling "no" HEENT: adentulous, dry MM CV: irreg/irreg, nl S1/S2, no MRG Resp: CTAB, no WRR Abd: soft, NT/ND, NABS Ext: cool, no edema Neuro: uncooperative with exam, moves all ext MSK: TTP R hip Pertinent Results: [**2118-7-24**] 04:30PM WBC-12.4* RBC-4.53* HGB-14.4 HCT-44.5 MCV-98 MCH-31.8 MCHC-32.3 RDW-13.7 [**2118-7-24**] 04:30PM NEUTS-86.9* LYMPHS-7.0* MONOS-5.6 EOS-0.3 BASOS-0.2 [**2118-7-24**] 04:30PM PLT COUNT-231 [**2118-7-24**] 11:46PM WBC-9.9 RBC-3.87* HGB-12.5* HCT-37.8* MCV-98 MCH-32.4* MCHC-33.1 RDW-13.4 . [**2118-7-24**] 04:30PM CK(CPK)-219* [**2118-7-24**] 04:30PM cTropnT-0.03* [**2118-7-24**] 04:30PM CK-MB-4 [**2118-7-24**] 11:46PM CK-MB-4 cTropnT-0.02* [**2118-7-24**] 11:46PM CK(CPK)-119 . [**2118-7-24**] 04:30PM GLUCOSE-96 UREA N-49* CREAT-1.3* SODIUM-134 POTASSIUM-9.0* CHLORIDE-100 TOTAL CO2-19* ANION GAP-24* [**2118-7-24**] 04:37PM LACTATE-4.0* K+-5.0 [**2118-7-24**] 11:46PM GLUCOSE-116* UREA N-42* CREAT-1.2 SODIUM-137 POTASSIUM-5.5* CHLORIDE-107 TOTAL CO2-19* ANION GAP-17 [**2118-7-24**] 11:59PM LACTATE-1.7 Brief Hospital Course: Assessment & Plan: The patient is a [**Age over 90 **]y/o M with a PMH of Alzheimer's Dementia and Atrial fibrillation presenting s/p fall with R femoral intertrochanteric fracture. . # R femoral intertrochanteric fracture - s/p fall. Xray demonstrates minimal displacement. Orthopedics consulted and recommended operative management. Consent was eventually obtained from patient's family; code status was reversed for operation and PACU only. Orthopedics placed an intratrochanteric [**Last Name (LF) **], [**First Name3 (LF) **] operation which was without complication. His post-operative course was complicated by atrial fibrillation with RVR, and he was transferred back to the MICU for further monitoring and rate control (see below). On post-operative day #2 incision site was clean, dry, intact on dressing change. [**First Name3 (LF) 1957**] recommended no restrictions on activity, advised 2 weeks total course of Lovenox, 30 mg daily. Followup orthopedics appointment scheduled with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP. [**2118-8-9**], at 11 am. [**Hospital Ward Name 23**] Building, [**Location (un) **]. . Morphine was given for pain control; this should be weaned to PO and then to non-opiate medications as tolerated. . # Atrial Fibrillation with RVR - Per records the patient has not been on a nodal [**Doctor Last Name 360**] due to history of bradycardia, family previously declined pacemaker. He also has not been anticoagulated. Responded well to diltiazem in ED, transitioned to beta blocker for pre-op management. Further episodes of RVR post-operatively, with transfer back to MICU for close management. ECG without ischemic changes, Trop with slight elevation to 0.03, likely secondary to transient demand from rapid rate. Pain was controlled with morphine. Digoxin was started for rate control. A fluid bolus was given for presumed hypovolemia, with good response. He was discharged with the plan to continue digoxin upon discharge. A non-trough digoxin level was 4.2 on the morning of discharge, likely based on an extra dose of digoxin given in the morning of discharge. See "digoxin level" as separate issue as below. Beta blocker was stopped as he became mildly bradycardic, and was not prescribed for discharge due to previous history of bradycardia. Pain control will be important in his post-operative heart rate management. . # Digoxin level. As above, a non-trough digoxin level was 4.2 on the morning of discharge, likely due to a recent extra dose of digoxin. This should be followed closely and digoxin held if levels continue to be supratherapeutic. We recommend holding the [**7-28**] dose of digoxin. It has already been given on [**7-27**]. . # Leukocytosis - This was judged likely to be reactive secondary to hip fracture. His CXR was without evidence of infiltrate. UA with 21-50 WBC, mod leuks/neg nitrites. Received Vanc/zosyn in ED. Afebrile. Urine culture returned negative, leukocytosis resolved. Antibiotics were stopped. Separately, cefazolin was given peri-operatively. . # Alzheimer's Dementia - Per records the patient was recently hospitalized for behavioral disturbances. Patient started on zyprexa 2.5mg QHS and citalopram and trazodone discontinued. Increased agitation post-operatively, Zyprexa dose increased to 5 [**Hospital1 **]. . # CHF - unclear baseline EF, echo (suboptimal image quality) showed EF 40%, preserved biventricular systolic function. Diuretic held during MICU course in the setting of fluid resuscitation. Plan to restart diuretic in 3 days ([**2118-7-30**]) or sooner if weight increase of >3 pounds. . # FEN - NPO peri-operatively, started back on regular diet, thickened puree consistency. Speech and swallow was consulted and recommended continuing honey-thick liquids and pureed solids with careful monitoring of fluid status and re-evaluation of swallowing ability as he improves post-operatively. Because honey-thick liquids often results in decreased fluid intake, nectar-thick liquids should be considered and fluid status should be carefully monitored. Electrolytes stable. . # Access - Midline and 18 gauge IV . # Prophylaxis - Home PPI continued during stay, Lovenox started post-operatively, to be continued for total course of 2 weeks post-op, as above per [**Month/Day/Year **] recommendations. Consider heparin SC or lovenox for DVT/PE prophylaxis thereafter. . # Code - DNR/DNI (reversed for procedure and PACU only, back to DNR/DNI post-operatively) . # Dispo - transfer back to Radius with care instructions and medication changes. Medications on Admission: Home Medications: Citalopram 10mg daily Tylenol 650mg q6 Trazadone 25mg daily Sennoside Multi-vitamin daily Bumetanide 1mg daily ASA 81mg daily Bisacodyl 10mg prn Omeprazole 20mg daily Trazodone 50mg Q 6-8 hrs PRN . [**Hospital 671**] Hospital Medications: Tylenol 325mg Q6 PRN ASA 81mg daily Dulcolax 10mg daily PRN Oscal 500mg [**Hospital1 **] Vitamin D 50000IU Q weekly MOM 2400mg daily PR MVI daily Zyprexa 2.5mg QHS Prilosec 20mg daily Senokot 2 tab daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Oxycodone 5 mg Tablet Sig: 1/2-1 Tablet PO Q6H (every 6 hours) as needed for pain: hold for sedation, rr<12. 8. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO BID (2 times a day) as needed for agitation. 9. Morphine 2 mg/mL Syringe Sig: [**12-10**] mgs Injection Q3H (every 3 hours) as needed for pain: hold for sedation, rr <12. 10. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush: Flush with 10 mL Normal Saline followed by Heparin as above, daily and PRN per lumen. 11. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: Three (3) mL Intravenous Q8H (every 8 hours) as needed for line flush: Flush with 3 mL Normal Saline every 8 hours and PRN. 12. Outpatient Lab Work trough digoxin levels daily with basic metabolic panel until level stable and therapeutic; q3 days for 2 weeks thereafter; or continue getting levels if creatinine is varying significantly 13. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day: Monitor digoxin per lab orders. Hold for [**7-27**] and [**7-28**]. Restart on [**7-29**] unless level still supratherapeutic. Hold for supratherapeutic levels. If patient not swallowing appropriately, please convert digoxin to same dose, in IV form. . 14. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) injection Subcutaneous once a day for 11 days: continue for 14 days after operation ([**7-25**]); discuss with orthopedics service at follow-up to eval for further need for prophylaxis. . 15. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 672**] Hospital Discharge Diagnosis: Primary diagnosis: R intratrochanteric femoral fracture atrial fibrillation with rapid ventricular response . Secondary diagnosis: Dementia, likely Alzheimer's type Discharge Condition: Good Discharge Instructions: Mr. [**Known lastname 10010**] was admitted to the [**Hospital1 18**] with a right femoral intratrochanteric fracture, which was repaired with an intratrochanteric [**Hospital1 **] on [**7-25**]. Before and after the operation he had some difficulties with atrial fibrillation and rapid ventricular response. This was controlled with beta blocker and digoxin, with beta blocker being discontinued prior to discharge because of slow heart rates. . Digoxin was started. A digoxin level was supratherapeutic on day of discharge. Digoxin should be held per medication list below, and restarted on [**7-29**] with regular lab checks for digoxin levels as well as basic metabolic panels. EKG for dig toxicity should be performed as clinically appropriate. . Mr [**Known lastname 10010**] should have physical therapy as tolerated and appropriate; and ongoing monitoring of his heart rate and modification of his rate control/heart failure regimen as necessary. He should continue to be cared for in an extended care facility given his poor functional status. We have had him on a dysphagia diet during this acute hospitalization but this should be revisited as his pain medication needs decrease. Fluid status should be monitored and consideration of IV or other fluid supplementation should be given if fluid intake is decreased. . Lovenox should be given for two to four weeks as per [**Known lastname 1957**]. He should be taken to follow-up appointment with orthopedics as shown below. Followup Instructions: Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2118-8-9**] 10:40 Provider: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP (orthopedics service) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2118-8-9**] 11:00 . Continue to provide medical care at his facility; or arrange primary care follow up for one week after discharge.

[ "427.31", "820.21", "294.10", "276.2", "401.9", "428.22", "428.0", "V12.51", "288.60", "584.9", "799.4", "E884.3", "331.0", "276.52" ]

icd9cm

[ [ [] ] ]

[ "79.15" ]

icd9pcs

[ [ [] ] ]

10266, 10321

3033, 7608

297, 303

10530, 10537

2152, 3010

12069, 12478

1748, 1817

8121, 10243

10342, 10342

7635, 7635

10561, 12046

1832, 2133

7653, 8098

223, 259

331, 1542

10473, 10509

10361, 10452

1564, 1637

1653, 1732

79,090

149,515

41694

Discharge summary

report

Admission Date: [**2151-7-29**] Discharge Date: [**2151-8-6**] Date of Birth: [**2067-6-10**] Sex: F Service: SURGERY Allergies: Codeine / aspirin / Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 598**] Chief Complaint: facial pain Major Surgical or Invasive Procedure: [**2151-7-29**] Left lateral canthotomy History of Present Illness: 84yoF with unknown PMedHx, fell down 5 stairs, landing on face; +LOC, unknown duration; seen at OSH with identified facial fractures (left superior orbital fx, with SDH, SAH and occipital fx) and worsening retrobulbar hematoma with proptosis. By report, the [**Hospital1 18**] ED recommended lateral canthotomy prior to transfer - not performed. Transferred to [**Hospital1 18**] ED, the patient was intubated due to changes in mental status; upon arrival, canthotomy performed in ED trauma bay with relief of proptosis. Past Medical History: PMH: HTN, Migraines, pelvic fracture PSH: cholecystectomy Social History: lives alone, no tobacco, No ETOH Family History: non contributory Physical Exam: Temp: 98.3 HR: 85 BP: 163/87 Resp: 18 O(2)Sat: 95 Normal Constitutional: Boarded and Collared, NAD HEENT: L periorbital eccymosis with propotosis and chemosis of the eye, L pupil irregular but appears post surgical (NOT tear drop shape) 5-->4. R pupil round 4-->3. Midface stable c-collar in place. L TM clear, R TM obscured by cerumen Chest: Clear to auscultation, no crepitus Cardiovascular: Regular Rate and Rhythm Abdominal: Soft, Nontender. FAST negative GU/Flank: pelvis stable Extr/Back: no long bone deformity Neuro: initial GCS 15 (spontaneous eye opening, MAEE and spontaneously) Psych: initially following commands Pertinent Results: [**2151-7-29**] 06:50PM WBC-17.9* RBC-4.35 HGB-13.4 HCT-39.5 MCV-91 MCH-30.9 MCHC-34.0 RDW-12.9 [**2151-7-29**] 06:50PM NEUTS-85.9* LYMPHS-10.9* MONOS-2.6 EOS-0.2 BASOS-0.3 [**2151-7-29**] 06:50PM PLT COUNT-262 [**2151-7-29**] 06:50PM PT-12.7 PTT-23.5 INR(PT)-1.1 [**2151-7-29**] 06:50PM GLUCOSE-168* UREA N-26* CREAT-1.0 SODIUM-145 POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-22 ANION GAP-21* [**2151-7-29**] Head Ct : 1. Large left inferior temporal and frontal contusions along with left subdural, left subarachnoid and cerebellar subarachnoid hemorrhages as mentioned above. Possible right cerebellar contusion. 2. Intraventricular layering hemorrhage without hydrocephalus. 3. Right arachnoid cyst with layering intralesional hemorrhage. 4. Left retrobulbar hematoma, which appears to be extraconal. Status post lateral canthotomy. 5. Right occipital fracture extending to skull base and separate minimally displaced left orbital roof fracture. [**2151-7-29**] CT Torso : 1. Right anterior fourth through seventh and posterior fourth through ninth rib fractures are seen. 2. Large hiatal hernia with resultant atelectasis. 3. ET tube in right main stem, beyond the carina by 2cm. This was discussed with Dr. [**Last Name (STitle) **] by Dr. [**First Name (STitle) **] at [**2169**] on [**2151-7-29**]. [**2151-7-30**] Head CT : 1. Overall stable appearance to multifocal areas of hemorrhage including within a right frontal arachnoid cyst, left intraparenchymal frontal and parietal contusions and subarachnoid hemorrhage along the left convexity. Additional subdural hematomas along the tentorium, midline falx and left posterior convexity are unchanged. 2. No new areas of hemorrhage [**2151-7-30**] CT Mandible : 1. Minimally displaced superior orbital roof fracture with underlying extraconal hematoma. No evidence for intracranial air. 2. Nondisplaced fracture through the right occipital condyle extending into the skull base. 3. Mild sinus opacification which may relate to patient's intubated status. [**2151-7-31**] Head CT : 1. Overall stable appearance to multifocal areas of intracranial hemorrhage. No new areas of hemorrhage. 2. Stable soft tissue swelling along the lateral aspect of the left orbit [**2151-8-2**] Cardiac Echo : Normal left ventricular cavity size with akinesis of the distal half with aneurysm c/w Takotsubo cardiomyopathy (cannot fully exclude mid-LAD lestion, but given the symmetry of the dysfunction, is less likely). Pulmonary artery hypertension. Increased PCWP. [**2151-8-3**] 6:00 pm URINE Source: Catheter. **FINAL REPORT [**2151-8-5**]** URINE CULTURE (Final [**2151-8-5**]): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 1 S Brief Hospital Course: Mrs. [**Known lastname **] was evaluated by the Trauma team in the Emergency Room and intubated as her mental status was waxing and [**Doctor Last Name 688**]. She was evaluated by Neurosurgery, Plastic Surgery and Opt homology additionally. After her scans were reviewed she was admitted to the Trauma ICU for further management. The Neurosurgery service recommended following her neuro exam along with Head CT's and on 3 consecutive CT's she had a stable appearance of her IPH and SAH and no significant edema. She had no seizure activity but was prophylactically placed on Dilantin for 7 days. Her neuro exam was difficult as she was sedated and still had periods of agitation requiring more sedation. She was extubated on [**2151-7-31**] and over the next few days remained confused and sometimes agitated. Her mental status gradually cleared to the point that she was alert and oriented to person, sometimes place and time but getting better daily. The Opt homology service evaluated her in the Emergency Room as a retrobulbar hematoma was noted on CT scan and a lateral canthotomy was done. She had no evidence of global injury. On subsequent exams her IOP was [**10-9**] with no proptosis. She is receiving NSAIDs and antibiotic eye drops which will continue. She will need a good eye exam to test visual acuity and should follow up with Opt homology next week. From a cardiopulmonary standpoint she was extubated easily on HD #3 and has remained free of any pulmonary complications. She did have problems with tachycardia in the ICU and was evaluated by the Cardiology service as she has a CPK bump along with a troponin of 0.77. She had an echo done which revealed an akinetic distal LV, possibly Takotsubo cardiomyopathy ( stress induced ). She was subsequently started on low dose beta blocker along with diuresis and her rate gradually improved. Her BP is in the 110-120/70 range and her heart rate is 80. She is no longer being diuresed and her most recent BUN/creat is 32/0.9. She will need to follow up with her PCP after discharge from rehab. Her nutritional status was compromised during her stay and she was started on tube feedings while intubated and for a total of 5 days. Following extubation she was evaluated by the speech and swallow service and is currently on a soft diet with thin liquids. She is eating modestly and calorie counts should continue. She started treatment for an enterococcal UTI on [**2151-8-5**] and should continue Augmentin through [**2151-8-11**]. Her Foley catheter was removed on [**2151-8-6**] at noon and she is due to void between 6-8pm tonight. Following her transfer out of the ICU on [**2151-8-4**] she has been hemodynamically stable with improving mental status and interactive. She was discharged to rehab on [**2151-8-6**] for further therapy prior to returning home. Medications on Admission: ultram, lisinopril, nexium, vesicare, fiorcet, amitriptyline Discharge Medications: 1. diclofenac sodium 0.1 % Drops Sig: One (1) Ophthalmic [**Hospital1 **] (2 times a day): left eye. 2. bacitracin-polymyxin B 500-10,000 unit/g Ointment Sig: One (1) Appl Ophthalmic Q2H (every 2 hours): left eye. 3. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 4. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One (1) Appl Ophthalmic Q2H (every 2 hours) as needed for eye injury: left eye. 5. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for itching/inflammation. 6. metoprolol tartrate 25 mg Tablet Sig: 0.25 Tablet PO TID (3 times a day): Hold for SBP < 100, HR < 60. 7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO BID (2 times a day) as needed for agitation. 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 13. amitriptyline 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 6 days. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at [**Hospital6 1109**] - [**Location (un) 1110**] Discharge Diagnosis: S/P Fall 1. TBI 2. Left IPH 3. Left SAH 4. Left orbital roof fracture 5. Retrobulbar hematoma 6. Right occipital skull fracture 7. Right rib fractures [**3-6**] 8. Enterococcal UTI 9. Stress induced cardiomyopathy Discharge Condition: Mental Status: Confused - sometimes. 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 after falling and you sustained multiple injuries including a skull fracture, bruising on your brain, an injury to your left eye and rib fractures. * You spent some time in the ICU as you were on a respirator and required frequent neurologic checks. Over the last week you have improved daily. You are tolerating a regular diet, working with Physical Therapy and Occupational Therapy and your memory is gradually getting better. * Continue to work hard with therapy so that in time you can get back home. You may have memory problems for awhile but hopefully you will continue to make progress. Followup Instructions: Call the [**Hospital 4695**] Clinic at [**Telephone/Fax (1) 1669**] for a follow up appointment in 4 weeks with Dr. [**Last Name (STitle) **]. You will have a Head CT at that time and the secretary can book that for you. Call the Plastic Surgery Clinic at [**Telephone/Fax (1) 6742**] for a follow up appointment in 2 weeks. Call the [**Hospital **] Clinic at [**Telephone/Fax (1) 253**] for a follow up appointment in 1 week. Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up appointment in [**12-31**] weeks. Call your primary care doctor after you return from rehab. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**] Completed by:[**2151-8-6**]

[ "372.73", "921.2", "921.1", "429.83", "801.16", "293.0", "553.3", "599.0", "E880.9", "376.30", "807.06", "401.9", "041.04" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04", "96.6", "08.51" ]

icd9pcs

[ [ [] ] ]

9229, 9374

4826, 7676

321, 363

9632, 9632

1747, 4803

10467, 11203

1065, 1083

7789, 9206

9395, 9611

7703, 7766

9810, 10444

1098, 1728

270, 283

391, 916

9647, 9786

938, 999

1015, 1049

27,192

118,968

26799

Discharge summary

report

Admission Date: [**2171-4-7**] Discharge Date: [**2171-4-24**] Date of Birth: [**2116-5-23**] Sex: M Service: CARDIOTHORACIC Allergies: Flagyl / Ceftazidime Attending:[**First Name3 (LF) 1283**] Chief Complaint: SOB/CP/AF Major Surgical or Invasive Procedure: [**2171-4-9**] - Redo Sternotomy, MV Repair (30mm Band), Full MAZE Procedure. [**2171-4-12**] - Exploratory diagnostic laparoscopy conversion to open. History of Present Illness: Mr. [**Known lastname **] is a 54 y/o gentleman admitted for a redo mitral valve repair and MAZE procedure. He has undergone several PVI procsdures for AF with his last being complicated by tamponade requiring emergent sternotomy. He now has 3+ MR documented by ECHO. He is admittedprior to surgery after stopping his coumadin for IV heparin in preparation for surgery. Past Medical History: -Atrial fibrillation -Atrial flutter -Hyperlipidemia, diet and exercise controlled -Mildly elevated LFTs . CARDIAC HISTORY: Mr. [**Known lastname **] was initially diagnosed with atrial fibrillation approximately four years ago. In [**2169**], he was evaluated at [**Hospital1 112**] and subsequently underwent a pulmonary vein isolation procedure by Dr. [**Last Name (STitle) 3271**]. Unfortunately, that procedure was complicated by a left ventricular hematoma and perforation resulting in a cardiac tamponade and cardiac arrest. Mr. [**Known lastname **] was taken emergently to the operating room for relief of his tamponade. He was in the intensive care unit for approximately 15 days and ultimately discharged one month later. Unfortunately, postoperatively, Mr. [**Known lastname **] [**Last Name (Titles) 65974**] to atrial fibrillation and was discharged on amiodarone. . In [**3-28**], he was found to be in atrial flutter, with heart rate in the 120s. At that time, his [**Date Range 8863**]-XL dose was increased, he failed DC cardioversion, and he was referred to Dr. [**Last Name (STitle) **]. In [**2169-4-22**], he underwent successful ablation of reentry around the anterior portion of the CS ostium by Dr. [**Last Name (STitle) **], which was complicated by a prolonged vagal response and post-procedure hypotension requiring dopamine infusion, IV fluids, and atropine for resolution. He was admitted to the CCU, and at that time developed CHF which was likely [**2-23**] to fluids given for hypotension in setting of decreased HR after ablation. . In [**12-28**], he was found at his follow-up visit to be back in aflutter. In [**2170-1-22**], a second atrial flutter ablation procedure was performed. . In [**1-28**], he had a successful atrial flutter ablation, completion of previously done TV-IVC isthmus line of block. . In [**3-29**], his amiodarone was discontinued after PFT's revealed a mild restrictive physiology and LFT's were found to be elevated. . In [**11-29**], he presented again with symptomatic palpitations and was started on Digoxin. He had a repeat PVI on [**2171-1-24**] and propafenone was initiated post-procedure. DCCV on [**2171-1-29**]. Social History: Social history is significant for the absence of tobacco use. There is no history of alcohol abuse. He was formerly a Pediatrician for 18 years in [**Country 3992**] prior to emigrating to the US ten years ago. He is married with three sons. Family History: His father died of complications of diabetes. There is no family history of premature coronary artery disease or sudden death. Physical Exam: 97.5 110/73 66 18 98% RA NAD Chest CTA. Well healed sternotomy. CV: RRR, [**2-27**] holosystolic murmur ABD: Benign EXT: Warm, well perfused Pertinent Results: [**2171-4-24**] 05:58AM BLOOD WBC-13.7* RBC-4.04* Hgb-12.1* Hct-36.3* MCV-90 MCH-30.0 MCHC-33.4 RDW-15.7* Plt Ct-563* [**2171-4-24**] 05:58AM BLOOD PT-16.6* PTT-116.3* INR(PT)-1.5* [**2171-4-23**] 04:33AM BLOOD Glucose-99 UreaN-20 Creat-0.8 Na-134 K-4.5 Cl-100 HCO3-25 AnGap-14 CHEST (PA & LAT) [**2171-4-23**] 4:18 PM CHEST (PA & LAT) Reason: evaluation of infiltrate [**Hospital 93**] MEDICAL CONDITION: 54 year old man with s/p mv repair REASON FOR THIS EXAMINATION: evaluation of infiltrate TYPE OF EXAMINATION: Chest PA and lateral. INDICATION: Status post mitral valve repair. Evaluate for infiltrates. [**Hospital **]: This is the first PA and lateral chest examination since the preoperative study before mitral valve re-do operation obtained on [**2171-4-7**]. There is status post sternotomy, including a row of cutaneous surgical clips in the midline. A left subclavian central venous line is in place, seen to terminate overlying the SVC at the level of the carina. No pneumothorax is identified. The overall heart size is now only slightly larger than it was on the pre-re-do examination of [**4-7**] and the cardiac configuration remains the same. A left-sided lateral pleural sinus obliteration has developed and as it does not continue into the posterior pleural sinus, it most likely represents postoperative scar formations. Comparison also reveals additional linear densities and a relatively crowded vasculature in the left lower lobe consistent with partial atelectasis, but no new parenchymal infiltrates are identified. When comparison is made with the most recent single view portable chest examination of [**2171-4-19**], the previously present multifocal parenchymal densities as well as pleural densities have regressed markedly and there is no evidence of new acute infiltrates or increased pulmonary congestion. As already noticeable on previous postoperative examinations, there exists a faintly visible semi-circular thin density consistent with a surgically performed mitral annuloplasty. IMPRESSION: Marked improvement of pulmonary infiltrates encountered postoperatively to mitral valve annuloplasty and MAZE procedure ([**2171-4-9**]). Moderate cardiomegaly as before, presently no signs of pulmonary vascular congestion. Left-sided basal scar formations and partial atelectasis. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname 65979**] [**Hospital1 18**] [**Numeric Identifier 65980**]Portable TEE (Complete) Done [**2171-4-12**] at 7:47:12 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 18**]/Department of Anesthesia [**Hospital1 41690**], CC540 [**Location (un) 86**], [**Numeric Identifier 718**] [**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2116-5-23**] Age (years): 54 M Hgt (in): 69 BP (mm Hg): 104/60 Wgt (lb): 160 HR (bpm): 64 BSA (m2): 1.88 m2 Indication: TEE for evaluation of ?shunt Left ventricular function. Mitral valve disease. ICD-9 Codes: 424.0, 424.2 Test Information Date/Time: [**2171-4-12**] at 07:47 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD Test Type: Portable TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5740**], MD Doppler: Full Doppler and color Doppler Test Location: West SICU/CTIC/VICU Contrast: None Tech Quality: Adequate Tape #: 2008W1-: Machine: Other Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 60% >= 55% [**Last Name (NamePattern4) **] RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. Normal interatrial septum. No ASD or PFO by 2D, color Doppler or saline contrast with maneuvers. LEFT VENTRICLE: Overall normal LVEF (>55%). No VSD. RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mitral valve annuloplasty ring. Well-seated mitral annular ring with normal gradient. Trivial MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate [2+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was sedated for the TEE. Medications and dosages are listed above (see Test Information section). The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally Conclusions 1. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. 2. Overall left ventricular systolic function is normal (LVEF>55%). 3. There is no ventricular septal defect. 4. Compared to the previous TEE on [**2171-4-9**], the right ventricular cavity is mildly dilated but remains with normal free wall contractility. 5. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 6. A mitral valve annuloplasty ring is present. The mitral annular ring appears well seated and is not obstructing flow. Trivial mitral regurgitation is seen. 7. The tricuspid valve leaflets are mildly thickened. Compared to the previous TEE, tricuspid regurgitation has increased to Moderate [2+] tricuspid regurgitation. CTA HEAD W&W/O C & RECONS [**2171-4-19**] 8:25 AM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Reason: r/o bleed [**Hospital 93**] MEDICAL CONDITION: 54 year old man with REASON FOR THIS EXAMINATION: r/o bleed CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: 54-year-old male with concern for intracranial hemorrhage or infarction. The patient is recently status post mitral valve replacement. COMPARISON: Non-contrast head CT [**2171-4-15**]. TECHNIQUE: Non-contrast head CT followed by CT angiogram of the neck, head and circle of [**Location (un) 431**] after Optiray IV contrast with multiplanar reformats and 3D reconstructions. CT OF THE HEAD WITHOUT IV CONTRAST: Overall, the appearance of the brain is unchanged compared to [**2171-4-15**]. There is no evidence of intracranial hemorrhage, shift of normally midline structures, mass effect, hydrocephalus, or vascular territorial infarction. Paranasal sinus mucosal thickening has improved and there is mild residual mucosal thickening of the floor of the right maxillary sinus and of the left sphenoid sinus air cell. There remains a small amount of fluid and a few bilateral mastoid air cells; however, a majority of air cells remain well aerated. CT ANGIOGRAM OF THE NECK WITH IV CONTRAST: The carotid and vertebral circulations are patent without evidence of aneurysm, stenosis, dissection or vascular malformation. At a level slightly superior to the carotid bifurcation, the left internal carotid artery measures 10 mm maximal diameter. Slightly inferior to the skull base, the left ICA measures 5 mm. At similar reference levels, the right internal carotid artery measures 9 and 6 mm respectively. Limited visualization of the upper lungs demonstrate airspace consolidation at both apices as well as moderate-sized pleural effusions layering dependently. CT ANGIOGRAM OF THE HEAD AND CIRCLE OF [**Location (un) **]: The anterior and posterior circulations as well as circle of [**Location (un) 431**] are patent without evidence of aneurysm, stenosis, dissection or vascular malformation. CT PERFUSION: The CT perfusion images are somewhat limited due to technical artifacts; although, no definite asymmetric perfusion defect is seen. IMPRESSION: 1. No evidence of acute infarction or hemorrhage. 2. Unremarkable CT angiogram of the neck, head, and circle of [**Location (un) 431**]. [**Hospital 93**] MEDICAL CONDITION: 54 year old man with s/ mv repair REASON FOR THIS EXAMINATION: Apparent anterior displacement of the lateral masses of C1 relative to the occipital condyles is incompletely evaluated on this head CT. Further evaluation with noncontrast CT of the cervical spine is recommended. CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: 54-year-old male found to have apparent anterior dislocation of the lateral masses of C1 relative to the occipital condyles on recent head CT, referred for evaluation of the cervical spine. COMPARISON: Non-contrast head CT, [**2171-4-15**]. TECHNIQUE: Non-contrast CT of the cervical spine with multiplanar reformats. [**Month/Day/Year **]: There is no evidence of fracture or malalignment of the cervical spine. The vertebral body heights are maintained. There is no significant central canal or neural foraminal stenosis. There is normal articular alignment of the bilateral lateral masses of C1 with their respective occipital condyles. There is no evidence of anterior dislocation of the lateral masses of C1 relative to the occipital condyles which was suspected on a limited evaluation by recent head CT. Paranasal sinus mucosal thickening and partial opacification of bilateral mastoid air cells are incompletely included in the field of view. Ground- glass opacity and interstitial thickening is noted of the visualized right lung apex. The patient is intubated with terminus out of view. IMPRESSION: 1. Normal articulation of the lateral masses of C1 with their respective occipital condyles. 2. No fracture or malalignment of the cervical spine. 3. Paranasal sinus mucosal thickening and bilateral mastoid air cells partial opacification not fully evaluated. 4. Ground-glass opacity at the visualized right lung apex may relate to infection as suspected on the patient's recent chest radiographs. CT ABD W&W/O C [**2171-4-13**] 1:06 PM CT CHEST W/CONTRAST; CT ABD W&W/O C Reason: pna, bowel ischemia [**Hospital 93**] MEDICAL CONDITION: 54 year old man with unexplained acidosis, question of pna REASON FOR THIS EXAMINATION: pna, bowel ischemia CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Unexplained acidosis, question of pneumonia and bowel ischemia. TECHNIQUE: Axial volumetric images have been obtained through the chest, abdomen and pelvis before and after administration of IV contrast. Delayed images in the venous phase through the abdomen and pelvis have also been obtained. Coronal and sagittal reformats were performed. CT CHEST: There are multifocal airspace opacities within the right and left lung, predominantly on the right with evidence of ground-glass opacities and air bronchograms. There is a questionable small right apical pneumothorax with no evidence of mediastinal gas. Endotracheal tube is in place. The heart is enlarged with evidence of small amount of pericardial effusion. Mediastinal catheters are in place. There are shotty mediastinal lymph nodes which are all less than 1 cm in diameter in short axis. There is no evidence for pleural effusion. There are two hypodense nodules within the right thyroid lobe for which an ultrasound is recommended. CT OF THE ABDOMEN: The patient is status post recent laparotomy two days ago. There are residual two small pockets of free air superior and anterior to the hepatic dome. The liver, the spleen, the pancreas, and the bilateral adrenal glands are unremarkable. The gallbladder appears slightly thick-walled and this is likely due to the presence of small amount of ascites in the abdomen. There is a short segment of proximal small bowel that is prominent measuring 3.2 cm in diameter. There is no evidence of transition point. The remainder of the bowel appears unremarkable. This is most likely due to postsurgical changes. There is no evidence of pneumatosis or portovenous gas. Small amount of free fluid in the abdomen. There are slightly prominent retroperitoneal lymph nodes, all of which are subcentimeter in diameter in short axis. There is no evidence of hydronephrosis. There is a small left upper pole cyst. Otherwise, the bilateral kidneys are unremarkable. CT PELVIS: The urinary bladder is decompressed with evidence of Foley catheter in the bladder. There is a small amount of free fluid in the pelvis. There is a right-sided femoral catheter within the right femoral artery. There is mild subcutaneous edema. MUSCULOSKELETAL: There are no lucent or sclerotic bony lesions. IMPRESSION: 1. Evidence of multifocal airspace disease concerning for multifocal pneumonia. [**Hospital **] were communicated to the fellow Dr. [**Last Name (STitle) 59499**] on [**2171-4-13**] at 4:00 p.m. 2. Questionable small right apical pneumothorax which may be tracking from catheter placement. Additional foci of gas in the anterior abdominal wall as described may also reflect gas tracking from the mediastinal catheters. 3. Two hypodense lesions within the right lobe of the thyroid for which an ultrasound is recommended. 4. Slightly thick-walled gallbladder which may be related to the small amount of ascites in the abdomen. Focal short segment dilatation of jejunum with no evidence of transition point. This is most likely post-surgical in nature. Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2171-4-8**] for surgical management of his mitral valve disease and his atrial fibrillation. As he had stopped coumadin, heparin was started as a bridge to surgery. On [**2171-4-9**], Mr. [**Known lastname **] was taken to the operating room where he underwent a redo sternotomy with a mitral valve repair using a 30mm band and a full MAZE procedure. Postoperatively he was taken to the intensive care unit for monitoring. On postoperative day one, Mr. [**Known lastname **] was extubated. Throughout the day, he became progressively agitated with an increase lactate causing acidosis. He was subsequently reintubated to protect his sternum and to allow his acidosis to clear. He developed copious secretions and an elevated white blood cell count. Vancomycin flagyl, ciprofloxacin and ceftaz were continued for coverage. An echo was performed which ruled out a ventricular septal defect. The infectious disease consult was obtained and a pneumonia was suspected. The general surgery service was consulted given his acidosis and distended bowel. An exploratory laparotomy was performed which was negative. He developed rapid atrial fibrillation and amiodarone was continued. Heparin was also started for anticoagulation. The nutrition service was consulted and tube feeds were started for nutritional support. The neurology service was consulted secondary to his continued unresponsiveness and CTA imaging was not suggestive of any acute process. An EEG was performed which was also negative. A toxic-metabolic encephalopathy was presumed possibly secondary to sedatives. Slowly his confusion and agitation improved. He was gently diuresed towards his preoperative weight. On [**2171-4-19**], Mr. [**Known lastname **] had a catatonic state and a head CT scan was performed which was negative. Of note, thyroid nodules were seen on his scan which should be followed as an outpatient. He quickly improved to his baseline. Later on [**4-19**], Mr. [**Known lastname **] was extubated. As Ceftaz and flagyl were associated with increased risk of seizure, they were both discontinued as they had completed their course. A bedside swallowing exam was performed which he failed and tube feeds were continued. On [**2171-4-20**], Mr. [**Known lastname **] was alert, orientated and following all commands. Coumadin was resumed for paroxysmal atrial fibrillation. A repeat swallowing exam was performed on [**2171-4-22**] which he proved that he could safely tolerate foods. A regular diet was thus started. Later on [**2171-4-22**], he was transferred to the step down unit for further recovery. The physical therapy service was consulted for assistance with his postoperative strength and mobility. He continued to make steady progress and was discharged to home on postoperative day 15. Medications on Admission: Lopressor 50" Coumadin 2.5' Digoxin 0.125' Lasix 20' Protonix 40' Lisinopril 5' Discharge Medications: 1. Outpatient [**Name (NI) **] Work PT/INR for coumadin dosing - Atrial fibrillation goal inr 2-2.5 First draw [**4-26**] with results to Dr [**Last Name (STitle) 65978**] [**Name (STitle) **] [**Telephone/Fax (1) 65213**] 2. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): please take 400mg for 5 days then decrease to 200 mg daily and follow up with Dr [**Last Name (STitle) **]. Disp:*50 Tablet(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 4. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 5. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: please take 2.5mg daily and have INR drawn [**4-26**] for further dosing. Disp:*60 Tablet(s)* Refills:*0* 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Aspirin EC 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* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: PAF/A-Flutter Mitral regurgitation Hyperlipidemia CHF Gastric Ulcer PNA Mental status changes postoperatively Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. Report any wound issues to your surgeon at ([**Telephone/Fax (1) 1504**] 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) You may shower daily and wash incision. No lotions, creams or powders to wound until it has healed. 5) No driving for 1 month. 6) No lifting greater then 10 pounds for 10 weeks from date of surgery. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 1290**] in 2 weeks. ([**Telephone/Fax (1) 1504**] Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. [**Telephone/Fax (1) 2934**] Please follow-up with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] 1 weeks. [**Telephone/Fax (1) 65213**] Please follow up with Dr. [**First Name (STitle) **] (Surgery) [**Telephone/Fax (1) 673**] in 1 week [**Name (NI) **] PT/INR for coumadin dosing - Atrial fibrillation goal inr 2-2.5 First draw [**4-26**] with results to Dr [**Last Name (STitle) 65978**] [**Name (STitle) **] [**Telephone/Fax (1) 65213**]. Scheduled Appointments- Provider: [**First Name4 (NamePattern1) 3520**] [**Last Name (NamePattern1) 3521**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2171-6-3**] 12:30 Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 9394**] (ST-3) GI ROOMS Date/Time:[**2171-6-3**] 12:30 Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 2934**] Date/Time:[**2171-5-17**] 3:20 Completed by:[**2171-4-24**]

[ "427.32", "486", "349.82", "997.3", "285.9", "518.5", "V64.41", "424.0", "995.91", "427.31", "038.9", "998.59" ]

icd9cm

[ [ [] ] ]

[ "38.93", "37.27", "33.24", "54.11", "96.6", "35.12", "37.33", "39.61" ]

icd9pcs

[ [ [] ] ]

21368, 21426

17097, 19951

296, 449

21580, 21587

3642, 4016

22116, 23195

3335, 3463

20081, 21345

13858, 13917

21447, 21559

19977, 20058

21611, 22093

3478, 3623

247, 258

13946, 17074

477, 848

870, 3059

3075, 3319

13,711

194,856

24704

Discharge summary

report

Admission Date: [**2127-8-7**] Discharge Date: [**2127-8-17**] Date of Birth: [**2073-3-21**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Diaphoresis/Chest pain Major Surgical or Invasive Procedure: Coronary artery bypass grafting x3 on [**2127-8-11**] History of Present Illness: This 54-year-old lady with the recent onset of cardiac symptoms was investigated and the coronary angiogram showed significant disease in the left anterior descending artery and in the circumflex system. The right coronary artery was moderately diseased with a 40% stenosis. The left ventricular function was well preserved. She was admitted soon after the angiogram for coronary artery bypass grafting. Past Medical History: 1. CAD, s/p CABG [**2127-8-11**] at [**Hospital1 18**]; LIMA to LAD, SVG sequentially to OM1, OM2 (40% residual RCA disease) 2. TTE [**2127-8-8**] with EF>60%, no diastolic dysfunction, no valvular disease, no wall motion abnormalities 3. Depression 4. Myocardial infarction Social History: smokes [**12-22**] ppd x 30+ yrs (has cut down since CABG), no EtOH/drugs, single, lives alone. Family History: Father died CAD in 70's, no other CAD, no DM Physical Exam: HEENT: NCAT, PERRL, EOMI, O/P Benign HEART: RRR, no murmur LUNGS: Clear ABD: Benign EXT: No edema, warm NEURO: Nonfocal Pertinent Results: [**2127-8-7**] 08:47PM PT-12.3 PTT-24.9 INR(PT)-1.0 [**2127-8-7**] 08:47PM WBC-9.7 RBC-4.26 HGB-14.0 HCT-41.4 MCV-97 MCH-32.9* MCHC-33.9 RDW-12.2 [**2127-8-7**] 08:47PM GLUCOSE-114* UREA N-8 CREAT-0.7 SODIUM-139 POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-26 ANION GAP-15 [**2127-8-7**] 08:47PM ALT(SGPT)-28 AST(SGOT)-30 LD(LDH)-179 ALK PHOS-68 TOT BILI-0.9 [**2127-8-16**] 05:12AM BLOOD Hct-29.0* [**2127-8-14**] 07:50AM BLOOD Plt Ct-252 [**2127-8-15**] 05:05AM BLOOD Glucose-107* UreaN-9 Creat-0.6 Na-138 K-3.4 Cl-102 HCO3-28 AnGap-11 [**2127-8-16**] 05:12AM BLOOD K-4.0 [**2127-8-13**] 06:18AM BLOOD Mg-1.9 CXR: [**2127-8-7**] - Mild fluid overload/CHF. Normal heart size. [**2127-8-11**] - The patient is status post interval median sternotomy and coronary artery bypass surgery. An endotracheal tube is in satisfactory position, but the cuff is slightly overdistended. A right internal jugular vascular catheter terminates in the lower superior vena cava, and a nasogastric tube terminates below the diaphragm. Mediastinal drain, and left-sided chest tube are present with abrupt curvature of the left-sided chest tube at the sideport level. Cardiac and mediastinal contours appear slightly widened compared to the preoperative radiograph. There is diffuse perihilar haziness and a subtle interstitial pattern within the lungs, likely reflecting interstitial pulmonary edema. Patchy and linear areas of opacity are seen in the left perihilar and infrahilar regions, attributed to atelectasis. No pneumothorax is evident on this supine chest radiograph. [**2127-8-8**] Carotid Duplex Ultrasound: On the right side, plaque in the internal carotid artery with less than 40% hemodynamic effect. On the left side, plaque extending from the carotid bulb into the internal carotid artery with plaque in the 40+ percent range. [**2127-8-8**] ECHO The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Tissue velocity imaging demonstrates an E/e' <8 suggesting a normal left ventricular filling pressure. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation may be present. 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 no pericardial effusion. [**2127-8-11**] ECG Baseline artifact Sinus bradycardia Modest nonspecific ST-T wave abnormalities Since previous tracing of the same date, atrial ectopy absent [**Last Name (NamePattern4) 4125**]ospital Course: Mrs. [**Known lastname 62317**] was admitted to the [**Hospital1 18**] on [**2127-8-7**] for surgical management of her coronary artery disease. She was worked-up in the usual preoperative manner including a carotid duplex ultrasound which revealed less then 40% stenosis on the right and around 40% stenosis on the left. An echocardiogram was performed which revealed preserved global and regional biventricular systolic function. On [**2127-8-11**], Mrs. [**Known lastname 62317**] was taken to the operating room where she underwent coronary artery bypass grafting to three vessels. Postoperatively she was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, she awoke neurologically intact and was extubated. On postoperative day two, she was transferred to the cardiac surgical step down unit for further recovery. She was gently diuresed towards her preoperative weight. The physical therapy service was consulted for assistance with her postoperative strength and mobility. She was transfused for postoperative anemia. Beta blockade, a statin and aspirin were resumed. Mrs. [**Known lastname 62317**] continued to make steady progress and was discharged home on postoperative day six. She will follow-up with Dr. [**Last Name (Prefixes) **], her cardiologist and her primary care physician as an outpatient. Medications on Admission: Prozac Spirinolactone Aspirin Lopressor Zocor Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 7 days. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Disp:*30 Tablet(s)* Refills:*2* 6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 7. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Coronary artery disease Discharge Condition: Good Discharge Instructions: [**Month (only) 116**] shower No lifting more than 10 lbs No cream or lotion on incision Followup Instructions: 1. Dr [**Name (STitle) 3876**] in 4 weeks 2. Cardiology Dr [**Last Name (STitle) 6254**] in 2 weeks Completed by:[**2127-9-12**]

[ "458.29", "V17.3", "410.71", "305.1", "272.0", "414.01" ]

icd9cm

[ [ [] ] ]

[ "39.61", "36.15", "36.12", "88.72", "99.04" ]

icd9pcs

[ [ [] ] ]

6713, 6772

343, 399

6840, 6847

1466, 4160

6984, 7115

1264, 1311

5663, 6690

6793, 6819

5593, 5640

6871, 6961

1326, 1447

4211, 5567

281, 305

427, 833

855, 1134

1150, 1248

26,384

133,926

1362+1363

Discharge summary

report+report

Admission Date: [**2186-12-31**] Discharge Date: [**2187-1-2**] Service: Medical Intensive Care Unit CHIEF COMPLAINT: Transferred for respiratory failure. HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old woman recently admitted to the [**Hospital1 188**] ([**2186-11-11**] through [**2186-11-27**]) with left sided pneumonia requiring intubation for airway protection and bronchoscopy for aspiration of a mucus plug and re-expansion of a collapsed lobe. Her hospital course then was also complicated by myocardial infarction with a peak troponin of 0.83 and the development of hematuria while receiving Heparin. She also had acute renal failure during that hospital stay attributed to receiving intravenous dye as well as decompensation of her congestive heart failure requiring nesiritide and furosemide infusions. Finally, her hospital stay was complicated by MRSA urinary tract infection for which she had a percutaneous inserted central catheter and received a course of Vancomycin intravenously. The patient refused cardiac catheterization at that time decided to desire to avoid aggressive procedures. On discharge, the patient's code status was made DNR/DNI, however, on arrival to the outside hospital with complaints very similar to those listed above, specifically respiratory distress preceding two days of shortness of breath, she and her husband asked that her code status be reversed. She was emergently intubated in [**Hospital6 8283**], and transferred to the [**Hospital1 69**] for further care. Her blood gas in the Emergency Department of said hospital was 7.23, 57, 227 without documentation of ventilatory settings. The EMS documentation reports that she received a total of furosemide 80 mg, midazolam 2 mg, pancuronium, morphine sulfate 2 mg, and succinylcholine as well as nitro paste. In our Emergency Department, the patient received another 2 mg of Morphine, and was transferred to the Intensive Care Unit for further management. PAST MEDICAL HISTORY: 1. Pneumonia with recent admission one month ago as well as one year ago. 2. Coronary artery disease status post myocardial infarction in [**2185-10-28**] initially when she refused intervention at that time, she was admitted to the Coronary Care Unit due to systolic congestive heart failure requiring intubation. See below for interval echocardiographic results. 3. Severe aortic insufficiency. 4. Acute on chronic renal failure. 5. Gout. 6. Status post total abdominal hysterectomy. 7. Thoracic aortic aneurysm. SOCIAL HISTORY: The patient is married. Her husband is [**Age over 90 **] years old and is involved in her care as is their niece. She does not smoke tobacco or drink alcohol. There is a well-documented history of poor compliance with regimens of medications. Indeed her husband states in her presence that she does not taking hydralazine as prescribed every six hours, but takes it approximately every eight. She has not taken diuretics consistently in the past either. Her niece is [**Name (NI) **] [**Name (NI) 3075**], her number is [**Telephone/Fax (1) 8284**]. ALLERGIES: She is allergic to penicillin. MEDICATIONS: As stated above. There is a history of poor compliance, however, she is prescribed the following cardiac regimen: 1. Aspirin 325 mg daily. 2. Isosorbide mononitrate 20 mg daily. 3. Hydralazine 50 mg every six hours for which she takes every three hours. 4. Furosemide 40 mg twice daily, however, she does not recall having this medication prescribed for her. 5. Bumetanide was prescribed in the past, however, she has not taken that consistently. 6. Calcium acetate 675 mg daily. 7. Albuterol and Atrovent. 8. Pantoprazole. 9. Senna. 10. Colace. 11. Magnesium oxide prn. PHYSICAL EXAMINATION: Temperature was not recorded initially. The heart rate was 86. The blood pressure was 135/65. The respiratory rate was 10. On volume supported assist control with a rate of 10, a PEEP was 10 cm, FIO2 was 0.6, the SPO2 was 100%. The pulsus paridoxicus was documented at 8 mm. Generally: Thin elderly woman, sedated, but waking occasionally. She shakes her head no to pain and nods that she is breathing adequately. HEENT: Pupils are equal, round, and reactive to light and they accommodate from 4 mm to 2.5 mm. Arcus senilis is present. Endotracheal tube and orogastric tube are in place. Neck: The jugular venous distention is clearly visible under the ears at 30 degrees. Chest: Lung fields are clear to auscultation bilaterally. Heart: Regular with a normal S1, S2. There is a 2/6 systolic murmur as well as a 1/6 systolic murmur at the base. Abdomen: Scaphoid, normal bowel sounds, soft, nontender, nondistended, no organs are palpable. There is a well-healed midline scar. Extremities: There is a right femoral vein catheter in place oozing a little bit of blood. There is no rash, clubbing, or cyanosis. There is mild lower extremity edema. Rectal examination reveals the presence of occult blood. LABORATORY EVALUATION: In the outside hospital, her hematocrit was 32, platelets were 335, her white blood cell count was 10,000. In our Emergency Department, the CBC was as follows: White blood cell count 9,000, hemoglobin 8.4 mg/dl, hematocrit 26.2%, platelets 171,000. INR 1.2. Chemistry panel: Sodium 144, potassium 4.1, chloride 109, bicarbonate 27. Blood, urea, and nitrogen 28, creatinine 1.9. Glucose 167. Calcium 9, phosphate 3.8, magnesium 2.2. Lactate 1.6. Cardiac troponin-T was 0.12. Arterial blood gas on ventilatory settings was described at 7.37, 48, 142. Blood cultures were drawn. ECG showed unchanged, sinus rhythm at 76 beats per minute and a presence of a left bundle branch block. Chest x-ray shows stable massive cardiomegaly. HOSPITAL COURSE: 1. Decompensated congestive heart failure: The patient was subjected to diuresis with furosemide over the first two days; approximately 3 kg of fluid were removed. She was successfully extubated on hospital day #2. Interval echocardiogram showed the following: 1. Left atrial enlargement. 2. Symmetric left ventricular hypertrophy. 3. Left ventricular ejection fraction of 15-20%. 4. +3 to +4 aortic regurgitation. 5. Normal right ventricular systolic function. 6. Large stable pericardial effusion without evidence of tamponade. Once the patient achieves her dry weight, furosemide 100 mg twice daily was instituted along with metoprolol 12.5 mg twice daily along with her nitrate and hydralazine regimen of 50 mg every six hours and isosorbide mononitrate 10 mg twice daily. As shown in the laboratory evaluation summarized above and in the OMR, the patient ruled in for myocardial infarction by elevated troponin. Serial CKs showed rapid clearance of cardiac markers. 2. Chronic renal failure: The patient tolerated diuresis adequately. There was no interval rise in her BUN or creatinine, although she did have a stable metabolic alkalosis after achieving her dry weight. 3. Gastrointestinal bleed: The patient was placed initially on pantoprazole 40 mg twice daily. Serial hematocrits did not show evidence of acute blood loss and her INR was normal as was her platelets. Aspirin therapy was reinitiated. The patient was transferred to the Medical [**Hospital1 **] for further management. A separate list of discharge medications should be included in that as well as Visiting Nurses Association arrangements to make sure the patient takes the stable cardiac medication regimen. [**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**] Dictated By:[**Name8 (MD) 7102**] MEDQUIST36 D: [**2187-1-2**] 12:01 T: [**2187-1-2**] 12:15 JOB#: [**Job Number 8286**] Admission Date: [**2187-1-2**] Discharge Date: [**2187-1-9**] Service: This will cover [**Hospital 228**] hospital course after the SICU stay from [**2187-1-2**] to [**2187-1-9**]. HISTORY OF PRESENT ILLNESS: Patient was initially admitted with a chief complaint of dyspnea and CHF exacerbation. She is a [**Age over 90 **]-year-old white female with history of severe AR, CHF, who was admitted to the VICU for dyspnea, and is now being called out to the floor. She was initially admitted on [**12-31**] after initially presenting to an outside hospital having chest pain and shortness of breath. She was intubated after an ABG at the outside hospital was 7.23, 57, and 227. She was given Lasix, Morphine, nitrates, and was transferred to [**Hospital1 18**]. She had a troponin of 0.12. Her hematocrit also was low at 26.2. She was started on Lasix, hydralazine, nitrates, and aspirin. She was extubated on [**2187-1-1**], and an echocardiogram was done as well as metoprolol was started. Currently, she denies any chest pain, shortness of breath, nausea, vomiting, abdominal pain. Denies cough, fevers, or chills. PAST MEDICAL HISTORY: 1. Recent pneumonia on admission from [**Date range (1) 8287**]. 2. Coronary artery disease status post MI in [**10-30**] as well as in [**10-31**]. 3. CHF with an EF of 15-20% on an echocardiogram obtained [**2187-1-1**]. This also showed severe [**3-1**]+ AR. 4. Chronic renal insufficiency. 5. History of MRSA UTI in [**10-31**]. 6. Gout. 7. Chronic pericardial effusion. Patient has refused pericardiocentesis numerous times, although there was no evidence of tamponade on the recent echocardiogram. 8. Left bundle branch block. 9. Total abdominal hysterectomy. 10. Thoracic aortic aneurysm. SOCIAL HISTORY: She is married for 72 years. No smoking or ethanol use. She has a history of medical noncompliance. ALLERGIES: 1. Penicillin. 2. Questionable of a beta blocker allergy. 3. Questionable history of ACE inhibitor allergy. PERTINENT FINDINGS ON EXAMINATION: Her blood pressure was 131/46. She was satting 98% on 4 liters. She was in for 950 and out for 1389. Length of stay she was 2 liters negative. She had dry mucous membranes. Her JVP was at 10 cm. She has bibasilar crackles without wheezing. She had a grade 3/6 systolic ejection murmur heard best at the right upper sternal border as well as a grade [**2-2**] blowing diastolic murmur heard best at the mid left sternal border. She had no peripheral edema. A peak troponin was 0.21 with a CK of 43 and a MB of 4. On [**2187-1-1**], she had a chest x-ray which showed a dense focal opacification behind the left side of the heart, either atelectasis or infiltrate. The left costophrenic angle was blunted, mild-to-moderate CHF. HOSPITAL COURSE BY PROBLEM: 1. CHF: As noted previously, the patient has a severely depressed ejection fraction along with 3-4+ AR. She was initially continued on her beta blocker, hydralazine, and Isordil. She was also kept on 100 mg p.o. b.i.d. of Lasix. Per the attending's recommendations, it was decided to start the patient on Natrecor for diuresis. She received two days of Natrecor diuresis and then was continued on 40 mg p.o. b.i.d. of Lasix. Also a CHF consult was obtained, and they recommended starting the patient on Toprol XL 12.5 mg q.d. She is also started on captopril 6.25 mg b.i.d, which she tolerated. Also on the day of discharge, the patient was discharged on lisinopril 5 mg p.o. q.d. 2. In terms of ischemia, the patient was continued on aspirin and also the patient was started on Plavix 75 mg p.o. q.d. The treatment team discussed the patient's therapeutic options for coronary disease, and the patient repeatedly refused invasive interventions such as cardiac catheterization. 3. In terms of her rhythm, she continued in left bundle branch block with no evidence of other dysrhythmia. A lipid panel was checked, and the patient was noted to have an appropriate LDL goal. On the evening of [**2187-1-7**], the patient had two episodes of chest pain, one at approximately 10:30 p.m. and one at approximately 12 a.m. associated with some anterolateral T-wave changes. The patient was given sublingual nitroglycerin during each of these episodes with relief. The patient had a peak troponin during this episode of chest pain at 0.11. Per extensive discussion with the attending, it was agreed not to start a Heparin drip on this patient as A. The patient has a history of hematuria and GI bleed while on Heparin, and B. Heparin is usually a bridge of treatment to definitive interventions such as cardiac catheterization or bypass, and therefore was agreed that the patient would not be started on a Heparin drip. 4. Patient was noted to have cloudy urine, and a urinalysis was sent which did reveal a urinary tract infection. She was started on levofloxacin 250 mg p.o. q.48h. (renally dosed for a total of 10 day course). 5. Chronic renal insufficiency: The patient's creatinine remained at her baseline during her admission. DISCHARGE DIAGNOSES: 1. Congestive heart failure. 2. Coronary artery disease. 3. Severe aortic regurgitation. 4. Non-ST-segment elevation myocardial infarction x2. 5. Respiratory failure. 6. Chronic renal insufficiency. 7. Left bundle branch block. 8. Chronic pericardial effusion without evidence of tamponade. DISCHARGE INSTRUCTIONS: Patient was instructed to call her primary care doctor or 911 if she began having chest pain, shortness of breath, severe difficulty laying down flat, leg swelling, fevers, chills, or any other complaints. Patient was also told to begin a Lasix sliding scale as directed. This will be accomplished through home VNA, who will help with her this. She was also told to followup with her cardiologist within two weeks, and she will be receiving home VNA through her niece. DISCHARGE MEDICATIONS: 1. Protonix 40 q.d. 2. Aspirin 325 q.d. 3. Metoprolol XL 12.5 mg p.o. q.d. 4. Lasix 40 mg p.o. b.i.d. 5. Plavix 75 mg p.o. q.d. 6. Sublingual nitrate prn. 7. Lisinopril 5 mg p.o. q.d. 8. Levofloxacin 250 mg one tablet p.o. q.48h. to finish [**2187-1-16**]. 9. She is also to receive potassium chloride prn through her VNA. The patient should have Chem-7s drawn approximately twice a week to follow her kidney function and her potassium levels as she is on both an ACE inhibitor and Lasix. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**] Dictated By:[**Name8 (MD) 8288**] MEDQUIST36 D: [**2187-1-9**] 10:00 T: [**2187-1-9**] 11:21 JOB#: [**Job Number 8289**]

[ "410.71", "599.0", "518.81", "428.0", "585", "428.20", "426.3", "414.01", "424.1" ]

icd9cm

[ [ [] ] ]

[ "96.71", "00.13" ]

icd9pcs

[ [ [] ] ]

12790, 13082

13602, 14347

5782, 7918

13107, 13579

3773, 5765

131, 169

10526, 12769

7947, 8864

8886, 9485

9502, 10498

58,747

174,572

13069

Discharge summary

report

Admission Date: [**2139-9-17**] Discharge Date: [**2139-10-7**] Date of Birth: [**2064-1-10**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 3913**] Chief Complaint: Weakness, diarrhea, atrial fibrillation with RVR Major Surgical or Invasive Procedure: NONE History of Present Illness: Ms [**Known lastname **] is a 75 yo woman with CLL diagnosed in [**2131**], atrial tachycardia, CAD s/p stent the RCA on '[**28**] who initially presented to the oncology clinic today with one week of profuse watery diarrhea, fevers/chills, and an elevated WBC count. She was recently admitted to the OMWS servuice from [**Date range (1) 19377**] with pneumonia, initially treated with vanc/cefepime, then switched to a course of cefpodoxime. She received first dose of campath on [**2139-9-1**], began to have fevers and a painful rash at the site of injetcion. Thus, the campath was stopped, last dose being [**9-7**]. . She was seen in clinic by Dr. [**Last Name (STitle) **] on [**9-15**], where she noted several episodes of loose, watery bowel movements. Plan was to send her home for that night, collect stool samples, and begin Rituxan and bendamustine treatment for CLL given her rising white count on [**9-16**]. She presented to clinic today stating that she was extremely weak and that she had 20 episodes of profuse, foul smelling watery diarrhea overnight. Her initial vitals in clinic were 103.1.BP 130/66, P 96 RR 20. For concern for c. diff, she was given flagyl and tylenol. While sleeping, her heart rate had increased to 140s and an ECG showed atrial fibrillation. She remained febrile and was given IV cefepime. She continued to have RVR into 190s with stable BPs in 120s-130s with chills and rigors. Of note, she had not taken any of her blood pressure or rate control medications today. She was sent to the ED for further evaluation, vitals on transfer were HR 136 132/66 24 98% 2L. . In the ED, inital vitals were 101 100 146/58 20. She apparently triggered immediately for heart rate in 150s and ECG showed atrial fibrillation. Lactate was .9. She was given 2L NS and her HR decreased to the low 100s with stable blood pressures. She was given 1 g of IV vancomycin as well. CT abdomen, which showed was done which showed pancolitis, no perforation, and concern for c diff. When resturning from her CT scan, patient went up to go to the commode, and HR increased to 170s. At this point, patient was given her dose of PO metoprolol 125 mg and her heart rate decreased to 113. Vitals on transfer were 101.5, 113, 147/77, 26 100% on 2L. . On the floor, . 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: CLL dx [**12/2131**]: - [**5-24**] weekly Rituxan x 8 weeks - [**10-24**] FCR x 6 months to [**3-25**] - relapsed [**1-26**] then 2 cycles of FCR [**2-26**] again - Bendamustine for 2 cycles in [**7-26**] - progression in [**1-27**] - [**Date range (1) 39954**] RCVP x 2 cycles - [**2139-6-12**] C1 R-[**Hospital1 **] Severe arm cellulitis, ?necrotizing fasciitis, admitted at [**Hospital1 112**] [**4-27**] Detached retina treated at [**Hospital **] SVT/Atrial Tachycardia Hyperlipidemia Osteoporosis CAD, RCA stent in [**2128**], EF 60% in [**5-27**] Hysterectomy in [**2130**] Hx of breast biopsy, benign History of bladder prolapse [**2130**] Toes turn blue in cold weather - seen by vascular surgery several times and told that this is not a vascular problem Social History: Divorced in the [**2108**]. Retired nurse. -Smoking Hx: Short interval at age 18-21, never since. -Alcohol Use: rare use. -Recreational Drug Use: none. Family History: One son had [**Name (NI) 4278**] lymphoma at age 25. Daughter has lupus. No other known cancer history. Physical Exam: On admission: Clinic 103.1.BP 130/66, P 96 RR 20 ED triage: HR 136 132/66 24 98% 2L. ICU transfer: 101.5, 113, 147/77, 26 100% on 2L. . Accept Note: 110/71, 101, 14, 96%RA General: Alert, oriented, no acute distress HEENT: Cachectic, patchy hairloss, Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, sporadic right sided rales, ronchi CV: Tachy, irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, distended, umbillical hernia, bowel sounds present, no rebound tenderness or guarding, no hepatomegaly and ++splenomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, mild cyanosis, no edema. Black blister/eschar over left forth toe. On Discharge: vitals: hr:81 BP:128/60 RR:20 T:96.8 o2sat:96%/RA HEENT: Cachectic, patchy hairloss, Sclera anicteric, anisocoria R>L, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: CTAB CV: irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, distended, umbillical hernia, bowel sounds present no rebound tenderness or guarding, splenomegaly, no hepatomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, +2 edema. Pertinent Results: [**2139-9-17**] 10:55AM WBC-309.8* RBC-2.56* HGB-8.2* HCT-25.2* MCV-99* MCH-32.1* MCHC-32.6 RDW-22.3* [**2139-9-17**] 10:55AM NEUTS-2* BANDS-0 LYMPHS-91* MONOS-4 EOS-0 BASOS-0 ATYPS-3* METAS-0 MYELOS-0 [**2139-9-17**] 10:55AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ ELLIPTOCY-1+ [**2139-9-17**] 10:55AM PLT SMR-VERY LOW PLT COUNT-38* [**2139-9-17**] 10:55AM LD(LDH)-361* [**2139-9-17**] 10:55AM UREA N-22* CREAT-1.0 SODIUM-130* POTASSIUM-4.9 CHLORIDE-98 TOTAL CO2-20* ANION GAP-17 [**2139-9-17**] 04:09PM LACTATE-0.9 [**2139-9-17**] 10:55AM BLOOD WBC-309.8* RBC-2.56* Hgb-8.2* Hct-25.2* MCV-99* MCH-32.1* MCHC-32.6 RDW-22.3* Plt Ct-38* [**2139-9-20**] 06:50AM BLOOD WBC-157.2* RBC-2.36* Hgb-8.1* Hct-23.9* MCV-101* MCH-34.4* MCHC-34.0 RDW-22.8* Plt Ct-21* [**2139-9-21**] 09:29AM BLOOD WBC-221.9* RBC-2.67* Hgb-9.0* Hct-26.5* MCV-99* MCH-33.9* MCHC-34.1 RDW-22.2* Plt Ct-48*# [**2139-9-22**] 01:00AM BLOOD WBC-190.4* RBC-2.67* Hgb-8.7* Hct-26.1* MCV-98 MCH-32.5* MCHC-33.3 RDW-22.5* Plt Ct-38* [**2139-9-26**] 12:00AM BLOOD WBC-392.7* RBC-2.67* Hgb-8.8* Hct-26.2* MCV-98 MCH-32.5* MCHC-33.5 RDW-21.5* Plt Ct-23* [**2139-9-27**] 12:10AM BLOOD WBC-413.0* RBC-2.58* Hgb-8.8* Hct-25.9* MCV-100* MCH-34.2* MCHC-34.1 RDW-21.3* Plt Ct-20* [**2139-9-28**] 12:00AM BLOOD WBC-415.0* RBC-2.49* Hgb-7.8* Hct-24.7* MCV-99* [**2139-10-1**] 12:00AM BLOOD WBC-322.2* RBC-2.63* Hgb-8.7* Hct-26.1* MCV-100* MCH-33.1* MCHC-33.2 RDW-20.4* Plt Ct-36* [**2139-10-5**] 12:05AM BLOOD WBC-187.4* RBC-2.77* Hgb-9.6* Hct-26.8* MCV-97 MCH-34.7* MCHC-35.9* RDW-21.4* Plt Ct-31* [**2139-9-18**] 03:57AM BLOOD Glucose-124* UreaN-20 Creat-0.8 Na-135 K-3.9 Cl-110* HCO3-15* AnGap-14 [**2139-9-21**] 09:29AM BLOOD Glucose-124* UreaN-15 Creat-0.6 Na-133 K-3.8 Cl-108 HCO3-12* AnGap-17 [**2139-9-22**] 12:00AM BLOOD Glucose-87 UreaN-13 Creat-0.5 Na-135 K-4.1 Cl-110* HCO3-16* AnGap-13 [**2139-9-25**] 12:00AM BLOOD Glucose-114* UreaN-24* Creat-0.7 Na-135 K-3.3 Cl-103 HCO3-22 AnGap-13 [**2139-9-28**] 12:00AM BLOOD Glucose-81 UreaN-23* Creat-0.5 Na-135 K-4.6 Cl-106 HCO3-25 AnGap-9 [**2139-10-2**] 12:01AM BLOOD Glucose-147* UreaN-39* Creat-0.6 Na-131* K-4.9 Cl-105 HCO3-20* AnGap-11 [**2139-10-4**] 12:00AM BLOOD Glucose-89 UreaN-15 Creat-0.4 Na-138 K-3.9 Cl-102 HCO3-29 AnGap-11 [**2139-10-5**] 12:05AM BLOOD Glucose-176* UreaN-15 Creat-0.5 Na-137 K-4.0 Cl-102 HCO3-28 AnGap-11 [**2139-9-17**] CT ABDOMEN WITH CONTRAST: The imaged lung bases demonstrate unchanged bibasilar opacities likely atelectasis or scarring. There is no pleural or pericardial effusion. Coronary calcifications are noted. The liver is normal in attenuation without focal lesion. Mild periportal edema is noted. The portal and hepatic veins appear patent. The gallbladder is nondistended with surrounding wall edema which could be related to the adjacent colonic edema. The pancreas is unremarkable. The spleen is not fully assessed, but is enlarged to at least 18.7 cm. The bilateral adrenal glands are unremarkable. The kidneys enhance and excrete contrast symmetrically. Exophytic upper pole right renal cyst is seen along with multiple hypodensities in the left kidney which are too small to be fully characterized. The small bowel is grossly unremarkable. There is pancolonic mural edema and thickening. There is surrounding stranding as well. There is no free intraperitoneal air. Extensive lymphadenopathy is seen within the periportal, mesenteric and paraaortic nodal chains without notable interval change from the prior study. Dense aortic calcifications are noted. CT OF THE PELVIS WITH CONTRAST: The bladder is distended. The uterus appears surgically absent. A circumferential rectal mural thickening is noted. There may be trace perirectal stranding without free pelvic fluid. Pelvic side wall, external iliac and inguinal lymphadenopathy is also noted to a similar degree as on the prior. OSSEOUS STRUCTURES: There is no lytic or sclerotic bony lesion concerning for osseous malignant process. Scoliosis is again seen with degenerative change centered in the upper lumbar spine. IMPRESSION: 1. Mural edema involving the entire colon extending to the rectum compatible with pancolitis and proctitis. Pseudomembranous colitis, such as C. difficile, is most likely. Other infectious colitides are secondary diagnostic considerations. 2. Unchanged extensive adenopathy compatible with provided history of CLL along with splenomegaly. [**2139-9-24**] MRI/A Head: FINDINGS: There is no acute intracranial hemorrhage, infarction, edema, mass effect or masses seen. Ventricles and sulci are of normal size and configuration. There is diffuse pachymeningeal enhancement. There appears to be diffusely abnormal [**Month/Day/Year 15482**] signal involving the calvarium and the visualized upper cervical spine. Multiple T2/FLAIR hyperintensities are seen in bilateral periventricular white matter, most likely represents small vessel ischemic disease. Chronic lacunar infarcts are seen in the right frontal white matter. The visualized orbits, paranasal sinuses, and mastoid air cells are unremarkable. Major intracranial flow voids appear normal. MRA BRAIN: Bilateral internal carotid arteries, vertebral arteries and basilar artery and their major branches show normal flow signal without evidence of stenosis, occlusion, dissection, or aneurysm formation. IMPRESSION: 1. Diffusely abnormal [**Month/Day/Year 15482**] signal in the calvarium and upper cervical spine, likely secondary to CLL involvement. 2. Diffuse pachymeningeal thickening and enhancement. This may be secondary to tumor involvement. However, it can also be seen secondary to intracranial hypotension from prior lumbar puncture, inflammatory or infectious etiologies. 3. Small vessel ischemic disease. [**2139-10-2**] MRI L-Spine FINDINGS: Study is limited due to patient motion-related artifacts, despite multiple attempts. There is also levoscoliosis, which limits assessment of the structures. Within these limitations, the following are the findings. The numbering used for the present study is shown on series 4, image 10. The lumbar vertebral bodies are grossly normal in height. There is heterogeneous signal intensity of the [**Month/Day/Year 15482**], two focal T2 hyperintense areas in the L1 and L3 vertebral bodies with minimal enhancement. These also demonstrate mildly increased signal intensity on the pre-contrast T1-weighted sequence and hence may represent atypical hemangiomas. There is diffuse hypointense signal of the [**Month/Day/Year 15482**] likely related to the underlying condition of CLL/other amrrow abn. On STIR sequence, there is no focal area of altered signal intensity to suggest a mass-like lesion in the lumbar vertebrae. Minimal areas of [**Month/Day/Year 15482**] edema are noted in the endplates and in the facets. There is disc desiccation at multiple levels. Mild bulge, with bilateral facet degenerative changes are noted at multiple levels, with mild indentation on the ventral thecal sac and mild foraminal narrowing. There is no significant canal or foraminal stenosis, on the axial images. The spinal cord ends at L1 level. The roots of the cauda equina are otherwise unremarkable. There is a small T2 hyperintense focus, at the posterior aspect of the S2 vertebral body measuring approximately 1.3 x 1.2 cm without enhancement and likely represents a Tarlov's cyst or perineural cyst. No pre- or para-vertebral soft tissue swelling or masses are noted within the limitations. No obvious abnormal enhancement is noted in the epidural space. There is atrophy of the paraspinal muscles, with fatty infiltration. A few T2 hyperintense foci, in the kidneys, please see the details on the CT torso from [**2139-9-23**]. IMPRESSION: 1. Study limited due to levoscoliosis and motion-related artifacts despite attempts. Within this limitation, multilevel multifactorial degenerative changes are noted in the form of facet degenerative changes and disc bulges without significant canal stenosis. Possible mild foraminal narrowing at multiple levels. No compression on the lower cord or roots of the cauda equina or abnormal enhancement. 2. Two small foci of increased STIR signal, in the L1 and L3 vertebral bodies, may relate atypical hemangiomas. Attention on followup can be considered. Hypointense signal intensity of the [**Last Name (LF) 15482**], [**First Name3 (LF) **] be related to the underlying condition of CLL. 3. A few T2 hyperintense foci, in the kidneys, please see the details on the CT torso from [**2139-9-23**]. Brief Hospital Course: 75 yo woman with CLL diagnosed in [**2131**], atrial tachycardia, CAD s/p stent the RCA on '[**28**] who initially presented to the oncology clinic today with one week of profuse watery diarrhea, fevers/chills, and an elevated WBC count, with atrial fibrillation with RVR. . #. C. diff colitis- The patient presented with fevers and severe hypovolemia secondary to severe C. diff colitis. A C. diff toxin was positive. A CT scan revealed mural edema involving the entire colon extending to the rectum compatible with pancolitis and proctitis. The patient was started on IV flagyl and PO vancomycin 500. Pt was also given IVIG. IV flagyl was switched to IV tigecycline after 7 days of minimal improvement. After resolution of diarrhea on hospital day 12, IV tigecycline was discontinued. The patient should continue PO vancomycin 500 QID after discharge and f/u with infectious disease to determine when to discontinue PO vanco. . #. CLL- The patient presented with a WBC greater than 300, which peaked at greater than 400. After resolution of diarrhea, bendamustine 170 mg (100 mg/m2) IV was given on [**2139-9-27**] and [**2139-9-28**] without incident. Rituxan 625 mg (375 mg/m2) IV was given on [**2139-9-30**] after pre-medicating with tylenol, methylprednisolone, Diphenhydramine, and famotidine. The patient should schedule a follow up with Dr. [**Last Name (STitle) **] for further monitoring and treatment. After discharge, twice weekly CBC should be faxed to Dr.[**Name (NI) 3930**] office at [**Telephone/Fax (1) 21962**]. . #. CLL in CSF- An LP was performed without complication. CSF was sent for cytology and flow cytometry, which revealed atypical lymphocytes with immunophenotypic findings highly suspicious for involvement by patient's known chronic lymphocytic leukemia (CLL). The patient was given Liposomal Cytarabine (Depocyt) 50 mg IT on [**2139-10-4**] and started on Dexamethasone [**Doctor Last Name 2949**]. Dexamethasone should be slowly tappered-4mg daily x 3 days, then 2mg daily x 3 days, then 1mg daily x 3 days, then stopped. The patient should follow up with neuro-oncology for further management and repeat IT-Liposomal Cytarabine the week of [**2139-10-19**]. . #. Afib with RVR- presented with sinus tachycardia to 140 [**2-18**] to hypovolemia. After aggressive fluid resuscitation, the patient developed paroxysmal a fib w/ venticular rates in the 60-70's. The patient was rated controlled with Metoprolol 125mg TID and Diltiazem 60 QID, which should be held for HR<60 or SBP<95. These medication should be continued after discharge. . #. prolapsed bladder- long standing. OB-Gyn recommended f/u after discharge in their clinic. Continue premarin gel twice weekly. . #. ? pna- The patient presented fevers and a possibile pneumonia by chest X-ray and was started on levoquin, cefepime, and vancomycin. A CT chest was not consistent with a pneumonia and these antibiotics were discontinued per ID recommendations. . #. Vision changes- The patient was seeing red spots during her hospitalization. Ophthalmology was consulted given the patient h/o retinal detachment. Her symptoms and exam were consistent with a intravitreous hemorrhage without evidence of retinal detachment. The patient should f/u with ophthalmology after discharge. Medications on Admission: ALLOPURINOL - 300 mg Tablet - 1 (One) Tablet(s) by mouth once a day DILTIAZEM HCL - (Prescribed by Other Provider) - 120 mg Capsule, Extended Release - 1 Capsule(s) by mouth twice a day FLUCONAZOLE - 200 mg Tablet - 1 (One) Tablet(s) by mouth once a day. LORAZEPAM - 0.5 mg Tablet - [**1-18**] Tablet(s) by mouth at bedtime METOPROLOL TARTRATE - (Prescribed by Other Provider) - 25 mg Tablet - 5 Tablet(s) by mouth three times a day OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 (One) Capsule(s) by mouth once a day PREDNISONE - 2.5 mg Tablet - 3 (Three) Tablet(s) by mouth once a day until next follow-up visit. SULFAMETHOXAZOLE-TRIMETHOPRIM - 400 mg-80 mg Tablet - 1 (One) Tablet(s) by mouth once a day. VALACYCLOVIR - (Prescribed by Other Provider) - 500 mg Tablet - 1 (One) Tablet(s) by mouth twice a day ZOLPIDEM - 5 mg Tablet - 1 (One) Tablet(s) by mouth at bedtime as needed for insomnia Medications - OTC B COMPLEX VITAMINS - (Prescribed by Other Provider) - Capsule - 1 (One) Capsule(s) by mouth once a day DOCUSATE SODIUM - (OTC) - 100 mg Capsule - 1 (One) Capsule(s) by mouth once a day as needed for constipation MULTIVITAMIN - (OTC) - Tablet - 1 (One) Tablet(s) by mouth once a day SENNOSIDES - (OTC) - 8.6 mg Tablet - 1 (One) Tablet(s) by mouth once a day as needed for constipation Discharge Medications: 1. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 4. metoprolol tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day): hold if HR<60 or SBP<100. 5. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO once a day for 3 days: then take Dexamethasone 2mg PO daily for 3 days, then take Dexamethasone 1mg PO daily for 3 days, then stop. 7. conjugated estrogens 0.625 mg/gram Cream Sig: One (1) Vaginal QMON/FRI (). 8. vancomycin 125 mg Capsule Sig: Four (4) Capsule PO four times a day. 9. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 10. multivitamin Tablet Sig: One (1) Tablet PO once a day. 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 12. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as needed for Constipation. 13. B complex vitamins Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day. 14. DILT-XR 120 mg Capsule,Ext Release Degradable Sig: One (1) Capsule,Ext Release Degradable PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital1 **] Discharge Diagnosis: Chronic Lymphocytic Leukemia Clostridium difficile Colitis Atrial Fibrillations Bladder Prolapse Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Ms. [**Known lastname **], You were admitted to [**Hospital1 69**] for severe dehydration from Clostridium difficile Colitis. We gave you intravenous fluids and antibotics and you are are now doing better. We also treated your chronic lymphocytic leukemia with chemotherapy and you will need to return to the [**Hospital 39955**] clinic for further evaluation and treatment of the chronic lymphocytic leukemia. Medication Changes: START taking Vancomycin 500mg by mouth every 6 hours Followup Instructions: Hematology/Oncology Dr. [**Last Name (STitle) **] at [**Location (un) 39956**]. [**Hospital Ward Name 23**] Center [**Location (un) 436**] [**2139-10-12**] 9:30am . Urology/Gynecology Phone: [**Telephone/Fax (1) 39957**] Dr. [**Last Name (STitle) 18522**], [**Name8 (MD) **] MD [**Location (un) **]; [**Hospital Ward Name **] [**Hospital Ward Name 23**] Center [**Location (un) **] Tuesday [**2139-10-13**] 8:00am . Opthalmology [**Telephone/Fax (1) 39958**] Dr. [**Last Name (STitle) **] [**Location (un) **]; [**Hospital Ward Name **] [**Hospital Ward Name 23**] Center [**Location (un) 442**] Thursday [**2139-10-15**] (9:45am) . Nuero-Oncology/Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 724**] [**Hospital Ward Name 23**] Center [**Location (un) **]; [**Hospital Ward Name **] Tuesday [**2139-10-20**] at 9:30am Phone: [**Telephone/Fax (1) 1844**] . Department: HEMATOLOGY/BMT When: WEDNESDAY [**2139-10-21**] at 1:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 3241**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Cardiology/Dr. [**Last Name (STitle) **] [**Last Name (STitle) **]: Friday [**2139-11-13**] 9:40am Phone: [**Location (un) 39959**]; [**Hospital Ward Name 39960**] Center; [**Location (un) 436**]

[ "276.2", "618.5", "427.31", "427.89", "780.61", "733.00", "272.4", "204.12", "379.23", "729.89", "799.4", "785.4", "276.52", "276.1", "V45.82", "427.0", "008.45", "709.2", "616.89" ]

icd9cm

[ [ [] ] ]

[ "03.92", "03.31", "99.25", "99.14" ]

icd9pcs

[ [ [] ] ]

20048, 20091

14056, 17348

322, 328

20232, 20232

5466, 14033

20927, 22361

4092, 4198

18715, 20025

20112, 20211

17374, 18692

20415, 20830

4213, 4213

4984, 5447

2668, 3116

20850, 20904

233, 284

356, 2649

4227, 4970

20247, 20391

3138, 3905

3921, 4076

3,796

195,517

52648

Discharge summary

report

Admission Date: [**2148-7-11**] Discharge Date: [**2148-7-17**] Date of Birth: [**2088-11-25**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2181**] Chief Complaint: hypotension/sepsis Major Surgical or Invasive Procedure: none History of Present Illness: 59 yo F with h/o osteomyelitis, HTN, depression, who presents from home with difficulty walking, feeling faint, and pale at home. Pt's abx were changed to nafcillin day prior. No cough, SOB, thrat swelling, rash, or cough. Overall pt states her health was unchanged. She did c/o headache today, no neck stiffness, no vision change. Pt has no pain including chest pain. Also no dietary or medication indiscretions. No diarrhea or abd pain. She did have [**12-11**] a beer yesterday and spent most of the day on her porch. Today she was too weak to get out of bed. In the ED, 99.0, HR 76, BP 63/30, 16, 97 % RA. Given 2L NS via EMS with little change in BP. Brown guiac positive stool on exam. Pt was mentating. Levofed started in the ED and given 1 mg ativan. Vancomycin given. Sepsis protocol intiated with BP improved to 115/64 on levofed. MAP 70s-80s. CVP 4-5. Admitted to [**Hospital Unit Name 153**] for hypotension. On arrival, initially somnolent but awoke with stimulation. Was hemodynamically stabilised in the [**Hospital Unit Name 153**] and then transferred to the floor for further management Past Medical History: s/p ant-inf MI with stent to pLAD ([**2142**]) CHF with EF 20-25% s/p Left foot HAV repair & 2nd digit PIPJ arthroplasty HTN Hypercholesterolemia Hx. of substance Abuse Hx. of EtOH Abuse Depression Anxiety Social History: (+) EtOH (+) Recreational Drug usage including Marijuana, but denies IVDU Family History: Father died of heart disease Physical Exam: Temp 97.5/96.5 c BP 109/67, 0.03 levofed gtt Pulse 66 Resp 14 O2 sat 98% 2 L, 96% RA Gen - Alert, no acute distress, arousable but would fall asleep without stimulation HEENT - PERRL, extraocular motions intact, anicteric, mucous membranes dry Neck - no JVD, no cervical lymphadenopathy, RIJ in place Chest - crackles at bases, no wheeze CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops Abd - Soft, nontender, nondistended, with normoactive bowel sounds Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally Neuro - Alert and oriented x 3, cranial nerves [**1-21**] intact, move all extremities, left antecub PICC line Skin - No rash Pertinent Results: [**2148-7-11**] 06:10PM PT-16.0* PTT-27.7 INR(PT)-1.5* [**2148-7-11**] 06:10PM PLT SMR-LOW PLT COUNT-135*# [**2148-7-11**] 06:10PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL [**2148-7-11**] 06:10PM NEUTS-89.1* BANDS-0 LYMPHS-5.6* MONOS-1.1* EOS-3.3 BASOS-0.7 [**2148-7-11**] 06:10PM WBC-7.0 RBC-2.88* HGB-9.8* HCT-26.8* MCV-93 MCH-34.1* MCHC-36.6* RDW-15.9* [**2148-7-11**] 06:10PM [**Month/Day/Year **]-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2148-7-11**] 06:10PM CRP-56.2* [**2148-7-11**] 06:10PM CORTISOL-19.7 [**2148-7-11**] 06:10PM HAPTOGLOB-148 [**2148-7-11**] 06:10PM ALBUMIN-3.5 CALCIUM-7.1* PHOSPHATE-2.3* MAGNESIUM-1.5* [**2148-7-11**] 06:10PM CK-MB-3 cTropnT-0.01 [**2148-7-11**] 06:10PM LIPASE-33 [**2148-7-11**] 06:10PM ALT(SGPT)-10 AST(SGOT)-52* LD(LDH)-255* CK(CPK)-128 ALK PHOS-64 AMYLASE-54 TOT BILI-0.7 CXR [**2148-7-15**]:Resolution of asymmetrical pulmonary edema. Focal right middle lobe opacity, likely due to atelectasis. New discoid atelectasis in the lingula. Gastric biopsy [**7-14**]: Mucosal biopsies. A. Antrum:No diagnostic abnormalities recognized. B. Duodenum:No diagnostic abnormalities recognized Brief Hospital Course: Hypotension: the hypotension could have been due to acute intestitial nephritis from nafcillin. was on levofed drip in the [**Hospital Unit Name 153**]. weaned off on the floor. BP was stable on the floor. AIN was treated with conservative treatment. BUN/Cr was monitored and IV fluids were given as needed. Nafcillin was stopped. Cr treanded down over the sourse of her stay. Pneumonia:CXR showed left and right lower lobe consolidation , either atelectasis or pneumonia. mild pulm edema. neg urine legionella antigen. was treated with ceftriaxone and azithromycin UTI: urine cx showed E.coli sensitive to all except ampi and piperacillin.was treated with ceftriaxone Renal failure: was due to AIN (rel to nafcillin). FENa of 9. rare eos in urine. AIN was treated with conservative treatment. BUN/Cr was monitored and IV fluids were given as needed. Nafcillin was stopped. Cr treanded down over the sourse of her stay. Hyponatermia: was likely hypovolemic hyponatremia. Na increased and stabilised around 134 Anemia: GI bleed in setting of guaiac +ve stool. low Fe, TIBC. high ferritin. Fe/TIBC < 18%. pt was transfused. GI was consulted. underwent EGD. no abnormality found. gastric biopsy did not show any abnormality. Psych: pt had threatned suicide. psych consulted. sitter was ordered. pt calmed down later. psych d/c ed sitter and ordered Utox which was neg. was continued on fluoxetine, risperidone. neurontin was held due to renal failure CAD: CE trended down. was continued on [**Last Name (LF) 17339**], [**First Name3 (LF) **] Osteomyelitis: nafcillin was stopped due to AIN and initially was treated with IV vanc.discussed with Dr [**Last Name (STitle) **] who was following the pt as an outpt. per him, she was given ancef 1g IV q8h for 2 days to complete the 6 week abx course for osteomyelitis of left foot. FEN: cardiac healthy diet Code: Full Access: PICC in left antecube. was pulled before d/c Medications on Admission: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): for heart disease. 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime: for cholesterol. 3. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily): for depression. 4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day): for anxiety. 5. Risperidone 0.5 mg Tablet Sig: one-half Tablet PO at bedtime as needed for insomnia for 4 days. 6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): for blood pressure and heart failure. 7. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily): for blood pressure and heart failure. 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): for heart failure. Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 4. Neurontin 300 mg Capsule Sig: One (1) Capsule PO three times a day. 5. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. [**Last Name (STitle) **]:*15 Tablet(s)* Refills:*0* 6. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 7. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Acute interstitial nephritis Discharge Condition: Stable Discharge Instructions: Please take all medications as prescribed If you have chest pain, shortness of breath, dizziness, fever, cough, abdominal pain please contact your primary care provider or go to the emergency room Followup Instructions: Please follow your appointment with DR [**First Name8 (NamePattern2) 7618**] [**Name (STitle) **] ([**Telephone/Fax (1) 457**]on [**2148-8-6**] at 10:30 am. Please make a follow up appointment with your primary care provider DR [**Last Name (STitle) **] ([**Telephone/Fax (1) **]) within one week of discharge Please make a follow up appointment with your psychiatrist or call ([**Telephone/Fax (1) 1387**]) to make an appointment with psychiatrist at the [**Hospital1 18**] Completed by:[**2148-7-19**]

[ "276.1", "401.9", "518.81", "412", "255.4", "428.0", "599.0", "038.9", "414.01", "E930.0", "272.0", "428.22", "580.89", "486", "730.27", "V45.82", "995.92", "785.52", "280.0", "578.9", "276.52" ]

icd9cm

[ [ [] ] ]

[ "45.16", "38.93", "99.04" ]

icd9pcs

[ [ [] ] ]

7233, 7239

3809, 5737

335, 341

7312, 7321

2539, 3786

7566, 8072

1816, 1846

6565, 7210

7260, 7291

5763, 6542

7345, 7543

1861, 2520

277, 297

369, 1478

1500, 1708

1724, 1800

25,008

170,999

46701

Discharge summary

report

Admission Date: [**2113-6-9**] Discharge Date: [**2113-6-15**] Date of Birth: [**2039-5-26**] Sex: M Service: NEUROLOGY Allergies: Aspirin / Iodine; Iodine Containing Attending:[**First Name3 (LF) 618**] Chief Complaint: Dizziness and vomiting Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 99134**] is a 74 year old R-handed man who was admitted on [**6-9**] after being transferred from [**Hospital3 934**] Hospital. His complaints started with a headache, on the top of his head, on [**6-5**]. [**6-6**] he started to vomit in the morning, while lying on the couch. At that time he felt like the room was spinning around him and he had some nausea. When the vomiting didn't stop he called 911. He was admitted with "gasteroenteritis". [**6-7**] he couldn't walk as usual, walking like a "drunk" and noticed he was clumsy in his hands. At that point, he did not have vertigo or nausea. After a MRI that showed a R-cerebellar infarct with hemorrhagic conversion and was brought to [**Hospital1 18**] (as surgical backup is present). He was admitted Neuro ICU and transferred to floor once he remained stable. Past Medical History: CAD, s/p CABG x 3 in [**2092**], repeat in [**2112**] AMI DM 2 HTN PVD, bilateral fem-[**Doctor Last Name **] bypass [**2106**] CRI (1.4-1.7) GERD Paget's disease s/p cholecystectomy [**2110**] PUD (ASA related) Hypothyroidism Afibb (after CABG) Social History: Not married, no children, lives alone. Retired (retail). Quit smoking '[**82**] (smoked for 20 years) Family History: Father: MI [**47**]'s, sister had CABG Physical Exam: Vitals T 97.8 HR 60 BP 120/76 sO2 95% RA RR 18 FSBS 102 i/o: 190/500(shift) General: NAD HEENT: mmm; no icterus Neck: no bruits over carotids; no LAD; no JVD, supple Cor: S1, S2, regular, no murmurs Pulm: CTA bilaterally Abd: soft, nt, nd, nl bs Extr: no edema, warm Neurological exam: Mental status: awake, alert, oriented to person, time and place. Cooperative. Attention: months of year backwards slowly without mistakes. Registration: [**1-19**]; Recall [**12-22**] after 3 minutes. No dysarthria, language fluent, comprehension intact, naming intact. [**Location (un) **] intact; writing not tested. No apraxia. No neglect for situation or space. Cranial nerves: II: pupils equal, round, reactive to light (direct as well as consensual). Fundoscopic exam not performed. Visual fields intact upon confrontation. III, IV, VI: extraocular movements intact with bilateral horizontal nystagmus (more pronounced to the R), saccades on horizontal gaze V: facail sensation intact VII: facial movements symmetrical VIII: hearing intact to fingerrub bilaterally IX-X: palate elevates in midline [**Doctor First Name 81**]: strength in trapezius and sternocleidomast. intact XII: tongue protrudes in midline Motor: normal bulk and tone. no fasciculations or tremor. No pronator or deltoid drift. Strength full in upper and lower extremities. Sensation: intact to pinprick, light touch, temperature (cold). Intact vibration throughout. Decreased proprioception in both toes. Reflexes: DTR: symmetrical (2+), toes upgoing bilaterally. Coordination: FNF slow, with dysmetria bilaterally (more on R), rebound increased, HTS intact on R, slightly impaired on L. [**Doctor First Name **]: slow bilaterally. Gait: not tested Pertinent Results: [**2113-6-12**] 06:40AM BLOOD WBC-10.3 RBC-4.63 Hgb-12.9* Hct-39.0* MCV-84 MCH-27.8 MCHC-33.0 RDW-16.9* Plt Ct-263 [**2113-6-12**] 06:40AM BLOOD Glucose-90 UreaN-24* Creat-1.0 Na-139 K-4.3 Cl-102 HCO3-23 AnGap-18 [**2113-6-12**] 06:40AM BLOOD Calcium-9.4 Phos-3.6 Mg-2.1 Bedside swallow: passed. regular diet. BRAIN MRI: Findings indicative of acute/subacute infarct with associated blood products and edema in the R cerebellar hemisphere and mass effect on the fourth ventricle with resultant moderate hydrocephalus. Old L- cerebellar stroke. MRA OF THE HEAD: Irregularity of the flow signal of the distal right vertebral artery in the vicinity of the origin of the posterior inferior cerebellar artery could be secondary to a thrombus or a focal dissection. CT ANGIOGRAPHY: The right vertebral artery is narrowed from its entry into the foramen magnum until the take off of the posterior inferior cerebellar artery. Although this area is partially obscured by dental artifacts, the finding is suggestive of a dissection. The cavernous portion of both carotid arteries shows some atheromatous change, but no evidence of dissection. The remainder of the circle of [**Location (un) 431**] and its major branches are patent. Surrounding osseous structures are remarkable for sternotomy wires on the right. Visualized lung apices are clear. CT head [**6-10**]: FINDINGS: There is no significant change from the previous study. Chronic left cerebellar infarction and subacute right cerebellar infarction are again noted. There is similar compressive effect on the fourth ventricle and secondary dilatation of the third and lateral ventricles. No new regional areas of hyperdensity are appreciated. There is similar appearance to high density along the left superior tentorium. No worsening or new intracranial hemorrhage identified. No shift of the normally midline structures. IMPRESSION: No significant change from prior study of [**2113-6-9**]. CT head [**6-14**]: Comparison with the prior [**2113-6-10**] head CT scan continues to show the mixed density large infarct within the medial aspect of the right cerebellar hemisphere, also occupying a portion of the vermis. There is perhaps slightly less compression of the fourth ventricle at this time. The smaller chronic left cerebellar infarct is again seen. There are no other overt interval changes identified. TEE [**6-15**]: The left atrium is mildly dilated. No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. There is a 1.0 x 0.9 round echodensity seen in the left atrial appendage, likely representing an organized thrombus. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is severely depressed. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Probable thrombus in the left atrial appendage (differential diagnosis also includes an atypical left atrial myxoma or other cardiac tumor). Moderate mitral regurgitation. Severe systolic left ventricular dysfunction, consistent with multivessel coronary artery disease. Brief Hospital Course: 74 year old R-handed male with CAD, DM, HTN, PVD, CRI presenting with nausea, vomiting, later followed by an ataxic gait and ataxia in his arms. Pt. was found to have an acute R-cerebellar stroke with hemorrhagic transformation and some compression on the 4th ventricle. Also old L-cerebellar stroke. Mr. [**Known lastname 99134**] had some episodes of intermittent double vision, but no dizziness, headache or vomiting during the remaining course of the hospitalization. 1) Neuro: acute R-cerebellar stroke with hemorrhagic transformation and compression on the 4th ventricle. The compression on the 4th ventricle has improved somewhat per CT-head [**6-14**]. CTA suggests dissection of R-vertebral artery (close to PICA) although the study was not optimal. Chol: 77. Prior to discharge, patient was able to ambulate with assistance. Lipitor should be continued, and aspirin was added after the acute phase (as the hemorrhage was not evolving). As the TEE showed the possibility of a thrombus in the left atrium, coumadin was started as well. A follow up TEE should be done after a month to see whether the thrombus has resolved or whether it represents a myxoma. If the finding per TEE represents a thrombus, this might have caused the intitial stroke. 2) Cardiovascular: Patient has a history of post-op afib. During the hospitalization he was in sinus, although frequent PVC's were noted while on telemetry. Amiodarone (Afibb), Toprol, spironolacton, valsartan were continued with adjustments in dosing to achieve optimal blood pressure control. 3) Hypothyroidism: Levoxyl was continued. No changes were made in dosing. 4) Prophylaxis: VD boots while in bed (DVT), no complications; ranitidine (PUD); colace, senna and dulcolax prn (BM) 5) Diet: Patient passed speech and swallow [**6-12**] and was started on a low sodium, cardiac diet which he tolerated well. Medications on Admission: Aldactone toprol xl lipitor ASA 81 amiodarone, diovan glyburide, HCTZ, synthroid Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 5. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO EVERY OTHER DAY (Every Other Day). 6. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 8. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Valsartan 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Levothyroxine Sodium 25 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 13. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 14. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: Two (2) units Subcutaneous per sliding scale: follow sliding scale; 2 units for FSBS>150 and <200; 4 units if >201 and <250; 6 units if >251 and <300. 15. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Discharge Disposition: Extended Care Facility: [**Hospital3 13990**] Health Care Center Discharge Diagnosis: 1. cerebellar stroke with hemorrhagic conversion 2. left atrial appendix (thrombu or myxoma) Discharge Condition: Good, with gait problems Discharge Instructions: Please follow up with your PCP and at the Stroke Clinica as instructed below. Please take your medications as instructed. If symptoms (as double vision or gait problems) worsen or if you experience nausea, vomiting, dizziness, or a severe headache, please seek medical assistance or call 911. INRs must be followed (started coumadin [**2113-6-15**]), goal INR [**12-22**]. Needs follow-up in one month with his PCP regarding repeat TEE to see if clot in left atrial appendage has resolved. Followup Instructions: Please follow up at the [**Hospital 4038**] Clinic, [**Hospital1 18**]: Please call the Clinic at [**Telephone/Fax (1) 1694**] to set up an appointment, update your demographics, and get directions (Dr. [**Last Name (STitle) **]. Please have your INR checked and coumadin dose adjusted to keep INR 2.0-3.0. Please follow up with your PCP [**Name Initial (PRE) 176**] 1 week. Dr. [**Last Name (STitle) 2539**] has been informed. Appointment for repeat TEE (transesophageal echocardiogram) in one month: [**2113-8-9**] at 9am, [**Hospital1 18**], Grizmish building, [**Location (un) **]. [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] Completed by:[**2113-6-15**]

[ "427.31", "272.0", "401.9", "431", "414.00", "530.81", "434.91", "412", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "88.72" ]

icd9pcs

[ [ [] ] ]

10389, 10456

6932, 8801

318, 324

10593, 10619

3399, 3946

11158, 11869

1600, 1640

8932, 10366

10477, 10572

8827, 8909

10643, 11135

1655, 1927

1946, 1946

256, 280

352, 1195

2329, 3380

3963, 6909

1961, 2313

1217, 1465

1481, 1584

65,985

187,922

35189

Discharge summary

report

Admission Date: [**2194-11-28**] Discharge Date: [**2194-11-30**] Date of Birth: [**2117-1-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 759**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 732**] is a very pleasant 77-year-old man who had an ERCP on [**11-19**] at [**Hospital6 4287**] for cholangitis attributed to gallstone pancreatitis complicated by post-sphincteromy bleeding. He underwent a second ERCP with vessel clipping on [**11-22**]. During that admission, his Hct decreased to 20, requiring 5 Units of PRBCs as well as FFP. He was discharged on [**11-25**] with Hct 24. He reports he was feeling fairly well and completed his course of levofloxacin and metronidazole on Wednesday. Since discharge he reports dark stools almost every day. On [**11-28**] he became Lightheaded with transient syncope while at work, no LOC, chest pain, palpitations, focal weakness, numbness, tingling. EMS activated and SBP 80 in the field per EMS--> [**Hospital3 **] ED. On arrival to [**Hospital3 **] ED, BP 107/43 with HR 67. Hct 29.4 --> 28.4 over 5 hrs in their ED. CE neg x 1. ECG with incomplete RBBB and LAD, LAFB with no acute ischmic changes. In the ED there, reportedly had hematochezia and recurrent episode of lightheadedness. Rx'd 1 L NS bolus and started on NS 150 cc/hr. Patient was conversant throughout. He was transferred to [**Hospital1 18**] for further management, and admitted to the [**Hospital Ward Name 332**] ICU. . On arrival to the [**Hospital Unit Name 153**], patient was clinically stable, conversational with SBP in the 130s-150s. . ROS: The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, chest pain, shortness of breath, orthopnea, PND, lower extremity oedema, cough, urinary frequency, urgency, dysuria, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: DM2 HTN CAD s/p in LAD in [**2186**] Diverticulosis Bilateral inguinal hernia repair Recurrent E. coli UTI Thoracic aortic aneurysm Social History: No smoking, drinking, or drug use. Lives with wife. [**Name (NI) **] works full-time at his farm - he owns [**Known lastname 732**] Farms, a large operation in [**Location (un) **] and southern [**Location (un) 3844**]. He and his sons work together in the family business. Family History: Mother died of an aneurysm in her 30's, when patient was 10 yrs old. He's the only child. Father died in his 70's from a heart condition. Physical Exam: GEN: Well-appearing, well-nourished elderly man, no acute distress, pleasantly conversational HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: regular rhythm, normal rate, normal S1/S2, 2/6 systolic murmur, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Patellar DTR +1. Plantar reflex downgoing. No gait disturbance. No cerebellar dysfunction. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. RECTAL: brown stool, guaiac positive Pertinent Results: [**2194-11-30**] 10:30AM BLOOD Hct-33.3* [**2194-11-30**] 06:55AM BLOOD WBC-6.0 RBC-3.15* Hgb-9.6* Hct-27.7* MCV-88 MCH-30.5 MCHC-34.7 RDW-15.3 Plt Ct-314 [**2194-11-29**] 04:20PM BLOOD Hct-31.3* [**2194-11-29**] 06:45AM BLOOD WBC-6.7 RBC-3.12* Hgb-9.7* Hct-27.5* MCV-88 MCH-31.1 MCHC-35.2* RDW-16.2* Plt Ct-312 [**2194-11-29**] 01:15AM BLOOD Hct-24.1* [**2194-11-28**] 09:30PM BLOOD WBC-7.1 RBC-2.98* Hgb-8.8* Hct-26.1* MCV-88 MCH-29.6 MCHC-33.7 RDW-15.4 Plt Ct-231 [**2194-11-30**] 06:55AM BLOOD PT-13.5* PTT-29.8 INR(PT)-1.2* [**2194-11-30**] 06:55AM BLOOD Glucose-143* UreaN-10 Creat-0.8 Na-140 K-3.7 Cl-108 HCO3-24 AnGap-12 [**2194-11-30**] 06:55AM BLOOD Calcium-7.7* Phos-2.1* Mg-1.9 Brief Hospital Course: 77-year-old man with DM2, CAD s/p LAD stent in [**2186**], HTN, recent ERCP for gallstones c/b bleeding leading to second ERCP on [**11-22**] who presented to [**Last Name (un) 1724**] with syncopal episode, likely due to hypovolemia from orthostatic hypotension, concerning for GI bleed with melena. The patient was transferred to the [**Hospital1 18**] ICU. He received 1 Unit PRBCs and was given only clear liquids to eat. He remained hemodynamically stable through the rest of his admission in the ICU and was called out to the General Medical Floor. Hospital Course: # GI bleed: likely secondary to recent sphincterotomy - serial Hcts --> Hct remained stable s/p transfusion - had two 18 g IV's in place - IVF x first day, then d/c'd - If bleeding recurrs/becomes more significant, may require urgent endoscopy. - started on PPI . # Pre-syncopal episode: likely orthostatic hypotension, secondary to possible GI bleed. ECG without evidence for acute ischemia. CE negative x 1 at OSH. No focal weakness to suggest stroke. - monitor BP. Antihypertensive meds held till evening of [**11-29**] when metoprolol 25 mg was given. On [**11-30**], Toprol XL 100 mg was started. - There were no events on telemetry. . # CAD: s/p LAD stent in [**2186**] - hold aspirin - hold ACE-I, CCB given recent hypotension; Hold Lisinopril and Amlodipine until further instructed by physician. . # HTN: - hold anti-hypertensives as above . # DM2: - hold glyburide and pioglitazone while in-house. - insulin s.s. . # FEN: clear liquids for now . # Access: large-bored IVs . # PPx: pneumoboots . # Code: FULL Medications on Admission: ASA 81 mg qday pioglitazone 30 mg qday doxazosin 2 mg qday Fe sulfate 325 mg [**Hospital1 **] metronidazole 500 mg tid - recently completed folate 1 mg qday furosemide 60 mg qday levoflox 750 mg qday - recently completed glyburide 1.25 mg qday ? [**Hospital1 **] amlodipine 10 mg qday lisinopril 40 mg qday metoprolol XL 200 mg qday Vicodin prn simvastatin 80 mg qhs Discharge Medications: 1. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Glyburide Oral 4. Actos Oral 5. Doxazosin Oral 6. Lasix Oral 7. Simvastatin Oral Discharge Disposition: Home Discharge Diagnosis: Primary: 1) Acute blood loss anemia 2) Bleeding at prior sphincterotomy site, s/p ERCP [**11-19**] for gallstone pancreatitis, s/p repeat endoscopy [**11-22**] with clipping of visible vessel at [**Hospital6 1597**] 3) Type 2 Diabetes Mellitus, uncontrolled 4) Hypertension 5) history of CAD s/p stents in [**2186**] 6) history of diverticulitis 7) history of E. coli UTI 8) s/p bilateral inguinal hernia repairs 9) history of thoracic aortic aneurysm Discharge Condition: Good, ambulating independently, tolerating a normal diet. Discharge Instructions: You were admitted to the hospital due to internal bleeding (acute blood loss anemia). It was felt this bleeding was related to the recent ERCP and sphincterotomy you had at [**Hospital1 4259**] earlier this month. You were given one unit of packed red blood cells in the ICU and did well. You should continue to take your pantoprazole 40 mg every day. This medication will help this spot in your intestine heal and will also help decrease any inflammation in your small intenstine that was seen on the endoscopy at [**Hospital3 **]. . **You should continue to take your Toprol XL (lopressor, extended release) 200 mg daily for your blood pressure. You may also continue to take your Lasix (furosemide) 60 mg daily. You may also take your simvastatin (Zocor). . *****STOP TAKING - DO NOT TAKE - your lisinopril or your amlodipine. These all can lower your blood pressure and your blood pressure was dangerously low when you were admitted. You did not need them while you were here. Your primary care doctor or cardiologist may want to restart these as your anemia improves and your blood pressure increases. . *****STOP TAKING - DO NOT TAKE - your aspirin. When your bleeding stops, you may consider restarting this medication for your heart, but please speak with your doctor before you do so. . Please take your diabetes pills (Actos (pioglitazone) and your glyburide). We did not give you these during your admission because you were not eating regularly. If for some reason you are not able to eat, you should not take these medications as your blood sugar could drop to dangerously low levels. . You may take your doxazosin (Cardura) as this might help your urinary tract. If you feel lightheaded, please stop taking this medication as one of its side-effects is lightheadness and fainting. . If you develop chest pain, shortness of breath, significant black stool (as we discussed), nausea, vomiting, abdominal pain, fainting, lightheadedness, sweaty feeling(s), etc, please call 911 or seek immediate medical attention. . DO NOT DRIVE A CAR IF YOU ARE FEELING UNWELL OR FAINT . Followup Instructions: Please follow up with Dr. [**First Name8 (NamePattern2) 2174**] [**Last Name (NamePattern1) 20932**] on Tuesday as previously arranged.

[ "414.01", "578.1", "250.02", "458.0", "441.7", "V45.82", "V04.81", "285.1" ]

icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

6646, 6652

4217, 4775

325, 331

7148, 7208

3503, 4194

9353, 9492

2524, 2665

6232, 6623

6673, 7127

5840, 6209

4792, 5814

7232, 9330

2680, 3484

277, 287

359, 2059

2081, 2214

2230, 2508

78,814

173,253

36025

Discharge summary

report

Admission Date: [**2126-3-29**] Discharge Date: [**2126-4-9**] Date of Birth: [**2049-5-4**] Sex: M Service: ORTHOPAEDICS Allergies: Levofloxacin / Quinolones Attending:[**First Name3 (LF) 16613**] Chief Complaint: Mr. [**Known lastname 50992**] presented for definitive treatment of chronic left ankle pain. Major Surgical or Invasive Procedure: Left hindfoot fusion [**2126-3-29**], [**2126-4-5**] left first toe amputation History of Present Illness: Mr. [**Known lastname 50992**] presented for definitve treatment of left ankle. Past Medical History: CAD, s/p CABG COPD, on 2L home 02 at night MS, with chronic L sided weakness, urinary retention Frequent UTIs Chronic L ankle fx, chronic L ankle ulcer x 9 months DM2 HTN Trigeminal neuralgia BPH GERD Social History: Lives with wife and daughter in [**Name (NI) 8072**], [**Name (NI) **], retired electronics tester. No tobacco or EtOH. Ambulates with walker or uses chair lift. Family History: NC Physical Exam: On discharge: Afebrile, All vital signs stable General: Alert and oriented, No acute distress Extremities: left lower Weight bearing: non weight bearing for total period 6 weeks Incision: intact, no swelling/erythema/drainage Dressing: clean/dry/intact Extensor/flexor hallicus longus intact Sensation intact to light touch Neurovascular intact distally Capillary refill brisk 2+ pulses Pertinent Results: [**2126-3-28**] CT chest w/o contrast 1. Increased multifocal consolidation, bronchiolitis and bronchial wall thickening, suggesting active infection. Left upper lobe pulmonary nodule is now hidden by adjacent consolidation, should be followed after antibiotic treatment. 2. Emphysema. Signs of small airway disease. 3. Gallstones. Calcification in the common bile duct with new foci of air in the gallbladder, should be correlated with prior instrumentation and patient's symptoms. 4. Unchanged calcifications in the left adrenal gland, likely due to prior hematoma or granulomatous exposure. [**2126-3-29**] 09:21PM GLUCOSE-131* UREA N-12 CREAT-0.6 SODIUM-139 POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-29 ANION GAP-10 [**2126-3-29**] 09:21PM CK(CPK)-50 [**2126-3-29**] 09:21PM CK-MB-5 cTropnT-0.07* [**2126-3-29**] 09:21PM CALCIUM-7.7* PHOSPHATE-3.8 MAGNESIUM-1.7 [**2126-3-29**] 09:21PM WBC-13.0*# RBC-3.10* HGB-9.3*# HCT-28.8* MCV-93 MCH-30.1 MCHC-32.4 RDW-15.6* Brief Hospital Course: Mr. [**Known lastname 50992**] was admitted to [**Hospital1 18**] on [**2126-3-29**] for an elective left total ankle fusion and left great toe amputation. Pre-operatively, he was consented, prepped, and brought to the operating room. Intra-operatively, he was closely monitored and remained hemodynamically stable. He tolerated the procedure well without any complication. Post-operatively, he was transferred to the PACU and unit for labile blood pressure and pulse. Urology was consulted for frank pus in urine. Urology recommends to continue on antibiotic for 3 weeks. He was followed by medical staff regarding betablockers and resumed them on [**4-1**]. On the floor, he remained hemodynamically stable with his pain was controlled. On [**2126-4-5**] he was brought back to the operating room for a left great toe amputation. He tolerated this well. He progressed with physical therapy to improve his strength and mobility. He was discharged in stable condition. He will remain in bivalve foot splint until post op appointment. Medications on Admission: a m i o d a r o n e , a r i x t r a , a s a , l a s i x , g l y b u r i d e , s e r t r a l i n e , s p i r i v a , m v i , a d v a i r , c a r v e d i l o l , m e t f o r m i n , c o a c e , s e n n a , c a r b a m a z a p i n e , g a b a p e n t i n , f l o m a x , o m e prazole,simvastatin,zonisamide,mylanta,tylenol,vicodin,albuterol All:Levofloxacin / Quinolones Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H () as needed. Disp:*60 Tablet(s)* Refills:*0* 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 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. 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO BID (2 times a day) as needed. 8. Fondaparinux 2.5 mg/0.5 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily) for 3 weeks. 9. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 12. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 13. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 15. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 16. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 17. Zonisamide 100 mg Capsule Sig: Two (2) Capsule PO QHS (once a day (at bedtime)). 18. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q4H (every 4 hours) as needed. 19. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 20. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for wheeze. 21. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 22. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 3 weeks. Disp:*qs * Refills:*0* 23. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Hospital Discharge Diagnosis: Left ankle fracture dislocation, left first toe infection Urinary tract infection Discharge Condition: stable Discharge Instructions: If you experience any shortness of breath, new redness, increased swelling, pain, or drainage, or have a temperature >101, please call your doctor or go to the emergency room for evaluation. You may not bear weight on your left leg. Please use your crutches/walker/wheelchair. Please resume all of the medications you took prior to your hospital admission. Take all medication as prescribed by your doctor. You have been prescribed a narcotic pain medication. Please take only as directed and do not drive or operate any machinery while taking this medication. There is a 72 hour (Monday through Friday, 9am to 4pm) response time for prescription refil requests. There will be no prescription refils on Saturdays, Sundays, or holidays. Please plan accordingly. Please continue your fondaparinux for 3 weeks to prevent blood clots. Please continue ceftriaxone for 3 weeks for your bladder infection. Feel free to call our office with any questions or concerns. Physical Therapy: Activity: Out of bed w/ assist Treatments Frequency: Keep your incision/dressing/cast clean and dry. Apply a dry sterile dressing daily as needed for drainage or comfort. Keep your left foot dry for 5 days after your surgery. Your skin staples/sutures may be removed 2 weeks after your surgery or at the time of your follow up visit. Please remove bivalve cast daily to inspect skin + wounds Followup Instructions: Provider: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3260**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**] Date/Time:[**2126-4-15**] 11:40 [**Name6 (MD) 13978**] [**Name8 (MD) **] MD [**MD Number(2) 16614**] Completed by:[**2126-4-9**]

[ "340", "707.03", "414.00", "600.00", "905.4", "250.00", "736.79", "342.90", "E929.9", "E928.9", "285.9", "350.1", "958.3", "458.29", "707.23", "427.31", "V45.81", "599.0", "496" ]

icd9cm

[ [ [] ] ]

[ "84.11", "83.85", "81.11", "81.13" ]

icd9pcs

[ [ [] ] ]

6147, 6203

2429, 3472

383, 464

6329, 6338

1432, 2406

7774, 8103

994, 998

3893, 6124

6224, 6308

3498, 3870

6362, 7335

1013, 1013

7353, 7386

7408, 7751

1028, 1413

250, 345

492, 573

595, 798

814, 978

58,303

182,161

38248

Discharge summary

report

Admission Date: [**2184-6-4**] Discharge Date: [**2184-6-22**] Date of Birth: [**2130-8-5**] Sex: F Service: CARDIOTHORACIC Allergies: Tegretol / Penicillins / Latex / Dilantin / Mysoline Attending:[**First Name3 (LF) 922**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**2184-6-10**] 1. Mitral valve replacement (25/33 On-X Conform-X),Tricuspid valvuloplasty ([**Doctor Last Name **] 32-mm MC cubed ring annuloplasty), Coronary bypass grafting x1(left internal mammary artery to left anterior descending coronary artery), Left ventricular biopsy,Resection of Left atrial appendage. History of Present Illness: Mr. [**Known lastname **] is a 53 year old woman who presented to the [**Location (un) **] ED with increasing SOB of several days duration. Workup led to the diagnosis of severe mitral and tricuspid regurgitation as well as acute systolic heart failure. Catheterization also revealed single vessel disease of the left anterior descending artery. She was referred for surgery. Past Medical History: Acute systolic heart failure Breast Cancer s/p right lumpectomy and chemo 7 yrs ago Seizure disorder [**Doctor Last Name 933**] disease Pulmonary hypertension Social History: Race:Asian Last Dental Exam:3 months ago Lives with:husband Occupation:receptionist Tobacco:occasional ETOH:occasional Family History: non-contributory Physical Exam: admission: Pulse:100 Resp:19 O2 sat: 99 RA B/P Right:98/62 Height: Five feet Weight:90 pounds 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 [x]II/IV syst murmur at apex 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 but anxious Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: - Left: - Pertinent Results: [**2184-6-8**] Carotid U/S: Right ICA stenosis 0%. Left ICA stenosis <40%. [**2184-6-10**] Echo: PRE-BYPASS: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). The right atrium is dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is severely depressed (LVEF= 20%). with moderate global free wall hypokinesis. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 40 cm from the incisors. 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. The mitral valve leaflets do not fully coapt. There seems to be a bileaflet restriction. Moderate to severe (3+) mitral regurgitation is seen. Mitral annulus is 37mm in the LAX view and 35 mm in the commisural view in the endsystolic postion. Moderate [2+] tricuspid regurgitation is seen. Tricuspid annulus is 40mm in the ME4C view. There is no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the results on Miss Shaughness prior to surgical incision. Post_Bypass: Patient is on milrinone and epinephrine. Moderate RV global hypokinesis. The tricuspid ring is in place, seated and well functioning with no regurgitation/stenosis. The m itral mechanical valve is in place and functioning well. The classic washing jets are present. There is no other regurgitation. There is no evidence of stenosis. Intact thoracic aorta. Overall LVEF is 30% to 35%. [**2184-6-20**] CXR: The patient is status post mitral and tricuspid valve replacement and CABG with intact median sternotomy wires. The heart is stably enlarged. Retrocardiac opacity likely representing atelectasis persists. Again seen are small bilateral pleural effusions which are not appreciably changed. Clips are noted in the right axilla. [**2184-6-4**] 08:05PM BLOOD WBC-10.7 RBC-4.39 Hgb-12.8 Hct-39.1 MCV-89 MCH-29.2 MCHC-32.8 RDW-15.2 Plt Ct-277 [**2184-6-10**] 06:21PM BLOOD WBC-18.1*# RBC-2.55*# Hgb-7.5*# Hct-23.2*# MCV-91 MCH-29.5 MCHC-32.4 RDW-15.0 Plt Ct-176 [**2184-6-22**] 07:24AM BLOOD WBC-11.5* RBC-3.27* Hgb-9.8* Hct-30.1* MCV-92 MCH-30.0 MCHC-32.6 RDW-15.5 Plt Ct-557* [**2184-6-6**] 03:57AM BLOOD PT-13.2 PTT-24.2 INR(PT)-1.1 [**2184-6-10**] 07:45PM BLOOD PT-16.2* PTT-39.8* INR(PT)-1.4* [**2184-6-21**] 11:15AM BLOOD PT-22.7* PTT-49.9* INR(PT)-2.1* [**2184-6-22**] 07:24AM BLOOD PT-25.2* PTT-142.7* INR(PT)-2.4* [**2184-6-4**] 08:05PM BLOOD Glucose-87 UreaN-25* Creat-0.8 Na-139 K-4.4 Cl-111* HCO3-21* AnGap-11 [**2184-6-10**] 07:30AM BLOOD Glucose-101* UreaN-35* Creat-0.8 Na-138 K-5.3* Cl-101 HCO3-25 AnGap-17 [**2184-6-22**] 07:24AM BLOOD Glucose-105* UreaN-17 Creat-0.7 Na-135 K-4.9 Cl-101 HCO3-26 AnGap-13 [**2184-6-5**] 05:13PM BLOOD ALT-49* AST-53* LD(LDH)-234 AlkPhos-101 TotBili-0.3 Brief Hospital Course: Mrs. [**Known lastname **] was transferred from outside hospital to [**Hospital1 18**] for operative management. Upon admission she was medically managed and underwent appropriate pre-operative work-up. Given her acute left ventricular dysfunction and her history of radiation and chemo therapy for breast cancer, a left ventricular biopsy was also planned to look for myocardial changes related to that treatment. On [**6-10**] she was brought to the operating Room where she underwent mitral valve replacement, tricuspid valvuloplasty, Coronary bypass graft x 1, left ventricular biopsy and resection of Left atrial appendage. Please see operative report for details. Following surgery she was transferred to the CVICU for invasive monitoring in stable condition. She initially did require inotropes and pressors but these were weaned off on post-op day one. On post-operative day one she was weaned from sedation, awoke neurologically intact and extubated. Beta-blockers and diuretics were initiated and she was diuresed towards her pre-op weight. Coumadin was initiated and a Heparin infusion was utilized as a bridge while Coumadin was loaded. Chest tubes and epicardial pacing wires were removed per protocol. She developed rapid atrial fibrillation which was treated with IV and po amiodarone. She then required cardioversion to SR on post-op day 11. She was evaluated by Physical Therapy and cleared for discharge to home. Arrangements were made for her Coumadin management by Dr. [**Last Name (STitle) 8579**]. Precautions, restrictions, medications and follow up were discussed with her prior to discharge. Medications on Admission: HCTZ 25mg daily Phenobarbital 15mg TID PTU 150mg [**Hospital1 **] Potassium 10mEq [**Hospital1 **] Discharge Medications: 1. Mephobarbital 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*1* 2. Propylthiouracil 50 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*1* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. 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* 8. 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* 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day: Goal INR 2.5-3.5 Please adjust dose as directed by Dr. [**Last Name (STitle) 8579**]. Disp:*60 Tablet(s)* Refills:*2* 11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please take daily for Atrial Fibrillation until discontinued by Dr. [**Last Name (STitle) 8579**]. Disp:*30 Tablet(s)* Refills:*1* Discharge Disposition: Home With Service Facility: [**Location (un) 932**] Area VNA Discharge Diagnosis: Mitral Regurgitationa s/p Mitral valve replacement(25/33 On-X) Tricuspid Regurgitation s/p Tricuspid valve repair Coronary Artery Disease s/p Coronary bypass graft x 1 acute systolic heart failure Breast Cancer s/p right lumpectomy and chemo 7 yrs ago Seizure disorder [**Doctor Last Name 933**] disease Pulmonary hypertension Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with percocet Incisions: Sternal - healing well, no erythema or drainage Leg Left - mild erythema Edema - trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) 914**] on Tuesday, [**7-27**] at 1pm Please call to schedule appointments with: Primary Care: Dr. [**First Name4 (NamePattern1) 333**] [**Last Name (NamePattern1) 40075**] ([**Telephone/Fax (1) 40076**]in [**12-6**] weeks Cardiologist Dr. [**Last Name (STitle) 8579**] ([**Telephone/Fax (1) 23882**]in [**12-6**] 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** Labs: PT/INR for Coumadin ?????? indication: Mechanical Mitral Valve Goal INR 2.5-3.5 First draw day after discharge Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by Dr. [**Last Name (STitle) 8579**] Results to Dr. [**Last Name (STitle) 8579**] (his office will draw labs also) phone: [**Telephone/Fax (1) 23882**] fax: [**Telephone/Fax (1) 25791**] Completed by:[**2184-6-22**]

[ "345.90", "424.0", "518.5", "416.8", "998.0", "428.21", "425.4", "242.00", "E849.7", "E878.2", "397.0", "599.0", "428.0", "V10.3", "414.01", "427.31", "285.9", "312.9", "348.1", "294.9" ]

icd9cm

[ [ [] ] ]

[ "37.36", "37.25", "35.24", "39.61", "35.33" ]

icd9pcs

[ [ [] ] ]

8545, 8608

5340, 6958

336, 651

8978, 9177

2107, 5317

10014, 11030

1390, 1408

7107, 8522

8629, 8957

6984, 7084

9201, 9991

1423, 2088

277, 298

679, 1056

1078, 1238

1254, 1374

50,254

156,062

53640

Discharge summary

report

Admission Date: [**2196-9-2**] Discharge Date: [**2196-9-20**] Date of Birth: [**2128-2-16**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor First Name 3290**] Chief Complaint: Headache, nausea and vomiting after fall. Major Surgical or Invasive Procedure: Central line placement Dobhoff placement X3 History of Present Illness: 68 year old male with past medical history of alcohol abuse (quit 2 months ago), hypertension, depression, spinal stenosis and ?CHF who was admitted to Neurosurgery from an OSH on [**2196-9-2**] after falling down [**2-12**] stair steps. Patient had yelled out while falling and woke up when his wife came to him. Did lose consciousness, however, and was found to have subdural and subarachnoid hemorrhages on CT head at OSH. The patient initially complained of headache at the OSH and upon arrival to [**Hospital1 18**]. He has a history of imbalance/vertigo and essential tremor being worked up by Neurology at the OSH as an outpatient. . Neurosurgery felt the hemorrhages were not operable so the patient was managed medically with Mannitol in the TICU. His hospital course has been complicated by increasing cerebral edema on serial CT scans although the most recent CT scan ([**2196-9-9**]) was stable. On admission and per TICU notes, he had been able to answer questions initially but became intermittently agitated and lethargic as his hospital course progressed. Over the last weekend of discharge he was responsive to light touch but has been non verbal for at least the last 10 days of his admission. He did have a few episodes of increased right shoulder twitching which resolved with lorazepam 0.5mg X1-2 (ordered by Neurosurgery after evaluating the patient). The patient also developed fevers and leukocytosis during his hospital stay. Neurosurgery did not feel that it was secondary to the intracerebral bleed. One blood culture of five sets subsequently grew out coagulase negative staph. Infectious Disease was consulted and the patient started on Vancomycin [**2196-9-7**] evening. There is question as to whether the blood culture X1 was due to contamination vs. a true infection. His left subclavian appears clean and TTE did not show any vegetations (although not ordered specifically to evaluate for endocarditis). Patient also had some hypernatremia and intermittent tachypnea. ABG revealed respiratory alkalosis. Hypernatremia improved with adjustment of free water boluses. Echo showed mild impairment in systolic function and basal hypokinesis, so he was intermittently given lasix. . ROS: Remains unable to obtain. Also had right shoulder twitching concerning for possible seizure activity. Past Medical History: * Congestive heart failure, ?secondary to cardiomyopathy (EF 55% from TTE on [**2196-9-2**]; previous TTE at OSH w/ EF 45% in [**2196-6-9**]) * Hypertension * Depression * History of alcohol abuse, quit 2 months prior to admission * Spinal stenosis * Recent hospitalization for pneumonia in [**Month (only) 205**] at OSH Social History: Married, lives with wife in [**Name (NI) **], MA. Was previously functional. Former alcohol abuse, quit two months ago. Family History: Noncontributory Physical Exam: Upon transfer to [**Hospital1 18**] for neurosurgical evaluation: O: T: 99 BP: 162/74 HR: 76 R 18 O2Sats 99% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 3 to 2 bilateral EOMs intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Orientation: Oriented to person, place, and date. Recall: [**2-10**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**4-13**] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin . EXAM upon transfer to Internal Medicine: Tm=99.3 Tc=98.9 BP=127/51 (127-158/51-60) HR=59 (58-67) RR20 (20-28) O2=98-100%RA GENERAL: Non-responsive, older man. Opens eyes once to loud verbal stimuli but otherwise does not follow commands. Rapid shallow breathing. HEENT: Pupils round and reactive to light, left pupil more dilated than right. Dobhoff in place. Moist mucus membranes with face mask/humidified air in place. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, gallops, rubs; left subclavian in place - clean, dry and intact with mild sanguinous drainage, no purulence or erythema LUNGS: CTAB anteriorly, no wheezing/rhonchi/rales, tachypneic ABDOMEN: +Bowel sounds, soft, non-tender/non-distended, overweight. No palpable hepatosplenomegaly EXTREMITIES: No cyanosis, ecchymosis, trace bilateral lower extremity edema SKIN: Warm, soft and supple. NEURO: Minimally responsive to loud verbal and noxious stimuli. Toes upgoing in bilateral lower extremities . EXAM upon discharge: Tm=98.1 146/61 77 18 100RA GENERAL: Opens eyes and reacts to gentle touch, occasionally to verbal stimuli. HEENT: Pupils round and reactive to light, left pupil more dilated than right. Dobhoff in place. Moist mucus membranes with face mask/humidified air in place. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, gallops, rubsLUNGS: CTAB anteriorly, no wheezing/rhonchi/rales, tachypneic ABDOMEN: +Bowel sounds, soft, non-tender/non-distended, overweight. No palpable hepatosplenomegaly EXTREMITIES: No cyanosis, ecchymosis, 1+ bilateral lower extremity edema NEURO: As in general, mildy responsive to stimulus. Pertinent Results: [**9-2**] Echo: Suboptimal image quality. The left atrium is moderately dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction suggested with basal inferior hypokinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). There is no valvular aortic stenosis. The increased transaortic velocity is likely related to increased stroke volume due to aortic regurgitation. Moderate (2+) aortic regurgitation is suggested. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . Head CT at OSH ([**2196-9-2**]): At the outside hospital he had a CT of his head that showed bilateral contusions, subarachnoid, epidural. There was no shift. Neck CT was negative. . Head CT upon admission ([**2196-9-2**]): increased size of left frontal/temporal hemorrhagic contusions with surrounding edema and local mass effect, but no midline shift. 5mm right lateral convex SDH, more apparent than on prior study. Increased SAH with more blood in the ambient cisterns stable 2x1cm left temporal tip epidural hematoma. . [**9-2**] Head CT: IMPRESSION: 1. Progression of intraparenchymal hemorrhages in the right frontal and temporal lobes. Stable left vertex intraparenchymal hemorrhage. There is local right-sided mass effect, but no midline shift 2. New right convexity and tentorial subdural hematoma. 3. Increased subarachnoid blood, particularly within the ambient cisterns. 4. Stable left temporal tip epidural hematoma. 5. Equivocal left sphenoid nondisplaced fracture. 1. Stable appearance of multiple foci of previously seen hemorrhage. . [**9-3**] Head CT: IMPRESSION: 1. Overall stable appearance of a large right temporoparietal hemorrhage with the peripheral zone of edema. Minimal increased mass effect as compared to 10 hours prior, now with a 3 mm leftward midline shift. Fluid level noted within is unchanged and may relate to ongoing hemorrhage/coagulopathy/anaemia. Close follow up as clinically indicated if no intervention is contemplated. 2. Stable left temporal tip extra- axial hematoma, diffuse subarachnoid hemorrhage, and left frontal vertex hemorrhage. No new focal hemorrhage. 3. Hypodensity within the mid brain stem is again appreciated, possibly artifactual. Clinical correlation and continued followup/MR (if not CI) is recommended. . [**9-4**] Head CT: IMPRESSION: 1. Expected evolution of right temporoparietal with fluid level, right frontal and left frontal intraparenchymal hemorrhages. Given the presence of fluid level in the right temporal hemorrhage on priro studies, which may relate to ongoing hemorrhage, coagulopathy, etc, consider close follow up if no intervention is contemplated. 2. Surrounding edema and mass effect, and midline shift are stable since the prior study. 3. Multiple scattered foci of subarachnoid hemorrhage, and small bilateral subdural hematomas, unchanged. . [**9-7**] Head CT: IMPRESSION: New, tiny left temporal subdural hemorrhage with no significant mass effect or shift of normally midline structures. Otherwise, no significant change in the previously visualized parenchymal, subarachnoid, subdural, or intraventricular hemorrhages. . [**9-8**] Head CT: IMPRESSION: Unchanged appearance of the bilateral intraparenchymal, subarachnoid, right subdural, and left temporal epidural hemorrhages with slight increase in the effacement of the right occipital lateral ventricle and with unchanged shift of midline structures. Otherwise, no significant interval change since the prior study. . [**2196-9-16**] Head CT: There is no significant interval change. There is large frontoparietal intraparenchymal hemorrhage stable in size with extension into the right temporal lobe as seen on prior study. There is associated extensive edema and stable mass effect on the right lateral ventricle. There is a stable leftward shift of midline structures, measuring 3 mm. There are bilateral stable in size hypoattenuating extra-axial subdural fluid collections. There is a small stable right posterior hyperattenuating extra-axial fluid collection consistent with stable subdural hematoma. There are bilateral foci of subarachnoid hemorrhage, unchanged. There is no area of new interval acute hemorrhage. There is no evidence of fracture. IMPRESSION: 1. No significant interval change. 2. Stable right-sided large intraparenchymal hemorrhage, stable 3 mm leftward shift of midline structures. Stable mass effect on the right lateral ventricle. 3. Stable bilateral subarachnoid and subdural collections. 4. No new interval hemorrhage. . [**9-4**] EEG: IMPRESSION: This is an abnormal video EEG study because of continuous focal slowing and frequent epileptiform discharges over the right hemisphere, maximal in frontal parasagittal region. These findings are indicative of a potentially epileptogenic focal structural lesion in this region. There was voltage attenuation on the left, which could be secondary either to left cortical injury or to fluid between brain and electrodes (e.g. subdural or subgaleal fluid collection). There was a slow posterior dominant rhythm and moderate diffuse background slowing consistent with a moderate encephalopathy. There were no electrographic seizures. . [**9-6**] EEG:IMPRESSION: This is an abnormal video EEG study because of continuous focal slowing and frequent epileptiform discharges over the right hemisphere, maximal in the right frontal parasagittal region. These findings are indicative of a potentially epileptogenic focal structural lesion in this region. Mild voltage attenuation on the left could be secondary either to left cortical injury or to fluid between brain and electrodes. There was a slow posterior dominant rhythm and moderate diffuse background slowing consistent with a moderate encephalopathy. There were no electrographic seizures. Compared to the prior day's EEG recording, this EEG is unchanged. . [**2196-9-13**] EEG: CONTINUOUS EEG: Showed a very low voltage slow pattern in all areas, similar to that from the few days before. Over the day, the voltage remained somewhat lower than on previous days' recordings. There were no areas of prominent focal change, and there were no epileptiform features. SPIKE DETECTION PROGRAMS: Showed some generalized sharp activity suggestive of arousal. This was infrequent and not epileptiform in appearance. There were no definite spike or sharp and slow wave discharges. SEIZURE DETECTION PROGRAMS: There was a single entry in this file. It showed no electrographic seizure. PUSHBUTTON ACTIVATIONS: There were none. SLEEP: No normal waking or sleeping patterns were evident. CARDIAC MONITOR: Showed a generally regular rhythm. IMPRESSION: This telemetry captured no pushbutton activations. The EEG showed a very slow and low voltage record throughout, indicative of a severe encephalopathy. There were no prominent focal changes, and there were no epileptiform features or electrographic seizures. . CXR ([**2196-9-14**]): Portable In comparison with study of [**9-13**], there are substantially lower lung volumes. Mild atelectatic changes are seen at the bases, but there is no definite acute pneumonia or vascular congestion. The Dobbhoff tube remains in place, though the tip is below the level of the image. . CXR ([**2196-9-9**]): (PA and Lateral The examination is limited by low lung volumes. A feeding tube and left subclavian central venous line are appropriately postitioned. There is no definite focal consolidation, pneumothorax, or pleural effusion. There is linear atelectasis in the lingula and a small amount of retrocardiac atelectasis. . CXR ([**2196-9-5**]): Feeding tube with a wire stylet in place loops in the upper stomach and ends in the midesophagus. Mild cardiomegaly is unchanged. Lungs are low in volume but clear. No pleural abnormality, pneumothorax, or significant pleural effusion. Left subclavian line ends in the upper SVC. . MICROBIOLOGY: [**2196-9-4**] 6:39 pm BLOOD CULTURE Source: Line-aline. Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 4 R OXACILLIN-------------<=0.25 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=0.5 S . Blood Culture, Routine (Final [**2196-9-16**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET ONLY. SENSITIVITIES PERFORMED ON REQUEST.. Anaerobic Bottle Gram Stain (Final [**2196-9-14**]): GRAM POSITIVE COCCI IN CLUSTERS. REPORTED BY PHONE TO [**First Name4 (NamePattern1) 5147**] [**Last Name (NamePattern1) **] ON [**2196-9-14**] @ 950 PM. . Hematology CBC WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2196-9-20**] 05:00 9.1 3.65* 11.9* 35.1* 96 32.5* 33.8 17.5* 150 [**2196-9-19**] 05:30 13.3* 4.12* 13.7* 39.3* 95 33.2* 34.9 17.4* 238 ADDED DIFF 10;21AM DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas [**2196-9-19**] 05:30 68.9 19.9 7.5 3.3 0.3 ADDED DIFF 10;21AM BASIC COAGULATION (PT, PTT, PLT, INR) Plt Ct [**2196-9-20**] 05:00 150 [**2196-9-19**] 05:30 238 . Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2196-9-20**] 05:00 941 23* 0.8 130* 4.52 104 21* 10 MODERATELY HEMOLYZED SPECIMEN [**2196-9-19**] 05:30 871 23* 0.7 133 4.0 103 24 10 . CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2196-9-20**] 05:00 8.1* 3.3 1.81 MODERATELY HEMOLYZED SPECIMEN [**2196-9-19**] 05:30 8.7 2.8 1.8 Brief Hospital Course: Mr. [**Known lastname **] was admitted to the ICU for close monitoring after a closed head injury. . Upon comparing his CT of the head done at the outside facility compared to the CT done here upon arrival to [**Hospital1 18**] we noted considerable evolution of his contusions. He was started on hypertonic saline and Mannitol to control intracranial edema. . On the mornig after his admission his clinical exam declined with him being very agitated with difficulty following commands and no comprehensible speech. . He was placed on twenty four hour EEG monitoring to rule out Seizures as the underlying cause of his altered mental status. EEG showed some spikes in the right hemeisphere but no clear seizure activity. Pt was febrile to 101.2 therefore he was pan cultured. . He remained in the ICU for two days on a Nicardipine gtt for blood pressure control with hourly neuro checks, mannitol and hypertonic saline administration. . On hospital day 4 he was transfered to the step down unit. The patient remained neurologically stable except that his left arm which was previously moving slightly, stopped moving. A head CT was performed which was negative for change. The patient was also persistently febrile and the blood cultures that were previously drawn started to grow gram positive cocci. ID consultation was requested. New blood cultures were drawn and he was started on vancomycin. . On [**9-8**] the patient continued to be febrile and not move his left upper extremity. Another head CT was performed which was also stable. He continued vancomycin per ID. Overnight patient was bladder scanned for 1 L of urine and a foley was placed. On [**9-9**], patient was seen to have a worsening exam, RUE spontaneous, but no movement in other extremities to noxious stimuli. He was tachypnic and medicine was consulted. A repeat head CT and CXR were ordered. . # SUBDURAL HEMATOMA/SUBARACHNOID HEMORRHAGE: Unfortunate situation of previously functional man s/p fall with worsening mental status likely in setting of ongoing cerebral edema and bleed. Concern for onset of seizures upon initial transfer from Neurosurgery to Medicine given twitching shoulder and persistent non-responsiveness. Previous EEGs had not shown seizure activity. Repeat 24-48 hour EEGs also did not show seizure activity so the patient's Keppra was tapered off. He was described to be encephalopathic on EEG so an ammonia level was sent and came back at 61 (upper limits of normal 60). Although the patient has known history of alcohol abuse with likely liver cirrhosis and moderate ascites on CT abdomen, he was not felt to be experiencing hepatic encephalopathy. No lactulose or rifaximin was started. Neurosurgery continued to follow the patient while on the Medicine service. Serial CT head showed interval stability of his brain bleeds. The patient was closely monitored neurologically and nutrition supplied by Dobhoff. The patient had initially been agitated, requiring Seroquel for agitation but by transfer to medicine, was minimally responsive to noxious stimuli so Seroquel was held. By day of discharge, the patient was more interactive and alert, would open eyes/turn his head/make verbal noises to verbal stimuli although still unable to follow commands. Did demonstrate ability to move right arm and leg, although not the left side. - Continue tubefeeds as prescribed via Dobhoff. [**Month (only) 116**] require intermittent restraints to prevent him from pulling Dobhoff out. He receives his meds/nutrition all via Dobhoff. - Patient is to follow-up with his primary neurosurgeon who followed him during this hospital course, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in [**Month (only) **] for evaluation of improvement. It was felt that the patient needs 3-4 weeks from time of discharge to recover and provide clearer picture of prognosis. - Continue to monitor mental status, neurological checks twice daily . # FEVER: Patient had low grade temperatures and then spiked to 101.8 on [**9-9**]. Infectious Disease was consulted when one blood culture grew out coagulase negative staph. The patient was empirically treated with IV Vancomycin (therapeutic levels) for six days but this was discontinued given unclar source and feeling that the blood culture had likely been a contaminant. The patient gradually developed a leukocytosis that peaked at 21. Given negative blood cultures, chest xrays, urine cultures, his central line was pulled and the tip cultured, which also was negative. His foley catheter was changed without improvement in his symptoms. When he developed fevers to 102.6 twice daily, Infectious Disease was called again who recommended empiric treatment with Vancomycin liquid. Cdiff toxin studies negative X3. Ultimately, Cdiff PCR was sent and returned negative. The patient had a second blood culture grow out coagulase negative staph as well. Given that this grew in an anaerobic bottle, the patient was resumed on IV Vancomycin. As he continued to improved, with resolving leukocytosis and no more fevers, he was empirically treated with IV and PO Vancomycin. When the CDiff PCR returned negative, his Vancomycin PO was discontinued without issues. - Continue to monitor leukocytosis and trend fever curve - Continue Vancomycin 750mg twice daily through [**9-22**] . # HYPERTENSION: Patient has a history of hypertension although was not taking antihypertensives prior to this admission. Hypertension felt due to central dysregulation from his SDH/SAH, possible ongoing discomfort as well. Per Neurosurgery, goal blood pressure of systolic <160 is adequate. Patient has borderline bradycardia. His clonidine was initially tapered off in hopes of eliminating all sedating medications but as he became more interactive, his blood pressures became less well controlled with occasional peaks in the SBP170s. - Please taper clonidine 0.2mg from twice daily down and titrate other medications upwards accordingly throughout his stay. - Continue lisinopril 40mg daily - Continue metoprolol three times daily - Continue hydralazine PRN SBP>160 . # TACHYPNEA: In discussions with Neurosurgery, this is felt likely related to his ongoing cerebral edema, bleeding; there may be a component of ongoing discomfort as well. CXR showed no acute cardiopulmonary processes and ABG with respiratory alkalosis. As patient's fevers were treated with tylenol/Vancomycin and his pain with morphine liquid, his tachypnea improved. As his SDH/SAH stabilized, the patient's tachypnea ultimately resolved. . # Sodium Balance: Patient had a free water deficit per calculations when initially transferred to medicine. His free water flushes were tweaked until his serum sodium was stable. - Please check sodium on [**9-22**] as patient beginning to have slight hyponatremia treated with lasix and decrease in free water flushes on day of discharge. . # Foley: Please remove foley and attempt voiding trial (no clear indication for presence of foley at this time). . # GOALS OF CARE: In discussions with the patient's wife who is his Healthcare Proxy, the patient was made DNR/DNI given his critical condition. The patient does have advanced directives and made it clear to his wife he did not wish to live out his days neurologically compromised or in a [**Hospital1 1501**]. . # Communication: [**Name (NI) **] [**Name (NI) **] (wife, [**Name (NI) 382**] at [**Telephone/Fax (1) 110171**] Medications on Admission: Wellbutrin Prozac Furosemide Allopurinol Propranolol Discharge Medications: 1. senna 8.6 mg Tablet [**Telephone/Fax (1) **]: 1-2 Tablets PO qHS:PRN as needed for Constipation. 2. docusate sodium 50 mg/5 mL Liquid [**Telephone/Fax (1) **]: One Hundred (100) mg PO DAILY (Daily) as needed for constipation. 3. lidocaine HCl 2 % Gel [**Telephone/Fax (1) **]: One (1) Appl Mucous membrane PRN (as needed) as needed for foley pain. 4. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette [**Telephone/Fax (1) **]: [**12-12**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 5. nystatin 100,000 unit/mL Suspension [**Month/Day (2) **]: Five (5) ML PO QID (4 times a day) as needed for oral care, thrush. 6. heparin (porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: 5000 (5000) units Injection TID (3 times a day). 7. miconazole nitrate 2 % Powder [**Month/Day (2) **]: One (1) Appl Topical TID (3 times a day): To groin region. 8. morphine 10 mg/5 mL Solution [**Month/Day (2) **]: 5-10 mg PO Q4H (every 4 hours) as needed for pain: Hold for sedation changed from current baseline, RR<12. 9. hydralazine 25 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Q6H (every 6 hours) as needed for prn SBP>160. 10. lisinopril 20 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO DAILY (Daily): hold for SBP<100. 11. metoprolol tartrate 25 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO TID (3 times a day): hold for SBP<100, HR<55. 12. thiamine HCl 100 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 13. folic acid 1 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 14. cyanocobalamin (vitamin B-12) 100 mcg Tablet [**Month/Day (2) **]: 0.5 Tablet PO DAILY (Daily). 15. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day): Per pharmacy, please crush tablet to powder first, then dissolve in water, prior to putting through Dobhoff . 16. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 17. clonidine 0.2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 18. vancomycin 750 mg Recon Soln [**Last Name (STitle) **]: Seven [**Age over 90 1230**]y (750) mg Intravenous twice a day for 2 days: Last dose on [**9-22**]. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary: Subdural hematoma, subarachnoid hemorrhage, presumed CDiff infection, possible coagulase-negative Staphylococcus infection Secondary: Systolic congestive heart failure, hypertension, history of alcohol abuse, depression, spinal stenosis Discharge Condition: Mental Status: Unable to assess Level of Consciousness: Alert and interactive to verbal stimuli, will turn head and open eyes but does not follow commands. Moves right arm and leg, but not purposeful. Activity Status: Bedbound. Discharge Instructions: Dear Mr. [**Known lastname **], . It was a pleasure taking care of you during your admission to [**Hospital1 18**]. You were admitted after a fall on a few stair steps and was found to have bleeding in the various layers in and around your brain. You were closely monitored in the ICU and given mannitol and blood pressure medications to decrease swelling/bleeding into your brain, which can be dangerous. Neurosurgery continued to follow you closely during your hospitalization until the bleeding in your brain stabilized. EEG monitoring showed you were not having seizures from the injury to your brain. . You developed fevers and your blood tests suggested you had an infection. You were empirically treated for Clostridium difficile, an infection of your intestines that can cause diarrhea; the exact test for this infection eventually came back negative so the oral antibiotic was stopped. You were also treated for an infection in your blood stream. You responded well and became more interactive and comfortable towards the end of your hospital stay. . You are being discharged to a long-term acute care hospital where there will be qualified nurses and physicians to help monitor your progress during this important time in the healing of your brain from your traumatic injury/fall. Followup Instructions: Please follow-up with your neurosurgeon, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], who will evaluate your progress after your traumatic brain injury. You will obtain a CT scan of your head before the appointment. Department: RADIOLOGY When: THURSDAY [**2196-10-27**] at 10:00 AM With: CAT SCAN [**Telephone/Fax (1) 327**] Building: CC CLINICAL CENTER [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: NEUROSURGERY When: THURSDAY [**2196-10-27**] at 11:00 AM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7746**], MD [**Telephone/Fax (1) 3666**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2196-9-20**]

[ "348.30", "E879.8", "E880.9", "790.7", "008.45", "999.31", "041.12", "789.59", "428.23", "276.3", "780.4", "348.5", "724.00", "303.93", "333.1", "276.0", "851.05", "428.0", "401.9", "311", "V49.86", "571.2", "425.4" ]

icd9cm

[ [ [] ] ]

[ "38.93", "33.24", "96.6" ]

icd9pcs

[ [ [] ] ]

26127, 26199

16308, 23715

357, 402

26489, 26489

6282, 7846

28058, 28833

3255, 3272

23818, 26104

26220, 26468

23741, 23795

26743, 28035

3287, 3816

14773, 16285

276, 319

430, 2757

3832, 5610

10303, 14729

26504, 26719

2779, 3102

3118, 3239

5631, 6263

24,691

100,744

23689

Discharge summary

report

Admission Date: [**2159-6-12**] Discharge Date: [**2159-6-27**] Date of Birth: [**2114-1-7**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1781**] Chief Complaint: Non healing left heal ulcer Major Surgical or Invasive Procedure: L fem-DP bpg L heel debridement Past Medical History: HTN IDDM with neuropathy Renal failure with peritoneal dialysis MWF MI in [**12-9**] Gallbladder removal '[**34**] Amps of L4 and L5 '[**49**] Left foot debridement sub 4th and 5th met heads '[**58**] Amp of Right 2nd [**2157**]. Social History: She used to smoke, however, has quit. Denies alcohol use. Family History: Medical problems significant for diabetes. Physical Exam: PE: AFVSS NEURO: PERRL / EOMI MAE equally Answers simple commands Neg pronator drift Sensation intact to ST 2 plus DTR Neg [**Name2 (NI) **] 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: [**2159-6-12**] 5:33 PM CHEST (PORTABLE AP) Reason: eval for cvl placement PORTABLE SUPINE FRONTAL RADIOGRAPH: FINDINGS: Lung volumes are reduced. Allowing for this and technique, cardiac and mediastinal contours are within normal limits. There is a right-sided IJ central venous catheter with its tip in the mid SVC. The patient is intubated with ET tube terminating above the level of the clavicles. An NG tube terminates within the stomach. No pneumothorax is seen on this supine radiograph. There is a small amount of atelectasis in the retrocardiac region. IMPRESSION: Reduced lung volumes with left retrocardiac atelectasis. Central venous catheter with its tip in the mid SVC [**2159-6-13**] LEFT HEEL, 2 VIEWS: The ulcer over the heel is noted. Some irregularity of the underlying portion of the calcaneus is within the range of normal. No focal bone destruction or periosteal new bone formation to confirm the presence of osteomyelitis is identified. No reactive sclerosis is detected. No fracture is identified. Vascular calcification and surgical clips noted. IMPRESSION: Ulceration. No osteomyelitis identified. [**2159-6-25**] Source: left heel. **FINAL REPORT [**2159-6-29**]** GRAM STAIN (Final [**2159-6-25**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). WOUND CULTURE (Final [**2159-6-28**]): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for Pseudomonas aeruginosa, Staphylococcus aureus and beta streptococcus). GRAM NEGATIVE ROD(S). MODERATE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH. OF TWO COLONIAL MORPHOLOGIES. ANAEROBIC CULTURE (Final [**2159-6-29**]): NO ANAEROBES ISOLATED [**2159-6-12**] 05:36PM WBC-12.7* RBC-3.26* HGB-9.2* HCT-27.7* MCV-85 MCH-28.3 MCHC-33.1 RDW-15.0 Brief Hospital Course: Pt admitted [**2159-6-12**] for ischemic foot. Pt pre-op'd cleared for surgery. IV Antibiotics started. Cx taken. Podiatry consulted / plastics / renal consulted. Pt recieved PD M/W/F. Pt underwent a Left common femoral artery to dorsalis pedis artery bypass graft in situ using greater saphenous vein, angioscopy and valve lysis, revision of distal anastomosis, and intraoperative arteriogram. Pt tolerated th procedure well. There were no complications. Pt acidotic transfered to the SICU in stable condition. Intubated. It was thought that the pt was in metabolic acidosis secondary to untreated renal failure, likely secondary to non compliance PD. [**2159-6-14**] - [**2159-6-17**] Pt extubated. Podiatry to debride wound. Pt remained in SICU. [**2159-6-18**] Pt underwent a debridement of left heel. Pt tolerated th procedure well. There were no complications. Pt extubted in the OR. Transfered to the PACU in stable condition. Once reccoperated from anesthesia pt transfered to the VICU in stable condition. Pt had VAC after the procedure. Pt recieved PRBC's [**2159-6-19**] - [**2159-6-25**] PT consult. Pt allowed OOB to chair. NWB left foot. Awaiting cx and sensitivities / vac in place. Foley DC'd. [**2159-6-26**] Vac removed. Wound improved. Plastics see pt. Want to see on f/u as out pt. Vac replaced. PICC placed at bedside for AB therapy. Pt dc'd in stable condition. Taking PO / ambulating with ASST, pos BM, pos urination. Medications on Admission: insulin 70/30 40 qam, 40 qpm, lasix 80 [**Hospital1 **], renagel 1200 [**Hospital1 **], zestril 40 daily. Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* 3. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:*60 Tablet(s)* Refills:*0* 6. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 1 months. Disp:*15 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous as needed per level < 15 for 1 months: blood levels should be checked every third day and dosed only if level < 15; dosing to be reviewed by peritoneal dialysis coordinator -- [**First Name8 (NamePattern2) 401**] [**Last Name (NamePattern1) **] @ [**Telephone/Fax (1) 60552**] Fax [**Telephone/Fax (1) 60553**] for any changes during therapy. Disp:*10 doses* Refills:*0* 9. Heparin Flush (Porcine) in NS 100 unit/mL Kit Sig: One (1) flush Intravenous per ccs protocol. Disp:*qs * Refills:*2* Discharge Disposition: Home With Service Facility: homehealth vna Discharge Diagnosis: HTN IDDM ESRD Heel ulcer Discharge Condition: Good Discharge Instructions: Go to an Emergency Room if you experience symptoms including, but not necessarily limited to: new and continuing nausea,vomiting, fevers (>101.5 F), chills, or shortness of breath. Proceed to the ER/EW/ED if your wound becomes red, swollen, warm, or produces pus. No driving while taking pain medications. Narcotics can cause constipation. Please take an over the counter stool softener such as Colace or a gentle laxative such as Milk of Magnesia if you experience constipation. You may resume your regular diet as tolerated. You may take showers (no baths) after your dressings have been removed from your wounds. Continue taking your home medications unless otherwise indicated at follow up with PCP. Followup Instructions: F/U with [**Doctor Last Name **] in [**1-7**] wks. F/U with Nephrology as per routine F/U with PCP soon after discharge to review medications and events Completed by:[**2159-8-21**]

[ "276.2", "041.84", "412", "285.9", "357.2", "276.7", "V15.81", "250.61", "707.14", "403.91", "250.41", "440.23", "780.6" ]

icd9cm

[ [ [] ] ]

[ "86.22", "96.71", "38.91", "93.57", "39.29", "38.93", "88.48", "54.98" ]

icd9pcs

[ [ [] ] ]

6229, 6274

3229, 4697

341, 375

6343, 6349

1249, 3206

7107, 7291

720, 764

4853, 6206

6295, 6322

4723, 4830

6373, 7084

779, 1230

274, 303

397, 628

644, 704

42,321

114,648

32969

Discharge summary

report

Admission Date: [**2121-12-7**] Discharge Date: [**2121-12-12**] Date of Birth: [**2041-5-16**] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Lidocaine Attending:[**First Name3 (LF) 2387**] Chief Complaint: Acute mental status change Major Surgical or Invasive Procedure: Chest tube placement Right internal jugular central venous line placement History of Present Illness: 80 year-old lady with history of dementia presents as transfer to medicine service. The patient was admitted to the CV-ICU on the night of [**2121-12-7**] because she had a central line placed in her left subclavian artery at an outside hospital. This was complicated by a left-sided hemopneumothorax for which a chest tube was placed at the outside hospital. The only other active medical issues upon transfer was the patient's recurrent acute on chronic renal failure and a recurrent UTI. The patient had an INR of 4.3 and HCT of 23 upon transfer to [**Hospital1 18**]. The goal upon admission to the vascular service was to transfuse her and correct her INR. The subclavian line would be pulled at the bedside [**2121-12-8**]. Past Medical History: A Fib, Dementia, HTN, Hypercholesterolemia, s/p CVA with hemiparesis, Anxiety disorder, depression, frequent UTIs, PNA, rib fractures, s/p R hip fracture, hydronephrosis, congenital UPJ obstruction [**Doctor First Name **] Hx: s/p R total hip replacement x 2 Social History: Lives at [**Hospital1 11851**] NH; no ETOH, DNR/DNI Family History: Noncontributory Physical Exam: Transfer exam VS: T 94.7 (Ax), HR 73, BP 108/53, RR 20, 94% 3L GEN: Anxious, communicates with groans NECK: supple, no bruits LUNGS: rhonchi B/L, wheezes B/L, no air leak on chest tube CV: irregularly irregular, nl S1 and S2 ABD: Soft, NT, ND EXT: L arm without any sign of ischemia, no c/c/e of LE, right foot slightly cooler than left, 2+ radial and 1+ ulnar on left VASC: Fem [**Doctor Last Name **] PT DP R 2+ 2+ D D L 2+ 2+ D 2+ Discharge Exam VS 97/97.2 155/70 70 20 98%RA Gen: NAD HEENT: MMM, OP clear, neck supple CV: Irregular S1+S2, no m/r/g Lungs: CTAB anteriorly Abd: S/NT/ND +bs Ext: no c/c/e Neuro: Oriented x1 (person). Continues to have echolalia although improved from yesterday. Pertinent Results: [**2121-12-12**] 07:35AM BLOOD WBC-10.1 RBC-3.55* Hgb-10.5* Hct-30.3* MCV-85 MCH-29.5 MCHC-34.6 RDW-15.1 Plt Ct-277 [**2121-12-11**] 07:00AM BLOOD WBC-10.2 RBC-3.43* Hgb-10.1* Hct-28.5* MCV-83 MCH-29.4 MCHC-35.4* RDW-15.1 Plt Ct-306 [**2121-12-10**] 07:07AM BLOOD WBC-12.1* RBC-3.84*# Hgb-11.4*# Hct-32.2*# MCV-84 MCH-29.6 MCHC-35.3* RDW-15.4 Plt Ct-360 [**2121-12-9**] 02:08AM BLOOD WBC-8.9 RBC-2.92* Hgb-8.6* Hct-24.5* MCV-84 MCH-29.3 MCHC-34.9 RDW-15.1 Plt Ct-274 [**2121-12-8**] 04:18PM BLOOD Hct-24.8* [**2121-12-8**] 04:58AM BLOOD WBC-9.8 RBC-3.26* Hgb-9.7* Hct-27.6* MCV-85 MCH-29.9 MCHC-35.3* RDW-14.9 Plt Ct-261 [**2121-12-7**] 08:46PM BLOOD WBC-8.8 RBC-3.09* Hgb-8.9* Hct-26.3* MCV-85 MCH-28.8 MCHC-33.8 RDW-15.1 Plt Ct-286 [**2121-12-7**] 08:46PM BLOOD Neuts-84.6* Lymphs-14.6* Monos-0.6* Eos-0 Baso-0.1 [**2121-12-7**] 08:46PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-1+ Ovalocy-1+ Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) **]1+ [**2121-12-12**] 07:35AM BLOOD Plt Ct-277 [**2121-12-12**] 07:35AM BLOOD PT-13.2 PTT-24.6 INR(PT)-1.1 [**2121-12-12**] 07:35AM BLOOD Glucose-87 UreaN-44* Creat-1.1 Na-148* K-3.3 Cl-113* HCO3-27 AnGap-11 [**2121-12-12**] 07:35AM BLOOD Calcium-8.1* Phos-2.4* Mg-1.5* [**2121-12-10**] 07:07AM BLOOD VitB12-1495* [**2121-12-10**] 07:07AM BLOOD TSH-1.2 [**2121-12-7**] 09:20PM BLOOD Type-[**Last Name (un) **] pO2-42* pCO2-53* pH-7.24* calTCO2-24 Base XS--5 CTH 1. No evidence of acute intracranial hemorrhage. Hypoattenuation involving the left basal ganglia extending into the corona radiata may represent sequela of previously stated remote CVA, however, interposed acute component cannot be entirely excluded. MRI may be obtained for further evaluation to exclude underlying acute component as discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at the time of dictation. 2. Minimal sinus disease as described above. 3. Right subinsular cortical infarct, old. NOTE ADDED AT ATTENDING REVIEW: The changes noted above involving the left thalamus, caudate body, internal capsule and periventricular white matter appear to reflect old infarction, perhaps with old hemorrhage. There is no evidence of recent infarction. However, in the setting of chronic infarction further ischemic injury in the same distribution can be difficult to detect with non contrast CT. CXR ([**2121-12-10**]) Probable persistent tiny left apical pneumothorax although difficult to discern from overlying rib shadows. Brief Hospital Course: 80 year old female with AF, dementia, HLP, CVA with residual hemiparesis, anxiety/depression, and congenital UPJ obstruction transferred from OSH for left subclavian arterial line placement and presumed UTI. 1. UTI:Patient has history of frequent UTIs with multiple admissions in the past year to OSH. She also currently has a chronic indwelling FC, increasing her risk of UTI. She has been treated with IV ciprofloxacin since being admitted to the OSH. Repeated urine cultures during admission were contaminated. Patient was initially treated with ciprofloxacin, but given past history of E.coli resistant to quinolones. Urinalysis at outside hospital performed without urine culture. Patient was converted to ceftriaxone, which she tolerated well even with reported history of PCN allergy. On discharge, she was coverted to cefpodoxime and instructed to complete a total of 7 days on ceftriaxone/cefpodoxime. 2. Anemia: Patient was transfused a total of 2u PRBC during admission at [**Hospital1 18**]. Although unclear, it appears as if she was also transfused 2u PRBC at OSH. On discharge, her hct was stable. 3. Left subclavian arterial line placement: Upon transfer, subclavian arterial line was removed and a chest tube was placed on the left for her hemopneumothorax. On hospital day 3 her chest tube was removed without adverse events. Of note, a follow-up CXR after chest tube removal demonstrated a small residual pneumonthorax. 4. Acute mental status change: Most likely multifactorial due to UTI, hospitalization, and medications including morphine and ativan that the patient received while in the ICU. The patient at [**Hospital1 11851**] has also been receiving remeron, ativan, and trazadone, which were discontinued. The patient appeared to have mild improvement in her delirium during her admission. Of note, a non-contrast CT head was performed during her admission that did not demonstrate an acute intracranial process. 5. Acute on chronic renal failure: Likely secondary to intravascular volume depletion. Patient received IVF during her admisison and on discharge, her creatinine was at baseline at 1.1. 6. Afib: Patient was initially admitted on atenolol 100 mg po bid. Given her acute on chronic renal failure, she was transitioned to metoprolol 50 mg po bid. After her hematocrit was stabilized, she was restarted on coumadin. She will need to have her INR monitored with a goal of [**2-9**]. 7. Hypertension: Beta blocker changed to metoprolol as above. Amlodipine 5 mg daily was added for additional blood pressure control. 8. Steroids: The patient was admitted to [**Hospital1 18**] one prednisone, which was continued during her admission. On discharge, she was instructed to continue with 10 mg daily prednisone. Although unclear as to the reason for her steroid use, it appears as if she was on a scheduled taper at [**Hospital1 11851**] of prednisone. She was instructed on discharge to follow-up with her physician at [**Name9 (PRE) 11851**] or her PCP with regard to prednisone taper. Medications on Admission: Coumadin 2 qd, Lasix 40 qd, MVI 1 qd, KDur 20 mEq qd, Atenolol 100 [**Hospital1 **], Remeron 30 qhs, Prednisone 10 qd, Cipro 500 [**Hospital1 **] (started [**12-5**]), Forastor probiotic 250 [**Hospital1 **], Tylenol 650 q 4 prn, Dulcolax prn, MOM prn, Trazodone 25 qhs prn, Ativan 0.5 mg q4 prn, Duonebs prn Discharge Medications: 1. Vantin 200 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp:*10 Tablet(s)* Refills:*0* 2. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO once a day. 3. Norvasc 5 mg Tablet Sig: One (1) Tablet PO once a day. 4. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 5. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 6. Multiple Vitamin Tablet Sig: One (1) Tablet PO once a day. 7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day. 8. DuoNeb 0.5-2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. 9. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day as needed for constipation. 10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital 11851**] Healthcare - [**Location (un) 620**] Discharge Diagnosis: Primary - UTI - Anemia Secondary A Fib, Dementia, HTN, Hypercholesterolemia, s/p CVA with hemiparesis, Anxiety disorder, depression, frequent UTIs, PNA, rib fractures, s/p R hip fracture, hydronephrosis, congenital UPJ obstruction Discharge Condition: Patient was discharged in stable condition. Discharge Instructions: 1. You were admitted for a urinary tract infection, which was treated with antibiotics. You will need to continue these antibiotics as an outpatient. The instructions for this medication are: Cefpodoxime 200 mg by mouth twice daily for 5 days (STOP ON [**2121-12-17**]) 2. You were also admitted for a subclavian arterial line placement. You received a blood transfusion while admitted. On discharge your hematocrit was stable. 3. Unless otherwise indicated, please resume all of your medications as take prior to admission. It is very important that you take your medications as prescribed. You were admitted on prednisone, which was continued during your admission. You will need to follow-up with your PCP or [**Name9 (PRE) 11851**] physician with regard to prednisone taper. 4. You will need to have you INR checked on Monday, [**12-15**] with a goal INR of [**2-9**]. You will need to have regular INR checks with your coumadin adjusted as necessary by your doctor [**First Name (Titles) **] [**Last Name (Titles) 11851**]. 5. It is very important that you make all of your doctor's appointments. 6. If you develop chest pain, shortness of breath, or other concerning symptoms, please call your PCP or go to your local Emergency Department immediately. Followup Instructions: Please follow-up with your PCP [**Last Name (NamePattern4) **] 2 weeks. You can schedule an appointment by calling [**Telephone/Fax (1) 6019**]. Completed by:[**2121-12-13**]

[ "438.50", "585.9", "276.0", "293.0", "294.10", "584.9", "403.90", "285.1", "272.0", "311", "753.21", "276.50", "427.31", "300.00", "860.0", "E879.8", "599.0", "331.0" ]

icd9cm

[ [ [] ] ]

[ "34.04", "99.04", "38.93", "99.07" ]

icd9pcs

[ [ [] ] ]

9186, 9270

4902, 7943

346, 422

9546, 9592

2359, 4879

10904, 11081

1555, 1572

8303, 9163

9291, 9525

7969, 8280

9616, 10881

1587, 2340

280, 308

450, 1185

1207, 1469

1485, 1539

81,006

139,830

38543

Discharge summary

report

Admission Date: [**2195-8-5**] Discharge Date: [**2195-8-13**] Date of Birth: [**2157-5-7**] Sex: M Service: SURGERY Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 148**] Chief Complaint: Jaundice Major Surgical or Invasive Procedure: [**2195-8-5**]: 1. Open cholecystectomy. 2. Liver wedge resection. 3. Pylorus preserving Whipple resection. 4. Segmental liver resection of the right lobe. History of Present Illness: Patient is s 38-year-old male retailer with a chief complaint of obstructive jaundice, which came on within the last month. This is painless in nature. He had a failed ERCP elsewhere and was transferred to [**Hospital1 18**], and Dr. [**Last Name (STitle) **] took care of this with an endobiliary stent. Brushings from this were negative and his jaundice resolved. He had a followup endoscopic ultrasound on the [**7-10**], which showed a 2.2 x 1.8 cm mass in the head of the pancreas with poorly defined borders. There is no evidence of vascular involvement. He currently reports sharp and periodic right upper quadrant pain with food. His jaundice has resolved completely. He has had a 10-pound weight loss over the last month, but he denies any progressive lingering problem over the last three to six months in terms of appetite changes or weight loss. Patient was evaluated by Dr. [**Last Name (STitle) **] in Pancreaticobiliary Surgery Clinic on [**2195-7-21**] and Whipple procedure was scheduled on [**2195-8-5**]. Past Medical History: GERD gallstones eczema Social History: Married, denies tobacco, EtOH, drugs Family History: Family history: gastric ca - grandmother stroke - father Physical Exam: On Discharge: VSS, Afebrile Gen: NAD CV: RRR no m/r/g Lungs: CTAB Abd: Bilateral subcostal incision open to air with steri strips, c/d/i Old JP sites with occlusive dressing and c/d/i Extr: warm, + PP Pertinent Results: [**2195-8-5**] 09:41PM WBC-21.2* RBC-5.19 HGB-16.0 HCT-47.4 MCV-91 MCH-30.9 MCHC-33.8 RDW-15.2 [**2195-8-5**] 09:41PM GLUCOSE-187* UREA N-15 CREAT-1.1 SODIUM-140 POTASSIUM-5.4* CHLORIDE-110* TOTAL CO2-21* ANION GAP-14 [**2195-8-5**] 09:41PM ALBUMIN-3.3* CALCIUM-8.6 PHOSPHATE-4.7* MAGNESIUM-1.6 [**2195-8-5**] 09:41PM ALT(SGPT)-202* AST(SGOT)-259* ALK PHOS-81 AMYLASE-66 TOT BILI-5.0* [**2195-8-10**] 05:21AM BLOOD WBC-5.7 RBC-3.18* Hgb-9.8* Hct-28.6* MCV-90 MCH-30.7 MCHC-34.1 RDW-13.9 Plt Ct-210 [**2195-8-10**] 05:21AM BLOOD Glucose-118* UreaN-6 Creat-0.5 Na-140 K-3.2* Cl-103 HCO3-32 AnGap-8 [**2195-8-7**] 02:52AM BLOOD ALT-146* AST-129* AlkPhos-71 TotBili-1.1 [**2195-8-10**] 05:21AM BLOOD Calcium-7.7* Phos-2.4* Mg-2.1 [**2195-8-5**] INTRAOP US: IMPRESSION: Two subcentimeter lesions in segment VI as described above concerning for metastatic disease. Two liver cysts. [**2195-8-8**] CHEST PORTABLE: The right internal jugular line tip is at the level of low SVC. Cardiomediastinal silhouette is stable. There is new left basal opacity noted. This might represent area of developing infection as well as atelectasis or aspiration. Close attention to this area is recommended on subsequent radiographs. There is no evidence of pneumothorax or significant pleural effusion. There is no evidence of failure. [**Hospital1 69**] [**Location (un) 86**], [**Telephone/Fax (1) 32424**] Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 85726**],[**Known firstname **] [**2157-5-7**] 38 Male [**-9/3234**] [**Numeric Identifier 85727**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] Gross Description by: DR. [**Last Name (STitle) **]. SHABANI/dif SPECIMEN SUBMITTED: Liver Lesion, gallbladder, Jejunum, WHIPPLE, SEGMENT 6 LIVER RESECTION. Procedure date Tissue received Report Date Diagnosed by [**2195-8-5**] [**2195-8-5**] [**2195-8-11**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/ttl DIAGNOSIS: I. Liver, segment 3, wedge resection (A-B): Metastatic pancreatic endocrine carcinoma. II. Liver, segment 6, resection (C-J): Metastatic pancreatic endocrine carcinoma, two nodules, not seen at examined resection margin. III. Jejunum, resection (K-L): Small intestinal segment, within normal limits. IV. Pancreas, duodenum, bile duct segment, Whipple resection (M-AB, AD-AI): A. Well-differentiated pancreatic endocrine carcinoma, see synoptic report. B. Seven of eight lymph nodes involved by well differentiated endocrine carcinoma ([**7-2**]). C. Chronic pancreatitis. D. Incidental low grade pancreatic intraepithelial neoplasia. V. Gallbladder, cholecystectomy (AC): Gallbladder, within normal limits. Pancreas (Endocrine): Resection Synopsis Staging according to American Joint Committee on Cancer Staging Manual -- 7th Edition, [**2193**] MACROSCOPIC Specimen Type: Pancreaticoduodenectomy (Whipple resection), partial pancreatectomy. Other organs/Tissues Received: Gallbladder, jejunum, segment 6 liver resection, segment 3 liver wedge resection. Tumor Site: Pancreatic head. Tumor focality: Unifocal. Tumor Size Greatest dimension: 2.1 cm. Additional dimensions: 2.0 cm x 2.0 cm. MICROSCOPIC Functionality type: Pancreatic endocrine tumor, functional status unknown. WHO Classification: Well-differentiated endocrine carcinoma (Gross local invasion and or metastases. Generally shows one or more of the following features: >= 2cm, angioinvasion, perineural invasion, 2 to 10 mitoses per 10 HPF). Mitotic activity: Less than 2 mitoses per 10 high power fields. Tumor necrosis: Not identified. MICROSCOPIC TUMOR OF EXTENSION Margins: Uninvolved by tumor. Distance from closest margin: 2 mm. Specified margin: Retroperitoneal margin. Primary Tumor: Tumor invades adjacent tissue/organs: Peripancreatic soft tissues and lymph nodes. Primary Tumor (pT): pT3: Tumor extends beyond the pancreas, but without involvement of the celiac axis or superior mesenteric artery. Regional Lymph Nodes (pN): pN1: Regional lymph node metastasis. Lymph Nodes Number examined: 8. Number involved: 7. Distant metastasis (pM): pM1: Distant metastasis, site(s)): liver, segments 3 and 6. Lymphatic/vascular Invasion: Present. Perineural invasion: Present. Additional Pathologic Findings: Chronic pancreatitis, low grade PanIn. Clinical: Pancreatic mass. Brief Hospital Course: The patient was admitted to the General Surgical Service on [**2195-8-5**] for treatment of metastatic neuroendocrine tumor. On [**2195-8-5**], the patient underwent pylorus-preserving pancreaticoduodenectomy (Whipple), open cholecystectomy, segmental and wedge liver resection which went well without complication (reader referred to the Operative Note for details). In PACU patient developed sinus tachycardia with HR up to 120 and urine output was low. Patient was resuscitated with fluid and transferred in ICU to continue monitoring. Patient was transferred NPO with an NG tube, on IV fluids, with a Foley catheter and a JP drain x [**Street Address(2) 8582**], and Dilaudid PCA for pain control. Pre-operatively patient received IT Morphine for pain control. Patient HR converted to regular rate, and patient's urine output improved to normal. Patient was transferred to the floor on POD#2. During surgery patient received 1 unit of RBC to replete his EBL 800cc. Post operativelly, patient's hematocrit continue to fall (47.4>36.1>26.6), on [**2195-8-9**] patient received 2 units of RBC. Hct improved to 28.4 after transfusion. Patient remained stable after transfusion, no further transfusions were indicated. The patient's recovery was uneventful after he was transferred from ICU. Post-operative pain was initially well controlled with Dilaudid PCA , which was converted to oral pain medication when tolerating clear liquids. The NG tube was discontinued on POD#2, and the Foley catheter discontinued at midnight of POD#3. The patient subsequently voided without problem. The patient was started on sips of clears on POD#3, which was progressively advanced as tolerated to a regular diet by POD#6. JP amylase was sent in the evening of POD#5; the JP # 1 was discontinued on POD# 7, and JP # 2 was discontinued on POD # 8. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirrometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. The patient's blood sugar was monitored regularly throughout the stay; sliding scale insulin was administered when indicated. At the time of discharge on [**2195-8-13**], the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Staples were removed, and steri-strips placed. The patient was discharged home with VNA services for wound check. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: None Discharge Medications: 1. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*80 Tablet(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. 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 With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: 1. Neuroendocrine tumor of the pancreas metastatic to the liver. 2. Sinus tachycardia 3. Low urine output Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**5-4**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 1231**] Date/Time:[**2195-8-28**] 11:30 [**Hospital Ward Name 23**] 3, [**Hospital Ward Name **] . Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2195-8-28**] 1:40 [**Hospital Ward Name **] 7, [**Last Name (NamePattern1) 439**] . Please foolow up with your PCP [**Last Name (NamePattern4) **] [**1-28**] weeks after discharge Completed by:[**2195-8-13**]

[ "790.01", "197.7", "530.81", "427.89", "576.2", "157.0", "577.1", "196.2" ]

icd9cm

[ [ [] ] ]

[ "50.22", "51.22", "52.7" ]

icd9pcs

[ [ [] ] ]

9803, 9859

6498, 9207

297, 455

10009, 10009

1947, 6475

11266, 11824

1649, 1711

9262, 9780

9880, 9988

9233, 9239

10160, 10738

10753, 11243

1726, 1726

1740, 1928

249, 259

483, 1517

10024, 10136

1539, 1563

1579, 1617

70,330

194,621

46993

Discharge summary

report

Admission Date: [**2141-11-7**] Discharge Date: [**2141-11-30**] Date of Birth: [**2076-9-25**] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 78**] Chief Complaint: Aphasia Major Surgical or Invasive Procedure: [**2141-11-9**]: Posterior fossa craniotomy for clot evacuation [**2141-11-9**]: Right EVD placement [**2141-11-17**]: Right VPS placement [**2141-11-23**]: extraction of teeth #7 & #8 History of Present Illness: 65 y/o M who presented last night with two episodes of aphasia. Patient went to see his PCP when he suddenly became mute. He was immediately transferred to the ED where code stroke was called. Patient's head CT showed no acute hemorrhage or infarct. His risk factors were high for stroke and he was given TPA at 6:30pm. His speech cleared after TPA was given. Overnight, his speech became slurred and n/v presented. He was taken for a stat head CT which revealed a L cerebellar hemorrhage. Past Medical History: * HTN * DM2 * Diabetic retinopathy OU * Cystoid macular edema OS * Supertemporal * back injury * hx of exposure to asbestos * hx of excision of a Lipoma on posterior neck [**2126**] * MRI [**2126**] of head and neck showed mild generalized atrophy inconsistent with his age,nonspecific white matter densities * Paranoid psychosis (recently untreated, but with multiple prior hospitalizations) Social History: Born and raised in [**Location (un) 669**], [**Location (un) 686**] and [**Location (un) 2268**] and as of [**2126**] he had been homelesss for 9 years. He reports that he now lives in [**Location 669**] in his own apt alone. He is single has never married and does not have any children. Hx of heavy use of ETOH but stopped drinking many years ago. H/o past use of marijuana and cocaine; none recently. Previous tobacco history. Family History: Brother w/ h/o admission to a psychiatric hospital. Physical Exam: On admission: PHYSICAL EXAM: BP:159/84 HR: 74 O2Sats:100% General: Awake,alert at times, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, awake. Does not answer questions. Follows commands. Opens eyes, squeezes hands , wiggles toes. Communicates for visual field testing by wiggling thumbs. No evidence of neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. Appears to move all 4 extremities symmetrically. -Sensory: Withdraws to pain ful stimuli. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. -Coordination: Appears intact upon observation. -Gait: Unable to assess. ON DISCHARGE: Eyes opening spontaneously and verbalising but will sometime not respond to questioning. A+O only to self. Good power in all 4 limbs but difficulties regarding cooperation. Pupils equal and reactive and no dysarthria. Mild dysmetria perhaps worse on left. Wound clean with no erythema or drainage. VP shunt placement good without irritation. Patient can be agitated. Pertinent Results: ADMISSION LABS: [**2141-11-7**] 05:50PM BLOOD WBC-9.3 RBC-4.63 Hgb-14.3 Hct-39.8* MCV-86 MCH-30.8 MCHC-35.8* RDW-13.9 Plt Ct-261 [**2141-11-7**] 05:50PM BLOOD Neuts-57.9 Lymphs-34.9 Monos-5.3 Eos-1.4 Baso-0.4 [**2141-11-7**] 05:50PM BLOOD PT-11.9 PTT-22.1 INR(PT)-1.0 [**2141-11-7**] 05:50PM BLOOD UreaN-14 [**2141-11-7**] 05:50PM BLOOD Creat-1.3* [**2141-11-7**] 09:52PM BLOOD Glucose-203* UreaN-14 Creat-1.4* Na-142 K-3.8 Cl-101 HCO3-30 AnGap-15 [**2141-11-7**] 05:50PM BLOOD ALT-16 AST-13 AlkPhos-85 TotBili-0.8 [**2141-11-7**] 05:50PM BLOOD Albumin-4.2 Calcium-9.6 Phos-3.8 Mg-2.0 . Other pertinent labs: [**2141-11-7**] 09:52PM BLOOD CK-MB-2 cTropnT-<0.01 [**2141-11-8**] 03:55AM BLOOD CK-MB-2 cTropnT-<0.01 [**2141-11-7**] 05:50PM BLOOD Lipase-38 [**2141-11-16**] 03:22AM BLOOD Albumin-2.8* Calcium-8.2* Phos-2.7 Mg-2.5 [**2141-11-7**] 09:53PM BLOOD %HbA1c-8.6* eAG-200* [**2141-11-7**] 09:52PM BLOOD Triglyc-87 HDL-41 CHOL/HD-3.6 LDLcalc-88 [**2141-11-7**] 09:52PM BLOOD TSH-1.5 [**2141-11-8**] 03:55AM BLOOD TSH-0.49 [**2141-11-7**] 05:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . INR trend: [**2141-11-7**] 05:50PM BLOOD PT-11.9 PTT-22.1 INR(PT)-1.0 [**2141-11-7**] 09:52PM BLOOD PT-14.6* PTT-32.5 INR(PT)-1.3* [**2141-11-8**] 03:55AM BLOOD PT-14.3* PTT-25.3 INR(PT)-1.2* [**2141-11-9**] 03:26AM BLOOD PT-13.3 PTT-22.3 INR(PT)-1.1 [**2141-11-9**] 03:17PM BLOOD PT-13.2 PTT-23.0 INR(PT)-1.1 [**2141-11-10**] 05:43AM BLOOD PT-15.0* PTT-28.4 INR(PT)-1.3* [**2141-11-11**] 01:21AM BLOOD PT-13.5* PTT-25.8 INR(PT)-1.1 [**2141-11-16**] 02:36PM BLOOD PT-13.1 PTT-25.8 INR(PT)-1.1 [**2141-11-17**] 03:02AM BLOOD PT-13.5* PTT-26.5 INR(PT)-1.1 [**2141-11-18**] 01:56AM BLOOD PT-13.1 PTT-25.9 INR(PT)-1.1 [**2141-11-23**] 11:00AM BLOOD PT-13.4 PTT-33.8 INR(PT)-1.1 [**2141-11-25**] 04:30AM BLOOD PT-12.4 PTT-30.9 INR(PT)-1.0 [**2141-11-26**] 06:15AM BLOOD PT-12.6 PTT-30.4 INR(PT)-1.1 [**2141-11-27**] 10:50AM BLOOD PT-13.3 PTT-33.4 INR(PT)-1.1 [**2141-11-28**] 04:25AM BLOOD PT-14.3* PTT-29.8 INR(PT)-1.2* [**2141-11-29**] 04:15AM BLOOD PT-16.3* PTT-29.2 INR(PT)-1.4* [**2141-11-30**] 04:25AM BLOOD PT-19.2* PTT-33.7 INR(PT)-1.7* . Discharge labs: [**2141-11-30**] 04:25AM BLOOD WBC-11.9* RBC-3.94* Hgb-11.7* Hct-36.0* MCV-91 MCH-29.7 MCHC-32.5 RDW-13.4 Plt Ct-387 [**2141-11-30**] 04:25AM BLOOD PT-19.2* PTT-33.7 INR(PT)-1.7* [**2141-11-29**] 04:15AM BLOOD Glucose-156* UreaN-17 Creat-0.9 Na-135 K-4.4 Cl-94* HCO3-33* AnGap-12 [**2141-11-16**] 03:22AM BLOOD ALT-13 AST-17 AlkPhos-84 TotBili-0.4 . . Urine: [**2141-11-7**] 06:33PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.035 [**2141-11-7**] 06:33PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG [**2141-11-9**] 10:01PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020 [**2141-11-9**] 10:01PM URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-1000 Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2141-11-9**] 10:01PM URINE RBC-18* WBC-2 Bacteri-FEW Yeast-NONE Epi-0 [**2141-11-10**] 09:31PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.034 [**2141-11-10**] 09:31PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-150 Ketone-TR Bilirub-NEG Urobiln-4* pH-6.0 Leuks-NEG [**2141-11-16**] 02:36PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.010 [**2141-11-16**] 02:36PM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [**2141-11-16**] 02:36PM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-0 [**2141-11-9**] 10:01PM URINE Mucous-RARE [**2141-11-7**] 06:33PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG . . Microbiology: [**2141-11-17**] 12:12 pm CSF;SPINAL FLUID Site: SHUNT **FINAL REPORT [**2141-11-23**]** GRAM STAIN (Final [**2141-11-17**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [**2141-11-23**]): NO GROWTH. . [**2141-11-16**] URINE URINE CULTURE-NO GROWTH [**2141-11-13**] MRSA SCREEN MRSA SCREEN-NOT DETECTED [**2141-11-11**] BLOOD CULTURE Blood Culture, Routine-NO GROWTH [**2141-11-10**] URINE URINE CULTURE-NO GROWTH [**2141-11-10**] BLOOD CULTURE Blood Culture, Routine-NO GROWTH [**2141-11-10**] MRSA SCREEN MRSA SCREEN-NOT DETECTED [**2141-11-9**] BLOOD CULTURE Blood Culture, Routine-NO GROWTH [**2141-11-9**] BLOOD CULTURE Blood Culture, Routine-NO GROWTH [**2141-11-9**] URINE URINE CULTURE-NO GROWTH [**2141-11-7**] MRSA SCREEN MRSA SCREEN-NOT DETECTED [**2141-11-7**] BLOOD CULTURE Blood Culture, Routine-NO GROWTH [**2141-11-10**] 1:37 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2141-11-10**]** GRAM STAIN (Final [**2141-11-10**]): [**12-5**] PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. . CTA Head & Neck [**2141-11-7**]: NON-CONTRAST CT HEAD: There is no evidence of acute intracranial hemorrhage or territorial infarction. Focal and confluent periventricular and subcortical hypodensities are noted in bilateral cerebral hemispheres, which likely represent sequelae of chronic small vessel ischemic disease. Hypodensity is noted in the pons which likely represents a lacunar infarct. There is prominence of ventricles, extra-axial CSF spaces and cortical sulci suggestive of mild generalized cerebral atrophy. The visualized paranasal sinuses and mastoid air cells are clear. The orbits are unremarkable. A fat density lesion is noted in the subgaleal soft tissues in midline in the frontal region which likely represents a lipoma. There is no significant change as compared to the prior CT. CTA NECK: The aortic arch is bovine-type with left common carotid artery arising from the brachiocephalic trunk. Atheromatous plaques are noted in the aortic arch and at the origin of left subclavian artery without significant stenosis. Bilateral common carotid arteries, internal and external carotid arteries appear normal. There is medialization of distal common carotid and internal carotid arteries. There is no evidence of focal flow limiting stenosis, occlusion or aneurysm greater than 3 mm. Bilateral vertebral arteries are patent. The proximal and distal right internal carotid arteries measure 6.5 and 5.5 mm respectively and proximal and distal left internal carotid arteries measure 5.9 and 4.2 mm respectively. Degenerative changes are noted in the cervical spine. CTA HEAD: The arteries of anterior circulation including bilateral intracranial internal carotid arteries, anterior cerebral and right middle cerebral arteries appear normal. There is mild atherosclerotic disease of left middle cerebral artery. The arteries of the posterior circulation including bilateral vertebral arteries, basilar artery, and posterior cerebral arteries appear normal. The P1 segment of left posterior cerebral artery appears hypoplastic. There is no evidence of focal flow-limiting stenosis, occlusion, or aneurysm greater than 3 mm. IMPRESSION: 1. No evidence of acute intracranial hemorrhage or territorial infarction. 2. Changes of chronic small vessel ischemic disease and lacunar infarct in pons. 3. No evidence of focal flow-limiting stenosis, occlusion or aneurysm greater than 3 mm in arteries of anterior and posterior circulation of head. 4. No evidence of occlusion, focal flow-limiting stenosis or aneurysm greater than 3 mm in arteries of neck. ECHO [**2141-11-8**]: The left atrium is normal in size. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with cough. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. No intracardiac source of embolism identified. Patient unable to cooperate with Valsalva maneuver. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. CT Head [**2141-11-8**]: IMPRESSION: 1. Acute large intraparenchymal hemorrhage centered at the left cerebellum, likely represents hemorrhagic conversion of stroke. 2. Equivocal trace hyperdensity layering at the right lateral ventricular occipital [**Doctor Last Name 534**], could represent trace intraventricular hemorrhage extension. 3. No evidence of developing hydrocephalus. Repeat CT Head [**2141-11-8**]: IMPRESSION: 1. No significant change in the size of the acute cerebellar hemorrhage, centered in the left cerebellar hemisphere. Associated tonsillar herniation, upward transtentorial herniation, and effacement of the fourth ventricle are not significantly changed. There is no significant further ventricular dilatation or transependymal migration of CSF to suggest acute obstructive hydrocephalus. 2. No significant change in the overall quantity of bihemispheric subarachnoid hemorrhage allowing for redistribution. Decreased layering hemorrhage within the bilateral occipital horns of the lateral ventricles. [**11-9**] CT head - 1. Interval increase in the amount of bilateral subarachnoid hemorrhages with increased intraventricular blood. 2. Unchanged left cerebellar hemorrhage. [**11-9**] CT head - 1. Expected post-operative changes status post evacuation of cerebellar hemorrhage via a suboccipital approach including residual blood products and mild pneumocephalus. 2. Persistent effacement of the fourth ventricle, tonsillar herniation, and likely upward transtentorial herniation. 3. No significant change in the size of the lateral ventricles or third ventricle status post placement of an external ventricular drain, which appears appropriately positioned. 4. Unchanged bihemispheric subarachnoid hemorrhage. Intraventricular hemorrhagic extension with increased hemorrhage layering in the right occipital [**Doctor Last Name 534**] and unchanged hemorrhage layering in the left occipital [**Doctor Last Name 534**] of the lateral ventricles. [**11-10**] Ct head - the mass effect on the fourth ventricle appears to be slightly less. Postoperative changes again identified with hemorrhage in the left cerebellar hemisphere, pneumocephalus and subarachnoid hemorrhage. Other findings as above including more blood seen on the current study in the occipital [**Doctor Last Name 534**] of the lateral ventricles. [**11-11**] CXR - The ET tube tip is 5.5 cm above the carina. The right internal jugular line tip is at the level of mid SVC. Cardiomediastinal silhouette is unchanged. There is interval improvement of left perihilar opacity but still vascular engorgement is present most likely consistent with mild volume overload. No new consolidations are present. Minimal left basal atelectasis is unchanged. [**11-15**] CT Head 1. New bilateral subdural hygromas consistent with the clinical history of "over-shunting." 2. Overall unchanged extent of residual subarachnoid and intraventricular blood. [**11-17**] CT Head 1. Interval increase of the mass effect in the posterior fossa with now complete effacement of the 4th ventricle and cerebral aqueduct and concern for worsening ascending transtentorial herniation. 2. Similar or slightly decreased bifrontal subdural hygromas. 3. Unchanged ventricles CT HEAD W/O CONTRAST [**2141-11-17**] 1. Interval increase of the mass effect in the posterior fossa with now complete effacement of the 4th ventricle and cerebral aqueduct and concern for worsening ascending transtentorial herniation. 2. Similar or slightly decreased bifrontal subdural hygromas. 3. Unchanged ventricles. 4. Small foci of gelfoam material/ fat in the posterior fossa- ucnhanged; however, attention on followup. MRI can be considered if not contra-indicated, when appropriate. LE Dopplers [**2141-11-21**]: DVT, with thrombus in the right peroneal and the left peroneal and posterior tibial veins. RUE Doppler: [**2141-11-22**] FINDINGS: The left and right subclavian veins demonstrate normal flow and symmetric waveforms. The right internal jugular, axillary, brachial, basilic and cephalic veins demonstrate normal compression, grayscale appearance, color flow and waveforms. IMPRESSION: No right upper extremity DVT. [**2141-11-23**] CT maxilla / mandible FINDINGS: The paranasal sinuses are normally aerated with no mucosal thickening or air-fluid levels. The ostiomeatal units are patent. The cribriform plates are intact. There is no nasal septal defect. The lamina papyracea is intact. In terms of dentition, there is reabsorption around the root of multiple teeth, most significant in the right maxillary molar (#2). There is also reabsorption around the left maxillary canine and the right maxillary incisors. In particular, teeth #2, #7, #8, #9, #10, #11 are affected by reabsorption. IMPRESSION: 1. Severe reabsorption around the root of the right second maxillary molar. Significant reabsorption around the root of the left maxillary canine and right maxillary incisors. 2. Otherwise, unremarkable sinus CT. [**2141-11-24**] LUE ULSTRASOUND COMPARISON: Right arm ultrasound, [**2141-11-22**]. FINDINGS: Grayscale, color, and Doppler images were obtained of the left IJ, subclavian, axillary, brachial, basilic, and cephalic veins. Normal flow, compression, and augmentation is seen in all of the vessels. IMPRESSION: No evidence of deep vein thrombosis in the left arm. [**2141-11-27**] B/l LE U/S FINDINGS: There is normal grayscale appearance, compressibility, waveforms, and response to augmentation in the left and right common femoral, superficial femoral and popliteal veins. LEFT CALF: One of the two posterior tibial veins on the left demonstrates echogenic clot and absent color flow consistent with thrombosis. The left peroneal vein is poorly visualized; however, there is no color flow in the expected location. RIGHT CALF: Right posterior tibial veins demonstrate normal color flow. The right peroneal vein demonstrates no color flow consistent with deep venous thrombosis. There may be color flow within the second peroneal vein which previously was thrombosed, however, evaluation is limited by acoustic window. IMPRESSION: Essentially stable examination without propagation of known bilateral calf DVTs. DVT involves right peroneal, left peroneal and left posterior tibial veins. CT HEAD W/O CONTRAST Study Date of [**2141-11-28**] 10:09 PM IMPRESSION: 1. No acute hemorrhage. 2. Significant interval improvement in bihemispheric subarachnoid and intraventricular hemorrhage. 3. Ventricles are stable in size and configuration. 4. Moderate-sized extra-axial fluid collection in the posterior fossa, largely at or superficial to the suboccipital craniotomy site. 5. Post-surgical changes in the posterior fossa with persistent mass effect. . . Neurophysiology: EEG Study Date of [**2141-11-8**] IMPRESSION: This is an abnormal waking EEG because of slow alpha rhythm and bursts of frontal intermittent rhythmic delta activity. These findings are indicative of moderate diffuse cerebral dysfunction. FIRDA can be seen with increased intracerebral pressure, diffuse hydrocephalus, and midline structural lesions and, less commonly, with brainstem dysfunction. In this case, the findings are likely secondary to increased intracranial pressure and/or hydrocephalus. These results were communicated to the neurology team at 6 p.m. on [**2141-11-8**]. EEG Study Date of [**2141-11-8**] IMPRESSION: This telemetry captured no pushbutton activations. The background appeared to show wakefulness at the beginning and then encephalopathy later. The bursts of frontally predominant delta slowing (often called FIRDA, frontal intermittent rhythmic delta activity) lasted no more than a few seconds at a time. It indicates a dysfunction in midline structures, but it cannot be determined how severe that dysfunction is or what the etiology is from the tracing alone. It can come from raised pressure. There were no prominent focal abnormalities, but encephalopathies may obscure focal findings. The lower voltage record (and resolution of the tachycardia) in the middle of the recording could represent more cortical dysfunction or more likely, sedating medication use, especially if the patient was agitated and received such medication. There were no clearly epileptiform features or electrographic seizures. EEG Study Date of [**2141-11-9**] IMPRESSION: Abnormal extended routine EEG due to a mildly slow low voltage background and due to the bursts of generalized slowing. These findings indicate a widespread encephalopathy. Medications, metabolic disturbances, and infection are among the most common causes. Occasionally, the slowing or sharp features were more evident on the right side, but there was no dependably localized or focal abnormality. Encephalopathies may obscure focal findings. There were no clearly epileptiform features. . . Pathology: Cerebellar hematoma [**2141-11-9**] H&E and trichrome stains show blood clot with minute fragments of brain tissue containing vasculature with thickened vessel walls, consistent with hypertensive changes. Beta-amyloid immunolabelling is negative. . . Cardiology: ECG Study Date of [**2141-11-15**] 8:51:42 AM Sinus arrhythmia. Moderate baseline artifact. Tendency toward low voltage in the standard leads. Compared to the previous tracing of [**2141-11-12**] no diagnostic interval change. Read by: [**Last Name (LF) **],[**First Name3 (LF) 125**] M. Intervals Axes Rate PR QRS QT/QTc P QRS T 68 158 94 454/468 77 72 58 Brief Hospital Course: 65M with T2DM and schizophernia presented with sudden onset of speech arrest and was assessed by neurology in the ED. Initial CT head revealed no evidence of acute intracranial hemorrhage or territorial infarction and he was treated with TPA for presumed stroke and admitetd to the neuro ICU under neurology. Later in the evening he was noted to have slurred speech and vomiting and a STAT head CT at 0200 on [**2141-11-8**] showed a L cerebellar hemorrhage with marked mass effect with effacement of the 4th ventricle, but no definite evidence of obstructive hydrocephalus and layering of blood in the lateral ventricles. Mannitol was given and the decision was initially to treat with medical therapy. On [**11-8**] AM his exam remained stable and a repeat Head CT was stable. Overnight he was noted to be very agitated and was sedated. On [**11-9**] he appeared more lethargic and was no longer following commands. A repeat Head CT showed increase in ventricle size. The patient was emergently taken to the OR for a posterior fossa craniotomy for clot evacuation and right EVD placement on [**2141-11-9**]. His post-op head CT remained stable with expected post-op changes. His post-op exam remained unchanged from pre-op. Mannitol was discontinued. On POD1 [**11-10**] he was febrile and cultures were sent. He was also seen to be tachycardic and was placed on a diltiazem gtt. Additional staples were added to his incision. On [**11-11**], he was extubated. Patient was seen have increased aggitation and was given ativan and haldol in which he then became very sedated. His SBP was also elevated. On [**11-12**], psych consult was called for evaluation of aggitation and catatonic schizophrenia. They recommended that we hold ativan and give haldol for aggitation. His EVD was raised to 20cmH20. His exam was improved with some speech and full strength. On [**11-13**], patient was doing well. Some leakage from incision was observed on patient's pillow. EVD was dropped to 10cmH20 as the drainage may have been due to CSF leak. His incision was oversewn. On [**11-16**] his EVD was clamped in an attempt to wean. His posterior surgical site began leaking clear fluid and his drain was reopened and placed at 10cm above the tragus. He was taken to the O.R on [**11-17**] for placement of R frontal VPS. He tolerated this procedure well with no complications. Post operatively, patient was sedated and intubated. Post op head CT was stable. He was transferred to the step down unit for conitnued care. He continued on with PT OT and ST evals. On screening lower extremity ultrasounds on [**11-21**], the patient was noted to have bilateral lower extremity DVTs. Upon consulting with the vascular team it was recommended that we repeat this study in [**6-17**] days and full anticoagulation for six weeks which we started with enoxaparin as a bridge to Coumadin on [**2141-11-22**]. Repeat doppler ultrasound was stable examination without propagation of known bilateral calf DVTs with DVT involving the right peroneal, left peroneal and left posterior tibial veins. INR on discharge was 1.7 and should be measured regularly at rehab. Enoxaparin was stopped when the INR was >1.5 on [**11-30**] with a goal INR 1.5-2 given recent hemorrhage aiming at the upper end of this range. His front tooth was noted to be loose by ST. He was seen by dental who recommended that he have all of his maxillary teeth extracted. In particular they felt that teeth #7 #8 were posing an aspiration risk to the pt. They recommended that oral surgery pull the teeth. OMFS was contact[**Name (NI) **] and they came to the bedside and with gauze extraction, removed teeth #7 #8 on [**2141-11-23**]. The pt tolerated this procedure well and was treated with a week course of penicillin to finish on [**12-1**] and 2 weeks of chlorhexadine oral rinse. In the ICU he was noted to have possible sleep apnea and PCP should consider sleep study to evaluate as an outpatient. His PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] was updated on his care. Patient will be followed up by neurology and neurosurgery with repeat CT head and patient will require dental follow-up regarding his teeth. Transitional issues: Patient was stable bilateral DVTs and enoxaparin was stopped on [**11-30**]. He should aim for INR 1.5-2 given recent hemorrhage with INR checks regularly at rehab. Patient was treated with a week course of enicillin post dental surgery to finish on [**12-1**]. Medications on Admission: ASA 81mg chewable qd Metformin 1000 mg [**Hospital1 **] Lisinopril 10mg qd Lantus 100 units/ml 42 units qd Toprol XL 50mg q 24 hrs Novasc 10mg qd Discharge Medications: 1. acetaminophen 650 mg/20.3 mL Solution Sig: [**2-12**] PO Q6H (every 6 hours) as needed for pain. 2. insulin glargine 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous once a day: At dinner. 3. insulin regular human 100 unit/mL Solution Sig: per sliding scale per sliding scale Injection four times a day. 4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) MG PO BID (2 times a day): Hold for loose stools. 9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. penicillin V potassium 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) for 2 days: To finish on [**12-1**]. 11. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day) for 8 days. 12. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO once a day: Please redose as appropriate daily based on INR. 13. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)). Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Primary diagnoses: Left cerebellar hemorrhage s/p TPA and s/p craniotomy and clot evacuation and VP shunt Bilateral deep vein thromboses Dental extractions . Secondary diagnoses: Possible sleep apnea Schizophrenia Type 2 diabetes Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr [**Known lastname **], You were seen in the hospital for inability to speak. You were given a clot [**Male First Name (un) 18701**] called alteplase (TPA) for a presumed stroke. Unfortunately, you had a complication from this and had a bleed in your cerebellum (the base of your brain). The bleed rapidly incraesed in size and ended up necessitating an operation to remove the blood. You also had placement of a ventriculoperitoneal shunt to decrease pressure as you had exessive drainage from your wound. During your stay you indicated that some of your upper front teeth were loose. You were seen by Dental and Oral maxilofacial surgery who pulled two of your upper/front teeth for your safety and were started on a 7 day course of antibiotics following this and a chlorhexadine oral rinse for 14 days. You were found to have blood clots in the veins of both of your legs and you were started on a blood thinner called warfarin which you will continue for likely 6 weeks. You were also started on an additional blood thinner called enoxaprin until your warfarin level was high enough. You will need to have warfarin levels taken regularly at rehab. You were agitated and risperidone was changed to olanzapine and this dose was increased. You were felt to have possible sleep apnea and your PCP [**Name9 (PRE) 97317**] consider [**Name Initial (PRE) **] sleep study for evaluation as an outpatient. You recovered well and were able to be sent to a rehab facility to get stronger. We made the following changes to your medications: We STOPPED aspirin We STOPPED metformin We DECREASED lantus to 20 units at dinner We INCREASED metoprolol to 50mg twice daily We STARTED an insulin sliding scale We STARTED laxatives We STARTED penicillin V 500mg every 6 hours which you should continue until [**12-1**] at night We STARTED pantoprazole 40mg daily We STARTED chlorhexadine rinse 15mg twice a day for 8 days We STARTED warfarin 7.5mg daily and this dose should be adjusted depending on INR We STARTED olanzapine 5mg at night Please continue to take your other medications as previously prescribed. It you experience any of the below listed Danger Signs, please contact your doctor or go to the nearest Emergency Room. It was a pleasure taking care of you on this hospitalization. Below you will find some general instructions on post-surgical care: General Instructions ?????? Check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. Followup Instructions: Please have general follow-up with Dr [**First Name (STitle) **] in 4 weeks with a Head CT w/o contrast. Please have rehab call [**Telephone/Fax (1) 4296**] to make this appointment. You will need to follow up with your dentist as you have several teeth that our dental team felt you should have monitored and that might need to be extracted. You will need to follow up follow up with your PCP withing two weeks of discharge to monitor and order your warfarin dosing and also to re-evaluate the status of your DVTs and determine an end date for anticoagulation. We recommended a total of 6 weeks. You will also need a formal sleep study after you are discharged - this can be arranged through your primary care physician. YOU ALSO HAVE AN APPOINTMENT WITH THE NEUROLOGY TEAM / THEY WERE TREATING YOU FOR YOUR STROKE Department: NEUROLOGY When: MONDAY [**2142-1-8**] at 2:30 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD [**Telephone/Fax (1) 2574**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "V15.84", "401.9", "293.0", "348.5", "362.01", "453.42", "431", "453.41", "525.8", "V49.87", "348.4", "331.4", "560.1", "295.32", "250.50", "276.0", "434.91" ]

icd9cm

[ [ [] ] ]

[ "96.6", "01.39", "23.19", "38.97", "96.71", "02.21", "02.34", "99.10" ]

icd9pcs

[ [ [] ] ]

28309, 28380

22224, 26462

315, 502

28654, 28654

4004, 4004

32019, 33192

1903, 1957

26943, 28286

28401, 28559

26772, 26920

28829, 30351

6187, 9189

2726, 3603

2002, 2506

28580, 28633

3617, 3985

26483, 26746

30380, 31996

268, 277

530, 1022

9198, 22201

4020, 4591

4613, 6171

1986, 1986

28669, 28805

1044, 1439

1455, 1887

28,019

198,825

7614

Discharge summary

report

Admission Date: [**2142-7-5**] Discharge Date: [**2142-7-9**] Date of Birth: [**2081-1-1**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 896**] Chief Complaint: Headache, nausea/vomiting Major Surgical or Invasive Procedure: None History of Present Illness: 61yoF with h/o 4v CABG [**2137**], PVD, ESRD on HD who presented to ED with complaints of headache since [**6-19**], nausea and emesis for past couple days, and recent high blood pressures. Was hypertensive at HD yesterday and sent to ED. Pt denied SOB, CP, abd pain, dizziness, visual changes, neuro sxs, neck stiffness/pain, blood in urine/stool. . Initial Vitals in ED: 98.5 59 [**Telephone/Fax (2) 27788**]%. BP's through ED course noted to be SBP 191-202. EKG noted to have STD's in V5-6 and II. Pt had CT head showing periventricular hypodensity within R frontal matter called as subacute to chronic infarction. Neuro was consulted who called this as subacute with areas of old infarct, no correlation to symptoms. . Pt was given 400 mg IV Ciprofloxacin, 40 mg IV Protonix, Zofran 4mg IV x2, 100 mg Labetalol IV, 1g IV Vancomycin, 4mg IV Morphine. She then was noted to have coffee ground emesis and had an NG tube placed which cleared with 750 cc's. GI was contact[**Name (NI) **]. . Admit vitals: 98.4 64 213/90 16 98% RA. In the ICU, pt is interviewed with telephone Chinese interpreter. She is c/o discomfort from the NG tube, but denies all other symptoms. She looks very tired and doesn't want to talk much. ROS as above, o/w negative all other systems. Past Medical History: Diabetes with ESRD on HD Hypertension Dyslipidemia CAD s/p CABGx4 (LIMA-LAD,SVG-Diag,SVG-OM,SVG-PDA) [**2138-11-28**] Retinopathy Chronic kidney disease on HD Myelodysplastic syndrome PVD s/p R com Fem to [**Doctor Last Name **] BPG in '[**37**] and Left [**Name (NI) 1793**] PTA/Stent [**2140-7-7**] GERD Anemia [**1-3**] MDS and ESRD Social History: -Lives with husband and son. [**Name (NI) 8230**]-speaking only. -Tobacco history: None -ETOH: None -Illicit drugs: None Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION EXAM: VS: 98.6 69 183/78 14 94%RA Thin, very tired and annoyed appearing Asian F, lays in bed with her eyes closed. Physical exam is limited. EOMI, no scleral icterus CTAB anteriorly, no w/c/r RRR no m/g Abd scaphoid, NT ND, benign No BLE edema, extremities are warm well perfused. Neuro exam very limited. Spoken to with telephone Chinese interpreter, initially would take the phone and speak with her, then stopped taking the phone but would talk into phone if held to her ear. Conversant, attentive, apparently appropriate and answered questions correctly . DISCHARGE EXAM: Vitals: T98.7/98.1, BP 148/62 (140-170s/50-70s), HR 59, RR 16, O2 97% RA GEN: thin, tired appearing woman, NAD, sitting up in bed. Speaks fluently with the pharm student acting as a translator. SKIN: L catheter site with some erythema, nontender to palpation and w/o drainage. HEENT: symmetrically small pupils. EOMI, MMM, OP clear. CV: well healed sternotomy scar. RRR, nl s1/s2. 2/6 systolic murmur on L sternal border. Lung: CTAB, fine crackles bibasilarly. no wheezes. Abd: soft, nondistended, nontender to palpation. +BS EXT: thin legs in pneumoboots, R thigh with well healed surgical scar. DP/PT pulses palpable bilaterally. No edema. Neuro: unable to complete full neuro exam due to language barrier, but patient with grossly intact CN exam, good FTN, and good strength grossly. Patient walking to bathroom on her own without gait problems. Pertinent Results: ADMISSION LABS: [**2142-7-5**] 05:55PM BLOOD WBC-6.7 RBC-4.70# Hgb-14.5# Hct-43.8# MCV-93 MCH-30.8 MCHC-33.1 RDW-16.0* Plt Ct-165 [**2142-7-5**] 05:55PM BLOOD Neuts-80.8* Lymphs-14.4* Monos-3.0 Eos-0.9 Baso-0.9 [**2142-7-5**] 05:55PM BLOOD Glucose-62* UreaN-25* Creat-4.9*# Na-136 K-5.7* Cl-98 HCO3-27 AnGap-17 [**2142-7-5**] 05:55PM BLOOD ALT-33 AST-90* CK(CPK)-123 AlkPhos-145* TotBili-0.4 [**2142-7-5**] 05:55PM BLOOD Lipase-54 [**2142-7-5**] 05:55PM BLOOD CK-MB-2 cTropnT-0.02* [**2142-7-5**] 05:55PM BLOOD Albumin-3.9 Cholest-127 [**2142-7-6**] 08:23AM BLOOD Calcium-9.1 Phos-4.6* Mg-1.9 [**2142-7-5**] 08:30PM BLOOD %HbA1c-5.4 eAG-108 [**2142-7-5**] 05:55PM BLOOD Triglyc-91 HDL-62 CHOL/HD-2.0 LDLcalc-47 [**2142-7-5**] 08:38PM BLOOD Lactate-1.4 K-4.6 . DISCHARGE LABS: [**2142-7-9**] 07:45AM BLOOD WBC-7.3 RBC-4.24 Hgb-13.0 Hct-39.3 MCV-93 MCH-30.6 MCHC-33.0 RDW-15.7* Plt Ct-153 [**2142-7-9**] 07:45AM BLOOD Glucose-177* UreaN-45* Creat-7.2*# Na-132* K-4.9 Cl-90* HCO3-28 AnGap-19 [**2142-7-9**] 07:45AM BLOOD Calcium-9.1 Phos-7.1* Mg-2.3 ================================= IMAGINGS: EKG [**2142-7-5**]: Sinus rhythm. Short P-R interval. Compared to the previous tracing of [**2142-6-5**] the rate is slightly faster and no longer bradycardic. computed P-R interval is shorter. Frontal plane axis is slightly more vertical. Non-specific repolarization abnormalities are somewhat more pronounced in the inferolateral leads. . CXR [**2142-7-5**]: Likely left base atelectasis/scarring. No definite focal consolidation. . NC HEAD CT [**2142-7-5**]: No acute intracranial process. Area of periventricular hypodensity within the right frontal white matter that may represent a site of subacute to chronic infarction. MRI is more sensitive and should be considered for further evaluation. . BRAIN MRI [**2142-7-7**]: There is an area of signal abnormality in the right basal ganglia which demonstrates high intense FLAIR signal as well as low FLAIR signal, indicative of a chronic right basal ganglia infarct. There is no mass effect, midline shift or hydrocephalus. A few punctate foci of T2 hyperintensity in the white matter indicate mild changes of small vessel disease. The diffusion images demonstrate no evidence of acute infarct. There is no mass effect, midline shift or hydrocephalus. . Echo [**2142-7-9**]: The left atrium is moderately dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . IMPRESSION: No cardiac source of embolism seen. Normal global and regional biventricular systolic function. Mild mitral regurgitation. Negative bubble study. ================================= MICROBIOLOGY: UCx [**2142-7-5**]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. BCx [**2142-7-5**]: NGTD, final result pending. MRSA screen [**2142-7-6**]: negative Brief Hospital Course: 61 yo F with PMH of 4v CABG ([**2137**]), PVD, ESRD on HD (TTSat) who presented to ED with complaints of HA x2 wks, nausea and emesis for x few days, hypertensive to 200's, and with reported coffee ground emesis in the ED. Monitored in MICU for coffee ground emesis and for hypertensive emergency, stable on the floor. #. Hypertensive emergency: patient with chronic hypertension, on 4 agents as an outpatient. She also has ESRD on HD, likely from her diabetes and hypertension. Per recent d/c summary, baselines are 160-170. In the ED, her SBP was >200 with complaint of headache. Noncontrast head CT was done to rule out a bleed and neuro was consulted. Nonfocal neuro exam per note and head CT was negative for a bleed, though there was a question of subacute or chronic infarct. BP goals per renal were SBP 150-160 and she was maintained on her home PO meds and IV labetalol prn in the MICU with relatively good control of her blood pressure. She complained of headache on the floor, but her neuro status remained stable and she was treated with tylenol prn for headaches. Her lisinopril was uptitrated to 20 mg as her SBP ranged from 140-170. She is being discharged on amlodipine 10 mg daily, metoprolol XL 100 mg daily, isosorbide mononitrate 30 mg daily and lisinopril 20 mg daily. #. Coffee ground emesis: Patient first had an episode of coffee ground emesis in the ED, which cleared quickly with NGT and lavage. GI was consulted, thought it would be likely due to [**Doctor First Name 329**]-[**Doctor Last Name **] tear given her recent nausea/vomiting at home. GI did not want to scope the patient given her hypertensive emergency and no evidence of active bleeding at the time, as her coffee ground emesis cleared very quickly. She was started on protonix IV BID and her aspirin and plavix were held. She was admitted to ICU for monitoring and had another episode of coffee ground emesis, which also cleared quickly with lavage. Patient's nausea/vomiting and her coffee ground emesis resolved. Her plavix is being held for 2 weeks on discharge and she should follow up with GI for possible outpatient EGD. # ?Infarct: In the ED, head CT was done to evaluate for bleed. No acute bleed was shown, but it showed possible chronic/subacute infarct. Neuro was consulted, and she had nonfocal neuro exam. Given the possible subacute infarct, neuro recommended SBP of 180-200s initially to maximize cerebral perfusion. Recommendation was made for brain MRI and CTA of neck/head for further evaluation. MRI brain w/o contrast was done to further evaluate, and only showed possible old infarct in basal ganglia without new or subacute infarct. CTA of neck and head was not done as patient still makes urine and renal thought additional injury with large contrast load would not be advisable. Neuro recommended blood pressure of SBP>110 as pt does not have evidence of acute stroke, and TTE only showed moderately dilated L atrium, mild symmetric LV hypertrophy and normal global/regional systolic function without septal defect. Her aspirin/plavix were held in the hospital given her coffee ground emesis. Atorvastatin was continued with good LDL control. # ESRD on HD: ESRD likely due to diabetes and hypertension. Renal was consulted to continue HD in house. She was continued on Tu/Th/Sat schedule. Her sevelamer was increased to 1600mg PO TID with meals and she was continued on nephrocaps daily. Renal recommended SBP of 150-160 and she was continued on home dose amlodipine, metoprolol and mononitrate, and her lisinopril was increased to 20 mg daily for better blood pressure control. She will have dialysis day after discharge at her [**Location (un) **] outpatient discharge center. # EKG changes: She had some EKG changes on admission without corresponding symptoms and negative cardiac enzymes. As elderly diabetic woman, her symptoms may not be typical angina. She was continued on tele given her continued hypertension and possibility of demand ischemia. No further changes seen on tele. # DM: On insulin at home with A1C of 5.4% on admission. She was continued on home insulin dosing and diabetic diet. Medications on Admission: 1.folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2.cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3.amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4.isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 5.ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6.lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7.sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8.docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): this is an over-the-counter. 9.atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10.Toprol XL 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 11.clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day. 12.oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 5 days. Disp:*10 Tablet(s)* Refills:*0* 13.aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 14.insulin aspart 100 unit/mL Solution Sig: 7 units at Noon, 4 units at 6pm units Subcutaneous twice a day. 15.insulin glargine 100 unit/mL Solution Sig: Sixteen (16) unitis Subcutaneous at bedtime. Discharge Medications: 1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 7. Toprol XL 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 8. insulin aspart 100 unit/mL Solution Sig: 7 units Subcutaneous at noon. 9. insulin aspart 100 unit/mL Solution Sig: Four (4) units Subcutaneous at 6 pm. 10. insulin glargine 100 unit/mL Solution Sig: Sixteen (16) units Subcutaneous at bedtime. 11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO once a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 12. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 13. calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO once a day. 14. sodium bicarbonate 650 mg Tablet Sig: One (1) Tablet PO once a day. 15. Vitamin B-6 50 mg Tablet Sig: Two (2) Tablet PO once a day. 16. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/headache: Please do not take more than 10 tablets per day. . 17. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*2* 18. multivitamin Tablet Sig: One (1) Tablet PO once a day. 19. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Hypertensive emergency Secondary diagnosis: coffee ground emesis, likely from [**Doctor First Name 329**]-[**Doctor Last Name **] tear 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 to take care of you at [**Hospital1 1535**]. You came into the hospital because of your high blood pressure. You also had headache, nausea and vomiting, and in the emergency department, had some vomit with blood in it, which cleared quickly. You were admitted to intensive care unit for monitoring of your blood pressure and vomiting. Your blood pressure was controlled with your home medications and also with intravenous blood pressure medication. Your nausea and vomiting improved as well. You had a scan of your head to rule out bleeding in the brain given your headache and high blood pressure. The scan of your brain did not show any bleeding, but did show a possible old stroke. You were continued on hemodialysis in the hospital and your blood pressure medications were adjusted to keep your systolic blood pressure in 150-160. . These changes were made to your medications: STOP ranitidine 150 mg by mouth daily STOP clopidogrel (Plavix) 75 mg by mouth daily for 2 weeks. You can start it again after 2 weeks. START pantoprazole 40 mg by mouth twice daily for you stomach START nephrocaps 1 capsule by mouth daily INCREASE lisinopril to 20 mg by mouth daily for your blood pressure INCREASE sevelamer carbonate (Renvela) to 1600 mg by mouth three times daily with meals. . Followup Instructions: Department: [**Location (un) **] [**Location (un) **] Location: [**State **], [**Location (un) **] [**Numeric Identifier 1415**] Phone: [**Telephone/Fax (1) 5972**] *You will see Dr. [**Last Name (STitle) 118**] at your next dialysis appointment, Tuesday, [**7-10**] at 3:30PM . Department: TRANSPLANT SOCIAL WORK When: THURSDAY [**2142-7-12**] at 3:30 PM [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage . Name: [**Last Name (LF) **],[**First Name3 (LF) **] G. Location: [**Hospital3 8233**] Address: [**State 8234**], [**Location (un) **],[**Numeric Identifier 8235**] Phone: [**Telephone/Fax (1) 8236**] When: [**Last Name (LF) 766**], [**7-16**], 2:30PM . Department: WEST [**Hospital 2002**] CLINIC When: WEDNESDAY [**2142-8-1**] at 2:00 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage

[ "403.91", "784.0", "272.4", "V45.81", "238.75", "V12.54", "414.00", "V45.11", "530.7", "585.6", "443.9", "250.00" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

14739, 14745

7449, 11578

326, 332

14943, 14943

3727, 3727

16451, 17590

2141, 2256

12965, 14716

14766, 14766

11604, 12942

15094, 16428

4503, 7426

2271, 2842

2858, 3708

261, 288

360, 1627

14829, 14922

3743, 4487

14785, 14808

14958, 15070

1649, 1986

2002, 2125

3,567

155,011

47537

Discharge summary

report

Admission Date: [**2158-1-6**] Discharge Date: [**2158-1-7**] Date of Birth: [**2089-12-19**] Sex: F Service: MEDICINE Allergies: Prilosec / Red Dye Attending:[**First Name3 (LF) 2297**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: 68F with locally advanced pancreatic adenocarcinoma, ECOG 2, LD gemcitabine [**12-14**], seen in clinic 2d ago with fatigue, poor PO intake, and somnolence, and new ARF (cr 1.4 from 0.3) presented to ED with hypotension and UTI. In ED, VS notable for Tmin 94.4, HR 120, BP 63/49. Labs notable for hypoglycemia upon trasnfer to 11, lactate 12.6, INR 7.3 (1.5 in [**11-26**]), Hct 26.7 down from 30 2d ago, U/A consistent with UTI, cr: 1.5. Code sepsis called. Femoral central line [**2-23**] to pt's coagulopathy, received 10mg Vit K, 2L IVF, Flagyl, Levofloxacin, and Vancomycin, 1 amp D50, 1mg glucagon. Put on Levophed with MAP:65 , CVP14:, SVO2 98%: ,UOP:150cc. Per ED record, family and patient reversed code status to FULL CODE. Past Medical History: PMHX: 1. Locally invasive pancreatic adenocarcinoma, unresectable, with vena cava invasion and portocaval lymph node involvement. Diagnosed [**6-/2157**], s/p biliary stent placement [**2157-7-1**], s/p biliary stent replacement on [**2157-10-28**], s/p replacement with metal stent on [**2157-11-2**]. On Gemcitabine, last dose on [**12-14**] . 2. H/O Breast CA, s/p mastectomy and LND. Received chemo/XRT, and completed 5 years of Tamoxifen. . 3. Hypercholesterolemia Social History: Lives in [**Location 100500**]. Married, 3daughters. 20pkyrs. Occasional alcohol use. No illicit drugs. Family History: Niece w/lymphoma at age 18 and breast cancer at age 32. Father died at age 47 from an accident. Mother died at age 27 from cardiac problems. Two sisters with DM2 Physical Exam: PE: Tmin 94.4, HR 112-120, 63-120/60, 17, 98% 100%NRB GEN: Elderly, ill-appearing, appears to be in pain, opens eyes to voice HEENT: icteric sclera, PERRL, OP dry MMM CV: reg tachycardia, S1, S2, no MRG PULM: diminished BS at bases otherwise clear ABD: mild distension, firm, tender throughout EXT: 1+ edema NEURO: Somnolent, non-verbal Pertinent Results: [**2158-1-6**] 03:31PM GLUCOSE-89 LACTATE-13.4* TCO2-19* [**2158-1-6**] 11:00AM GLUCOSE-180* UREA N-33* CREAT-1.5* SODIUM-139 POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-20* ANION GAP-24* [**2158-1-6**] 11:00AM ALT(SGPT)-163* AST(SGOT)-342* LD(LDH)-621* AMYLASE-50 TOT BILI-4.9* [**2158-1-6**] 11:00AM PT-31.1* PTT-95.1* INR(PT)-7.3 [**2158-1-6**] 11:00AM WBC-9.0 RBC-3.18* HGB-8.9* HCT-26.9* MCV-85 MCH-28.0 MCHC-33.1 RDW-21.3* [**2158-1-6**] 11:00AM URINE RBC-0-2 WBC->50 BACTERIA-MANY YEAST-NONE EPI-0 . Abd CT [**1-6**] - CONCLUSION: 1. Predominantly right-sided colitis highly suggestive of C. diff/pseudomembranous colitis. Correlation with toxins and clinical history is recommended. 2. Locally advanced pancreatic malignancy with secondary obstruction. The patient's stent appears to be working. 3. There is no evidence of hepatic metastasis but posteriorly in segment VII, there is identified an unusual vascular blush that has an appearance of a portovenous fistula. This was present on previous study from [**2157-12-6**]. Brief Hospital Course: A/P: 68F with pancreatic CA, on gemicitabine, presenting with progressive fatigue, hypotension, and UTI. . 1. Sepsis: Code sepsis for Urosepsis though hepatobiliary source likley as well. Pt was placed on Zosyn for hepatobiiary/UTI coverage and Flagyl for possible Cdiff. She had a very high Lactate level, and remained hypotensive requiring Levophed and IVF's. She continue to require increasing doses of Levophed, and Vasopressin was added. She also deveped hypoxia with evidence of pulmonary edema after IVF's. . The patient began to develop severely elevated LFT's c/w shock liver, and her lactates remained elevated. She became anuric with increasing creatinine and decreased bicarb, and began to develop evidence of DIC as well with dramatic throbocytopenia. Given her multiorgan system failure, a family meeting was held and it was decided the patient be made CMO. She was placed on a Morphine drip, and passed away at 11:30pm on [**2158-1-7**] of presumed septic shock. The family declined autopsy. The attending Dr [**First Name (STitle) **] was notified, as well as the patient's primary oncologists Dr [**Last Name (STitle) **] and Dr [**First Name (STitle) **]. . Medications on Admission: 1. Celexa 20 mg qd 2. Lasix 20 mg qd 3. Protonix 40 mg qd 4. oxycodone 5 mg q4-6h p.r.n. 5. potassium chloride 40 mEq qd Discharge Disposition: Expired Discharge Diagnosis: Septic Shock Discharge Condition: Expired Discharge Instructions: Pt made CMO Followup Instructions: None Completed by:[**2158-1-8**]

[ "286.6", "995.92", "584.9", "038.9", "599.0", "785.52", "V10.3", "157.8", "570", "272.0", "008.45", "285.9", "196.2" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

4647, 4656

3293, 4475

290, 297

4713, 4723

2225, 3270

4783, 4818

1690, 1853

4677, 4692

4501, 4624

4747, 4760

1868, 2206

239, 252

325, 1060

1082, 1553

1569, 1674

72,355

137,177

39281

Discharge summary

report

Admission Date: [**2193-1-3**] Discharge Date: [**2193-1-17**] Date of Birth: [**2130-9-30**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1481**] Chief Complaint: esophageal cancer Major Surgical or Invasive Procedure: minimally invasive esophagectomy Balloon angioplasty of left subclavian artery. History of Present Illness: The patient is a 62-year-old man with a history of significant peripheral vascular disease who has esophageal cancer in the distal esophagus from 38-42 cm, he initially presented with dysphagia. Biopsy of the distal esophagus showed poorly differentiated invasive adenocarcinoma with focal glandular differentiation and signet ring features. PET-CT on [**9-20**], [**2192**], showed FDG avidity with an SUV of 9.8 at the distal esophagus, corresponding to the known esophageal carcinoma; there was a 1-cm rounded opacity at the left lung base with mild FDG avidity with an SUV of 2.9, which was not clearly seen on a prior CT from [**2192-8-28**], and was felt to represent a focus of infectious or inflammatory change or atelectasis; a lymph node immediately superior to the celiac axis measured 1.6 cm with an SUV of 3. In summary, he has no evidence of metastatic disease. He is also a significant vascular patient with bad aorto-iliac disease. He is status post axillary [**Hospital1 **]-fem bypass. In this admission his subclavian site was found to be narrowed, requiring a subclavian angioplasty. He has an echo from [**2192-12-11**] which showed good ejection fraction and no significant wall motion abnormalities. Thoracic surgery was consulted to assist with minimally invasive esophagectomy. Past Medical History: -Esophageal CA - dx [**7-14**] - recieved 28 cycles of XRT and chemo - with last cycle 7 days prior to admission. Primary oncologist - Dr. [**First Name (STitle) **] [**Name (STitle) **] with [**Hospital1 **] - pt reporting done with treatment currently -HTN, -Hypercholesterolemia -PAD Social History: Retired special education teacher. Lives with girlfriend, [**Name (NI) **] (is [**Name8 (MD) **] RN). Current non-smoker, having quit 1 year ago. Prior to that had a 30 pack-year history. Denies alcohol use for the past 6-7 years; records indicate history of abuse. Denies illicit drug use (remote past +MJ and LSD). Family History: Mother and sister with lung CA (both with +tob history) Physical Exam: 976 97.6 70 102/58 16 95RA AOx3, NAD RRR fine crackles bilaterally abdomen soft, appropriately tender, wound c/d/i, no drainage or erythema Pertinent Results: Admission labs [**2193-1-5**] 05:35AM BLOOD WBC-7.3 RBC-3.42* Hgb-10.8* Hct-31.2* MCV-91 MCH-31.5 MCHC-34.5 RDW-18.6* Plt Ct-114*# [**2193-1-3**] 12:15PM BLOOD PT-19.0* PTT-30.8 INR(PT)-1.7* [**2193-1-4**] 06:30AM BLOOD Glucose-100 UreaN-18 Creat-0.5 Na-137 K-3.9 Cl-103 HCO3-28 AnGap-10 [**2193-1-4**] 06:30AM BLOOD Albumin-3.2* Calcium-8.3* Phos-3.1 Mg-1.8 Iron-58 Discharge labs: [**2193-1-17**] 04:42AM BLOOD WBC-8.0 RBC-2.64* Hgb-8.5* Hct-24.9* MCV-94 MCH-32.3* MCHC-34.3 RDW-18.2* Plt Ct-140* [**2193-1-17**] 04:42AM BLOOD Glucose-124* UreaN-15 Creat-0.4* Na-135 K-3.6 Cl-104 HCO3-28 AnGap-7* [**2193-1-17**] 04:42AM BLOOD Calcium-7.6* Phos-3.2 Mg-1.7 Brief Hospital Course: Mr. [**Known lastname 7474**] was admitted to the vascular service prior to his esophagectomy for an: 1. Ultrasound-guided puncture of the left brachial artery. 2. Catheter placement into the aortic arch. 3. Left subclavian arteriogram. 4. Balloon angioplasty of the left subclavian artery. for Left subclavian artery stenosis. After his procedure he was started on his home medications. He was started on Lovanox on [**2193-1-4**]. On [**2193-1-4**], his diet was advanced and tube feeds adjusted. On [**2193-1-7**] he was made NPO for his esophagectomy. He tolerated his procedure (see operative notes for full details, transferred to the PACU for recovery. He was then transferred to the ICU for further stabilization. He had a foley, JP drains, and bilateral chest tubes to dry suction. His J tube was clamped. He was on heparin SQ and PPI for prophylaxis. He was placed on a dilaudid PCA for pain control. He received boluses to maintain urine output and manage tachycardia and his electryolytes were repleted, and put on an insulin sliding scale. On [**2193-1-8**], he received 2uPRBC for a hct of 23.9, his post transfusion hct was 26.4. He also received another LR 500cc bolus. On [**2193-1-9**], his chest tubes were put to water seal and his tube feedings started and advanced per protocol. A urinalysis was sent which was WNL. He was seen by ENT for laryngoscopy which showed no vocal cord paralysis after it was noted that his cough reflex was less than optimal. On [**2193-1-10**], his foley was d/ced and he voided. He was started on aspirin per rectum. His insulin sliding scale was adjusted to optimize blood sugar control. On [**2193-1-11**], he received two 250cc LR boluses before being tranferred to the floor. He continued his heparin SQ and PPI for prophylaxis. He stayed NPO, on tube feeds with an NGT. His chest tubes were removed by the thoracic team on [**2193-1-12**] and [**2193-1-13**]. His NGT was discontinued and his upper GI study did not show an anastomotic leak.However, he hasd a signifant aspiration of barium into his trachea. Bronchoscopy was negative for fistula. A physical therapy consult was placed and he was seen by physical therapy on [**2193-1-15**]. Hi tube feeds were held [**2193-1-15**] in anticipate for a bronchoscopy. Free water j tube flushes were initiated on [**2193-1-14**]. His bronch showed mucous. He also received a 1 uPRBC transfusion for a hct of 21.1. His post transfusion hct was 24.6. On [**2193-1-16**] his tube feeds and insulin sliding scale were adjusted. On [**2193-1-17**] he was switched pain medications by tube, and his home medications were started including coumadin. He was discharged to a rehabilitation facility in stable conditioning on tube feeds. He remains strict NPO pending swallow reevaluation in 2 weeks. Medications on Admission: asa 325', atenolol 50', ativan 1 qhs prn ,warfarin 5' Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) syringe Injection TID (3 times a day). To be discontinued when INR in range. 2. aspirin 300 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily). 3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 4. insulin lispro 100 unit/mL Solution Sig: One (1) dose Subcutaneous ASDIR (AS DIRECTED): as directed in sliding scale. 5. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 6. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Dose to be adjusted according to INR, which should be checked daily until in range. 7. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) **] @[**Location (un) 1821**] Discharge Diagnosis: esophageal cancer Peripheral artery disease with subclavian artery narrowing. 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: Wound Care: Your staples should be removed fourteen days postoperatively at rehab. Tube Feeds: TO Tubefeeding: Isosource 1.5 Cal - 2/3 strength Full strength; Goal rate: 105 ml/hr Residual Check: q4h Hold feeding for residual >= : 200 ml Flush w/ 30 ml water q6h Other instructions: flush with water Medications: restart all your home medications. You need daily INR checks for your coumadin. Continue taking your home dose of coumadin 5 mg by mouth daily. Your goal INR is [**2-7**]. Nutrition: Please do not eat or drink anything by mouth. You had an episode of aspiration in the hospital. You will be scheduled for a video swallow evaluation per Dr. [**Last Name (STitle) **] as an outpatient. Labs: You experienced some tingling in your fingers. B12 and folate labs test were sent off. Your rehab facility or primary care physician should follow up on these lab results in case you need vitamin supplementation. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in [**1-6**] weeks. Please call his office to make this appointment.

[ "263.1", "512.1", "V85.1", "272.0", "401.9", "V15.82", "440.8", "150.8", "V44.4", "V15.3", "288.60", "V87.41" ]

icd9cm

[ [ [] ] ]

[ "00.40", "96.6", "33.22", "88.49", "31.42", "42.41", "39.50" ]

icd9pcs

[ [ [] ] ]

7033, 7155

3322, 6137

321, 402

7277, 7277

2638, 3006

8404, 8528

2396, 2453

6241, 7010

7176, 7256

6163, 6218

7460, 7460

3023, 3299

2468, 2619

263, 282

7472, 8381

430, 1735

7292, 7436

1757, 2045

2061, 2380