ChanBeDu/relevant_section_length · Datasets at Hugging Face

29,657

111,632

33751

Discharge summary

report

Admission Date: [**2191-2-22**] Discharge Date: [**2191-4-12**] Date of Birth: [**2148-10-29**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4691**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [**2191-2-23**] Splenectomy [**2191-3-9**] PICC placement History of Present Illness: 42 yo male inmate who presents with LUQ/LLQ abdominal pain on transfer from [**Hospital **] Hospital with scan showing ungraded splenic laceration. He is s/p unspecified abdominal trauma to Left side during "running game" in the prison yard two days ago ([**2-20**]). HCT at [**Hospital1 **] 29. Past Medical History: Type II DM (diet controlled) Cirrhosis, Hepatitis C Family History: Noncontributory Physical Exam: Exam on Admission: Tc 100.7 HR 84 BP 143/64 RR 22 Sats 100% RA GEN: WDWN M in NAD HEENT: PERRLA CV: RRR, no murmurs, rubs or gallops RESP: CTAB GI/ABD: soft, slightly distended Ext: no cyanosis, clubbing or edema Exam on discharge: GEN: WD, thin M w/ no movement HEENT: icteric sclera, pupils fixed at 6mm, nonreactive, blood dripping from nose, excoriated lips with dried blood present CV: no rhythm, no radial pulses, no brachial pulse, no carotid pulse RESP: no respirations, no breath sounds, no respiratory effort Skin: grossly jaundiced Pertinent Results: [**2191-2-22**] 07:50PM GLUCOSE-96 UREA N-8 CREAT-0.8 SODIUM-136 POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-23 ANION GAP-13 [**2191-2-22**] 07:50PM AST(SGOT)-129* [**2191-2-22**] 07:50PM WBC-5.9 RBC-3.00* HGB-9.3* HCT-29.2* MCV-97 MCH-30.8 MCHC-31.7 RDW-13.4 [**2191-2-22**] 07:50PM PLT SMR-VERY LOW PLT COUNT-81* [**2-22**] CTA ABD: There is mild dependent atelectasis, (left greater than right). A left pleural effusion is minute. A hiatal hernia is small. There is a complex splenic laceration, which traverses the spleen at multiple sites. There are also multiple sites of devascularized parenchyma, which comprise less than 25% of the total splenic volume. In the arterial phase of enhancement, there is an 8-mm contrast collection in the parenchyma, which is contiguous with a splenic artery branch in the hilum (3A, 39). There is a second 3- mm focus in the anterior superior spleen (3A, 25), which is surrounded by more ill defined high attenuation in the arterial phase. These focal collections are suggestive of pseudoaneurysms, as they do not increase in size and in fact become less conspicuous on delayed phases. The hyperattenuation surrounding the smaller focus is suggestive of active contrast extravasation. The spleen is enlarged at 16.2 cm. There is a heterogeneously hyperattenuating capsular hematoma, which measures 33 mm in thickness. There is moderate hemoperitoneum, particularly in the pelvis. The liver, pancreas, adrenal glands, and kidneys are within normal limits. There are multiple mildly enlarged periportal, portacaval, celiac and retroperitoneal nodes, which measure up to 13 mm in short axis and may be reactive. Gallstones are present. There is no bowel dilatation or free intraperitoneal air. The osseous structures are intact. IMPRESSION: 1. Complex splenic laceration (grade III/IV) with two pseudoaneurysms, the smaller of which appears to be associated with active extravasation. There is a moderate splenic capsular hematoma and associated hemoperitoneum. [**2-23**] Liver biopsy: 1. Advanced fibrosis with bridging, sinusoidal fibrosis and multifocal early nodule formation, suspicious for evolving cirrhosis (stage 3-4, confirmed by trichrome stain). 2. Mild-to-moderate portal septal, mild periportal and lobular predominantly mononuclear cell inflammation (grade 2). 3. Mild cholestasis. 4. No significant steatosis or intracellular hyalin seen. 5. Iron stain shows mild focal iron deposition in hepatocytes and Kupffer cells. Note: The findings are consistent with chronic viral hepatitis, clinically HCV. The sinusoidal fibrosis is suggestive of a component of prior toxic/metabolic injury. [**3-2**] CT head: Normal head CT without evidence of brain edema [**3-2**] Abd US: The liver shows no focal or textural abnormalities. The gallbladder contains sludge and shows wall edema. No intra or extrahepatic biliary dilatation is appreciated. The common duct measures 4 mm. The portal vein is patent with hepatopetal flow. Small amount of ascites is present. The pancreas is poorly visualized. The patient is status post splenectomy. [**3-3**] CT Abd/pelvis: Status post splenectomy with small amount of fluid remaining in the abdomen, but no evidence of abscess or recurrence of hematoma. New bibasilar pulmonary parenchymal opacities could reflect pulmonary edema/ARDS, aspiration or pneumonia. Correlation is recommended. Diffuse mild dilation of small bowel, most likely representing ileus. Decreased size of a small rim-enhancing collection in the right lower quadrant, which could reflect appendiceal pathology including improving tip appendicitis. However, there is a question of coloenteric fistula and therefore repeat CT with contrast is recommended when symptoms have resolved. [**3-10**] Abd US: No significant interval change in the appearance of gallbladder. Although these findings may be related to hypoalbuminemia and prolonged NPO status, acute cholecystitis cannot be excluded. Right pleural effusion. Brief Hospital Course: He was admitted to the Trauma service on [**2-22**]. He was taken to the Trauma ICU for close monitoring. His hematocrit was followed closely; he continued to have left shoulder pain and tachycardia; concerning for hemorrhage. He was taken to the operating room for splenectomy on [**2-23**]. There were no intraoperative complications. Postoperatively his tachycardia persisted; he also had a low urinary output. He was given intravenous fluid bolus with increased urine output. He required supplemental oxygen because of low oxygen saturations; incentive spirometer use was strongly encouraged. On post operative day 1 ([**2-24**]) he was transfused 1 unit pRBC and transferred to the floor. On [**2-25**] he was again transfused for a low hematocrit. On post op day 3, he developed increasing somnolence and he was started on lactulose, his narcotics were discontinued and hepatology was consulted. An ammonia level was 71 and he continued to have low urine output. He was started on rifaximin and albumin. On [**2-27**] his mental status worsened, he had vomiting and his abdominal wound dehisced with an ascitic leak. He was transferred back to the trauma ICU for further care. He was started on tube feeds for nutrition. A VAC dressing was placed in the abdominal wound. He was intubated for worsening mental status and airway protection on [**2-28**]. 1 of 2 blood cultures drawn on [**3-1**] returned as positive for vancomycin sensitive enterococcus and he was started on Vancomycin and Zosyn on [**3-2**], which was continued for 10 days. He had a normal head CT and a RUQ ultrasound which showed a sludge filled gallbladder and no stones. He continued to have an ascitic leak, and his bloodwork results were followed closely for increasing bilirubin, creatinine peak of 2.4, moderately increased LFTs and pancreatic enzymes, elevated INR (peak of 1.9) and increased ammonia levels. He was extubated on [**3-8**] and his mental status improved. His bilirubin remained elevated, his ammonia level decreased and his creatinine returned to baseline. He was awake and alert and was able to be transferred to the floor on [**3-11**] and was started on a regular diet on [**3-12**]. He continued to have an ascitic leak and his vac was changed every 3 days on the floor. His INR and bilirubin continued to increase. In discussions with MDs regarding his overall poor prognosis, he clarified that he still preferred aggressive treatment unless he was dying of irreversible liver failure. Psychiatry evaluated him and determined that he was currently competent to make this decision despite any underlying encephalopathic process. He was evaluated and treated by physical therapy. A repeat CT abdomen on [**3-19**] showed slight increase in the free fluid in the pelvis, decreased left subphrenic collection and improvement in the bibasilar aspiration and pneumonia of the lung fields. A chest xray on [**4-1**] showed marked improvement in widespread pulmonary opacities with no definite new abnormalities to suggest acute pneumonia. Mr. [**Known lastname **] was made DNR/DNI per Dr. [**Last Name (STitle) **] on [**3-29**]. On the evening of [**4-11**] the patient had blood pressures that dropped into the 80s/50s while resting in a chair. He was found to have electrolytes that were very irregular on the evening of [**4-11**]. Mr. [**Known lastname **] started to have agonal breathing later that evening, and started bleeding persistently from his nose and mouth. On the morning of [**4-12**] the patient appeared in distress with agonal, noisy wet sounding breaths. The patient was made CMO by Dr. [**Last Name (STitle) **] on [**4-12**]. Mr. [**Known lastname **] died secondary to respiratory failure on [**4-12**] at 1:09PM. Neuro: The patient was started on a narcotic pain regimen upon admission to the trauma service. He was weaned off of the narcotics on [**2-25**]. His mental status was noted to be worsened on [**2-27**]. Between the dates of [**2-27**] and [**4-10**], his mental status has waxed and waned persistently. On [**4-11**] his mental status deteriorated profoundly to the point where the patient was nonverbal and only moved his head in response to other people's voices. On [**4-12**] the patient became unresponsive to others in the room. He was put on a morphine drip which was titrated for comfort. HEENT: The patient had intermittent nose bleeds during his hospitalization. An ENT consult was placed on [**3-29**] for persistent nose bleeds. Absorbable packing was placed intranasally which controlled the bleeding for some time. On [**3-31**] ENT was reconsulted because the patient started bleeding from the nose again and the bleeding vessel was identified and cauterized. Nonabsorbable packing was placed intranasally and antibiotics were started at that time. His packing was removed 5 days later and he did not have another nose bleed at that time. CV: The patient had no problems with his cardiovascular status during his hospitalization. RESP: The patient had low oxygen saturations postoperatively. He was extubated on [**3-8**]. He was weaned off of supplemental oxygen when he was transferred to the floor on [**3-11**]. He developed agonal breathing on [**4-11**] due to his worsening encephalopathy and persistent, uncontrolled bleeding. GI: The patient was started on lansoprazole on [**3-11**] for GI prophylaxis. He was also started on lactulose for his chronic hepatic failure. On admission his liver function panel had some slightly elevated values. His ALT was 89 , AST [**Last Name (un) **] 175, T bili 3.1 D bili 1.8 Alb 2.4. His liver function panel on [**4-9**] had an AST 342, ALT 140, T bili 28 D bili 15.4. A hepatology consult was called on [**2-26**] and it was suggested that he be started on rifamixin. On [**3-11**] hepatology agreed with continuing his rifamixin and albumin replacement for wound vac losses. GU: The patient had no problems with this system during his hospitalization. FEN: The patient was started on a regular diet on [**3-12**]. He was tolerating a regular diet until [**4-10**] when he started having less of an appetite. Mr. [**Known lastname 17391**] electrolytes were monitored every third day showing a persistent hyponatremia starting on [**3-13**]. His BUN had a bimodal distribution of elevation first peaking at 45 on [**3-6**] and then peaking again at 97 on [**4-11**]. His potassium peaked at 5.5 on [**2-24**] but then returned to [**Location 213**] only to peak again on [**4-11**] to 7.0. His creatinine initially peaked at 2.4 on [**3-5**] and then returned to [**Location 213**] levels until he peaked on [**4-11**] to 6.9. HEME: Mr. [**Known lastname 17391**] admitting coagulation profile was PT 14.7 INR 1.3 PTT 31.3. His admitting hematocrit was 29.2 and platelets were 81. Postoperatively, the patient received 2units of packed red blood cells for a hematocrit of 23.9. On [**3-29**], he received a unit of FFP and a unit of packed red blood cells. His last hematocrit on [**4-9**] was 27.1. ID: The patient had [**1-19**] positive blood cultures on [**3-1**] for vancomycin sensitive enterococcus. He also had a positive sputum culture on [**3-1**] which grew haemophilus influenza. He was started on vancomycin and zosyn on [**3-2**] for the positive cultures. The antibiotics were stopped on [**3-9**]. Mr. [**Known lastname **] was started on Augmentin on [**4-1**] for prophylaxis against gram positive microbes while he had nasal packing in place. It was discontinued on [**4-5**]. The patient had a history of viral hepatitis. Discharge Disposition: Expired Discharge Diagnosis: s/p Assault Grade III/IV splenic laceartion s/p splenectomy hepatic encephalopathy respiratory failure multi organ system failure chronic hepatitis C Discharge Condition: deceased Followup Instructions: N/A

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icd9cm

[ [ [] ] ]

[ "21.03", "96.04", "87.03", "96.72", "41.5", "93.59", "96.6", "21.01", "99.04", "50.11", "88.76", "38.93", "99.07" ]

icd9pcs

[ [ [] ] ]

13003, 13012

5408, 12980

330, 390

13206, 13217

1404, 4060

13240, 13247

808, 825

13033, 13185

840, 845

276, 292

418, 717

1073, 1385

4069, 5385

859, 1054

739, 792

77,600

158,551

5173

Discharge summary

report

Admission Date: [**2149-5-17**] Discharge Date: [**2149-5-24**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: Abdominal pain, nausea, vomiting. Major Surgical or Invasive Procedure: [**2149-5-18**]: 1. Exploratory laparotomy. 2. Resection of small intestine with anastomosis. 3. Lysis of adhesions greater than 3 hours. History of Present Illness: [**Age over 90 **] year old male presents with 8/10 colicky abdominal pain across mid-abdomen x 12 hours. He ate dinner and then threw up. The emesis helped his pain. He had a similar SBO episode in [**Month (only) 404**], which resolved with conservative measures. He did have a normal bowel movement today. Past Medical History: PMHx: BPH status-post TURP, hypercholesterolemia, sigmoid diverticulitis, and status-post a colostomy . PSHx: notable for a right inguinal hernia repair in [**2120**], incarcerated right inguinal hernia repair with mesh [**2142-10-4**], a left carotid endarterectomy, multiple orthopedic procedures, x-lap for perforated diverticulitis in [**2122**] with a colostomy, status-post a reversal. Social History: He is retired. He lives alone in an independent retirement community in [**Location (un) 745**]. No tobacco or ETOH use. Family History: Non-contributory. Physical Exam: VS: 97.5 88 211/94 12 99 GEN: NAD, A&Ox4 COR: RRR LUNGS: CTAB ABD: soft, mildly ttp, midline scars well healed, no hernias EXTREM: warm, no edema. Pertinent Results: On Admission: [**2149-5-17**] 07:40AM GLUCOSE-100 UREA N-18 CREAT-1.1 SODIUM-140 POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-27 ANION GAP-13 [**2149-5-17**] 07:40AM CALCIUM-9.0 PHOSPHATE-3.1 MAGNESIUM-2.0 [**2149-5-17**] 07:40AM WBC-12.4* RBC-4.79 HGB-14.0 HCT-42.7 MCV-89 MCH-29.2 MCHC-32.8 RDW-13.9 [**2149-5-17**] 07:40AM PLT COUNT-289 [**2149-5-17**] 03:00AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]->1.035 [**2149-5-17**] 03:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2149-5-16**] 10:58PM LACTATE-1.8 [**2149-5-16**] 08:45PM GLUCOSE-115* UREA N-22* CREAT-1.2 SODIUM-139 POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-28 ANION GAP-15 [**2149-5-16**] 08:45PM ALT(SGPT)-16 AST(SGOT)-19 ALK PHOS-105 TOT BILI-0.6 [**2149-5-16**] 08:45PM LIPASE-1505/14/10 08:45PM WBC-14.2*# RBC-5.24 HGB-15.1 HCT-46.3 MCV-88 MCH-28.9 MCHC-32.7 RDW-13.8 [**2149-5-16**] 08:45PM NEUTS-88.2* LYMPHS-7.6* MONOS-3.3 EOS-0.5 BASOS-0.4 [**2149-5-16**] 08:45PM PLT COUNT-317# . IMAGING: [**2149-5-17**] KUB/upright: SUPINE AND UPRIGHT RADIOGRAPH OF THE ABDOMEN: Bowel gas pattern is nonspecific and non-obstructive with large amount of gas and fecal material noted throughout the colon. Small air-fluid levels are present in the right mid abdomen. No distended bowel loops to indicate a high-grade obstruction. There is no pneumatosis or pneumoperitoneum. Surgical clips are seen in the left hemipelvis. There is hardware in the left femur. Suture material and surgical clips are present in the pelvis. IMPRESSION: No evidence of obstruction. . [**2149-5-17**] ABD/PELVIC CT W/CONTRAST: High grade small-bowel obstruction with transition at the right lower quadrant and associated mesenteric edema suggesting a component of congestion. No evidence of [**Year (4 digits) **] bowel ischemia. . [**2149-5-19**] AP CXR: Newly occurred right pleural effusion with potential supra-pulmonic component. Left retrocardiac atelectasis. Normal size of the cardiac silhouette. No evidence of pneumonia. . [**2149-5-22**] AP CXR: As compared to the previous radiograph, the nasogastric tube has been removed. Unchanged size of the cardiac silhouette, but increasing extent of pleural effusions on the right and newly occurred small pleural effusion on the left, with mild basal atelectasis. No evidence of focal parenchymal opacities suggesting pneumonia. . DIAGNOSTICS: [**2149-5-19**] ECG: Baseline artifact. Sinus tachycardia with borderline first degree A-V block and atrial premature beats. Left axis deviation consistent with left anterior hemiblock. Right bundle-branch block. Non-specific ST-T wave abnormalities. Compared to the previous tracing of [**2149-1-29**] heart rate has increased. Intervals Axes: Rate PR QRS QT/QTc P QRS T 99 [**Telephone/Fax (3) 21158**]/438 58 -82 65 . [**2149-5-20**] ECG: Sinus tachycardia with borderline first degree A-V block. Left axis deviation consistent with left anterior hemiblock. Right bundle-branch block. Non-specific ST-T wave abnormalities. Compared to tracing #1 heart rate has increased. Intervals Axes: Rate PR QRS QT/QTc P QRS T 116 210 140 342/440 60 -80 76 . PATHOLOGY: [**2149-5-18**] SPECIMEN SUBMITTED: SMALL BOWEL. DIAGNOSIS: Small intestinal, resection (A-D): 1. Subtotal mural infarction. 2. Fibrous adhesions. 3. Viable surgical resection margins. Clinical: Small bowel obstruction. Gross: The specimen is received fresh and labeled with the patient's name, "[**Known lastname 21159**], [**Known firstname **]", the medical record number and additionally labeled "small bowel". It consists of a single portion of small bowel measuring 56 cm in length and 6 cm in average diameter when opened. The serosa and mesentery is dark brown/red and hemorrhagic. The specimen is opened to reveal bloody fecal material. The mucosa is brown/red hemorrhagic. There are no lesions, masses or perforations identified. The specimen is not oriented. Two stapled margins are identified each measuring 3 and 4 cm. No lymph nodes are identified. The specimen is represented as follows: A=surgical resection margins, B-D=cross sections of the small bowel wall. Brief Hospital Course: The patient was admitted to the General Surgical Service on [**2149-5-17**] for evaluation and treatment of a small bowel obstruction. Admission abdominal/pelvic CT revealed a high grade small-bowel obstruction with transition at the right lower quadrant and associated mesenteric edema suggesting a component of congestion. There was no evidence of [**Year (4 digits) **] bowel ischemia. He was made NPO, started on IV fluids, and he was given Morphine IV PRN for pain. On [**2149-5-18**], the patient underwent exploratory laparotomy, resection of small intestine with anastomosis, and lysis of adhesions, which went well without complication (reader referred to the Operative Note for details). After a brief, uneventful stay in the PACU, the patient arrived on the floor NPO with an NG tube, on IV fluids, with a foley catheter in place, and a Dilaudid PCA for pain control. He received two doses of IV Cefazolin. The patient was hemodynamically stable. . Hospital course was complicated by hypotension, low urine output, and runs of SVT, for which the patient was transferred to the TICU for further management on POD#2. Pre-renal failure due to intravascular hypovolemia resolved with aggressive IV rescusitation. Cardiology was consulted for SVT, determining that the rhythm was specifically atrial tachycardia with PACs. He responded to electrolyte repletion and increasing Metoprolol to 25mg QID. He expereinced transient confusion while in the ICU, most likely ICU delerium, which resolved with Haldol. Once stabilized, he was transferred back to the inpatient floor in the afternoon of POD#3. . Post-operative pain was initially well controlled with the Dilaudid PCA, which was converted to oral pain medication when tolerating clear liquids. The NG tube was discontinued on POD#3, and the patient was started on clear liquids. Diet was progressively advanced as tolerated to a heart healthy regular diet by POD#5. The foley catheter was discontinued on POD#3. The patient subsequently voided without problem. The incision remained clean and intact. . During this hospitalization, the patient ambulated early and frequently with assistance, was adherent with respiratory toilet and incentive spirrometry, and actively participated in the plan of care. Physical Therapy followed the patient during this admission. 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. Labwork was routinely followed; electrolytes were repleted when indicated. . At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. He was discharged to an extended care facility for rehabilitation. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation four times a day as needed for shortness of breath or wheezing. 2. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Medications: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation four times a day as needed for shortness of breath or wheezing. 2. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for fever or pain. 6. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. 7. Zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Discharge Disposition: Extended Care Facility: [**Last Name (un) 1687**] - [**Location (un) 745**] Discharge Diagnosis: 1. Small bowel obstruction 2. Atrial tachycardia/PACs 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 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 [**5-12**] 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: Please call ([**Telephone/Fax (1) 11501**] to schedule a follow-up appointment with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD (Surgery) in 2 weeks. . Please call ([**Telephone/Fax (1) 8427**] to arrange a follow-up appointment with Dr. [**Last Name (STitle) 2204**] (PCP) in [**2-5**] weeks. . Other Appointments: Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2149-10-27**] 9:30 Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2149-10-27**] 10:00 Completed by:[**2149-5-23**]

[ "788.99", "998.2", "458.29", "E870.0", "569.89", "427.89", "276.7", "562.10", "276.52", "272.0", "560.81", "293.0" ]

icd9cm

[ [ [] ] ]

[ "45.62", "54.59" ]

icd9pcs

[ [ [] ] ]

10087, 10165

5764, 8789

295, 435

10263, 10263

1549, 1549

11557, 12192

1347, 1366

9231, 10064

10186, 10242

8815, 9208

10446, 11029

11045, 11534

1381, 1530

222, 257

463, 777

1564, 5741

10278, 10422

799, 1192

1208, 1331

29,480

142,703

1185

Discharge summary

report

Admission Date: [**2180-2-17**] Discharge Date: [**2180-2-21**] Date of Birth: [**2100-10-20**] Sex: M Service: CARDIOTHORACIC Allergies: Adhesive Tape Attending:[**First Name3 (LF) 922**] Chief Complaint: Dizziness Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 7527**] is a 79 y/o male who is s/p Type A dissection repair who has a known desc. thoracic aneurysm which is followed by Dr. [**Last Name (STitle) **]. He was seen in clinic on [**2-16**] and had a repeat CT scan which showed ? increase size. Today he experienced Past Medical History: hypothyroidism, anxiety, prior MI, 17 x 13 mm pulmonary nodule at the left lung base, focal short-segment dissection in the right superficial femoral artery, CRI (baseline 1.8) PSH: repair of a type A dissection by Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] in [**2165**], surgery in '[**58**] for ? blood [**Last Name 7528**] problem in [**Name (NI) **], appy Social History: Smoking hx: 1.5 ppd x 40yrs. Previous heavy ETOH use - quit 30 yrs ago. Family History: brother with MI at age 36 Physical Exam: VS: 70 135/76 14 Gen: A&O x 3 Lungs: Clear with decreased BS at bases Cor: RRR -murmur Abd: Soft, NT/ND Ext: warm, well-perfused -edema Pertinent Results: [**2-16**] Chest: 1. 17 x 13 mm pulmonary nodule at the left lung base is highly worrisome for a neoplasm. A PET-CT may be performed for further evaluation. 2. Extensive dissection of the aorta involving the thoracic and abdominal aorta and extending into the proximal right common iliac artery. There is also a focal short-segment dissection in the right superficial femoral artery as described above. 3. Atrophic right kidney with stable right renal hypodensity, likely a cyst. [**2-17**] CXR: Abnormal aortic contour concerning for aortic dissection as reported. No prior radiograph available to assess for chronicity and acute change. [**2-19**]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 60-70%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate ([**1-19**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. [**2180-2-17**] 07:10PM BLOOD WBC-9.1 RBC-3.56* Hgb-11.5* Hct-33.0* MCV-93 MCH-32.4* MCHC-34.9 RDW-13.2 Plt Ct-236 [**2180-2-21**] 05:25AM BLOOD WBC-10.3 RBC-3.27* Hgb-10.4* Hct-29.9* MCV-91 MCH-31.8 MCHC-34.8 RDW-13.3 Plt Ct-202 [**2180-2-17**] 07:10PM BLOOD PT-12.9 PTT-25.7 INR(PT)-1.1 [**2180-2-17**] 07:10PM BLOOD Glucose-93 UreaN-22* Creat-1.8* Na-134 K-4.8 Cl-98 HCO3-27 AnGap-14 [**2180-2-21**] 05:25AM BLOOD Glucose-111* UreaN-23* Creat-1.8* Na-136 K-4.3 Cl-103 HCO3-25 AnGap-12 [**2180-2-18**] 04:05AM BLOOD ALT-9 AST-17 LD(LDH)-152 AlkPhos-62 TotBili-0.5 [**2180-2-21**] 05:25AM BLOOD Calcium-9.0 Phos-2.4* Brief Hospital Course: Mr. [**Known lastname 7527**] was initially admitted to medicine for blood pressure control. Thoracic surgery was consulted secondary to lung nodule found on CT. Vascular surgery and cardiology were also consulted in assistance with Mr. [**Known lastname 7529**] care. He was transferred to CSURG service in the CVICU in which her received IV therapy for his hypertension. He was eventually weaned to PO HTN medication. On [**2-20**] he was transferred to the telemetry floor for further care. On [**2-21**] his blood pressure was well controlled and he was discharged home with the appropriate medications and follow-up appointments. Medications on Admission: Aspirin 81mg qd, Clonidine 0.1mg [**Hospital1 **], Cozaar 25mg qd, Labetolol 50mg [**Hospital1 **], Levothyroxine 40mg qd, Norvasc 10mg qd, Alprazolam 25mg qd Discharge Medications: 1. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Clonidine 0.3 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*0* 4. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). Disp:*30 capsules* Refills:*0* 5. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 7. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 8. Norvasc 10 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Type B Dissection Lung Nodule s/p repair of a type A dissection by Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] in [**2165**], surgery in '[**58**] for ? blood [**Last Name 7528**] problem in [**Name (NI) **], appy Discharge Condition: Stable Discharge Instructions: Follow up with thoracic surgery for your lung nodule Followup Instructions: The thoracic surgery office will call you to set up follow-up. Follow up with Dr. [**Last Name (STitle) 914**] after thoracic surgery work-up is complete. Follow up with Dr. [**Last Name (STitle) **] in [**1-19**] weeks. Completed by:[**2180-3-13**]

[ "300.00", "403.90", "443.22", "585.9", "441.03", "244.9", "518.89", "412" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

4982, 5040

3373, 4009

290, 296

5315, 5323

1318, 3350

5424, 5676

1120, 1147

4218, 4959

5061, 5294

4035, 4195

5347, 5401

1162, 1299

241, 252

324, 612

634, 1015

1031, 1104

9,635

178,481

1131+1132+55260

Discharge summary

report+report+addendum

Admission Date: [**2151-1-8**] Discharge Date: [**2151-2-4**] Date of Birth: [**2073-5-13**] Sex: M Service: Neurosurgery ADDENDUM: On [**2151-1-29**] the patient was awake, alert, and moving his upper extremities spontaneously and withdrawing his lower extremities. The patient was transferred to the regular floor. The patient was evaluated by Physical Therapy and Occupational Therapy and felt to require acute rehabilitation. The patient was also seen by Speech and Swallow who felt the patient was clearly aspirating, and a percutaneous endoscopic gastrostomy tube was placed in Interventional Radiology without complications. Neurologically, the patient remained awake, verbally responding, somewhat inattentive, and followed commands inconsistently. The patient's speech was still somewhat dysarthric. The patient is extremely hard of hearing, so it was difficult to get him to follow commands due to his [**Last Name **] problem. The patient remained stable with stable vital signs. A head computed tomography just prior to discharge will be completed. The patient's neurologic status was stable, and he was ready for discharge. MEDICATIONS ON DISCHARGE: (His medications at the time of discharge included) 1. Dilantin 200 mg per nasogastric tube once per day. 2. Dilantin 100 mg per nasogastric tube twice per day. 3. Insulin sliding-scale. 4. Vancomycin 1000 mg intravenously q.24h. 5. Hydralazine 75 mg by mouth q.6h. (hold for a systolic blood pressure of less than 100 or a heart rate of less than 50). 6. Lisinopril 20 mg by mouth once per day (hold for a systolic blood pressure of less than 100 or a heart rate of less than 50). 7. Metoprolol 150 mg by mouth three times per day (hold for a systolic blood pressure of less than 100 or a heart rate of less than 50) 8. Subcutaneous heparin 5000 units subcutaneously q.12h. 9. Famotidine 20 mg by mouth once per day. 10. Ferrous sulfate 325 mg by mouth once per day. 11. Tamsulosin 0.8 mg by mouth at hour of sleep. 12. Gabapentin 600 mg by mouth twice per day. 13. Colace 100 mg by mouth twice per day. 14. Albuterol nebulizers one nebulizer q.6h. as needed. CONDITION AT DISCHARGE: The patient's condition on discharge was stable. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient's staples and sutures will be removed prior to discharge. 2. The patient was instructed to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in two weeks for a repeat head computed tomography. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2151-2-4**] 08:13 T: [**2151-2-4**] 08:36 JOB#: [**Job Number 7247**] Admission Date: [**2151-1-8**] Discharge Date: [**2151-2-4**] Date of Birth: [**2073-5-13**] Sex: M Service: Neurosurgery HISTORY OF PRESENT ILLNESS: Patient is a 77-year-old gentleman status post a right frontal VP shunt placement on [**2150-10-13**], who has been doing well until mid [**Month (only) **] when he began complaining of headache. He was admitted to the [**Hospital3 **] at that time with a subdural hematoma. The VP shunt was ligated, and the patient was discharged to rehab again. Head CT at that time of D/C showed increased hydrocephalus, but stable. Patient was sent to rehab and became increasingly confused and not able to follow coherent streams of thought or commands. Family called Dr. [**First Name (STitle) **] and felt that repeat head CT needed to be done which showed an increase in the subdural hematoma especially on the left to 3-4 cm in width, and the patient was admitted for bedside drainage. PAST MEDICAL HISTORY: 1. Diabetes. 2. Hypertension. 3. Hypercholesterolemia. 4. Benign prostatic hypertrophy. 5. Incontinence. 6. NPH. 7. Peptic ulcer disease. 8. Chronic renal insufficiency with a creatinine of 2. 9. Dementia. 10. Clostridium difficile. 11. Ataxia. 12. Cellulitis. The patient was admitted to the ICU. PHYSICAL EXAMINATION: His temperature was 98.3. Blood pressure was 136/62. Heart rate 69. Respiratory rate 17. Sats 97%. HEENT: Neck was supple, no meningismus. Mental status: Awake and alert, but not oriented. Language is fluent. Attention is slow, but intact. Recall is 0/4. Cranial nerves II through XII intact. Motor exam: Strength in the upper extremities: His right deltoid, wrist extension, and triceps are [**5-3**]. Does not follow commands to the left. Sensory is really unable to test. Does not follow commands. Reflexes were 0 in the upper extremities, 2+ at the knees, 0 at the ankles. His toes withdraw. HOSPITAL COURSE: He was admitted to the ICU setting. Had a bedside drainage of a subdural hematoma without interprocedural complication. The patient had the drain left in place overnight. CT on [**1-11**] after bedside drainage shows unchanged right subdural hematoma, left subdural fluid collection was slightly increased. Repeat scan that the drainage procedure was unsuccessful, and ........... the left subdural hematoma. Therefore, the patient was taken to the OR on [**2151-1-12**] to undergo a craniotomy and drainage of the left subdural hematoma. The surgery of the drainage of the subdural was on [**2151-1-13**]. On [**2151-1-14**], the patient opened his eyes to voice. His speech was dysarthric. He was following commands, squeezing hands, flexing his legs, showing two fingers. Drain put out 30 cc. Patient had a head CT, which showed a decrease in the size of the left subdural fluid collection and decrease in the left to right midline shift. No change in ventricle size. Patient's drain was removed. On [**1-16**], he was arousable by voice, drowsy, tended to keep his eyes closed. Not really following commands. Speech was fluent, but mumbled. He was spontaneously moving his upper and lower extremities and purposeful. On [**1-16**], the patient dropped his sats and had a blood gas with a pO2 of 52. The patient was urgently intubated. There were no complications with intubation. Chest x-ray showed decrease in the volume on the left side. CTA showed no evidence of pulmonary embolus. Ultimately when patient was opening his eyes, biceps were [**5-3**] on the right, [**6-2**] on the left. He moves his feet to commands. Follows commands inconsistently. He had a head CT on [**1-17**] which showed a left frontal collection with no change and no change in the ventricle size. Tap of the VP shunt on [**1-18**] showed an opening pressure of 25, and patient remained neurologically stable, arousable, following commands, opening eyes. Repeat head CT was done which showed worsening subdural hematoma. Patient had externalization of his VP shunt. Was extubated on [**2151-1-17**] successfully without any problems. On [**1-21**], neurologically opening his eyes to voice. Withdraws briskly to stimulation. He is purposeful on the left greater than right. His drain was at 15 cm above the tragus, now raised to 20. The vent drain was changed to 5-10 cc an hour titrating to get 5-10 cc/hour of CSF drainage. CT on [**2151-1-22**] showed decrease in subdural fluid and no change in ventricular size. On the 26th, the patient was awake and following commands, attentive, and face was symmetric. He had antigravity strength in his bilateral upper extremities left greater than right. Grasps were [**6-2**] on the left, [**5-3**] on the right. IPs is [**6-2**] bilaterally. Patient was out of bed sitting in a chair. Drain was raised to 25 cm above the tragus and titrated to keep drainage 10 cc every four hours. On [**2151-1-26**], the patient went to the operating room to have revision of his VP shunt. He tolerated the procedure well. There were no intraoperative complications. Postoperatively, he was monitored in the Intensive Care Unit. He was awake, attentive, localizing briskly in the upper extremities, withdrawing bilateral lower extremities. His incision was clean, dry, and intact. On [**2151-1-28**], patient status post VP shunt revision was awake, dysarthric, no drift, and impersistently following commands. His vital signs were stable. He was transferred to the regular floor on [**2151-1-27**]. On [**2151-1-29**], he was awake..... INCOMPLETE DICTATION [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2151-2-4**] 08:03 T: [**2151-2-4**] 08:20 JOB#: [**Job Number 7248**] Name: [**Known lastname 917**], [**Known firstname 63**] Unit No: [**Numeric Identifier 918**] Admission Date: [**2151-1-8**] Discharge Date: [**2151-2-4**] Date of Birth: [**2073-5-13**] Sex: M Service: Patient was found to be positive for MRSA through nasal swab as early as [**2151-1-18**], also had MRSA positive Staphylococcus aureus in his sputum diagnosed on [**2151-1-27**]. Patient is on Vancomycin IV q.12h. Vancomycin was started on [**2151-1-28**] and will be discontinued on [**2151-2-10**] to complete a two week course of Vancomycin for MRSA in the sputum. CONDITION ON DISCHARGE: Patient's condition was stable at time of discharge. His cefazolin was D/C'd on [**2151-2-4**], and patient was discharged to rehab in stable condition. [**First Name11 (Name Pattern1) 919**] [**Last Name (NamePattern4) 920**], M.D. [**MD Number(1) 921**] Dictated By:[**Last Name (NamePattern1) 366**] MEDQUIST36 D: [**2151-2-4**] 08:24 T: [**2151-2-4**] 08:35 JOB#: [**Job Number 922**]

[ "250.00", "401.9", "996.2", "507.0", "432.1", "272.0", "331.3", "482.41", "600.00" ]

icd9cm

[ [ [] ] ]

[ "02.42", "43.11", "01.39", "01.02" ]

icd9pcs

[ [ [] ] ]

1196, 2191

4748, 9259

2289, 2956

4115, 4730

2206, 2256

2985, 3770

3792, 4092

9284, 9712

9,364

150,054

6109

Discharge summary

report

Admission Date: [**2138-2-5**] Discharge Date: [**2138-2-11**] Date of Birth: [**2085-11-10**] Sex: M Service: MEDICINE Allergies: Iodine; Iodine Containing Attending:[**First Name3 (LF) 1974**] Chief Complaint: Found unresponsive Major Surgical or Invasive Procedure: . Diagnostic Paracentesis x 2 . History of Present Illness: Mr. [**Known lastname 4186**] is a 52 year old male with PMH of CAD s/p CABG in [**7-/2129**], cirrhosis, and asthma who presented this morning after being found in his apartment unresponsive. Per family, patient was last seen last evening with the mother of his daughter but they got in an altercation and the patient was left [**Location (un) 23930**]. In retrospect he may have been somewhat confused at this time. After family members were unable to get in touch with him overnight, a friend was sent to his apartment where he was found passed out in his chair, unresponsive and unarousabe, cell phone at his feet. He was brought to the [**Hospital1 18**] for further management (normally a patient at [**Hospital1 112**]). Per the family, the patient had no symptoms in last few days such as cough, fever, URI sxs, abd pain, GI sxs, sick contacts. Did have nose bleeding after recent stent. He is compliant with all medications and diet, and actually lost 30-40 lbs in past couple of month (intentional) d/t new diabetic diet. . In the ED the patient was tachycardic and febrile to 100.2(vs 100.6), normotensive, only able to open eyes to command but noncommunicative. A diagnostic and therapeutic paracentesis (4L) was performed and demonstrated 350 WBC's, 5% polys but was treated for SBP anyways with CTX and vancomycin. SBPs dropped to 80's after paracentesis and additional NS was given for a total of 4L (no albumin). Ammonia 61. CXR with bilateral opacities and blunting of CP angle suggestive of CHF. Also was given dexamethasone 10 mg x 1 in ED. Unclear if the steroids may have been empiric. . Of note, recently hospitalized from 12/20-12-29/06 with NSTEMI s/p stent placed at [**Hospital1 112**] (see below) - in note states pt was d/c'd off lasix, but discharge meds state he was taking lasix. Seen in ED on [**2-3**] for abdominal pain and distension, at which time all labs were WNL including WBC, LFTs (INR slightly elevated, ammonia 81). Plan was for paracentesis but pt refused and ED unable to get in touch with his GI doctor, so discharged home. Admitted on [**11-2**] with hepatic encephalopathy, felt to be d/t dehydration, sedation (sleeping pills), poor compliance with low protein diet, and lasix was decreased and spironolactone stopped. Past Medical History: # Nonalcoholic steatohepatitis, undergoing liver transplant workup - HAV and HCV reactive, HBV negative, Sm muscle ab + - Large volume ascites with multiple [**Doctor First Name 4397**] ([**12-10**], 11/29+11/30=15L off, [**2139-1-29**]) - liver bx [**11-8**] with portal mononuclear inflammation, micro/macro vesicular steatosis, focal sinusidal fibrosis # CAD s/p stent - Cath in [**2138-1-30**] revealed prox LAD with ostial 90% disease, 50% post LIMA touchdown, 90% ostial LCx, TO'ed RCA, grafts with patent LIMA to LAD and patent SVG to PDA and fadial to diag but radial to OM was TO'ed. PCI wo LCx # CABG in 6/98 with LIMA to LAD, SVG to PDA and radial graft to OM and diagonal. Asymptomatic since CABG, but in w/u for liver transplant pt was intubated for liver bx - trops elevated and taken to cath as above # HTN # DM # Asthma # Obesity # Thrombocytopenia # ARF in setting of large volume taps Social History: H/O tobacco x 35 ppd, h/o ETOH quit couple of months ago, no IVDU, lives at home alone with frequent VNA and services (can not bath himself, occ. can walk) Family History: Mother died of breast CA Father died of MI at 61, liver disease, HTN Sister with liver disease Physical Exam: Vitals: 97.6, 103/62, 103, 18, 100% 3L Gen: opens eyes to commands, squeezes hands, no speech HEENT: PERRL, EOMI, anicteric sclera, no conjunctival hemorrhage, MM dry, OP clear Neck: obese, supple, unable to assess JVP Cardiac: RRR, NL S1 and S2, no MRGs Lungs: bibasilar crackles, right > left Abd: obese, round, distended, NT, +BS, +dullness to percussion [**3-8**] way up bilaterally, unable to palpate liver or spleen, scar marks on belly, no caput, no spiders, +palmar Ext: warm, 2+ DP pulses, 2+ LE edema to knees Neuro: MAE, not alert Pertinent Results: CXR [**2137-2-5**] - S/P CABG, heart markedly enlarged, fractures in the lower most three sternal wires which are difficult to visualize on the most recent study because of exposure - the wire fracture, third from the bottom, is new since [**2130-11-5**], but the others are unchanged. Allowing for technique there is probably little significant change. There are bilateral opacities suggesting pulmonary edema. There are no definite effusions, however, or pneumothorax. No free air. . CT Head [**2137-2-5**] - No intracranial hem or mass effect. . RUQ U/S [**2137-2-5**]: 1. Marked cirrhosis. No focal lesions. 2. Gallbladder wall edema which is likely secondary to cirrhosis and a hypoproteinemia. 3. Marked ascites. A spot was marked in the right lower quadrant for paracentesis to be performed by the clinical team. . Renal u/s [**2137-2-11**]: RENAL ULTRASOUND: The right kidney measures 11.2 cm, and the left kidney measures 12.2 cm. Both kidneys are normal without hydronephrosis, renal calculi, or renal masses. The bladder demonstrates a trabeculated wall. No bladder stones or masses noted. Large amount of ascites is present. IMPRESSION: Normal appearance of the kidneys. Trabeculated appearance of the bladder wall. . Alpha-1 antitrypsin: 174 [**2138-2-5**] WBC-5.9 RBC-4.01* Hgb-11.6* Hct-35.0* MCV-88 MCH-29.1 MCHC-33.3 RDW-17.2* Plt Ct-133* [**2138-2-11**] WBC-6.6 RBC-4.29* Hgb-12.8* Hct-37.9* MCV-88 MCH-29.7 MCHC-33.7 RDW-17.7* Plt Ct-136* [**2138-2-5**] Neuts-75.4* Lymphs-13.5* Monos-10.2 Eos-0.8 Baso-0.1 [**2138-2-5**] PT-16.4* PTT-30.8 INR(PT)-1.5* [**2138-2-11**] PT-18.1* PTT-32.5 INR(PT)-1.7* [**2138-2-5**] Fibrino-305 [**2138-2-5**] Glucose-112* UreaN-41* Creat-1.2 Na-129* K-5.9* Cl-98 HCO3-15* AnGap-22* [**2138-2-8**] Glucose-97 UreaN-23* Creat-1.0 Na-141 K-4.2 Cl-109* HCO3-17* AnGap-19 [**2138-2-9**] Glucose-97 UreaN-29* Creat-1.3* Na-140 K-4.7 Cl-109* HCO3-12* AnGap-24* [**2138-2-10**] Glucose-90 UreaN-36* Creat-1.5* Na-141 K-4.2 Cl-108 HCO3-22 AnGap-15 [**2138-2-10**] Glucose-91 UreaN-39* Creat-1.5* Na-142 K-3.9 Cl-109* HCO3-20* AnGap-17 [**2138-2-11**] Glucose-76 UreaN-40* Creat-1.4* Na-139 K-4.3 Cl-110* HCO3-16* AnGap-17 [**2138-2-5**] BLOOD ALT-34 AST-61* LD(LDH)-317* AlkPhos-66 TotBili-2.0* [**2138-2-6**] ALT-28 AST-46* LD(LDH)-177 AlkPhos-47 TotBili-1.5 [**2138-2-7**] ALT-26 AST-47* LD(LDH)-196 AlkPhos-48 TotBili-1.0 [**2138-2-11**] ALT-25 AST-44* LD(LDH)-329* AlkPhos-52 TotBili-1.5 [**2138-2-5**] 02:00PM BLOOD CK-MB-12* MB Indx-3.4 cTropnT-0.49* [**2138-2-6**] 01:59AM BLOOD CK-MB-14* MB Indx-3.4 cTropnT-0.33* [**2138-2-6**] 04:30AM BLOOD CK-MB-15* MB Indx-6.3* cTropnT-0.42* [**2138-2-7**] 04:35AM BLOOD CK-MB-11* MB Indx-10.3* cTropnT-0.24* [**2138-2-7**] 03:15PM BLOOD CK-MB-NotDone cTropnT-0.15* [**2138-2-5**] 02:00PM BLOOD Albumin-3.5 [**2138-2-6**] 04:30AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.2 [**2138-2-5**] 02:00PM BLOOD VitB12-973* Folate-GREATER TH [**2138-2-8**] 08:00AM BLOOD Triglyc-110 HDL-19 CHOL/HD-8.4 LDLcalc-118 LDLmeas-110 [**2138-2-5**] 02:00PM BLOOD Ammonia-61* [**2138-2-5**] 02:00PM BLOOD TSH-2.6 [**2138-2-5**] 02:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2138-2-9**] 09:50AM BLOOD Type-ART pO2-27* pCO2-40 pH-7.33* calTCO2-22 Base XS--5 [**2138-2-5**] 02:17PM BLOOD Lactate-2.1* [**2138-2-5**] 05:44PM BLOOD Lactate-1.6 K-5.0 [**2138-2-9**] 09:50AM BLOOD Lactate-2.9* calHCO3-21 [**2138-2-11**] 12:51PM BLOOD Lactate-2.1* [**2138-2-10**] 06:56PM URINE Osmolal-618 [**2138-2-10**] 06:56PM URINE Hours-RANDOM UreaN-929 Creat-300 Na-<10 [**2138-2-6**] 03:58AM URINE RBC-0-2 WBC-[**12-23**]* Bacteri-MOD Yeast-NONE Epi-0-2 [**2138-2-10**] 06:56PM URINE RBC-38* WBC-0 Bacteri-NONE Yeast-NONE Epi-<1 [**2138-2-5**] 02:30PM ASCITES Amylase-21 [**2138-2-9**] 11:26AM ASCITES TotPro-3.1 Glucose-120 LD(LDH)-86 Albumin-1.7 [**2138-2-5**] 02:30PM ASCITES WBC-340* RBC-7900* Polys-5* Lymphs-26* Monos-42* Mesothe-19* Macroph-8* [**2138-2-9**] 11:26AM ASCITES WBC-300* RBC-4300* Polys-12* Lymphs-23* Monos-33* Mesothe-32* Micro: Peritoneal fluid [**2-5**]: negative RPR negative Blood cx: negative x2 Urine cx [**2-6**]: negative Brief Hospital Course: A/P: 52 year old male with CAD s/p CABG, cirrhosis, asthma, who presents after being found unresponsive in his chair. . # Hepatic encephalopathy/NASH/Hep C cirrhosis - Based on patient's PMH, recent hospitalizations, and presentation, mental status change thought to be c/w hepatic encephalopathy. Possible precipitants included not taking lactulose, med noncompliance/confusion, dehydration d/t poor PO in setting of abd. pain, nonadherence to low protein diet. The patient had a 4L paracentesis done initialy which revealed no evidence of SBP. However he developed hypotension to 80's, requiring fluid resuscitation totalling 4 L of IVF (NS). He was transferred to the MICU for monitoring. He was treated with lactulose, rifaximin with steady improvement in his mental status. Tox screen negative. Head CT negative for bleed. U/S with dopplers show that the portal vein was patent with appropriate directional flow. Lasix and aldactone were held. U/A was concerning for UTI and pt was treated with 7 d course of cipro although urine culture failed to grown out an organism. . # CAD s/p CABG - pt with recent NSTEMI in [**1-8**] treated with LCx PCI with bare metal setnt. After initial 4L paracentesis, patient was noted to develop elevated cardiac enzymes in the setting of hypotension. Cardiac enzymes trended up to Trop T 0.49, CK 410, MB 15. No chest pain was or EKG changes were noted. Cardiology was consulted and he was managed medically. ASA, plavix were continued. He was initially maintained off statin due to concern for his liver disease, but the liver team felt it was safe to start atorvastatin at 40mg, which was done. In addition, he was started on nadolol. Lisinopril and nifedipine were held in setting of borderline BP and renal dysfunction. . # Guiac-positive stool - The patient was found to have guiac positive stools. Daily hematocrits were stable and he remained hemodynamically stable. Plan for outpt f/u. . # DM: The patient was previously on Metformin and Avandia. He was put on an ISS, and FS during his hospitalization. His blood sugars were under adequate control. . # h/o ARF - The patient has a history of renal failure. Upon admission, his Cr 0.8-0.9. Upon restarting his Lasix and Aldactone, his creatinine increased to 1.5. He was given 500cc NS and 25gm albumin. Repeat diagnostic paracentesis (20cc) was negative for SBP. Lasix and Aldactone were held and Cr remained stable at 1.4. Renal u/s did not show any evidence of obstruction. . # FEN: Volume restriction, low sodium diet . # HTN - No longer hypertensive. Held all antihypertensives during initial hospital course given that patient was hypotensive and had NSTEMI. Antihypertensives can be restarted as an outpatient. . # PPX: lactulose, Hep SQ, PPI . # Code - FULL code . The patient was transferred to [**Hospital6 1708**], per his request, as his hepatologist is based there. Medications on Admission: Albuterol 2 puffs QID Nexium 40 QD Advair 500/50 1 puff [**Hospital1 **] ASA 81 PO QD Plavix 75 QD Lasix 20 PO QD (decreased from 40, prior from 80) Metformin 850 TID Avandia 8 QD Appears should be on lactulose 30ml QD, starting on [**1-9**] (not on d/c list from [**1-30**] discharge from cards) . Spironolactone (decreased from 150 to 100 to off), lisinopril, nifedipine all stopped d/t increased Cr during paracenteses . ALL: IV contrast - urticaria metoprolol - bronchospasm Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed. 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 6. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO once a day. 8. Atorvastatin 40 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 Q12H (every 12 hours). 10. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) Units Injection TID (3 times a day). Discharge Disposition: Extended Care Discharge Diagnosis: Primary: Hepatic encephalopathy NSTEMI NASH, Massive ascites . Secondary: Obesity Discharge Condition: . Stable, Encephalopathy improving; Taking good PO intake; Ambulating Discharge Instructions: You are being transferred to [**Hospital 756**] Hospital for further care as per your request. Follow-up with your doctors as needed after your discharge. Followup Instructions: Follow-up as recommended by your doctors. Completed by:[**2138-2-11**]

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icd9cm

[ [ [] ] ]

[ "54.91" ]

icd9pcs

[ [ [] ] ]

13069, 13084

8611, 11512

305, 339

13210, 13282

4440, 8588

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3767, 3863

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13306, 13462

3878, 4421

247, 267

367, 2651

2673, 3578

3594, 3751

68,720

121,329

42134+58501

Discharge summary

report+addendum

Admission Date: [**2115-1-4**] Discharge Date: [**2115-1-11**] Date of Birth: [**2057-8-22**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1406**] Chief Complaint: exertional chest pain/stable angina Major Surgical or Invasive Procedure: [**2115-1-7**] Coronary artery bypass x2: Left internal mammary artery to left anterior descending, and reverse saphenous vein graft to ramus. History of Present Illness: Mr. [**Known lastname 91391**] is a 57 year old gentleman with a PMH significant for severe hypertension, mild hyperlipidemia, and a family history of heart disease, who presented to his PCP at the end of [**Month (only) **] with two months of exertional sub-sternal chest pain. His symptoms started at the end of [**Month (only) 205**] when he noticed burning substernal pain while walking his dog briskly. Symptoms were predictable in onset with exertion and always subsided with rest. The pain occassionally radiated to his left arm, but he denies nausea/vomiting or diaphoresis. Never had symptoms at rest. He presented to his PCP who sent him to the [**Hospital1 3597**] ED, where he was noted to have hypertension to 244/110. His blood pressure medications were changed at that time. He has long-standing hypertension, but does not recall his prior regimen before this change. He also underwent exercise MIBI at [**Hospital3 7362**], during which he went 4 minutes 36 seconds on a [**Doctor First Name **] protocol and developed 2mm ST depressions in the inferior lateral leads. He did experience chest discomfort. Imaging showed a large and severe defect involving the mid anterior wall extending to the anterior apex. In addition there was another defect involving the mid to distal septum. There was transient ischemic dilation of the left ventricle. LVEF was noted at 64%. He was referred to [**Hospital1 18**] for left heart catheterization which revealed multivessel coronary artery disease.Cardiac surgery was consulted for coronary revascularization. Past Medical History: Primary: Coronary Artery Disease pulmonary embolism (incidental finding pre-operatively) Secondary: Hypertension Hyperlipidemia Hypothyroidism Left femur fracture Social History: Patient is divorced with three children. He lives with girlfriend and his girlfriend's two daughters. Previously worked at Papa Ginos as a general manager. Was laid off in [**Month (only) **]. Tobacco: Never ETOH: Rare Recreational drugs: Denies Home services: Denies Family History: Father died of early MI at age 46. Mother had some type of cancer and was in remission when she died in retirement home (cause unknown). No family hx of arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: PHYSICAL EXAMINATION ON ADMISSION: VS: T=98.4 BP=135-158/77-83 HR=75 RR=18 O2 sat= 96(RA) GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. No elevated JVP. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RRR, normal S1, S2. No m/r/g. LUNGS: CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, mildly obese, NTND. No HSM or tenderness. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: Labs on Admission: [**2115-1-4**] 09:40AM BLOOD WBC-9.3 RBC-4.26* Hgb-12.4* Hct-34.5* MCV-81* MCH-29.1 MCHC-35.9* RDW-13.2 Plt Ct-154 [**2115-1-4**] 09:40AM BLOOD Neuts-70.9* Lymphs-23.1 Monos-3.8 Eos-1.9 Baso-0.2 [**2115-1-4**] 09:40AM BLOOD PT-13.7* INR(PT)-1.2* [**2115-1-4**] 09:40AM BLOOD Glucose-193* UreaN-20 Creat-1.2 Na-141 K-3.3 Cl-106 HCO3-24 AnGap-14 [**2115-1-4**] 09:40AM BLOOD ALT-22 AST-26 AlkPhos-65 TotBili-0.6 [**2115-1-4**] 09:40AM BLOOD Albumin-3.6 Iron Studies/HgbA1c: Iron-64 [**2115-1-4**] 09:40AM BLOOD calTIBC-246* Ferritn-162 TRF-189* [**2115-1-4**] 09:40AM BLOOD %HbA1c-5.5 eAG-111 Urinanalysis: [**2115-1-5**] 12:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019 [**2115-1-5**] 12:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-NEG Urine Metanephrines: Micro: [**2115-1-4**] 8:34 pm Staph aureus Screen Source: Nasal swab. [**2115-1-5**] 12:00 pm URINE Source: CVS. Imaging/Studies: Cardiac Cath [**2115-1-4**]: 1. Selective corobary angiography of this right dominant system demonstrated three vessel coronary artery disease. The LMCA is a large caliber vessel with a 30% ostial stenosis. The LAD has an ostial 90% stenosis prior to an ulcer, followed by a 95% stenosis. There is diffuse disease through the mid-LAD to 60%. The LAD is short and does not extend to the apex with TIMI 1 flow. The Lx is a large caliber vessel with diffuse plaquing. There is a modest ramus/OM1 with proximal 65% stenosis. There is a moderate OM2 with moderate origin stenosis. There is a tiny OM3. There is a tortuous branching OM4 with mild stenosis at the origin of the lower pole. There is a large OM5/LPL that is diffusely diseased to LPL2 with 60% mid-vessel stenosis. The RCA has an ectatic origin with a proximal-mid tubular 50% stenosis. There is diffuse plaquing throughout with a distal 30% stenosis into RPDA with 50% stenosis at the origin of its first lateral sidebranch. There are faint collaterals to the LAD. 2. Limited resting hemodynamics revealed mildly elevated left-sided filling pressures with LVEDP averaging 13, max 21 mmHg. 3. Left ventriculography revealed no mitral regurgitation, an LVEF of 70%, and no regional wall motion abnormalities. 4. Left radial artery hemostasis achieved with TR Band. Chest Xray PA/Lat [**2115-1-4**]: IMPRESSION: Heart is normal size. Lungs are clear. Fullness in the right tracheobronchial angle is explained by fat deposition in the mediastinum projecting over a transverse process of the thoracic spine. There is no good evidence for central lymph node enlargement or pleural abnormality. Lungs fully expanded and clear. TTE [**2115-1-5**]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. 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 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. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. No pathologic valvular abnormality seen. Mildly dilated aortic root and ascending aorta. Renal Artery Ultrasound [**2115-1-5**]: IMPRESSION: 1. Normal kidneys and bladder. 2. Segmental arterial resistive indices within normal limits, ranging from 0.58 to 0.67. No evidence of renal artery stenosis. CTA Coronaries [**2115-1-6**]: Impression: 1.Extensive involvement of the coronary arteries by diffuse and focal abnormalities as described in details in the body of the report. Those findngs in conjunction with focal areas of coronary arteries dilataions ca raise the suspicion of vasculitis with some degree of atherosclerosis as well. Given the lack of coronary calcifications in the presence of such an extensive unvolvement of coronary arteries, vasculitis might first diagnostic consideration. 2.Segmental and subsegmental pulmonary embolism. 3. Persistent Left SVC Findings were discussed with Dr. [**Last Name (STitle) 8807**] over the phone by Dr [**Last Name (STitle) **] on Monday, [**2115-1-7**] at 10 am. DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**] Approved: MON [**2115-1-7**] 2:11 PM Imaging Lab [**2115-1-7**] Intra-op TEE Conclusions PRE-BYPASS: No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The descending thoracic aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results at time of surgery. POST-BYPASS: The patient is in sinus rhythm. The patient is on no inotropes. Biventricular function is unchanged. Mitral regurgitation is unchanged. The aorta is intact post-decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2115-1-7**] 16:24 ?????? [**2106**] CareGroup IS. All rights reserved. [**2115-1-10**] 05:50AM BLOOD WBC-12.4* RBC-3.34* Hgb-9.9* Hct-28.8* MCV-86 MCH-29.7 MCHC-34.5 RDW-14.1 Plt Ct-139* [**2115-1-9**] 06:10AM BLOOD WBC-14.6* RBC-3.54* Hgb-10.5* Hct-29.8* MCV-84 MCH-29.5 MCHC-35.1* RDW-14.7 Plt Ct-125* [**2115-1-11**] 06:40AM BLOOD PT-17.5* INR(PT)-1.6* [**2115-1-10**] 05:50AM BLOOD PT-14.4* INR(PT)-1.3* [**2115-1-9**] 06:10AM BLOOD PT-14.0* INR(PT)-1.3* [**2115-1-7**] 05:06PM BLOOD PT-14.5* PTT-35.3* INR(PT)-1.3* [**2115-1-7**] 03:38PM BLOOD PT-14.9* PTT-30.0 INR(PT)-1.3* [**2115-1-4**] 09:40AM BLOOD PT-13.7* INR(PT)-1.2* [**2115-1-11**] 06:40AM BLOOD UreaN-18 Creat-1.0 Na-140 K-3.6 Cl-102 [**2115-1-10**] 05:50AM BLOOD Glucose-116* UreaN-18 Creat-1.1 Na-140 K-3.6 Cl-105 HCO3-30 AnGap-9 Brief Hospital Course: Mr. [**Known lastname 91391**] is a 57 year old gentleman with a history of hypertension, hyperlipidemia, and strong family hx of heart disease who presented for scheduled cardiac catherization after a positive stress MIBI at OSH, found to have severe CAD requiring admission for heparin drip and evaluation for cardiac bypass surgery. After conclusion of preoperative work up, Mr. [**Known lastname 91391**] was taken to the operating room on [**2115-1-7**] and underwent Coronary artery bypass x2(Left internal mammary artery to left anterior descending, and reverse saphenous vein graft to ramus) with Dr.[**Last Name (STitle) **]. Please see operative report for further surgical details. CARDIOPULMONARY BYPASS TIME: 54 minutes. CROSS-CLAMP TIME: 45 minutes. He tolerated the procedure well and was transferred to the CVICU intubated and sedated. He awoke neurologically intact and was extubated without incident. He weaned off pressor support and was started on Beta-blocker/Statin/Aspirin and diuresis. All lines and drains were discontinued per protocol. POD#1 he was transferred to the step down unit for further monitoring. Physical Therapy was consulted for evaluation of strength and mobility. Anticoagulation with Coumadin was initiated for Pulmonary embolism seen on MRA on [**2115-1-6**]. He continued to progress and on POD 4 he was cleared for discharge to home with VNA. All follow up appointments were advised. Medications on Admission: CARVEDILOL - 25 mg PO BID HYDRALAZINE - 20 mg PO TID HYDROCHLOROTHIAZIDE - 25 mg PO qAM LEVOTHYROXINE - 112 mcg PO qAM LISINOPRIL - 40 mg PO qAM SIMVASTATIN - 40 mg PO qPM ASPIRIN - 81 mg PO QD Discharge Medications: 1. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Outpatient Lab Work Labs: PT/INR for Coumadin ?????? indication, pulmonary emboli Goal INR [**3-15**] First draw [**2115-1-12**], then Monday, Wednesday, Friday for 2 weeks. Results to phone [**0-0-**], Dr. [**Last Name (STitle) **] (confirmed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 17**]) 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 11. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: Dr. [**Last Name (STitle) **] to dose for goal INR [**3-15**]. dx: PE. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: AllCare VNA Discharge Diagnosis: Primary: Coronary Artery Disease Secondary: Hypertension Hyperlipidemia Hypothyroidism Left femur fracture Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesia Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema 1+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2-14**] at 1:00pm Dr [**Last Name (STitle) 10166**] on [**2-12**] at 11:00am wound check on [**1-22**] at 10:45am Please call to schedule appointments with your Primary Care Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**2-11**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication, pulmonary emboli Goal INR [**3-15**] First draw [**2115-1-12**], then Monday, Wednesday, Friday for 2 weeks. Results to phone [**0-0-**], Dr. [**Last Name (STitle) **] (confirmed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 17**]) Completed by:[**2115-1-11**] Name: [**Known lastname 14390**],[**Known firstname 126**] Unit No: [**Numeric Identifier 14391**] Admission Date: [**2115-1-4**] Discharge Date: [**2115-1-11**] Date of Birth: [**2057-8-22**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 135**] Addendum: Mr. [**Known lastname **] was also discharged on HCTZ- his home dose of 25mg daily. Discharge Medications: 1. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 2. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Outpatient Lab Work Labs: PT/INR for Coumadin ?????? indication, pulmonary emboli Goal INR [**3-15**] First draw [**2115-1-12**], then Monday, Wednesday, Friday for 2 weeks. Results to phone [**0-0-**], Dr. [**Last Name (STitle) 14392**] (confirmed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]) 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 11. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: Dr. [**Last Name (STitle) 14392**] to dose for goal INR [**3-15**]. dx: PE. Disp:*60 Tablet(s)* Refills:*2* 12. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: AllCare VNA [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**] Completed by:[**2115-1-11**]

[ "V15.51", "413.9", "401.9", "427.1", "272.4", "415.19", "244.9", "V17.3", "414.01", "305.1" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

17408, 17607

10066, 11500

345, 491

13341, 13564

3316, 3321

14488, 15837

2582, 2819

15860, 17385

13210, 13320

11526, 11721

13588, 14465

2834, 2855

270, 307

519, 2093

3335, 10043

2115, 2281

2297, 2566

54,301

180,997

35987

Discharge summary

report

Admission Date: [**2113-1-11**] Discharge Date: [**2113-1-12**] Date of Birth: [**2068-12-19**] Sex: F Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 99**] Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: None. History of Present Illness: 44 y/o F w/ h/o breast cancer metastatic to the skull and liver, with acute respiratory and hemodynamic collapse in the ED. Presented to the ED with abdominal pain. At presentation VS were BP122/86, HR 111, RR 24, O2 sat 92%RA, pain [**10-21**]. Patient was triaged to the core. Within 5 minutes was. non FSG of 97 on presentation, tachycardic with abdominal pain, AOx3 on presentation. Within 5 minutes went into peri-arrest. Became unresponsive with agonal respirations. Intubated without sedation. Hypotensive into 30's and 40's. Not pulseless, never needed CPR. R-femoral line, and left subclavian line placed. Got insulin, bicarb, calcium for hyperkalemia given peaked T-waves. Started on levophed gtt. Head CT negative but lack of contrast. She is now moving all extremities. 5L of IVF's given in ED, and started on vanco/zosyn empirically. . At time of transfer: HR 104, BP 105/66, O2 Sat 100%, CMV FiO2 100%, RR 18, TV 500, PEEP 5, over breathing up to 21. Lactate 14. . On arrival to the ICU, patient was intubated, but following commands. Attentivness waxed and waned, but patient denied pain, and denied any toxic ingestions Past Medical History: PMH: -Metastatic breast cancer Social History: Married, two children at home. Family History: NC Physical Exam: Gen: comfortable, intubated, arousable off sedation HEENT: NCAT, PERRL Neck: overweight, JVP not elevated Lungs: CTA-anteriorly, mechanical breathsounds, symmetric Heart: RRR no m/r/g Abd: obsese, soft, non-tender, non-distended Ext; cool to touch, dopplerable pulses in lower extremity bilaterally, and palpable radial pulses. Neuro: Moving all extremities, following commands Pertinent Results: [**2113-1-11**] 02:20PM BLOOD WBC-27.9* RBC-3.06* Hgb-7.7* Hct-26.0* MCV-85 MCH-25.3* MCHC-29.8* RDW-16.6* Plt Ct-108* [**2113-1-11**] 08:04PM BLOOD WBC-29.5* RBC-2.89* Hgb-7.2* Hct-23.8* MCV-82 MCH-24.8* MCHC-30.2* RDW-18.2* Plt Ct-56* [**2113-1-11**] 02:20PM BLOOD Neuts-78* Bands-6* Lymphs-10* Monos-1* Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-3* NRBC-15* [**2113-1-11**] 02:20PM BLOOD PT-25.1* PTT-71.0* INR(PT)-2.5* [**2113-1-11**] 08:04PM BLOOD PT-28.5* PTT-54.7* INR(PT)-2.9* [**2113-1-11**] 08:04PM BLOOD Fibrino-142* [**2113-1-11**] 02:20PM BLOOD Glucose-317* UreaN-59* Creat-2.4* Na-133 K-5.1 Cl-97 HCO3-17* AnGap-24* [**2113-1-11**] 08:04PM BLOOD Glucose-135* UreaN-47* Creat-1.7* Na-137 K-4.1 Cl-108 HCO3-15* AnGap-18 [**2113-1-11**] 08:04PM BLOOD ALT-408* AST-2472* LD(LDH)-[**Numeric Identifier **]* AlkPhos-486* Amylase-141* TotBili-3.3* [**2113-1-11**] 02:20PM BLOOD ALT-258* AST-1286* CK(CPK)-625* AlkPhos-429* TotBili-1.6* [**2113-1-11**] 02:20PM BLOOD Lipase-577* [**2113-1-11**] 08:04PM BLOOD Lipase-383* [**2113-1-11**] 02:20PM BLOOD CK-MB-4 cTropnT-<0.01 [**2113-1-11**] 02:20PM BLOOD Albumin-1.6* Calcium-13.9* Phos-6.9* Mg-2.9* [**2113-1-11**] 08:04PM BLOOD Calcium-6.3* Phos-4.7*# Mg-2.1 Cholest-33 [**2113-1-11**] 08:04PM BLOOD D-Dimer->21,000 [**2113-1-11**] 08:04PM BLOOD Triglyc-74 HDL-5 CHOL/HD-6.6 LDLcalc-13 [**2113-1-11**] 02:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-7.7 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2113-1-11**] 02:20PM BLOOD LtGrnHD-HOLD [**2113-1-11**] 01:56PM BLOOD Glucose-191* Lactate-14.4* Na-128* K-7.2* Cl-90* [**2113-1-11**] 02:28PM BLOOD Glucose-254* Lactate-11.1* Na-133* K-3.6 Cl-109 [**2113-1-11**] 08:35PM BLOOD Lactate-9.2* [**2113-1-11**] 08:47PM BLOOD Lactate-9.9* [**2113-1-11**] 11:00PM BLOOD Lactate-5.5* [**2113-1-12**] 12:45AM BLOOD Glucose-192* Lactate-14.5* Na-165* K-6.3* Cl-125* [**2113-1-11**] 01:56PM BLOOD Hgb-11.3* calcHCT-34 O2 Sat-97 COHgb-2 MetHgb-0 [**2113-1-11**] 01:56PM BLOOD freeCa-1.11* [**2113-1-11**] 02:28PM BLOOD freeCa-1.26 Brief Hospital Course: Patient was admitted to the medical ICU for management of shock s/p arrest in the ED. On arrival, patient was intubated, comfortable without sedation. Initial impression was for sepsis + DIC. On arrival she was continued on vasopressin and levophed. Patient became hypotensive on arrival and received multiple fluid boluses of LR and NS. Attempts at arterial line placement were undertaken but unsuccessful. Dopamine was added for additional BP support. Concern was raised for possible PE/tamponade and a bedside echo was performed by Cardiology showing no evidence of pericardial effusion. Her RV was noted to be mildly hypokinetic and PE could not be exluded. Decision was made to defer heparin, but to attempt tPA if patient became unstable. Patient then PEA arrested shortly after arrival in the ICU. Code Blue was called. Multiple rounds of epi/bicarbonate were given. During the code patient was given tPA w/o successful return of pulses. Patient expired that morning. No pulse was recovered during the arrest. Medications on Admission: - Risperidone - Celexa - Oxycodone - Vicodin Discharge Medications: Patient expired. Discharge Disposition: Expired Discharge Diagnosis: PEA Arrest Sepsis and DIC Metastatic Breast Cancer Discharge Condition: Deceased Discharge Instructions: Patient deceased. Followup Instructions: None.

[ "995.92", "785.52", "198.5", "584.5", "038.9", "197.7", "780.97", "518.81", "174.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

5220, 5229

4050, 5083

310, 318

5324, 5335

2020, 4027

5401, 5410

1603, 1607

5179, 5197

5250, 5303

5109, 5156

5359, 5378

1622, 2001

256, 272

346, 1484

1506, 1539

1555, 1587

14,126

126,340

43816

Discharge summary

report

Admission Date: [**2181-4-25**] Discharge Date: [**2181-5-4**] Service: MEDICINE Allergies: Amiodarone / Quinidine/Quinine Attending:[**First Name3 (LF) 3326**] Chief Complaint: CC:[**CC Contact Info 94136**] Major Surgical or Invasive Procedure: hemodialysis History of Present Illness: HPI: This is a 88My.o male with h/o of afib on comadin, CHF, OSA, and advance prostate CA s/p TURP, h/o urosepsis sp b/l stents, seen in clinic c/foul smelling urine today. . Patient describes that over the last 2 days he has been feeeling more tired, lack of energy and his urine is coming out "milky and foul smelling". He was given two doses of TMP/SMX or ?Cipro last night and one this morning. . He denies any fever, chills, nausea, vomit, diaphroesis, shortness of breath, chest pain, back pain, diarrhea, aabdominal pain, but reported 10 lb wt loss in the past 3 months due to loss of appetite from lost of taste budd. When asked about his bruise on his left forehead, he said that he bumped his head on Sunday with the refrigerator. He did not lose any conciousness. Denies any headachees, blurred vision or unsteady gait associated after the episode. . In ED, hemodynamically stable, has +UA, received Levoflox, and cefepime. Past Medical History: PMH - - OSA - History of sinus infections. - Prostate CA s/p XRT/resection - DM2 - A. fib on Coumadin - Right cataract. - Left retinal tear. - Macular degeneration status post laser treatment. - Gout. - [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] tear. - Squamous cell carcinoma of ear followed by derm - IBS w/chronic diarrhea for years/lactulose intolerance - myelodysplasia . PSH - - Spontaneous pneumothorax 15 years ago. - s/p cholecystectomy - s/p left inguinal hernia repair, - s/p hemorrhoidectomy - Prostate CA s/p TURP and XRT s/p urethral stricture - back surgery Social History: SH - Retired psychiatrist. Lives at home with his wife. Quit tobacco many years ago. No EtOH, no illicits. Family History: FH - NC Physical Exam: Physical Exam: Vitals: T 96.9 P: 67 BP 146/66 RR 17 Sats 96%RA General: Awake, alert, NAD. HEENT: dry oral mucose. echimosis on his left forehead. Neck: supple, no JVD, left side adenopathy x 2, small, non tender, mobile. Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: BS+, soft, obese non tender, mildly distended. Liver 1cm below costal margin. Extremities: asymetric bilateral LLE edema 2+. Neurologic: -mental status: Alert, oriented x 3. CNII-XII intact. Movilizing all extremities. Pertinent Results: Laboratory Data: see below EKG: afib, with VR 70x, left axis, no st changes, difuse flattenin t waves on v4-v5-v6. QTC 460 . Radiologic Data: Renal US: pending . [**2181-4-25**] 05:40PM BLOOD WBC-12.1* RBC-4.64 Hgb-12.5* Hct-40.4 MCV-87 MCH-26.9* MCHC-30.8* RDW-17.3* Plt Ct-258 [**2181-5-4**] 04:21AM BLOOD WBC-19.7* RBC-3.46* Hgb-9.9* Hct-29.9* MCV-87 MCH-28.6 MCHC-33.0 RDW-18.5* Plt Ct-93* [**2181-4-25**] 05:40PM BLOOD PT-74.7* PTT-42.8* INR(PT)-9.7* [**2181-4-25**] 05:40PM BLOOD Plt Smr-NORMAL Plt Ct-258 [**2181-5-4**] 04:21AM BLOOD PT-23.7* PTT-29.7 INR(PT)-2.4* [**2181-5-4**] 04:21AM BLOOD Plt Smr-LOW Plt Ct-93* [**2181-4-25**] 05:40PM BLOOD Glucose-304* UreaN-59* Creat-2.4* Na-136 K-4.2 Cl-101 HCO3-20* AnGap-19 [**2181-5-3**] 05:41AM BLOOD Glucose-89 UreaN-63* Creat-3.7* Na-125* K-6.6* Cl-94* HCO3-10* AnGap-28* [**2181-5-4**] 04:21AM BLOOD Glucose-116* UreaN-60* Creat-3.6* Na-130* K-5.2* Cl-91* HCO3-13* AnGap-31* [**2181-4-27**] 06:45AM BLOOD ALT-32 AST-57* LD(LDH)-529* AlkPhos-312* TotBili-1.0 [**2181-5-4**] 04:21AM BLOOD ALT-476* AST-PND LD(LDH)-PND AlkPhos-573* TotBili-1.9* [**2181-5-4**] 04:21AM BLOOD Albumin-2.2* Calcium-7.2* Phos-8.5* Mg-2.0 [**2181-4-27**] 06:45AM BLOOD PSA-<0.1 [**2181-5-3**] 12:51PM BLOOD Type-ART pO2-81* pCO2-25* pH-7.04* calHCO3-7* Base XS--23 [**2181-5-3**] 07:11PM BLOOD Type-[**Last Name (un) **] Temp-35.0 O2 Flow-3 pO2-37* pCO2-28* pH-7.20* calHCO3-11* Base XS--16 Intubat-NOT INTUBA Brief Hospital Course: 87 y/o male with advanced prostate CA s/p TURP, h/o bilateral hydronephrosis due to tumor at trigone s/p post stents (Right), OSA, afib on coumadin who presents with UTI and ARF on CRI, and elevated INR. Given worsening renal failure secondary to underlying metatstaic malingnancy and poor prognosis, [**Name (NI) 1094**] wife and family decided to concentrate on comfort and avoid aggressive measures. After several sessions of hemodialysis, Family chose to further withdrawl care. Pt pronounced dead at 15:36 on [**2181-5-4**]. Family present in the room. Autopsy deferred . #. Acute on chronic renal failure - Patient has a baseline Cr of 1.6 with an elevation in BUN/Cr to 59/2.4. Pt with progressive renal failure [**1-18**] to underlying malignancy and associated obstruction. Pt initiated on Hemodialysis which he tolerated well. Discussed with urology who recomended revision of uretral stents which was not pursued as family wished to stress comfort. . # UTI: u/a compatible with urinary tract infection. Given prior history of VRE and gram negative bacteremia (pseudomona) in recent past, Pt was covered broadly. . #. Anion Gap Acidosis: Mixed lactic acidosis with acute renal failure. BG elevated on presentation, but urine ketones negative. Pt started on NaHCO3 and HD with little improvement in acidosis. Worsening lactic acidosis [**1-18**] tumor necrosis Medications on Admission: . Medications: Lasix 60 mg a day, Glipizide ER 10 mg, Lipitor 10 mg, Casodex 50 mg, Allopurinol 100 mg, potassium 10 mEq, Verapamil 40 mg, Prilosec OTC 20 mg, vitamin B-12, Coumadin, 1-2.5 mg as dosed by his INR, folic acid 1 mg a day, cholestyramine 1 pack daily, ferrous sulfate, nitrofurantoin which he just finished as I mentioned, and Ambien XL 6.25 mg. Discharge Medications: na Discharge Disposition: Home with Service Discharge Diagnosis: renal failure hyperkalemia Discharge Condition: deceased Discharge Instructions: none Followup Instructions: NA

[ "238.7", "585.9", "276.7", "276.51", "276.1", "362.50", "584.9", "188.8", "274.9", "414.01", "585.6", "599.0", "366.9", "780.57", "428.0", "197.7", "185", "250.00", "427.31" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

5873, 5892

4055, 5435

267, 282

5963, 5974

2588, 4032

6027, 6033

2008, 2017

5846, 5850

5913, 5942

5461, 5823

5998, 6004

2047, 2487

198, 229

310, 1246

2502, 2569

1268, 1867

1883, 1992

70,954

130,133

1785

Discharge summary

report

Admission Date: [**2144-11-11**] Discharge Date: [**2144-12-17**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8388**] Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: ERCP PTC drain placement and revisions X5 Hemodialysis temporary catheter Foley catheter Flexiseal History of Present Illness: 86 year-old Russian speaking male with h/o HTN, stage IV renal failure who presents with severe RUQ pain and vomiting. His pain started one week ago when he had RUQ pain and severity [**5-10**]. He had no N/V at that time. His pain disappeared for a few days then returned yesterday in the late morning. Pain yesterday has been [**10-10**] He had 2 episodes of bilious vomit. He had yellow diarrhea twice prior to going to the ED. No blood in stools. He has had ? low-grade temps at home. He most recently ate yesterday AM. In the emergency department VS were 98.1 140/56 63 16 98% RA. A RUQ ultrasound showed a distended gallbladder with sludge and mild wall edema. Positive [**Doctor Last Name **] sign. Findings were concerning for acute cholecystitis in appropraite clinical setting. CBD 13 mm. Mild intrahepatic biliary dilatation. In ED he received zosyn 4.5mg IV, unasyn 3g IV x1, zofran 4mg IV x1, tylenol 1g po x1, morphine 4mg IV x2, toradol 25mg IV x1. Exam notable for marked tenderness in RUQ and epigastric region. + [**Doctor Last Name **] sign. Pt spiked fever to 102.8 BP remained stable. HR 90-124. 3L of IVF were given and pt had 375 cc out the foley. Pt had R IJ placed. The patient was seen by surgery in the ED who recommended NPO, foley catheter, IVF, unasyn IV, am LFTs, and ERCP in am for bilary decompresson. . Patient was found to have cholangitis and admitted to the MICU. He had an ERCP but biliary cannulation was unsuccessful. He thus underwent a PTC which showed stones and had a PTC drain placed. The patient improved, however, his bilirubin increased and reimaging showed now flow into the small bowel with filling defects in the CBD. Dilation of the ampula and removal of distal CBD stones was performed with new PTC drain placement. The bili intially dropeed but again started to rise with a decrease in drain output. MRI was suggestive of cholangitis. PTC drainage was done again. The patient currently has climbing bilirubin levels once again. . The patient also had S. bovis and E. coli in his blood cultures. In addition to that the patient had E. cloacae in his bile culture. The patient is currently being treated with vancomycin and meropenem. Of note, prior colonoscopy [**4-/2144**] was performed with two angioectasias, a single sessile polyp, which was completely removed and multiple diverticula. The patient has iron deficiency anemia requiring transfusions. No gross bleeding during this admission. . The patient also has a climbing creatinine, which is being followed by nephrology. Currently they think the patient has ATN. He produced 1L of urine yesterday. . The patient has waxing and [**Doctor Last Name 688**] mental status. Much below his baseline functional level. Surgery wanted to place dobhoff, family refused. He is on TPN. . Currently he has some abdominal pain which is much improved from baseline. He denies any other pain, nausea, vomiting, diarrhea or constipation. He has some chills, though denies fevers or nightsweats. He does not have an appetite and eats very little. Past Medical History: # Hepatitis C (although pt unaware of this dx) - per family no h/o LFT abnormalities, bleeding, ascites, or encephalopathy. no history of drug use or recent transfusions. # Status post gastric resection in [**2085**] for peptic ulcer disease. # DM 2 # Thrombocytopenia, anemia that in part was attributed to B12 deficiency. The patient is on vitamin B12 supplementation. There is also concern for MDS. # Hypertension # Osteoarthritis # BPH # Chronic renal failure Social History: Pt lives with his wife at home. He ambulates independently. He does the shopping, his wife cooks, and they have some help during the week. Patient has two sons, one of whom is [**Name8 (MD) **] MD living in the area, other is urologist in [**Location (un) 4551**]. No history of smoking. Patient drinks 1 drink per week, per son no history of EtoH abuse. Family History: Non contributory Physical Exam: PHYSICAL EXAM GENERAL: Pleasant, well-appearing elderly Russian M in NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA. dry MM. OP clear. Neck Supple, No LAD. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**] appreciated LUNGS: mild crackles at lung bases B/L, no wheeze ABD: soft, NABS TTP in RUQ, abdomen non-tender otherwise, no hernias, no masses, guaic negative in ED EXT: healing scar over R knee, + LE edema R>L, [**1-3**]+ DP.PT pulses B/L NEURO: A&O x3 (in Russian) Pertinent Results: [**2144-11-11**] 08:00PM GLUCOSE-255* UREA N-61* CREAT-2.9* SODIUM-137 POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-19* ANION GAP-15 [**2144-11-11**] 08:00PM ALT(SGPT)-76* AST(SGOT)-53* LD(LDH)-162 ALK PHOS-459* TOT BILI-2.1* DIR BILI-1.6* INDIR BIL-0.5 [**2144-11-11**] 08:00PM WBC-8.3 RBC-3.38* HGB-9.9* HCT-29.5* MCV-87 MCH-29.2 MCHC-33.4 RDW-15.2 [**2144-11-11**] 08:00PM NEUTS-81.9* LYMPHS-11.5* MONOS-5.2 EOS-1.0 BASOS-0.4 [**2144-11-11**] 08:00PM PT-13.5* PTT-29.5 INR(PT)-1.2* . [**2144-11-11**] RUQ u/s: FINDINGS: Suboptimal evaluation of the liver due to patient discomfort. No definite focal liver lesions are seen. Mild intrahepatic biliary duct dilatation. CBD is dilated and measures 13 mm. The gallbladder is distended with a hydropic shape and ++ son[**Name (NI) 493**] [**Name2 (NI) 515**] sign. There is sludge within the lumen of the GB. There is no definite GB wall thickening or pericholecystic fluid. IMPRESSION: Findings concerning for early acute cholecystitis. . [**2144-11-12**] ERCP FINDINGS: Images show a contrast-filled pancreatic duct in the head of the pancreas without evidence of filling defects or strictures. Per ERCP report, cannulation of the biliary duct was unsuccessful. Per ERCP report, a pancreatic duct stent was placed. The stent is visualized on the fluoroscopy images. IMPRESSION: Normal opacification of the pancreatic duct in the pancreatic head without evidence of filling defects or strictures. . [**2144-11-14**] T-Tube cholangiogram: IMPRESSION: Cholangiogram through internal-external biliary drainage catheter demonstrating opacification of the biliary tree, which appears decompressed compared to prior study, however, no internal drainage into the bowel is demonstrated due to either constrictive narrowing at the lower CBD or an occluded catheter tip. . [**2144-11-19**] MRI: 1. Percutaneous transhepatic biliary drain in good position. Biliary tree decompressed. No choledocholithiasis or obstructing mass identified on this non-contrast study. However, there is marked edema about the portal triads within the right hepatic lobe which could correlate with given history of cholangitis (evaluation for enhancement is not possible given noncontrast technique). 2. Cholelithiasis. 3. Numerous pancreatic cystic lesions. The largest of the body which measures 2.5 cm is concerning for IPMN. No definite solid components identified on this non-contrast study. Six-month MRCP followup recommended. 4. Small amount of perihepatic ascites, heterogeneous appearance of the liver and mildly enlarged lymph nodes of the porta hepatis are consistent with chronic liver disease. 5. Borderline splenomegaly. 6. Bilateral renal cysts. . [**2144-11-19**] T-Tube cholangiogram: IMPRESSION: 1. External component of indwelling 10-French internal-external biliary drain was occluded. 2. Cholangiogram demonstrating 1.1 x 1.6 cm filling defect within the lower common bile duct. 3. Stone was macerated with a wire basket with minimal residual fragments within the common bile duct. 4. Good flow established from the biliary tree into the duodenum. 5. Placement of a new 10-French internal-external biliary drain in similar position to prior with attached three-way stopcock to allow for easy flushing. . [**11-30**] KUB: A single frontal radiograph of the abdomen demonstrates unchanged position and normal appearance of PTC drain. Bowel gas is seen throughout the visulaized GI tract through the rectum is not fully included. No abnormal dilation or air-fluid levels are seen. No obstruction or ileus. . [**2144-12-9**] Common Bile Duct punch biopsies and brushings: Blood, fibrin and scant degenerate cells, likely reactive Brief Hospital Course: 86M with DM, HCV admitted with cholangitis s/p PTC drain course c/b sepsis, [**Last Name (un) **] and recurrent drain obstruction. . #. Cholangitis with bacteremia: The patient had cholangitis with sepsis. He was treated with vanc and [**Last Name (un) 2830**]. He had a PTC drain in place that required multiple revisions with increase in stent size. Ultimately, bilirubin trended back up and bile draining into outside pouch was found to be very thick. It was felt that patient likely had cholangiocarcinoma given need for repeat PTC revisions without improvement and a repeatedly visualized "filling defect" in CBD on imaging. Biopsies only yielded blood, fibrin and reactive debris. Patient continued to decompensate, becoming more uncomfortable, delirious and unresponsive. In extensive discussions between the family and four gastroenterology attendings, one renal attending, patient was made DNR/DNI given his extremely poor prognosis. The goal was ultimately for comfort measures and patient expired on [**2144-12-17**] with family at the bedside. . #. Portal hypertension/cirrhosis/HCV: The patient appeared to have HCV cirrhosis with portal hypertension. He had minimal ascites - mostly abdominal distension from gas due to lactulose. Patient was too ill during this hospitalization for interferon and ribavirin. His Hep X viral load was not significantly high. His total bilirubin was trended and was ~16-18 when patient expired. . #. Delirium: Likely multifactorial including infection, hepatic encephalopathy, ICU delirium. Exam nonfocal. SBP unlikely with small amount ascites. Patient's family was at the bedside, or in room, 24/7 and reoriented patient. Patient was continued on lactulose and rifaximin as long as could be tolerated and sedating medications were minimized. Ultimately, patient was given standing morphine and benadryl for comfort measures prior to expiring. . #. [**Last Name (un) **]: Urine lytes confirmed ATN on top of chronic renal failure. HRS was less likely given FeNa >1%. Creatinine continued to climb with decreasing urine output despite avoiding nephrotoxins and albumin challenge. Patient was ultimately dialyzed X1 week but experienced siginificant rigors in dialysis. It was felt that it was inappropriate to continue hemodialysis given poor prognosis. Temporary HD line was pulled and cultured, which did not grow anything back. . # Leukocytosis - Initially WBC 20 and did improve to ~11 while on broad-spectrum antibiotics (meropenem, vancomycin). Antibiotics were continued for more than two weeks given worsening physical exam and increase in WBC again. CDiff assays were sent X3, all negative. Multiple mycolytic, regular blood and urine cultures were sent, all negative. Ultimately, all antibiotics were stopped per Infectious Disease recommendations without significant change in TBili or white count. Of note, patient did develop a significant, pruritic drug rash felt likely secondary to Meropenem +/- Flagyl. Patient was treated with Sarna lotion, benadryl and atarax. Initial leukocytosis felt likely secondary to cholangitis, which was likely treated to completion. . #. Nutrition: Patients family amenable to dobhoff [**11-29**]; however, PO intake initially on floor was felt to be adequate, with family prompting. Patient was continued on TPN. A Dobhoff was ultimately placed early in [**Month (only) 1096**] but patient pulled it out within 12 hours of placement, before tube feeds could be started. By the end of [**Hospital 228**] hospital course, TPN was discontinued and patient/patient family encouraged to take in PO diet ad lib. . #. Anemia: Followed by heme as outpt, felt to be multifactorial. Concerning for colon carcinoma in setting of S. bovis initially but last colonoscopy in [**2140-5-1**] was negative for malignant/pre-malignant lesions. Does have known angioectasias. Limited upper endoscopy (done for ERCP) without abvious source of bleed at that time. Patient was continued on B12/iron/folate as long as tolerated. . #. HTN: Continued on nifedipine. Lasix and ace-inhibitor were held throughout hospital course in setting of acute on chronic renal failure. Patient did develop atrial fibrillation with rapid ventricular response the last week of [**Month (only) **] which responded to IV metoprolol/diltiazem. Medications on Admission: Cyanocobalamin 1000 mcg qday Vit B 1 tab qday Glyburide 1.25 mg qday folic acid 1 mg qday fosinopril 20 mg qday Nifedipine SR 30 mg daily Lasix 20 mg daily Doxazosin 4 mg qhs??? unsure if pt is on this medication Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Cholangitis, liver failure and acute on chronic renal failure with likely cholangiocarcinoma Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A

[ "427.31", "038.9", "250.00", "572.3", "584.9", "263.9", "403.90", "600.00", "287.5", "574.31", "281.1", "995.91", "571.5", "576.1", "585.4", "070.70" ]

icd9cm

[ [ [] ] ]

[ "99.15", "39.95", "99.04", "51.96", "51.12", "38.95", "38.93", "51.98", "96.08", "87.54", "87.51" ]

icd9pcs

[ [ [] ] ]

13236, 13245

8646, 12941

279, 379

13381, 13390

4954, 8623

13442, 13448

4337, 4355

13204, 13213

13266, 13360

12967, 13181

13414, 13419

4370, 4935

225, 241

407, 3460

3482, 3948

3964, 4321

15,824

181,244

48043

Discharge summary

report

Admission Date: [**2158-9-13**] Discharge Date: [**2158-9-19**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 371**] Chief Complaint: s/p Pedestrian Struck by Auto Rib pain Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] yo female pedestrian who was struck by auto while crossing the street, at aprrox. 25-30 mph. By EMS report patient alert at scene; left leg deformity with stable VS. Patient transferred to [**Hospital1 18**] for trauma care. Past Medical History: Vertigo Hard of Hearing s/p appendectomy Social History: Lives alone in [**Location (un) **]. Employed full-time as a bookkeeper at a law firm in [**Location (un) 86**]. Denies ETOH/tobacco Family History: Non-contributory Physical Exam: VS upon arrival to trauma bay: HR 76 BP 90/45 RR 20 room air Sats 97% Gen-Alert, NAD HEENT-NCAT Neck-c-collar in place Chest-painful to palp right side; equal BS bilat Cor-RRR no murmurs GI-soft, NT/ND FAST exam negative Rectum-guaiac negative Pelvis-stable Extr-right post calf laceration; left leg deformity Pertinent Results: [**2158-9-13**] 11:27PM LACTATE-2.7* [**2158-9-13**] 11:10PM HCT-28.0* [**2158-9-13**] 11:05PM GLUCOSE-119* UREA N-19 CREAT-0.7 SODIUM-135 POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-21* ANION GAP-17 [**2158-9-13**] 11:05PM CALCIUM-7.4* PHOSPHATE-2.2* MAGNESIUM-1.0* [**2158-9-13**] 07:13PM UREA N-25* CREAT-1.3* [**2158-9-13**] 07:13PM PLT COUNT-258 [**2158-9-13**] 07:13PM FIBRINOGE-280 CHEST (PORTABLE AP) [**2158-9-13**] 8:53 PM CHEST (PORTABLE AP) Reason: Please assess mediastinum. [**Hospital 93**] MEDICAL CONDITION: [**Age over 90 **] year old woman pedestrian struck. REASON FOR THIS EXAMINATION: Please assess mediastinum. INDICATION: Pedestrian struck, assess mediastinum. COMPARISON: [**2154-3-19**] TECHNIQUE: Single AP portable upright chest. FINDINGS: The heart size and mediastinal contours are within normal limits, with unfolding of the thoracic aorta, and appear unchanged from [**2154-3-19**]. No focal pulmonary parenchymal consolidation is identified. There is bibasilar atelectasis versus scarring and slight blunting of the left costophrenic angle consistent with pleural thickening versus effusion, unchanged from [**2154-3-19**]. The osseous structures demonstrate osteopenia. No fractures are identified. IMPRESSION: Stable radiographic appearance of the chest. Bibasilar atelectasis versus scarring and small left pleural effusion versus pleural thickening. No mediastinal widening identified. TIB/FIB (AP & LAT) RIGHT [**2158-9-13**] 7:54 PM TIB/FIB (AP & LAT) RIGHT Reason: please assess for injury. [**Hospital 93**] MEDICAL CONDITION: [**Age over 90 **] year old woman pedestrian struck. REASON FOR THIS EXAMINATION: please assess for injury. INDICATION: Trauma. COMPARISONS: None. RIGHT TIP/FIB, THREE VIEWS: There are degenerative changes seen within the right knee joint. There is diffuse osteopenia. No fractures are identified. CT PELVIS W/CONTRAST [**2158-9-13**] 7:31 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Reason: PEDESTRIAN STRUCK BY CAR.R/O INTERNAL INJURY Field of view: 34 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: [**Age over 90 **] year old woman pedestrian struck, pelvic fx. REASON FOR THIS EXAMINATION: Please assess for injury. CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: Trauma. COMPARISON: None. TECHNIQUE: MDCT acquired contiguous axial images from the lung bases to pubic symphysis were acquired following the administration of 150 cc of IV Optiray. Nonionic contrast was administered secondary to the rapid bolus requirement needed per protocol. Coronal and sagittal reconstructions were obtained. CT OF THE ABDOMEN WITH IV CONTRAST: Mild atelectatic changes are noted at the lung bases. Additionally, within the posterior periphery of the left lower lobe, there is a 1.2 cm nodular opacity present. Mild right pleural thickening is also identified. There is a large axial hiatal hernia noted. The stomach is distended and filled with fluid. The liver, gallbladder, spleen, adrenal glands, and loops of small and large bowel appear unremarkable. Tiny cortically based linear subcentimeter hypodensities are noted, which may represent areas of prior scarring. Both kidneys enhance symmetrically and excrete normally. The proximal ureters are unremarkable. The pancreas is mildly atrophic, but otherwise appears unremarkable. The abdominal aorta is normal in caliber, and demonstrates diffuse moderate calcified atherosclerotic disease throughout. There is no free air or free fluid. No pathologically enlarged mesenteric or retroperitoneal lymph nodes are noted. There is no evidence of bowel obstruction. CT HEAD W/O CONTRAST [**2158-9-13**] 7:23 PM CT HEAD W/O CONTRAST Reason: r/o bleed [**Hospital 93**] MEDICAL CONDITION: [**Age over 90 **] year old woman s/p peds vs. auto REASON FOR THIS EXAMINATION: r/o bleed CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: [**Age over 90 **]-year-old woman, status post trauma, hit by motor vehicle. COMPARISON: None. TECHNIQUE: Non-contrast head CT. HEAD CT WITHOUT IV CONTRAST: No definite intra- or extraaxial hemorrhage, mass effect, or shift of midline structures is demonstrated. There is a tiny focus of high attenuation within the right temporal lobe white matter, likely representing volume averaging with the adjacent temporal bone. Periventricular white matter hypodensities are present, most likely representing chronic microvascular infarction. There is widening of the sulci and ventricles, consistent with cerebral atrophy. There is no hydrocephalus. A large left posterior parietal scalp hematoma is present. The osseous structures are intact. Mild polypoid mucosal thickening is seen within the left maxillary sinus. Remaining visualized paranasal sinuses and mastoid air cells are clear. IMPRESSION: No definite intracranial hemorrhage or mass effect. Periventricular chronic microvascular infarction. Left posterior parietal scalp hematoma. CT OF THE PELVIS WITH IV CONTRAST: A Foley catheter is seen within the bladder, which appears unremarkable. The uterus demonstrates coarse calcifications, likely representing fibroids. The pelvic loops of bowel are within normal limits. There is no free fluid. BONE WINDOWS: Comminuted superior and minimally-displaced inferior right pubic rami fractures are noted. Additionally, there are minimally-displaced fractures involving the left anterior fifth and sixth ribs, and likely the seventh anterior rib as well. Multilevel degenerative changes are seen within the axial skeleton. CT RECONSTRUCTIONS: Coronal and sagittal reconstructions were essential in confirming the above findings. IMPRESSION: 1. Comminuted right superior and minimally-displaced inferior pubic rami fractures. 2. Minimally-displaced left anterior fifth, sixth, and likely seventh rib fractures. 3. Peripherally based 1.2 cm parenchymal opacity within the left lower lobe. Correlation with prior x-rays or CT scans is recommended. Otherwise, follow up CT of the chest can be performed to evaluate for stability. 4. No significant intra-abdominal or intrapelvic traumatic injury seen. 5. Large axial hiatal hernia with fluid filled distended stomach. Brief Hospital Course: Patient admitted to the trauma service. Neurosurgery and Orthopedics were immediately consulted. There were no neurosurgical issues; head imaging was negative for any intracranial hemorrhage. Orthopedics consulted for her pelvic and left tib/fib fractures. The decision was made to not to operate; recommendations for patient's weight bearing status was to not bear any weight on LLE and only touch down weight bearing on RLE for transfers from bed to chair. Social work, Physical therapy and Nutrition were consulted as well. Patient with episode of confusion on HD 5, a U/A was sent and was positive; she is currently being treated with Cipro po for a 5 day course. Patient was started on her pre-hospital meds; Calcium and Vit D were added to her regimen her Ticlid was restarted on day prior to admission once deemed she had no issues with bleeding. She will need to follow up with Orthopedics in [**5-10**] weeks after discharge. Medications on Admission: Imdur 30 qd; ASA; Meclizine 25 qid; Ticlid 250 [**Hospital1 **]; Pecid 20 qd; Fosamax 70 qweek; Toprol 100 qd Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for HR less than 60 and/or SBP less than 100 mmHg. 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Meclizine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for dizziness. 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 13. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSAT (every Saturday): give 30 min prior to bkfst with 8 oz water with patient sitting at 90 degrees; remain upright for at least 30 min after taking. 15. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): Continue for 5 days then d/c. 16. Ticlopidine 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 3765**] - [**Location (un) 1514**] Discharge Diagnosis: s/p Pedestrian Struck by Auto Right Superior/Inferior Pubic Ramus Fracture Left 5th & 6th Anterior Rib Fracture Left Non-displaced Tib/Fib Fracture Discharge Condition: Stable Discharge Instructions: Do not bear any weight on your left lower extremity; you may touch down weight bear on your right lower extremeity for transfers from bed to chair with assist. Follow up with Orthopedics in [**5-10**] weeks. Complete your antibiotic course for your urinary tract infection. Followup Instructions: Follow up with Dr. [**Last Name (STitle) 1005**], Orthopedics, in [**5-10**] weeks. Call [**Telephone/Fax (1) 1228**] for an appointment. Follow up with your primary doctor after your discharge from rehabilitation. Completed by:[**2158-9-19**]

[ "808.2", "599.0", "V10.05", "280.0", "823.82", "272.0", "E814.7", "807.09" ]

icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

10133, 10207

7360, 8296

299, 306

10399, 10408

1177, 1677

10730, 10976

810, 828

8456, 10110

4924, 4976

10228, 10378

8322, 8433

10432, 10707

843, 1158

221, 261

5005, 7337

334, 579

601, 644

660, 794

30,285

168,147

3373

Discharge summary

report

Admission Date: [**2119-10-20**] Discharge Date: [**2119-10-27**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 301**] Chief Complaint: Patient admitted with lower gi bleed. Major Surgical or Invasive Procedure: 1. Subtotal colectomy with ileal rectal anastomosis. 2. Rigid proctoscopy. History of Present Illness: 85 year old male with past medical history significant for MI, cva x 2 and pacer has been at [**Hospital1 **] for 4 days now w/ LGIB. Has undergone tagged rbc scan, c-scope x 2 and got a total of 13U of blood over 4 days. He has per report been fairly hemodynamically stable throughout with lowest sbp in the 90s, mentating and not tachycardic. His bleeding has been intermittent, stopping, and therefore no bleeding ever seen on c-scope, just some old cauterized avms. tagged scan per report shows ? localiztion in right colon. Never had angio. Currrently he is hemodynamically stable, denies any ab pain/cp/sob/fever/chills/n/v. Just had another episode of brbpr on arrival to [**Hospital1 **]. Past Medical History: two prior MI??????s, dual chamber pacer, small CVA [**2113**] with mild facial droop on the left, htn, hyperlipidemia, prostate ca s/p surgery (has stress incontinence). Social History: no tobacco, no EtOH, founding member of "Little [**First Name4 (NamePattern1) **] [**Known lastname 1140**] and the Thrillers", recently inducted into the Doo-Wop [**Doctor Last Name **] of Fame. Family History: non-contributory. Physical Exam: 98.3 84 109/62 16 100% 2L nc NAD AOx3 CTAB (some coarseness) RRR soft ntnd no rebound or guarding guiac positive Pertinent Results: [**2119-10-21**] 12:24AM BLOOD WBC-9.4 RBC-3.67* Hgb-11.7* Hct-31.9* MCV-87# MCH-31.8 MCHC-36.6* RDW-15.8* Plt Ct-106*# [**2119-10-22**] 01:00AM BLOOD WBC-13.3*# RBC-3.11* Hgb-9.9* Hct-27.2* MCV-87 MCH-31.8 MCHC-36.4* RDW-16.3* Plt Ct-118* [**2119-10-25**] 04:25AM BLOOD WBC-8.2 RBC-2.86* Hgb-8.8* Hct-25.6* MCV-89 MCH-30.9 MCHC-34.6 RDW-16.1* Plt Ct-197 [**2119-10-25**] 09:10PM BLOOD Hct-32.5*# [**2119-10-26**] 07:00AM BLOOD WBC-8.7 RBC-3.51* Hgb-10.6* Hct-31.2* MCV-89 MCH-30.3 MCHC-34.1 RDW-15.8* Plt Ct-246 [**2119-10-26**] 07:00AM BLOOD Plt Ct-246 [**2119-10-22**] 01:00AM BLOOD Plt Ct-118* [**2119-10-21**] 12:24AM BLOOD PT-14.5* PTT-32.9 INR(PT)-1.3* [**2119-10-21**] 12:24AM BLOOD Glucose-128* UreaN-13 Creat-0.9 Na-142 K-3.9 Cl-115* HCO3-23 AnGap-8 [**2119-10-23**] 03:13AM BLOOD Glucose-146* UreaN-13 Creat-0.8 Na-143 K-3.8 Cl-118* HCO3-22 AnGap-7* [**2119-10-25**] 04:25AM BLOOD Glucose-115* UreaN-16 Creat-0.8 Na-144 K-3.5 Cl-116* HCO3-24 AnGap-8 [**2119-10-23**] 03:05PM BLOOD CK(CPK)-330* [**2119-10-21**] 04:46PM BLOOD CK-MB-11* MB Indx-6.4* cTropnT-1.02* [**2119-10-23**] 09:17AM BLOOD CK-MB-18* MB Indx-4.7 cTropnT-0.69* [**2119-10-23**] 03:13AM BLOOD Calcium-7.5* Phos-2.1* Mg-2.1 [**2119-10-26**] 07:00AM BLOOD Calcium-8.0* Phos-2.1* Mg-2.0 Brief Hospital Course: Patient admitted from an outside hospital with 4 days now w/ LGIB. Has undergone tagged rbc scan, c-scope x 2 and got a total of 13U of blood over 4 days. He has per report been fairly hemodynamically stable throughout with lowest sbp in the 90s, mentating and not tachycardic. His bleeding has been intermittent, stopping, and therefore no bleeding ever seen on c-scope, just some old cauterized avms. tagged scan per report shows ? localiztion in right colon . . On [**2119-10-21**] he underwent a Subtotal colectomy with ileal rectal anastomosis. He tolerated the procedure well and went to the intensive care unit postoperatively. On [**2119-10-24**] he ruled in for a myocardial infarction with positive troponins. Cardiology was consulted and echo was done. . Studies: Echo ([**10-23**]): Suboptimal image quality. LV systolic dysfunction c/w multivessel CAD (LVEF 50%). Mild-moderate AR. Mild MR. Moderate TR. He was transferred to the floor and slowly progressed to a soft diet. He was transfused one unit of packed cells per cardiology and restarted on asa as well as a beta blocker. He will be transferred to a rehab facility to help him regain his prior level of functioning with follow up with his primary care and his surgeon Dr. [**Last Name (STitle) **]. Medications on Admission: Aggrenox, Atorvastatin, Procrit, Zetia, flonase, Lasix 40, Zoladex, Isosorbide mononitrate, Metoprolol, Nitroglycerin PRN Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr Sig: One (1) Cap PO BID (2 times a day). 3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for rhonchi. 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection every twelve (12) hours. 5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: [**Hospital3 15644**] Long Term Health - [**Location (un) 47**] Discharge Diagnosis: Primary Diagnosis: Lower Gi Bleed Secondary Diagnosis: Subtotal Colectomy with postoperative MI. Discharge Condition: Stable Discharge Instructions: Please call your doctor or return to the emergency room if you have any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. Followup Instructions: Please call and make an appointment with your primary care provider to review your medications and further need for cardiology work up. Please call and make an appointment in 2 weeks to follow up with Dr. [**Last Name (STitle) **]. His number is [**Telephone/Fax (1) 3201**] Completed by:[**2119-10-27**]

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icd9cm

[ [ [] ] ]

[ "45.8", "45.92" ]

icd9pcs

[ [ [] ] ]

5491, 5581

2986, 4261

300, 377

5722, 5731

1700, 2963

6566, 6874

1531, 1551

4433, 5468

5602, 5602

4287, 4410

5755, 6543

1566, 1681

223, 262

405, 1104

5657, 5701

5621, 5636

1126, 1298

1314, 1515

56,289

150,691

14932

Discharge summary

report

Admission Date: [**2126-9-25**] Discharge Date: [**2126-10-2**] Date of Birth: [**2077-3-25**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4679**] Chief Complaint: esophageal cancer Major Surgical or Invasive Procedure: [**2126-9-25**]: 1. Minimally-invasive Ivor-[**Doctor Last Name **] esophagectomy. 2. Buttressing of intrathoracic anastomosis with pericardial fat. History of Present Illness: The patient is a 49-year-old male with a locally advanced esophageal cancer. He had completed chemoradiation therapy and now presents for esophagectomy. He has had a feeding tube placed previously. Before the operation, we met and discussed in detail the conducts and risks of the operation. Through a translator we discussed the risk of bleeding, anastomotic leak, pneumonia, need for reoperation and death. Please note that Dr. [**Last Name (STitle) **] performed the surgery as the first assistant as there were no qualified residents to assist given the complexity of the operation. Past Medical History: HTN, esophageal cancer s/p chemoradiation Social History: [**Location 7972**] but understands spanish. Work involved packing vegetables for shipping. Former smoker, [**12-9**] ppd x 20 yrs. History of EtOH abuse but last drink a few months ago. Married with wife and children in [**Country 3587**]. Some family in MA. Family History: Mother - cancer, type unknown by pt. Physical Exam: VS: Afebrile, VSS Constitutional: Well appearing, no acute distress Neck: No masses CV: RRR, no murmurs Resp: CTAB, no wheezes or crackles Wound: clean, dry, intact. Abd: Soft, nondistended Ext: Warm, distal pulses palpable bilaterally Pertinent Results: CBC: [**2126-9-25**] 04:45PM BLOOD WBC-9.6 RBC-2.88* Hgb-9.6* Hct-29.1* MCV-101* MCH-33.4* MCHC-33.0 RDW-15.0 Plt Ct-152# [**2126-9-26**] 12:37AM BLOOD WBC-8.7 RBC-2.68* Hgb-8.8* Hct-26.8* MCV-100* MCH-32.8* MCHC-32.7 RDW-15.2 Plt Ct-159 [**2126-9-30**] 06:45AM BLOOD WBC-5.5 RBC-2.84* Hgb-9.1* Hct-27.7* MCV-97 MCH-31.8 MCHC-32.7 RDW-15.3 Plt Ct-238 [**2126-10-1**] 07:00AM BLOOD WBC-5.4 RBC-3.00* Hgb-9.6* Hct-28.8* MCV-96 MCH-32.0 MCHC-33.4 RDW-15.2 Plt Ct-234 [**2126-9-25**] 04:45PM BLOOD PT-13.4 PTT-28.1 INR(PT)-1.1 Chemistry: [**2126-9-25**] 04:45PM BLOOD Glucose-137* UreaN-19 Creat-0.7 Na-137 K-4.1 Cl-102 HCO3-26 AnGap-13 [**2126-9-26**] 12:37AM BLOOD Glucose-114* UreaN-17 Creat-0.6 Na-135 K-4.0 Cl-101 HCO3-29 AnGap-9 [**2126-9-30**] 06:45AM BLOOD Glucose-126* UreaN-16 Creat-0.5 Na-138 K-3.8 Cl-102 HCO3-27 AnGap-13 [**2126-10-1**] 07:00AM BLOOD Glucose-116* UreaN-16 Creat-0.4* Na-140 K-3.7 Cl-106 HCO3-24 AnGap-14 [**2126-9-25**] 04:45PM BLOOD Calcium-9.4 Phos-5.6* Mg-1.3* Imaging: [**2126-9-25**] CXR: Right chest tube has its tip in the apex. Right main central catheter tip is in the upper right atrium. There is no pneumothorax. Ill-defined opacities in the right lower lobe could be due to atelectasis or aspiration. Widened mediastinum is due to esophagectomy. There is no pleural effusion. [**2126-9-28**] CXR: Upper gastric tube ends in the mid third of the neoesophagus. Right jugular line ends in the right atrium. Mediastinal drain in place. Right lung clear. Left lung base remains consolidated probably due to atelectasis. No appreciable pleural effusion is present. Heart size is normal. The neoesophagus is not dilated. Heart size top normal. No pneumothorax. [**2126-10-1**] Barium Swallow Study: No leak, brisk gastric emptying Pathology: DIAGNOSIS: I. Esophagus and stomach, esophagogastrectomy (A-BA): 1. Invasive poorly-differentiated squamous cell carcinoma of the esophagus; see synopsis report. 2. Nine of sixteen lymph nodes positive for carcinoma ([**8-23**]). Brief Hospital Course: Mr. [**Known lastname 24049**] was admitted to the thoracic service on [**2126-9-25**] after he underwent a minimally invasive esophagectomy for esophageal cancer. The patient tolerated the procedure well. He was initially admitted to the ICU post-op for close monitoring and transferred to the floor on POD3. Summary by system: Neuro: Post-operatively, the patient had an epidural in place and roxicet for pain control to relatively good effect. Attempts were made to start the patient on narcotic medication but he had borderline low SBPs and he received intermittent fentanyl for pain. He was switched to a dilaudid PCA once on the floor and epidural was continued until POD 4 when he pulled out his epidural. When tolerating oral intake, the patient was transitioned to oral pain medications. CV: The patient was initially tachycardic post-op with SBP in 80s and 90s. He was bolused with LR multiple times with good reponse although he would again become symptomatic. He was transfused one unit of blood on POD 2 and hct went from 22 to 25 appropriately. He was stable from a pulmonary standpoint; vital signs were closely monitored. He was given metoprolol for his tachycardia and HR went from 110s to 90s on the floor. GI/GU: Post-operatively, the patient was given IV fluids and TF were started at 20cc/hr on POD 1 and increase by 20cc every 24 hr to goal of 80cc/hr. IVFs were stopped then and patient continued on TF until POD 6. The CT was placed to water seal on POD 2 and did not have a leak. Swallow study on POD6 did not show a leak and his JP drain and chest tube were removed. The drainage from both drains remained serosanguinous throughout his post-op course. He was started on a full liquid diet on POD 6. Foley was removed when epidural pulled. Intake and output were closely monitored. ID: Post-operatively, the patient was not placed on any antibiotics and he remained afebrile without signs of infection. Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. At the time of discharge on POD#7, the patient was doing well, afebrile with stable vital signs, tolerating a full liquid diet, ambulating, voiding without assistance, and pain was well controlled. Medications on Admission: atenolol 25', omeprazole 20'', oxycodone 5mg q4h prn Discharge Medications: 1. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. Disp:*500 ML(s)* Refills:*0* 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 3. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 4. Tube feed Isosource 1.5 kcal 60 mL x 18 hrs Flush J-tube with water every 8 hours with 1 cup of water, before and after starting tube feeds and giving medications through tube Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Esophageal Cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience: -Fevers greater than 101 or chills -Increased shortness of breath, cough or chest pain -Nausea, vomiting (take anti-nausea medication) -Increased abdominal pain -Incision develops drainage -Chest tube site remove dressing and cover site with a bandaid Pain -Roxicet via J-tube as needed for pain -Take stool softners with narcotics Activity -Shower daily. Wash incision with mild soap & water, rinse, pat dry -No tub bathing, swimming or hot tub until incision healed -No driving while taking narcotics -No lifting greater than 10 pounds until seen -Walk 4-5 times a day for 10-15 minutes increase to a Goal of 30 minutes daily Followup Instructions: Follow-up with Dr. [**First Name (STitle) **] [**0-0-**] on [**2126-10-15**] at 10 am on [**Location (un) 8939**] [**Hospital Ward Name 23**] Center. Please come 30 early and go to [**Location (un) **] to obtain a chest x-ray. Completed by:[**2126-10-2**]

[ "276.52", "V15.3", "338.18", "150.8", "V15.82", "458.29", "196.1", "E935.2", "401.9", "V87.41", "V44.1" ]

icd9cm

[ [ [] ] ]

[ "96.6", "42.52", "42.41" ]

icd9pcs

[ [ [] ] ]

6800, 6857

3801, 6073

328, 479

6919, 6919

1766, 3778

7809, 8068

1456, 1494

6176, 6777

6878, 6898

6099, 6153

7070, 7786

1509, 1747

271, 290

507, 1097

6934, 7046

1119, 1162

1178, 1440

3,238

120,558

22821

Discharge summary

report

Admission Date: [**2118-1-16**] Discharge Date: [**2118-1-27**] Date of Birth: [**2050-1-24**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2387**] Chief Complaint: abdominal pain with nausea Major Surgical or Invasive Procedure: intubation History of Present Illness: Pt is a 68 yo with pmh sig for htn, s/p cardiac catheterization on [**2118-1-12**], who developed abdominal pain and nausea on [**2118-1-13**], presented to OSH on [**2118-1-16**] and had MRA abdomen c/ aortic dissection, transferred to [**Hospital1 18**] for surgical eval and further medical care Past Medical History: Htn Hypothyroidism Irritible Bowel Syndrome Diverticulosis Social History: Lives alone near son and daughter Family History: Family history of CVA Physical Exam: BP 130's/90's HR 60-70 RR 16 98% RA NAD Neck without JVD, no thyromegaly Cardiac exam with 2/6 SEM at aortic space Lungs clear Abdomen soft nt nd nabs Extremities wwp, no cce, 2+ distal pulses Back without tenderness Pertinent Results: [**2118-1-16**] 07:43PM PT-12.8 PTT-23.4 INR(PT)-1.0 [**2118-1-16**] 07:43PM PLT COUNT-211 [**2118-1-16**] 07:43PM WBC-7.3 RBC-3.86* HGB-12.1 HCT-34.8* MCV-90 MCH-31.5 MCHC-34.9 RDW-13.2 [**2118-1-16**] 07:43PM CALCIUM-9.3 PHOSPHATE-2.4* MAGNESIUM-1.8 [**2118-1-16**] 07:43PM CK-MB-NotDone cTropnT-<0.01 [**2118-1-16**] 07:43PM CK(CPK)-57 [**2118-1-16**] 07:43PM GLUCOSE-101 UREA N-8 CREAT-0.8 SODIUM-136 POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-31* ANION GAP-9 . CHEST CT: CT CHEST WITHOUT & WITH CONTRAST: There has been interval extubation. Again identified are bilateral pleural effusions with associated reactive atelectasis, not significantly changed in size or appearance from the previous study. These again measure low (approximately 10 [**Doctor Last Name **]) in density and show no evidence of hemorrhagic component. Fluid is again seen tracking into the fissures, suggesting fluid overload. The descending aortic dissection is again visualized beginning at approximately the T8-9 vertebral body level, and extending downward. The superior aspect of the false lumen between T8 and T11 again demonstrates no enhancement, presumably secondary to thrombus. The [**Last Name (LF) 58992**], [**First Name3 (LF) 899**], and celiac are again identified off the true lumen. The kidneys and major abodminal organs show no evidence of ischemia. All of the renal arteries with the exception of the inferior accessory renal artery on the right originate off the true lumen. There is no evidence of interval increase in diameter of the aorta and no evidence of rupture. The dissection is again visualized descending to the level of the external iliac artery on the right. The intimal flap is not clearly seen to extend into the femoral. The liver, spleen, adrenal glands, and kidneys are unremarkable. BONE WINDOWS: Multiple hemangiomas seen within the lumbar vertebrae, otherwise unremarkble osseous structures. CT RECONSTRUCTIONS: Type B descending aortic dissection extending from above the celiac axis down into the right external iliac artery. Stable compared to previous study. IMPRESSION: 1) Stable appearance of Type B descending aortic dissection extending from the mid thoracic aorta to the right external iliac artery. Perfusion to each of the major arterial branches is again seen. There is no evidence of rupture. 2) Stable appearance of bilateral pleural effusions with associated reactive atelectasis. 3) Interval extubation. Brief Hospital Course: Upon arrival to [**Hospital1 18**] blood pressure controlled on IV agents, CT scan completed showing aortic dissection from celiac trunck to right external iliac artery. False lumen without obstruction of any aortic branches. Medical therapy without surgery, on antihypertensives. On hospital day 3 pt became severely hypotensive and lethargic after receiving dose of antihypertensive nifedipine, requiring intubation. Extubated the next day without incident. Multiple CT scans over course of hospitalization without change in aortic dissection. Blood pressure difficult to control, finally optimized on labaetolol, diltiazem, amlodopine, lisinopril. Hospital course complicated by short course (less than 1 hour) of atrial fibrillation which reverted to sinus spontaneously. Decision for no anticoagulation due to aortic dissection. Pt was stable with systolic blood pressure in 130's at time of discharge. Discharge Medications: 1. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Labetalol HCl 200 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 4. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 7. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: Aortic dissection Hypertension Discharge Condition: stable Discharge Instructions: Please call your doctor or go to the emergency department if you develop chest pain, worsening abdominal pain or shortness of breath. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 7389**] within one week. Completed by:[**2118-1-27**]

[ "458.29", "244.9", "401.9", "518.81", "441.03", "998.2", "530.81", "511.8", "427.31" ]

icd9cm

[ [ [] ] ]

[ "38.91", "96.04", "99.04", "00.17", "88.72", "96.71" ]

icd9pcs

[ [ [] ] ]

5099, 5158

3586, 4504

342, 355

5233, 5241

1107, 3563

5423, 5527

832, 855

4527, 5076

5179, 5212

5265, 5400

870, 1088

276, 304

383, 683

705, 765

781, 816

19,294

125,280

13179

Discharge summary

report

Admission Date: [**2103-7-24**] Discharge Date: [**2103-8-8**] Date of Birth: [**2025-11-21**] Sex: M Service: CSU CHIEF COMPLAINT: Mr. [**Known lastname 39868**] is a 77 year old male referred by Dr. [**Last Name (STitle) 2912**] for MVR, TVR, coronary artery bypass graft. HISTORY OF PRESENT ILLNESS: The patient has been experiencing increasing shortness of breath and dyspnea on exertion times seven months. Told in [**Month (only) 404**] that he had a leaking valve that might require follow up. However, the patient became increasingly dyspneic over the next several months culminating in admission to [**Hospital6 **] on [**Month (only) 116**] of this month with congestive heart failure. He was diuresed at that time and an echocardiogram done during that admission showed dilated left ventricle, LA, and RA with aortic and mitral sclerosis with mild AS, trace aortic regurgitation, moderate to severe mitral regurgitation, and moderate to severe tricuspid regurgitation. Cardiac catheterization done on [**2103-7-18**] showed a normal left main, left anterior descending coronary artery with no disease, circumflex with total obstruction at the distal take of the posterior descending coronary artery. Right coronary artery with no significant disease. Severe mitral regurgitation, moderate pulmonary hypertension, an ejection fraction of 47 percent. PAST MEDICAL HISTORY: The patient's past medical history is significant for coronary artery disease status post right coronary artery stent in [**2095**], hypertension, hypercholesterolemia, bilateral knee arthroscopies, partial gastrectomy, atrial fibrillation, congestive heart failure, right bundle branch block, asthma, hernia repair. The patient has been O2 dependent at home for the past year, mostly at night, however, since [**Month (only) 956**] has been home O2 dependent throughout the day as well. ALLERGIES: The patient states an allergy to sulfa which causes a rash. MEDICATIONS ON ADMISSION: His medications prior to admission include Aldactone 25 mg q d, Coreg 12.5 mg [**Hospital1 **], Captopril 50 mg tid, Coumadin 3 mg alternating with 4 mg - held since [**2103-7-19**], Lasix 40 mg [**Hospital1 **], Flovent two puffs [**Hospital1 **], Combivent two puffs qid, Verapamil 120 mg q d, Fergon one tab [**Hospital1 **], and Zoloft 25 mg q d. SOCIAL HISTORY: Married, lives with wife. Remote tobacco use. Quit 24 years ago. 150 pack years prior to quitting. Rare alcohol use. REVIEW OF SYSTEMS: No diabetes, cerebrovascular accident, or transient ischemic attacks. No seizures, cancer, orthopnea, paroxysmal nocturnal dyspnea. Positive dyspnea on exertion. Positive asthma. Positive chronic obstructive pulmonary disease, no cough. No abdominal pain, melanoa, hematochezia. History of peptic ulcer disease status post gastrectomy. No claudication, peripheral vascular disease, or deep venous thrombosis. No coagulopathies. LABORATORY DATA: At the time of admission, white count 6, hematocrit 36.4, platelets 162. PT 17.2, PTT 38, INR 2.0. Sodium 139, potassium 3.2, chloride 95, CO2 32, BUN 32, creatinine 1.2, glucose 55. ALT 9, AST 24, alkaline phosphatase 90, direct bilirubin 1, total protein 6.9. Urinalysis was negative. Chest x-ray showed mild ventricular failure, moderate cardiomegaly with a right effusion. Electrocardiogram was atrial fibrillation with a rate of 73, right bundle branch block, nonspecific ST changes. PHYSICAL EXAMINATION: Heart rate 98 in atrial fibrillation. Blood pressure 100/70. Respiratory rate 22. O2 saturation 96 percent on three liters nasal prongs. Neurologically alert and oriented times three. Moves all extremities. Follows commands, nonfocal examination. Respiratory - faint rales at the bases. Cardiovascular - irregularly irregular, III/VI systolic ejection murmur. Abdomen is soft, nontender. Normal active bowel sounds with hepatic margin one to two finger breadths below the costal margin. Extremities are warm and well perfused with 3+ edema. Pulses - radial 2+ bilaterally, carotid 2+ bilaterally without a bruit, femoral 2+ bilaterally, and dorsalis pedis 1+ bilaterally. HEENT - pupils equal, round and reactive to light. Extraocular movements intact. Anicteric. Mucous membranes - moist. Normal oropharynx. Neck is supple with no lymphadenopathy and no bruits. HOSPITAL COURSE: The patient was admitted to the Cardiothoracic service for a preoperative work up. Started on Heparin. Preoperatively the patient has an abdominal CAT scan given his liver margins, as well as his bilateral pedal edema, as well as given Vitamin K to correct his INR. CT showed an enlarged nodule liver suspicious for cirrhosis. The patient's surgery was rescheduled for Friday, [**2103-7-27**]. On [**2103-7-27**] the patient was brought to the Operating Room where he underwent mitral valve replacement, tricuspid valve repair, and coronary artery bypass graft times one. Please see the Operating Room report for full details. In summary, the patient had a coronary artery bypass graft times one with a saphenous vein graft to the obtuse marginal. Mitral valve replacement with a #31 [**Last Name (un) 3843**]-[**Doctor Last Name **] porcine valve, and a tricuspid valve repair with a 36 mm ring. His cross clamp time was 118 minutes with a bypass time of 150 minutes. He tolerated the surgery and was transferred from the Operating Room to the cardiothoracic intensive care unit. In the immediate postoperative period the patient had postoperative bleeding and he returned to the Operating Room for exploration and ligation of bleeding vessels. The patient was in the Operating Room approximately one hour and returned to the cardiothoracic intensive care unit. At the time of return the patient's mean arterial pressure was 80. He was atrial fibrillation at 74 beats per minute with a CVP of 25 and PAD of 33. He had Levophed at 0.9 mcg/kg per minute, Dobutamine at 5 mcg/kg per minute, and Propofol at 30 mcg/kg per minute. Following reexploration the patient remained hemodynamically stable. He had no further bleeding from his chest tubes. He was kept sedated and ventilated throughout the night of his operative day. On postoperative day #1, the patient continued to be hemodynamically stable with no further drainage from his chest tubes. His sedation was weaned off. An attempt to wean the patient from the ventilator was unsuccessful. He developed hypercarbia and therefore remained intubated. On postoperative day #2, the patient continued to be hemodynamically stable. He was weaned from his Levophed drip. Again an attempt was made to wean the patient from the ventilator, this time successfully and he was ultimately extubated. On postoperative day #3, the patient continued to progress. He was begun on diuretics. Central venous lines were removed. However, he remained in the intensive care unit for close hemodynamic monitoring as well as pulmonary support given his persistent oxygen requirement. Postoperative day #4, this patient continued slow progression. He remained hemodynamically stable. His chest tubes and temporary pacing wires were discontinued and again the patient remained in the intensive care unit because of a persistent oxygen requirement. Postoperative day #5, the patient remained hemodynamically stable in the intensive care unit. A chest x-ray done showed a moderate size right sided pleural effusion and a thoracentesis done that at the bedside drained 800 cc of serosanguinous fluid following which the patient's oxygen requirement was improved. The patient was also restarted on Coumadin given his chronic atrial fibrillation and transferred to the floor for continuing postoperative care and cardiac rehabilitation. Over the next several days the patient had an uneventful postoperative course. His activity level was gradually increased with the assistance of the nursing staff and physical therapy. He was slowly anticoagulated for his chronic atrial fibrillation. On postoperative day #11, it was decided that the patient was stable and ready to be transferred to an extended care facility for continuing postoperative care. On the following day, postoperative day #12, the patient was accepted for placement at rehabilitation center. At the time of this dictation the patient's physical examination is as follows: Vital signs - temperature 98.0, heart rate 72 and atrial fibrillation, blood pressure 103/62, respiratory rate 20, O2 saturation 99 percent on three liters. LABORATORY DATA: INR 1.7. Potassium 4.6, BUN 18, creatinine 1.0. Weight preoperatively 106 kilograms, at discharge 95.8 kilograms. PHYSICAL EXAMINATION: Neurological - alert and oriented times three. Moves all extremities. Follows commands. Nonfocal examination. Respiratory - clear to auscultation on the left with diminished breath sounds on the right one third of the way up. Cardiovascular - irregularly irregular. Sternum is stable. Incision with staples, open to air, clean, and dry. Abdomen is soft, nontender, nondistended with positive bowel sounds. Extremities are warm and well perfused with 1-2+ edema. Right leg saphenous vein graft harvest site with Steri-strips, open to air, clean and dry. DISCHARGE MEDICATIONS: Metoprolol 50 mg [**Hospital1 **], Aspirin 81 mg q d, Colace 100 mg [**Hospital1 **], Plavix 75 mg q d times three months, Protonix 40 mg q d, Digoxin 0.125 mg q d, Albuterol 2 puffs qid, Flovent two puffs [**Hospital1 **], Atrovent two puffs qid, Tamsulosin 0.4 mg q d. Sertraline 25 mg q d, Potassium Chloride 20 mEq tid, Lasix 40 mg tid, Warfarin q d for a goal INR of [**2-19**].5. His last four doses have been 6, 6, 4, 4. Also Tylenol 650 q six prn and Percocet 5/325 one to two tabs q four prn. DISCHARGE DIAGNOSES: Coronary artery disease status post coronary artery bypass grafting times one with saphenous vein graft to the obtuse marginal and a stent to the right coronary artery done in [**2095**]. Mitral regurgitation status post mitral valve replacement with a #31 [**Last Name (un) 3843**]-[**Doctor Last Name **] porcine valve. Tricuspid regurgitation status post tricuspid valve repair with a #36 ring. Hypertension. Hypercholesterolemia. Bilateral knee arthroscopies. Partial gastrectomy. Atrial fibrillation. Congestive heart failure. Right bundle branch block. Asthma. Hernia repair. CONDITION ON DISCHARGE: Good. He is to be discharged to rehabilitation. He is to have follow up with Dr. [**Last Name (STitle) 2912**] in two to three weeks and follow up with Dr. [**Last Name (STitle) **] in four weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**] Dictated By:[**Last Name (NamePattern4) 1718**] MEDQUIST36 D: [**2103-8-8**] 11:59:56 T: [**2103-8-8**] 13:30:01 Job#: [**Job Number 40190**]

[ "427.31", "414.01", "397.0", "396.2", "398.91", "E878.8", "511.9", "286.9", "998.11" ]

icd9cm

[ [ [] ] ]

[ "35.23", "96.71", "99.06", "89.62", "89.64", "36.11", "34.03", "96.04", "35.14", "39.64", "39.61", "38.91", "88.72", "89.61" ]

icd9pcs

[ [ [] ] ]

9811, 10405

9284, 9789

2004, 2356

4383, 8675

8698, 9260

2514, 3464

154, 298

327, 1391

1414, 1977

2373, 2494

10430, 10899

3,272

162,630

45057

Discharge summary

report

Admission Date: [**2109-9-16**] Discharge Date: [**2109-9-27**] Service: CARDIAC SURGERY HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is an 82-year-old female with a history of congestive heart failure and moderate to severe symptomatic mitral regurgitation secondary to failed posterior leaflet, now presenting with worsening shortness of breath. Her most recent admission to the hospital was in [**2109-8-4**] for dyspnea. At the time, the patient was diuresed, and her symptoms improved. At the same time, the patient underwent cardiac catheterization which, on [**2109-8-23**], demonstrated no angiographically significant coronary artery disease. In addition, there was mild inferoapical hypokinesis with an estimated left ventricular ejection fraction of 50%. An echocardiogram performed at the time showed mildly thickened mitral valve leaflets with moderate to severe mitral valve prolapse with partial mitral leaflet flail. Severe eccentric anteriorly directed 4+ mitral regurgitation was seen. Compared with a prior report, mitral regurgitation appeared more severe. The patient consequently presented to the cardiac surgeon for a possible surgical solution. PAST MEDICAL HISTORY: 1. Mitral regurgitation (secondary to failed posterior leaflet) 2. Congestive heart failure 3. Coronary artery disease 4. Possible myocardial infarction in [**2066**] 5. Mild pulmonary hypertension PAST SURGICAL HISTORY: 1. Status post cholecystectomy 2. Appendectomy MEDICATIONS: 1. Aspirin 81 mg by mouth once daily 2. Accupril 5 mg by mouth once daily ALLERGIES: No known drug allergies. FAMILY HISTORY: History of Parkinson's disease in the family. PHYSICAL EXAMINATION: Afebrile, heart rate 67, blood pressure 132/68, respiratory rate 20. General: Elderly female, in no apparent distress. Skin within normal limits. Head, eyes, ears, nose and throat: Upper and lower dentures present, no jugular venous distention, no bruits. Neck: Full range of motion. Chest: Clear to auscultation bilaterally. Cardiac examination: Regular rate and rhythm, IV/VI systolic ejection murmur at the left sternal border. Abdomen: Bowel sounds present, soft, nontender, nondistended. Extremities: Mild edema, pulses present bilaterally in upper and lower extremities. Varicosities: None. Neurologically grossly intact. LABORATORY DATA: Hematocrit 35.3, white blood cell count 5.3, platelets 437. INR 1.2, PTT 29. Glucose 82, BUN 16, creatinine 0.9, sodium 134, potassium 4.0. ALT 13, AST 22, alkaline phosphatase 49, total bilirubin 0.5. Electrocardiogram: Sinus rhythm with occasional ventricular ectopy. HOSPITAL COURSE: The patient was admitted to the Cardiac Surgery service. Given worsening symptomatic mitral regurgitation, the decision was made to provide a surgical solution. On [**2109-9-16**], the patient underwent mitral valve repair with 26 mm [**Doctor Last Name 405**] ring annuloplasty. The patient tolerated the procedure well. There were no complications. Postoperative ejection fraction was estimated at 30 to 35%. Please see the full operative report for details. The patient was then transferred to the Intensive Care Unit in stable condition. She remained intubated. She was extubated on postoperative day one, which she tolerated well. The patient was weaned off of inotropic support. Aggressive pulmonary toilet was initiated. The patient was maintained on the amiodarone drip. She was making adequate urine. She was diuresed appropriately. The patient continued to do well. Her chest tubes and Foley catheter were removed on postoperative day two. The patient remained afebrile, with a stable hematocrit. However, she was transfused with one unit of red blood cells on postoperative day three for a hematocrit of 23.1. The patient also experienced an episode of rapid atrial fibrillation with heart rate in the 140s. She was treated with Lopressor and amiodarone boluses. She converted spontaneously on postoperative day three. Physical Therapy was consulted, which followed the patient during her hospitalization and recommended a rehabilitation center after discharge. The patient was transferred to the floor on postoperative day four in stable condition. She was continued on intravenous heparin and also Coumadin. The central line was removed. Her urine grew pansensitive Enterococcus. The patient experienced another episode of atrial fibrillation on postoperative day seven. Her Lopressor was increased, her pacing wires were removed. She converted to sinus rhythm within 24 hours. The patient was discharged to a rehabilitation facility on [**2109-9-27**]. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Rehabilitation facility. DISCHARGE DIAGNOSIS: 1. Mitral regurgitation status post mitral valve repair 2. Atrial fibrillation 3. Congestive heart failure 4. Coronary artery disease DISCHARGE MEDICATIONS: 1. Coumadin, dose to be adjusted to the goal INR of 2.0 to 2.5 for atrial fibrillation 2. Lopressor 50 mg by mouth twice a day 3. Reglan 10 mg by mouth three times a day 4. Amiodarone 400 mg by mouth once daily for 30 days 5. Aspirin 81 mg by mouth once daily 6. Percocet one to two tablets by mouth every four to six hours as needed for pain 7. Colace 100 mg by mouth twice a day as needed for constipation 8. Milk of magnesia as needed 9. Lasix 20 mg by mouth twice a day for seven days 10. Potassium chloride 20 mEq by mouth twice a day for seven days DISCHARGE INSTRUCTIONS: 1. Coumadin dose to be adjusted to the INR goal of 2.0 to 2.5. 2. Follow up with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **], her cardiac surgeon, in approximately four weeks. 3. Follow up with Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **], Cardiology, in two to three weeks. 4. Follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2204**], her primary care physician, [**Name10 (NameIs) **] one to two weeks. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 10097**] MEDQUIST36 D: [**2109-9-27**] 20:33 T: [**2109-9-28**] 01:37 JOB#: [**Job Number 96308**]

[ "424.0", "429.5", "428.0", "414.01", "427.31", "997.1" ]

icd9cm

[ [ [] ] ]

[ "88.72", "35.12", "39.61" ]

icd9pcs

[ [ [] ] ]

4718, 4744

1644, 1691

4927, 5492

4765, 4904

2668, 4662

5516, 6266

1449, 1627

1714, 2650

130, 1200

1222, 1426

4687, 4694

7,874

136,302

43143+58589

Discharge summary

report+addendum

Admission Date: [**2198-11-26**] Discharge Date: [**2198-12-3**] Service: MEDICINE Allergies: Tylenol / Motrin / Valium / Cipro / Bactrim / Tetracycline / Amoxicillin / Verapamil / Enalapril / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 1973**] Chief Complaint: Hypothermia Declining Mental Status Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a 88 yo female with [**Hospital 92988**] medical problems including HTN, diabetes, CHF, CRI, and recent history of cognitive decline last hospilatized in [**7-3**] with similar complaints of confusion and aphasia presenting after having slurred speech and hallucinating in adult daycare today. Pt transferred to MICU on evening of admission for hypothermia (91.1) requiring bear-hugger. Pt confused and unable to add to history. Past Medical History: 1. Hypertension 2. CAD s/p MI [**2182**], [**2184**] 3. CHF - diastolic, EF 55% 4. Type II diabetes mellitus 5. Osteoarthritis 6. Chronic kidney disease (baseline creat 2.4-2.5) 7. Hypercholesterolemia 8. Hypothyroidism 9. h/o CHB s/p DDD pacemaker 10. Paget's Disease 11. Gout 12. h/o rectal cancer s/p resection [**2189**] 13. Anemia of chronic disease, iron deficiency, and B12 deficiency 14. s/p right femur rod placement 15. s/p cholecystectomy [**08**]. chronic left shoulder pain from accident 20 years ago Social History: Prior to may lived alone with home health aide, walker at baseline no tob, EtOH. [**Doctor First Name **] [**Telephone/Fax (1) 92989**], [**Doctor First Name **] [**Telephone/Fax (1) 92990**], [**Doctor Last Name **] [**Telephone/Fax (1) 92991**] Family History: NC Physical Exam: GEN: pleasant, comfortable, NAD, interactive but confused HEENT: left surgical pupil, right pupil ERRL, EOMI, anicteric, MM mildly dry, op without lesions NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: CTA b/l CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: no rashes/no jaundice, grey discoloration of LLE which is old NEURO: oriented to person and place but not which hospital or date could not name daughters names without being prompted. Said that she has "lost all her thoughts". Cn III-XII intact. [**5-2**] strength in LE, 5/5 strength in upper exrtremities. No sensory deficits to light touch appreciated. 2+DTR's-patellar, toes down going RECTAL: trace guaiac positive stool per ED Pertinent Results: Admit Labs [**2198-11-26**] 06:00PM BLOOD WBC-6.4 RBC-3.75* Hgb-11.3*# Hct-33.5*# MCV-89# MCH-30.2 MCHC-33.9 RDW-15.6* Plt Ct-108*# [**2198-11-26**] 06:00PM BLOOD Neuts-66.8 Lymphs-22.8 Monos-5.6 Eos-4.5* Baso-0.3 [**2198-11-26**] 06:00PM BLOOD Glucose-177* UreaN-76* Creat-2.9* Na-144 K-3.7 Cl-108 HCO3-23 AnGap-17 [**2198-11-26**] 06:00PM BLOOD PT-12.4 PTT-30.0 INR(PT)-1.1 [**2198-11-26**] 06:00PM BLOOD ALT-136* AST-110* LD(LDH)-205 CK(CPK)-83 AlkPhos-119* TotBili-0.2 [**2198-11-27**] 05:25AM BLOOD Lipase-80* [**2198-11-26**] 06:00PM BLOOD CK-MB-8 cTropnT-0.03* [**2198-11-27**] 05:25AM BLOOD CK-MB-NotDone cTropnT-0.01 [**2198-11-26**] 06:00PM BLOOD Albumin-3.7 [**2198-11-27**] 05:25AM BLOOD T4-9.1 T3-70* calcTBG-0.97 TUptake-1.03 T4Index-9.4 Free T4-1.5 [**2198-11-26**] 06:00PM BLOOD TSH-9.2* [**2198-11-26**] 06:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2198-11-27**] 05:25AM BLOOD Acetmnp-NEG [**2198-11-26**] 07:43PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009 [**2198-11-26**] 07:43PM URINE Blood-NEG Nitrite-POS Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [**2198-11-26**] 07:43PM URINE RBC-0-2 WBC-0-2 Bacteri-MANY Yeast-NONE Epi-0 TransE-0-2 [**2198-11-26**] 07:52PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG . Micro [**11-26**] Blood Culture - no growth . URINE CULTURE (Final [**2198-11-28**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000 ORGANISMS/ML.. FOR SENSITIVITIES REQUESTED BY DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (#[**Numeric Identifier 92992**]) [**2198-11-29**]. 2ND ISOLATE. <10,000 organisms/ml. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE . . Imaging . [**11-26**] CT Head w/o contrast: Markedly stable examination relative to [**2198-6-26**]. No acute intracranial process. Chronic ischemic changes as well as osseous findings as above. . [**11-26**] CXR: No acute cardiopulmonary process. Brief Hospital Course: Pt is a 88yo female with h/o hypertension, CAD s/p MI, CHF, DM2, hypothyroidism, CHB s/p pacer presenting from rehab with confusion and aphasia 1. Mental status changes: ddx was broad included toxic metabolic, UTI, stroke, seizure amongst others. Although initial UA was unremarkable, UTI was thought to be most likely cause as UCX showed coag neg staph greater than 100,000. Once UCX posted, vancomycin was started on [**11-28**] on renal dosing pattern. Pt's elevated TSH prompted endocrine consultation, who recommended increasing levothyroxine dose to 100 mcg/day; of note, endocrine consultation did not believe that hypothyroidism was responsible for acute decline in MS. [**Name14 (STitle) 1094**] electrolytes were significant for hypernatremia, which resolved s/p 1 L of D5W. Neurology workup at last admission concluded that baseline dementia is secondary to chronic multiple ischemic events. CT head was negative for IC mass or hemorrhage. Pt's mentals status waxed and waned, from conversational to paranoid to pleasant but cofused. At discharge, her mental status was improved, although she did show evidence of a resolving deirium. 2. UTI - UCX revealed coag-neg staph sensitive to vancomycin. She completed a 5-day course of vancomycin. 3. Acute on chronic renal failure- baseline cr 2.5, 3.0 on admission. It was likely prerenal in origin. She received 2 L IVF over her first day. She then was taking in good POs, and creatinine went to 2.4-2.5 her baseline. We continued pt's epoetin per outpatient doses. Her Hct will need to monitored to make sure it does not go too high with the epoetin. 5. DM 2- Glipizide was held as pt initially was taking poor POs. She was started on a regular insulin sliding scale with BS 120-200 range in the ICU. Once on the floor, she was maitained on her home dose of glipizide. 6. Left shoulder pain- chronic in nature from accident 20 years ago. She got injected at rehab. 7. CV- a. CAD- continued ASA, metoprolol, and Statin. b. Pump- h/o diastolic CHF. euvolemic-dry on exam. We held her Lasix and monitored fluid status qday. She was euvolemic on discharge. c. Rhythm- sinus on EKG 8. HTN- continued regimen of metoprolol, amlodipine, and Imdur. 9. Hypothyroid- TSH elevated at 15. Levoxyl increased to 100 mcg from 75 mcg qday. Ms. [**Known lastname 92993**] will need her TSH to be checked 6 weeks from discharge. 10. Anemia-continued epoetin per outpt regimen as above as well as iron supplementation. Medications on Admission: Floxin 200 mg PO QD lopressor 100 mg po QD Foasamax 70 mg QSun Norvasc 5 mg Po QD Lipitor 10 mg Po QD levothyroxine 88 mcg Po QD Colace PRn Calcium and vitmin D Glipizide 5 mg Po QD Ecotrin 81 mg po QD Prilosec 20 mg Po QD Ferrous gluconate 324 mg po QD MVI Potassium 10 meq po QD lasix 20 mg Po QD Procrit 10,00 units Q 2 weeks B12 Q monthy Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 13. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Epoetin Alfa Injection Discharge Disposition: Extended Care Facility: [**Hospital3 9475**] Care Center - [**Location (un) 3146**] Discharge Diagnosis: UTI Delirium Discharge Condition: Stable, ambulatory, afebrile Discharge Instructions: Please return to the hospital if you experience fevers, chest pain, shortness of breath. . Please take all of your medications as prescribed. Followup Instructions: Please call Dr.[**Name (NI) 92994**] office at [**Telephone/Fax (1) 37171**] to make a follow-up appointment within the next 2 weeks. Name: [**Known lastname 14644**],[**Known firstname **] Unit No: [**Numeric Identifier 14645**] Admission Date: [**2198-11-26**] Discharge Date: [**2198-12-3**] Date of Birth: [**2110-1-25**] Sex: F Service: MEDICINE Allergies: Tylenol / Motrin / Valium / Cipro / Bactrim / Tetracycline / Amoxicillin / Verapamil / Enalapril / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 653**] Addendum: Given initial hypotension, acute renal failure and hypothermia along with mental status changes, although there is contribution of hypothyroidism, it is consistent with sepsis given response to early goal directed therapy and antibiotics. Discharge Disposition: Extended Care Facility: [**Hospital3 14646**] Care Center - [**Location (un) 3744**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 655**] MD [**MD Number(2) 656**] Completed by:[**2199-1-22**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9959, 10201

4725, 7201

364, 370

8882, 8913

2526, 4702

9104, 9936

1660, 1664

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289, 326

398, 841

863, 1378

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23,707

104,817

5790

Discharge summary

report

Admission Date: [**2147-11-8**] Discharge Date: [**2147-11-15**] Date of Birth: [**2092-4-12**] Sex: F HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old woman with mastocytosis activation syndrome with one urine histamine of 9000. She was admitted with chest pain on this admission. Previously, on [**2145-10-9**], she was admitted after a reaction to gadolinium in which she developed severe nausea, and airway tightness, and shortness of breath. She was given epinephrine and developed severe chest pain. Serial electrocardiograms at that time showed ST-T wave changes and a troponin of 20 which then decreased to 1.5. An echocardiogram at that time showed akinesis at the base of fraction of 35%. Since that admission, she has had chest pain every day, usually muscle pain episodes each day. The pain is worse with food, and occasionally worse with exercise, and occasionally awakens the patient from sound sleep. She uses nitroglycerin (two at a time) every two to three days. She also gets chest pain which radiates to her back accompanied by occasional shortness of breath. The chest pain has been worse over the past several days and finally has required her to seek treatment in the Emergency Department. The patient has chronic abdominal pain which improved on Gastrocrom 200 mg p.o. q.i.d. which was increased this Fall from 100 mg p.o. q.d. However, because the patient's abdominal pain was improved she decreased her dose to 100 mg of Gastrocrom q.i.d. She notes that the Gastrocrom did not help her chest pain. The patient has also been on Vistaril, [**Doctor First Name **], and Zantac for histamine suppression. On previous hospitalizations, she has required steroids. Additionally, the patient notes the presence of chills and joint pain. Her hands have become worse with swelling and erythema since discontinuing her Vioxx at last admission when she was started on Coumadin for cardiomyopathy. She denies any fevers or night sweats and has no headaches or change in her bowels. She does describe some malaise. She says she has not played tennis since her [**Month (only) 359**] admission. She has a minimal appetite and is forcing herself to eat. She does say she noted some bright red blood per rectum mixed with stool that had streaks of dark color on the day of admission. The patient does have a history of internal hemorrhoids. PAST MEDICAL HISTORY: 1. Cholecystectomy in [**2143**]; followed by a bile leak that was treated with a stent. She subsequently had pancreatitis in [**2143-7-3**] and in [**2144**]. She had increased liver function tests, and a sphincterotomy times two. 2. In [**2145-4-3**] she had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 16164**] procedure (uterine suspension) followed by increased lipase and liver function tests accompanied by abdominal pain. 3. In [**2145-10-3**], sural nerve biopsy, and endoscopic retrograde cholangiopancreatography muscle biopsy, and liver biopsy. Subsequently, multiple admissions for abdominal pain accompanied by increased liver function tests and increased amylase and lipase. 4. In [**2147-6-3**], tarsal tunnel release and subsequent neuropathy. 5. In [**2147-7-3**], abdominal pain with scleral icterus. 6. Esophagogastroduodenoscopy on [**2146-12-13**] showed prominent mass cells with granulation in the duodenum and mild esophagitis. 7. Additionally, the patient is status post multiple episode of anaphylaxis treated by epinephrine. 8. The patient also has seronegative arthritis. ALLERGIES: COMPAZINE, DROPERIDOL, GADOLINIUM, SULFA. MEDICATIONS ON ADMISSION: 1. Coumadin 7.5 mg p.o. q.d. 2. Protonix 40 mg p.o. q.d. 3. Lisinopril 10 mg p.o. q.d. 4. Zantac 300 mg p.o. q.h.s. 5. [**Doctor First Name **] 180 mg p.o. q.d. 6. Ativan p.o. as needed. 7. Cromolyn 100 mg p.o. q.i.d. 8. Vistaril 25 mg p.o. q.h.s. 9. Glucosamine and chondroitin sulfate. FAMILY HISTORY: Mother with a myocardial infarction at the age 76. SOCIAL HISTORY: The patient is married and active in sports. Two children who are well. The patient is an Emergency Room technician. PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 98, blood pressure was 120/66, heart rate was 60, respiratory rate was 20, oxygen saturation was 100% on room air. In general, the patient was in pain, holding her chest. Head, eyes, ears, nose, and throat examination revealed anicteric. Erythematous lids. The mouth was moist without ulcers. The neck revealed no adenopathy. The thyroid was normal. Cardiovascular examination revealed a regular rate and rhythm. Normal first heart sound and second heart sound. No murmurs. The lungs revealed inspiratory wheezes posteriorly on the left. Expiratory wheezes scattered bilaterally. Normal to percussion. The abdomen was nondistended with tenderness and guarding in the epigastric region. Positive bowel sounds. Rectal examination revealed no stool or blood, normal tone. Extremities revealed swelling and tenderness on the right and left proximal interphalangeal joint and distal interphalangeal joint, left third distal interphalangeal was warm to touch. The patient without lower extremity edema. There was mild palmar erythema. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories revealed white blood cell count was 5.1, hematocrit was 34.3, platelets were 231. Electrolytes were within normal limits. PT was 17.4, PTT was 32.1, INR was 2. Creatine kinases and troponin were normal times three. ALT was 22, AST was 32, amylase was 83, lipase was 93. RADIOLOGY/IMAGING: CT revealed left lung base with a small nodule. Splenic calcifications. Normal aorta, celiac, superior mesenteric artery, and internal mammary artery takeoff. No aneurysm. Electrocardiogram was notable for nonsloping ST-T wave changes, poor progression in V1 and V2, generally low voltage. HOSPITAL COURSE: 1. CARDIOVASCULAR SYSTEM: The patient's primary issue during her hospitalization was her chest pain. She typically had three episodes of severe debilitating chest pain per day during her admission. She described these as 7/10 chest pain in general, radiating to her back, and were accompanied with nausea and dry heaves. On each occasion during her admission, an electrocardiogram was obtained, and there was never any change in her electrocardiograms. Her pain generally resolved with several sublingual nitroglycerin coupled with 2 mg to 4 mg of intravenous Dilaudid, and Zofran and Ativan were also frequently required. Her chest pain in general did not seem to improve during her admission, in that it did not decrease in frequency or severity. Her histamine blockade was increased with her Gastrocrom, and she was started on steroids, however, it became evident during her admission that she was throwing away her prednisone. Cardiology was involved and did not feel that her chest pain was consistent with a cardiac etiology. An echocardiogram was obtained and showed that her ejection fraction had rebounded to 75% from 35% on her last admission. An Allergy consultation was obtained, and there was some suggestion that histamine release could cause coronary with muscle spasm; however, this was felt to be somewhat less likely. Additionally as her repeat electrocardiogram showed no evidence of ischemia with chest pain, and her cardiac function was normal, we felt the patient's cardiovascular status was good. 2. GASTROINTESTINAL SYSTEM: Possible gastrointestinal etiology for the patient's symptoms were closely considered. This was felt to be somewhat likely given the patient's history of gastrointestinal manifestations of mast cell activation. There was suspicion for esophageal spasm given the resolution of symptoms with nitroglycerin in the presence of no electrocardiogram changes. GI was involved and an esophagogastroduodenoscopy was performed which was grossly normal. However, biopsy specimens were taken. The patient may still require [**Doctor Last Name **] test in the future for possible esophageal spasm. In terms of the patient's lower gastrointestinal bleed, a flexible sigmoidoscopy was performed and revealed only hemorrhoids. The patient's abdominal pain was well controlled throughout her admission with histamine blockade and Gastrocrom. 3. PULMONARY SYSTEM: As the patient's chest pain episodes continued throughout her admission, she began to experience increasing respiratory distress with these episodes. Her respiratory issues consisted of wheezing during her chest pain episodes and were worrisome for anaphylaxis. On two occasions, the patient received epinephrine which seemed to help symptoms to some degree. However, on the second occasion, after receiving racemic epinephrine and still having some stridorous sounds worrisome for anaphylaxis, the patient was transferred to the Medical Intensive Care Unit for observation. She was closely observed there but did not have any further events and was stable from a pulmonary perspective. It was unclear to what extent her wheezing was related to histamine release and anaphylaxis, as there also seemed to be some anxiety component that was worsening these episodes. Her arterial blood gas after the episode causing the Medical Intensive Care Unit transfer was consistent with some degree of a panic attack. The patient was started on a chromone inhaler in house. 4. HEMATOLOGY: The patient's mastocytosis syndrome was aggressively treated with antihistamines and cromolyn. Prednisone was started on admission; however, the patient refused this medication. A tryptase alpha and beta were sent. A 24-hour urine was performed; however, it was unclear to what extent to the 24-hour urine was collected properly. 5. PSYCHIATRY: On the day prior to discharge, the patient began to act in a hypomanic state. Her speech became tangential and pressured. The patient was adamant that she wanted to be discharged to home. It was revealed that the patient had been taking her own Effexor 75 mg p.o. q.d. throughout the hospital stay. Psychiatry was consulted, and it was felt that it was very likely that the patient's mood and anxiety contributed in some way to the patient's physical symptoms. Additionally, Psychiatry felt that she had no active psychiatric problem that should delay her discharge. She was to follow up with outpatient psychiatric treaters. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: Discharged to home. DISCHARGE DIAGNOSES: 1. Mastocytosis syndrome. 2. Internal hemorrhoids. 3. Anxiety. MEDICATIONS ON DISCHARGE: 1. [**Doctor First Name **] 180 mg p.o. b.i.d. 2. Vistaril 25 mg p.o. q.a.m. and 50 mg p.o. q.h.s. 3. Ranitidine 300 mg p.o. b.i.d. 4. Vioxx 25 mg p.o. q.d. 5. Gastrocrom 200 mg p.o. q.i.d. 6. Inhaled cromolyn 100 mg q.i.d. 7. Sublingual nitroglycerin as needed. 8. Isosorbide mononitrate 60 mg p.o. q.d. 9. Multivitamin. 10. Lisinopril 10 mg p.o. q.d. 11. Percocet one to two tablets p.o. q.4-6h. as needed for pain (the patient has home supply). DISCHARGE FOLLOWUP: The patient was to follow up with Dr. [**Last Name (STitle) 79**] in two weeks and to follow up with primary care physician in two weeks. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 21723**] Dictated By:[**Last Name (NamePattern1) 23006**] MEDQUIST36 D: [**2147-11-21**] 13:22 T: [**2147-11-22**] 10:16 JOB#: [**Job Number 23007**]

[ "786.50", "202.60", "410.92", "789.00", "455.2", "425.4" ]

icd9cm

[ [ [] ] ]

[ "48.23", "45.16" ]

icd9pcs

[ [ [] ] ]

3943, 3995

10505, 10572

10599, 11067

3628, 3926

5894, 10393

10408, 10484

11089, 11474

148, 2397

2419, 3602

4012, 5877

9,363

153,588

52325

Discharge summary

report

Admission Date: [**2155-10-13**] Discharge Date: [**2155-10-16**] Date of Birth: [**2091-10-21**] Sex: F Service: MICU HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 101878**] is a 63-year-old female with a past medical history significant for methicillin-resistant Staphylococcus aureus pneumonia, end-stage renal disease secondary to lithium toxicity, papillary thyroid cancer status post tracheostomy and complicated by vocal cord paralysis and Crohn's disease who was admitted through the Emergency Department on [**2155-10-13**], with hypotension, shortness of breath, fever and leukocytosis. The patient states that she had been in her usual state of health until a few days prior to admission. She described shortness of breath as well as some slight increase in her baseline thick sputum production. She denied cough, denied night sweats, denied sick contacts. She also denied any other physical complaints. Specifically, she denied abdominal pain, no diarrhea or constipation, no headache or visual changes, no urinary symptoms, no weakness. On the day of admission after the patient had gone to Hemodialysis she developed a temperature of 103 and was subjectively short of breath. Upon arrival to the Emergency Department her blood pressure was 50/30 and the patient was started on Levophed. Her temperature at that time was 101.9 degrees Fahrenheit. The patient's oxygenation was also slightly decreased from baseline. She was 96% on four liters nasal cannula. A chest x-ray in the Emergency Department was negative for focal infiltrate. There was also no evidence of volume overload/congestive heart failure. Blood cultures times two sets were sent from the Emergency Department. The patient was also given a dose of one gram of vancomycin and 80 mg of gentamicin. These intravenous antibiotics were chosen for empiric coverage of sepsis and were also chosen after consultation with Infectious Disease as the patient has multiple drug allergies that will be listed below. REVIEW OF SYSTEMS: Again the patient only complained of slightly increased shortness of breath and slightly thickened mucus production from baseline. She also described some nausea but no vomiting. Otherwise review of systems was negative. PAST MEDICAL HISTORY: 1. Methicillin-resistant Staphylococcus aureus pneumonia left lower lobe diagnosed in [**2153-10-18**]. MRSA screen in [**2155-7-18**] during the patient's previous hospitalization was positive. 2. End-stage renal disease. The patient is anuric at baseline. She has been on hemodialysis for 11 years. The end-stage renal disease is secondary to lithium toxicity. She has a dialysis line tunneled into the left subclavian vein. 3. Papillary thyroid cancer status post tracheostomy that was complicated by vocal cord paralysis. 4. Intention tremor secondary to lithium. 5. Osteoporosis. 6. Crohn's disease status post ileostomy with a history of chronic diarrhea. Also has a history of perineal sinus status post colectomy and a history of a perineal abscess. 7. Basal cell carcinoma right lower extremity. 8. History of recurrent right upper extremity arteriovenous graft thrombosis and pseudoaneurysm formation. 9. History of upper gastrointestinal bleed secondary to NSAIDS. 10. Hypoparathyroidism. MEDICATIONS ON ADMISSION: 1. Remeron 45 q. hs. 2. Ambien 5 h.s. 3. Digoxin 0.125. 4. Synthroid 0.125 mcg q. day. 5. Nephrocaps one cap q. day. 6. Midodrine 5 mg q. day Tuesday, Thursday, Saturday, [**Year (4 digits) 1017**]. 7. Protonix 40 mg q. day. 8. Premarin 0.625 q. day Tuesday, Thursday, Saturday, [**Year (4 digits) 1017**]. 9. Oxycodone 10 mg Monday, Wednesday, [**Year (4 digits) 2974**] with hemodialysis. 11. Renagel 300 t.i.d. 12. Atrovent. 13. Salmeterol. 14. PhosLo 667 Tuesday, Thursday, [**Last Name (LF) 2974**], [**First Name3 (LF) 1017**]. 15. Humibid two b.i.d. 16. Mucinex 600 b.i.d. PHYSICAL EXAMINATION IN EMERGENCY DEPARTMENT: Temperature 101.9 with a T-max of 103. Blood pressure was 73/53 which rose to 110/70 on Levophed and intravenous fluids. Pulse was 113, respiratory rate 24. Sat was initially 90% on four liters nasal cannula which rose to 96% on four liters nasal cannula. In general, the patient was in no apparent distress. She was alert and oriented times three. The patient has no voice at baseline secondary to vocal cord paralysis but is able to clearly mouth her words. HEENT: Pupils equal, round and reactive to light and accommodation, extraocular movements intact, anicteric sclerae. Heart: S1, S2. No murmurs, rubs or gallops. Lungs were clear to auscultation. Abdomen was diffusely tender, greatest in the left lower quadrant but no rebound and no guarding and normoactive bowel sounds. Colostomy was clean, dry and intact with moderate amounts of stool. Extremities: No clubbing, cyanosis or edema. Good distal pulses. Very warm extremities. LABORATORY ON ADMISSION: Significant for white count of 21.9. Differential 95.7 neutrophils and 0 bands. Hematocrit was 43.9, platelet count 347,000. Chemistries were within normal limits aside from a creatinine of 3.7, baseline creatinine [**4-24**]. RADIOLOGY: Chest x-ray showed no consolidation, normal pulmonary vasculature. Tracheostomy tube was in stable condition. There was minimal blunting of the left costophrenic angle, however, this was unchanged from previous chest x-rays. ELECTROCARDIOGRAM: Sinus, slightly prolonged PR interval at 210 milliseconds. No ST changes. No change from old electrocardiograms. ECHOCARDIOGRAM: Patient's most recent echocardiogram was on [**2153-6-29**], that showed a left ventricular ejection fraction of greater than 60% and moderately dilated left atrium and asymmetric left ventricular hypertrophy of the left ventricular apex. This study was said to be consistent with a hypertrophic cardiomyopathy, atypical variant. P-MIBI on [**2153-7-3**], showed no perfusion defects and, again, hypertrophy anterior and apically of the left ventricle. IMPRESSION: This was a 63-year-old female with a past medical history of end-stage renal disease on hemodialysis, Crohn's disease status post ileostomy, history of MRSA pneumonia, who presented with sepsis. In particular, the patient had hypotension, fever, leukocytosis with an uncertain source. HOSPITAL COURSE: 1. Sepsis: As stated, patient presented with hypotension, fever and leukocytosis, thereby, by definition, sepsis. It was unclear on presentation the etiology of the sepsis. Our differential diagnosis included a pneumonia with her history of shortness of breath, however, her initial chest x-ray was negative. Also in the differential was line sepsis and, therefore, multiple blood cultures were sent. Also in the differential was an abdominal source with her Crohn's disease and history of abscess. For the workup of the sepsis sputum cultures were sent and the chest x-ray was repeated, however, no definite pulmonary source was found on the sputum culture. The repeat chest x-ray was negative for infiltrate. As far as an abdominal source, an abdominal CT and pelvic CT was performed on hospital day two that showed no evidence of small bowel inflammation or obstruction nor abscess. Clostridium difficile cultures were also sent that were negative. Multiple sets of blood cultures were sent that were all negative. The initial concern was perhaps that the patient was septic from a hemodialysis line infection, however, no blood cultures grew out any organisms. The patient was given empiric antibiotics including vancomycin to cover for any line infection, gentamicin to cover for Gram negative, specifically, Pseudomonas and any bowel organisms, and Flagyl to cover for anaerobes. By hospital day three all cultures were negative and the patient's leukocytosis and fever had resolved, therefore, it was decided to discontinue gentamicin and Flagyl. The patient was to receive vancomycin on her day of discharge with hemodialysis and then continue the vancomycin empirically for one week post discharge. 2. Infectious Disease: As above, patient was covered empirically with vancomycin, gentamicin and levofloxacin. No blood cultures grew out any organisms. All respiratory cultures and stool cultures were also negative, therefore, all antibiotics were discontinued on the day of discharge aside from vancomycin which was to be given with hemodialysis for one week post discharge. 3. End-stage renal disease on hemodialysis: The patient was continued on her hemodialysis. Her normal dialysis days are Monday, Wednesday and [**Year (4 digits) 2974**]. The patient was dialyzed on Tuesday as she received a dye load with the CT of the abdomen and pelvis and she was subsequently dialyzed on Wednesday prior to discharge. She was continued on her Nephrocaps, Renagel and PhosLo. Her electrolytes remained stable. 4. Bipolar disease: Patient was continued on all of her outpatient medications. A lithium level was checked that was slightly subtherapeutic at 0.21. 5. Cardiovascular disease: The patient is on digoxin and it is not clear from the [**Location (un) 1131**] the records or the patient why she is on this medication as her PR interval was slightly prolonged from baseline on admission. As the patient was bradycardic when she first came to the floor with a heart rate between 40 and 50, this medication was held. A digoxin level was checked that was 0.8 which is within normal limits, normal limits being 0.9 to 2.0. The patient was weaned off of Levophed within hours of being brought to the MICU on her first hospital day. 6. Endocrine: The patient's TSH was checked on admission. It was 5.1. It was felt that in an acute setting no changes should be made to her current Synthroid regimen, therefore, she was kept on her outpatient dose of Synthroid. 7. Cervicalgia: The patient has baseline cervicalgia secondary to spinal disease and nerve root compression. She was continued on her Duragesic patch, her Elavil and oxycodone for breakthrough pain. 8. Code: The patient stated she wished to be full code. DISCHARGE DIAGNOSIS: Transient sepsis of unclear source. Most likely patient has a tracheobronchitis. DISCHARGE DISPOSITION: To [**Hospital **] Rehabilitation on [**2155-10-15**]. DISCHARGE MEDICATIONS: Patient was discharged on all of her regular medications as listed below the addition of vancomycin times one week to be given with dialysis. 1. Oxycodone 10 mg Monday, Wednesday, [**Year (4 digits) 2974**] with hemodialysis. 2. Renagel 800 t.i.d. 3. Atrovent two puffs b.i.d. 4. Salmeterol, one puff Tuesday, Thursday, Saturday and [**Year (4 digits) 1017**]. 5. PhosLo 667 b.i.d. Tuesday, Thursday, Saturday, [**Year (4 digits) 1017**]. 6. Heparin 5000 subcu b.i.d. 7. Humibid two tabs b.i.d. 8. Mucinex 600 b.i.d. 9. Lithium 700 three times a week post hemodialysis. 10. Remeron 45 h.s. 11. Ambien 5 h.s. 12. Duragesic patch 125 mcg q. 72h. transdermal. 13. Elavil 75 h.s. 14. Mirtazapine 30 h.s. 15. Loperamide 2 mg q. 8h. p.r.n. diarrhea. 16. Tylenol p.r.n. 17. Oxycodone 10 mg q. 4h. p.r.n. pain. 18. Maprotiline 125 mg Tuesday, Thursday, Saturday, [**Year (4 digits) 1017**]. 19. Premarin 0.625 q. day Tuesday, Thursday, Saturday, [**Year (4 digits) 1017**]. 20. Promatine 5 q. day Tuesday, Thursday, Saturday, [**Year (4 digits) 1017**]. 21. Protonix 40 mg q. day. 22. Nephrocaps one cap q. day Tuesday, Thursday, Saturday, [**Year (4 digits) 1017**]. 23. Synthroid 0.125 mcg q. day. 24. Digoxin 0.125 q.o.d. 25. Vancomycin 1 gram q. hemodialysis one week post discharge. DR.[**Last Name (STitle) 1177**],[**First Name3 (LF) 1176**] 12-AFL Dictated By:[**Last Name (NamePattern1) 5851**] MEDQUIST36 D: [**2155-10-15**] 12:40 T: [**2155-10-15**] 12:01 JOB#: [**Job Number 108189**]

[ "038.9", "296.7", "466.0", "V44.2", "425.1", "585", "244.9", "V44.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10241, 10297

10321, 11854

10135, 10217

3330, 4934

6346, 10113

2043, 2267

169, 2023

4949, 6329

2289, 3304

67,554

164,714

1696

Discharge summary

report

Admission Date: [**2126-4-4**] Discharge Date: [**2126-4-9**] Date of Birth: [**2063-9-11**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2356**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: EGD [**2126-4-4**] with clipping in injection of bleeding gastric ulcer. History of Present Illness: 62M with h/o multiple stents, HL, present to ED s/p syncopal episode. Pt reports feeling week this morning, progressing to lightheadedness. This lasted about 30 min, during which pt sat down, and walked outside for fresh air. He then called his friend, and in the middle of the phone call lost consciousness. As his fall was unwitnessed, he is unsure if he had any head or other trauma, but now has soreness in his neck, and awoke near a metal chair. Pt also describes diaphoresis and feeling hot. However denies nausea, vomiting, incontinence, tongue lesions, post syncopal confusion. When he awoke his friend had arrived and called EMS and reports that he had been passed out for just several seconds and was very pale. . On arrival of EMS, pt had low SBP, was given 500mL IVF and SBP and color improved. This am - was talking on the phone and felt that he was going to faint - next thing he knows he was sitting on the floor. EMS arrived and sbp low - given 500cc IVF and color and SBP improved. Pt. denied cp/sob/n/v/diarrhea - otherwise in his normal state of health. . On arrival to the ED, initial vitals were 96.4 90 114/60 18 98%. Labs were significant for WBC of 11.1, 74%N, Neg cardiac enzymes x 1, Dig level of 0.8, K 4.9, Cr 0.9, Hct 35.6. . Patient was admitted to the medical floor for w/u of syncope, while on the floor, patient had large volume of coffee ground emesis. HD stable during and after event. HCT down 4 points. Transferred to MICU for evaluation of GI bleed. Past Medical History: CAD HTN HL atrial fibrillation s/p PCI with stents [**2122**] Social History: Denies tobacco, alcohol, drug use Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: 37.2 119/58 112 27 97%2LNC GENERAL: Well appearing in NAD HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Mucus membranes dry. No xanthalesma. NECK: Supple without JVP CARDIAC: S1S2 irreg irreg tachycardic. No murmurs LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Mild basilar rales ABDOMEN: Soft, obese, ND. Mild tenderness to palpation epigastric/LUQ EXTREMITIES: No c/c/e. No femoral bruits. Pertinent Results: Discharge labs: [**2126-4-9**] 07:10AM BLOOD WBC-9.9 RBC-4.05* Hgb-12.4* Hct-34.8* MCV-86 MCH-30.7 MCHC-35.8* RDW-15.3 Plt Ct-259 [**2126-4-9**] 07:10AM BLOOD Plt Ct-259 [**2126-4-9**] 07:10AM BLOOD Glucose-103 UreaN-13 Creat-0.9 Na-140 K-3.8 Cl-104 HCO3-25 AnGap-15 [**2126-4-8**] 07:00AM BLOOD Calcium-9.2 Phos-3.3 Mg-2.1 . [**2126-4-4**] CT C spine: IMPRESSION: 1. No acute fracture or malalignment. 2. Severe degenerative changes of the cervical spine, causing multilevel neural foraminal narrowing and moderate-to-severe canal stenosis as described above. In the setting of trauma, these degenerative changes predispose the patient to ligamentous injury and cord contusion. MRI should be considered for further evaluation if clinically indicated. . [**2126-4-4**] EGD: Impression: Blood in the stomach Erosion/ulceration in the antrum (injection, endoclip) Blood in the duodenum Otherwise normal EGD to second part of the duodenum Recommendations: Routine post procedure orders Continue pantoprazole 40 mg IV BID. Serial HCT's. Maintain HCT >30. If shows more signs of bleeding, please give platelets. NPO. Aspiration precautions. If develops recurrent hematemesis, hemodynamic instability, or is unresponsive to blood products, will repeat EGD. If remains stable, then repeat EGD in 6 weeks. . [**2126-4-5**] TTE: The left atrium is moderately dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is mildly to moderately depressed (LVEF = 35-40%). The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The ascending aorta is moderately dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild to moderate global left ventricular systolic dysfunction, c/w diffuse process (tachycardia, toxic, metabolic, etc.) or multivessel CAD. Mild global right ventricular systolic dysfunction. Mild pulmonary hypertension. Brief Hospital Course: Mr. [**Known lastname 9765**] is a 62 yo M with hx CAD, afib, cardiac stents who presented to the ED with a syncopal episode in the setting of mild epigastric abd pain x1d, admitted to medical service for syncope work-up, had episode of large volume coffee ground emesis and found to have HCT drop 4 points, tranferred to MICU for UGIB . #GI bleed: Admitted to MICU after large volume coffee ground emesis in setting of HCT drop 4 point after 7 hrs. GI consult performed EGD on MICU admit which was significant for ulceration in antrum of stomach with overlying clot. Epinephrine and clips placed with no active bleeding seen during EGD. Hemodynamically stable post-EGD. Pt was transfused a total of 5 units PRBCs during the hospitalization and was discharged with stable hematocrit tolerating regular diet. He will follow up with GI for rpt EGD on [**5-23**] and also with his PCP. [**Name10 (NameIs) 9766**] and Plavix were held. This outpt providers will have to decide if the pt ever restarts these weighing risks and benefits of doing so. He will continue to take a [**Hospital1 **] PPI for which insurance prior auth was eventually obtained. OF NOTE: Pt will need H pylori testing with biopsies at his rpt EGD. . # Syncope: This was thought to be [**2-4**] acute GI bleed although TTE was done on the 3rd with results above and pt was ruled out for MI. Telemetry was unremarkable for any arrhythmia which could have caused syncope. . # Leukocytosis: Without signs of infection, was thought most likely related to stress reaction from GI bleed. WBC was trended. . # Anemia: Hct 36 on admission with drop to 32, previous HCT 39 back in [**2122**], likely acute blood loss. Pt transfused a total of 5 units as above and discharged with stable Hct at 34.8. . # Atrial Fibrillation: Hx afib on digoxin, atenolol. Dig level 0.8 on admit. Atenolol was initially held [**2-4**] concerns about hypotension but pt was discharged on a higher dose of atenolol for better HR control as well as digoxin. . # Hyperlipidemia: Continued zocor Medications on Admission: [**Month/Day (2) 9766**], plavix, atenolol, simvastatin, digoxin Discharge Medications: 1. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. 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* 5. Atenolol 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:*50 Tablet(s)* Refills:*2* 6. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO three times a day as needed for gout for 2 days: Take up to 3 times daily as tolerated for gout. Call your doctor if pain does not resolve in 1 day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Bleeding Gastric Ulcer Secondary diagnoses: Blood loss anemia s/p several transfusions CAD Atrial fibrillation Discharge Condition: Good. Hct stable for last 3 days prior to discharge. Discharge Instructions: You were admitted after passing out. While you were here, we determined that this episode was due to a bleed from an ulcer in your stomach. The gastroenterology service was consulted and did an endoscopy during which they injected and clipped the ulcer to stop the bleeding. We monitored you for several days to make sure you were still not bleeding. You did require 5 blood transfusions while you were here. At the time of discharge, you are doing well without evidence of further bleeding. . We made the following changes to your medications: We stopped your [**Month/Day (2) **] and plavix as these can cause easy bleeding. We increased your atenolol to 75mg daily from 50mg daily. We started you on a twice daily acid blocking medication called pantoprazole or protonix. We are giving you a prescription for colchicine for your gout. This medication causes diarrhea. You can take it up to 3 times a day as tolerated for up to 2 days. Do NOT use indocin or indomethicine for your gout as this can cause bleeding in your stomach. If your gouty pain does not resolved in [**1-4**] days, call your PCP. . Please follow up with your doctor as below. . Please call your doctor or return to the ED if you have any chest pain, shortness of breath, dizziness, lightheadedness, vomitting, blood in your stool or any other concerning symptoms. Followup Instructions: Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1270**] Tuesday [**4-30**] at 3:15p in the [**Location (un) 4628**] office. This office number is [**Telephone/Fax (1) 9767**]. . You will need a follow up endoscopy on [**5-23**] at 7:45am. They will send you literature but you should not eat after midnight the night before this study. If you have any questions, please call ([**Telephone/Fax (1) 2233**]. [**First Name4 (NamePattern1) 1730**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 2362**] Completed by:[**2126-4-15**]

[ "V45.82", "276.52", "780.2", "414.01", "272.4", "285.1", "531.40", "427.31" ]

icd9cm

[ [ [] ] ]

[ "44.43" ]

icd9pcs

[ [ [] ] ]

8003, 8009

5077, 7117

322, 398

8183, 8238

2749, 2749

9625, 10227

2074, 2190

7232, 7980

8030, 8030

7143, 7209

8262, 8778

2766, 5054

2205, 2730

8093, 8162

8807, 9602

274, 284

426, 1920

8049, 8072

1942, 2006

2022, 2058

6,336

124,369

14325+14326

Discharge summary

report+report

Admission Date: [**2127-11-19**] Discharge Date: [**2127-12-1**] Service: Neurosurgery HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old right handed gentleman who presented with longstanding history of atherosclerotic vascular disease with prior history of mini strokes and transient ischemic attacks and status post a coronary artery bypass graft in [**2121**], also Plavix presents with a 48 hour after an episode of lightheadedness, lack of coordination and clumsiness and leaning and falling to the right lasting three minutes. The patient called his primary care doctor after this episode and was sent to the [**Hospital1 1474**] Emergency Room and then transferred to [**Hospital6 256**] for possible angiogram. ADMISSION MEDICATIONS: 1. Atenolol 25 mg po bid 2. Lipitor 20 mg po q day 3. Enteric coated aspirin 325 po q day 4. Plavix 75 po q day PAST MEDICAL HISTORY: 1. Coronary artery disease with coronary artery bypass graft in [**2121**] 2. Hypercholesterolemia 3. Anemia 4. Atrial fibrillation ALLERGIES: The patient has no known allergies. EXAM: GENERAL: Awake, alert and oriented x3. HEAD, EARS, EYES, NOSE AND THROAT: Pupils equal, round and reactive to light. EOMs full. Tongue midline. No fasciculations. Smile symmetric, face symmetric. NECK: Supple. Carotids 1 to 2 without bruit. LUNGS: Clear to auscultation. CARDIAC: Atrial fibrillation with a rate of 88, no murmurs, rubs or gallops. ABDOMEN: Positive bowel sounds x4, soft, nontender, nondistended. EXTREMITIES: Warm, dry and pink. Distal DP and PT pulses present. NEUROLOGIC: Cranial nerves intact. Gait within normal limits. Slow, short steps, negative Romberg, no clonus. Strength was [**4-6**] in all muscle groups. Sensation was intact to light touch. His deep tendon reflexes were 2+ throughout with the exception of the ankles which were absent and his toes were downgoing. ADMISSION LABS: White count 9.7, hematocrit 31.8, platelet count 230. PT 12.8, PTT 24.2, INR 1.0. IMAGING: Head CT at an outside was within normal limits. HOSPITAL COURSE: The patient was admitted to the neurosurgery service under Dr. [**Last Name (STitle) 1132**] and underwent an angiogram which showed 70% right CCA stenosis, 50% left common carotid stenosis and a hypoplastic right vertebral artery and a left vertebral artery origin stenosis of >75%. On [**2127-11-24**], the patient underwent stent angioplasty of the left vertebral artery origin. On post procedure, the patient was monitored in the Intensive Care Unit. His neurologic status remained stable. He was awake, alert and oriented x3 with no drift, no episodes of transient ischemic attacks or lightheadedness. She remained on heparin. Post procedure, the patient did have a low sodium down to 130, started on salt tablets and fluid restriction. Patient was started on Coumadin with goal INR to be 2.5 to 3 and aspirin was decreased from 325 po q day to 81 mg po q day. The patient remained neurologically stable. On [**2127-12-1**], his INR was 3.0. His PT was 21.1. He is currently receiving 2.5 mg of Coumadin, 81 mg of aspirin q day, Plavix 75 mg po q day, atenolol 25 po bid, Lipitor 20 po q day, Epogen 6000 units subcutaneous 3x a week. The patient will get 2.5 of Coumadin po today. He was also on Epogen 6000 units subcutaneous 3x a week q Monday, Wednesday and Friday. The patient's condition was stable at the time of discharge and he will follow up with Dr. [**Last Name (STitle) 1132**] in one week. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2127-12-1**] 09:58 T: [**2127-12-1**] 10:13 JOB#: [**Job Number 42500**] Admission Date: [**2127-11-19**] Discharge Date: Service: ADDENDUM TO PREVIOUS DISCHARGE SUMMARY: Patient's discharge was delayed until [**2127-12-5**] secondary to a swelling in the right leg. Patient had an ultrasound which showed a right common femoral artery pseudoaneurysm. Patient had a repeat ultrasound done on [**2127-12-4**] which showed increase in the size of the pseudoaneurysm, therefore, it was treated under ultrasound guided needle thrombin, which was injected into the pseudoaneurysm, which caused complete occlusion of the pseudoaneurysm. The patient's groin is clean, dry and intact. He continued to have edema in the right lower extremity. There was a CT scan done of his iliac veins; the results of which are pending to rule out deep vein thrombosis, although, the patient is on Coumadin for a vertebral stent. There will be no other treatment necessary for this deep vein thrombosis. Patient will just require follow-up of deep vein thrombosis in the future. He will be discharged to rehabilitation. He is in stable condition with positive pedal pulses in the right lower extremity. He should keep that right leg elevated with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] stocking or ACE wrap and he will follow-up with Dr. [**Last Name (STitle) 1132**] in one to two weeks time. MEDICATIONS AT THE TIME OF DISCHARGE: Coumadin 2.5 mg po q.d. keeping INR at 2.5 to 3 at all times. CONDITION AT DISCHARGE: Patient's condition was stable at the time of discharge. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2127-12-5**] 14:15 T: [**2127-12-5**] 12:58 JOB#: [**Job Number 42501**]

[ "998.12", "442.3", "433.30", "V45.81", "437.0", "276.1", "997.79", "272.0", "427.31" ]

icd9cm

[ [ [] ] ]

[ "39.50", "88.41", "39.90", "99.29" ]

icd9pcs

[ [ [] ] ]

2087, 5221

763, 880

5236, 5552

127, 740

1926, 2069

902, 1909

19,213

114,282

52446

Discharge summary

report

Admission Date: [**2204-1-14**] Discharge Date: [**2204-2-1**] Date of Birth: [**2168-10-6**] Sex: F Service: MEDICINE Allergies: Insulin Pork Purified / Insulin Beef / Erythromycin Base / Codeine / Aspirin / Compazine / Peanut Attending:[**First Name3 (LF) 783**] Chief Complaint: Seizure Major Surgical or Invasive Procedure: Placement of left femoral central venous catheter Placement of left subclavian central venous catheter Lumbar Puncture History of Present Illness: 35 yo female w/med hx of DMI and multiple admissions for DKA, DM complicated by nephropathy on PD and multiple skin infections, HTN, asthma initially admitted to the MICU [**1-13**] for witnessed seizure. Daughter reported to find her seizing with rhythmic arm and leg movements so EMS called. Pt given valium 10mg with resolution. Pt had 2 other episodes of seizure in ambulance and another in the ED. She also had multiple episodes of coffee ground emesis in the ED so GI was consulted and recommended [**Hospital1 **] PPI and watch since hct stable and hs of gastritis in the past. Chem 7 revealed her to be in DKA with a gap of 18 and hyprglycemic to 600's. She was started on an insulin gtt which was continued for 48 hours although AG within 7 hours of starting gtt. Head CT revealed left convexity subdural hematoma. VS were stable in the ED and pt was transferred to the MICU for DKA, seizure and SDH. She was evaluated by neurology who reported pt to have multiple medical reasons to have seizure and recommended dilantin loading until medical issues controlled. Neurosurgery was also consulted for SDH but recommended frequent neuro checks and no need for surgical intervention. Follow-up MRI revealed foci of signal abnormalities in both frontal lobes, right greater than left, with faint enhancement of the right frontal lobe lesion with differential including demyelinating disorder or infection. LP was attempted on [**1-15**] but aborted due to pt intolerance. She also continued to have abdominal pain with elevated WBC so peritoneal fluid was sent for cell count and cx with cx pending and cell count w/o leukocytosis. Renal was following and TPA'd PD catheter with good response on [**1-16**] with 5L of drainage and improvement in pain. Once off insulin gtt and monitored with frequent neuro checks for 48 hours she was transferred to the floor. Past Medical History: 1. Diabetes mellitus type 1, diagnosed at age 7. The patient has had multiple episodes of diabetic ketoacidosis in the past. Her DM is complicated by neuropathy, nephropathy, and retinopathy. 2. Chronic renal insufficiency, now failure with creatinine around 7, starting peritoneal dialysis 3. History of gastroparesis, with episodes of nausea and vomiting. 4. Atypical chest pain. 5. Hypertension. 6. Asthma. 7. Chronic right foot ulcer being followed by Dr. [**Last Name (STitle) 108352**] of [**Last Name (STitle) **]. 8. Chronic diarrhea- incontinant of stool since abcess removed ([**2194**]). 9. Recurrent pyelonephritis. 10. ECHO [**3-5**]: EF 75%. No WMA/valvular abnormalities. 11. Chronic diarrhea since [**2194**] when she had an abcess removed from her anus. Since then she has been on chronic loperimide. 12. history of hematemesis and EGD on [**9-21**] revealed Grade IV esophagitis with contact bleeding was seen in the distal esophagus, Erythema in the stomach body and fundus compatible with gastritis. Social History: The patient lives in [**Location 686**]. Her PCP is [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Per his OMR note, her children have recently been taken by DSS, hence they no longer live with her. She has a long history of medical noncompliance. She previously noted that she smokes 2 packs of cigarettes every 5 days but says that she is smoking less now. She has smoked for the past 7 years. She denies use of alcohol or illicit drugs. Had been in abusive home relationship but has recent restraining order against fiance, who is in jail. Has close support with multiple family members nearby. Worked prev as nurse's aide in [**Hospital1 2025**] psych [**Hospital1 **]. Currently attending classes for nursing degree. Family History: Father with type 2 DM, CHF, CVA Physical Exam: T 98.3 HR 85 BP 121/67 25 97%RA HEENT: PERRL, MMM, no nuchal rigidity, no ant or post cerv LAD, thyroid nonpalp, no bruits CVS: RRR nS1S2 3/6 SEM at RUSB w/o rad to carotids Lungs: Clear bilat Abd: Soft, diffusely tender and distended, no rebound or guarding, could not asses organomegaly due to intolerance to deep palpation Extr: Warm, 2+ rad and dp pulses, trace bilat LE edema, no asterixis Skin: 2 L medial breast incision w/o drainage or surrounding erythema. Multiple smaller 1-2 cm nodules noted on R shoulder with one incision and surrounding tegaderm w/ wet to dry dressing intact and minimal tendernes to palpation. Multiple excoriated areas on chest, arms, back., sacral decubitus ulcer stage I with stool in it Neuro-CNII-XII intact, 5/5 strength in flexors and extensors of hip knee ankle shoulder elbow wrist grip bilat, gait not assessed, pt not compliant with sensory exam or reflexes, toes downgoing Pertinent Results: [**2204-1-14**] 11:49PM GLUCOSE-57* UREA N-66* CREAT-8.6* SODIUM-142 POTASSIUM-3.7 CHLORIDE-110* TOTAL CO2-20* ANION GAP-16 [**2204-1-14**] 11:49PM CALCIUM-7.5* PHOSPHATE-6.6* MAGNESIUM-1.6 [**2204-1-14**] 11:49PM HCT-29.4* [**2204-1-14**] 07:57PM GLUCOSE-142* UREA N-69* CREAT-8.6* SODIUM-139 POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-19* ANION GAP-17 [**2204-1-14**] 07:57PM CK(CPK)-174* [**2204-1-14**] 07:57PM CK-MB-4 cTropnT-0.07* [**2204-1-14**] 07:57PM CALCIUM-7.0* PHOSPHATE-6.8* MAGNESIUM-1.6 [**2204-1-14**] 07:57PM HCT-30.8* [**2204-1-14**] 04:04PM URINE HOURS-RANDOM CREAT-49 SODIUM-37 [**2204-1-14**] 03:17PM GLUCOSE-146* UREA N-71* CREAT-8.9* SODIUM-140 POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-18* ANION GAP-19 [**2204-1-14**] 03:17PM CALCIUM-6.8* PHOSPHATE-7.0* MAGNESIUM-1.6 [**2204-1-14**] 03:17PM HCT-30.1* [**2204-1-14**] 10:30AM ASCITES TOT PROT-<0.2 GLUCOSE-720 LD(LDH)-10 ALBUMIN-LESS THAN [**2204-1-14**] 10:30AM ASCITES WBC-6* RBC-68* POLYS-1* LYMPHS-11* MONOS-0 MACROPHAG-88* [**2204-1-14**] 10:27AM GLUCOSE-64* UREA N-76* CREAT-8.7* SODIUM-139 POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-18* ANION GAP-17 [**2204-1-14**] 10:27AM CK(CPK)-173* [**2204-1-14**] 10:27AM CK-MB-4 cTropnT-0.08* [**2204-1-14**] 10:27AM CALCIUM-6.7* PHOSPHATE-6.9* MAGNESIUM-1.7 [**2204-1-14**] 10:27AM HCT-27.3* [**2204-1-14**] 08:04AM SODIUM-141 POTASSIUM-3.6 TOTAL CO2-17* [**2204-1-14**] 08:04AM CALCIUM-7.2* PHOSPHATE-6.7* MAGNESIUM-1.6 [**2204-1-14**] 08:04AM OSMOLAL-314* [**2204-1-14**] 08:04AM HCT-22.7* Brief Hospital Course: 1. seizure-Pt has no hx of seizure in past but has multiple reasons for seizure on current admission including hyponatremia, subdural hematoma, acidemia and new med of flagyl and hypodensity seen on MRI. She was dilantin loaded but developed dizinees with uptitration despite subtherapeutic levels although free % was elevated likely due to CRF. Pt started on Keppra so that dilantin toxicity would not cloud the diziness and ataxia picture. Dilantin was then titrated off. Hypodensity on MR [**First Name (Titles) **] [**Last Name (Titles) 108356**]g for cause of seizure focus if infection or demyelinating lesion although LP showed no WBC's, [**Male First Name (un) 2326**] virus neg, cytology neg and no oligoclonal bands seen. RPR neg ruled out neurosyphillis. She suffered no additional seizures and will continue on keppra with plans to follow up with neurology in about 1 month. 2. headaches: Pt's headache was initially felt to be most likely post LP headache and we reconsulted anaesthesia for blood patch, but they felt that her symptoms were more consistent with migaraine. Attempted SC sumitriptan to decrese HA frequency altough it made her more nauseous. She was eventually managed with RTC tylenol and oxycodone prn. Repeat MR w/o gadolinium shows no change with possible decrease in size of frontal hyperintensities. As above pt will follow up with neuro. 3. SDH- size of SDH stable on follow-up MRI and not viusalized on any of her 4 follow-up CT's. Per neurosurg no need for intervention since she has no nueurologic deicits and lesion is stable. [**Month (only) 116**] also be contributing to headache. Repeat Head CT was normal. 4. High PVR-pt initially had 500cc PVR after foley removal on [**1-16**]. Pt has no history of urinary retention and repeat PVR 100 so no further intervention required. 5. DMI-FS were high throughout the hospitalization. Pt was titrated up on her lantus dose and was discharged with 35 units qhs in addition to humalog SS. She has an appointment to follow up with Dr. [**Last Name (STitle) 978**] at [**Last Name (un) **]. 6. Coffee ground emesis-Patient cont to have nausea and vomiting but no coffee grounds. Pt has had multiple EGD's with last one in [**9-4**] which revealed only esophagitis. Seen by GI who recommend [**Hospital1 **] PPI which will cont. Pt's renal failure is most likely cause of anemia and has required chronic transfusions in the past so uptitrated procrit per renal recs. 7. Asthma-No wheeze on PE at this time. Cont on outpt albuterol MDI. 8. Abdominal pain-Resovled with improved PD drainage improving. Pt moving bowels well and no sign of obstruction on KUB. PD fluid cell count not suggestive of infection and cx still has no growth. She continued to have N/V which she states is a chronic issue related to her gastroparesis. This was managed with SL ativan and po phenergan. The patient stated these meds helped a little, though her N/V is a chronic issue. 9. Elevated WBC-WBC stable and pt afebrile despite no antibiotic use. She has multiple skin sources for infection although abscesses healing well. Blood cx and U/A were negative. Pt has chronic diarrhea and was on flagyl so C. diff was felt to be unlikely. Flagyl was stopped and her diarrhea did not recur. 10. ESRD on PD -renal diet, potassium elevated despite kayexalate. Renal was aware and recommended restarting Lasix at [**Hospital1 **] dosing but improvement was minimal. She will follow up with Dr.[**First Name (STitle) 805**] regarding her PD and management of renal issues. Medications on Admission: Zolpidem Tartrate 5 mg qhs Insulin Glargine 26U qhs Humalog slide scale Loperamide HCl 2 mg qid Furosemide 40 mg qd Promethazine HCl 25 mg qid Metoprolol Succinate 50 mg qd Ferrous Sulfate 325 qd Pantoprazole Sodium 40 mg qd Albuterol MDI q6h prn Atorvastatin 10mg qd Hectorol 2.5 mcg qd Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day). Calcium Acetate 667 mg 2 tabs tid Darbepoetin Alfa-Albumin 10000uqwk Percocet 5-325 mg 1-2 Tablets PO every 4-6 hours Discharge Medications: 1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Zolpidem Tartrate 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed. Disp:*30 Tablet(s)* Refills:*1* 3. Calcium Acetate 667 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Insulin Glargine 100 unit/mL Solution Sig: Thirty Five (35) units Subcutaneous at bedtime: 35 Units qhs. Disp:*qs one month* Refills:*2* 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO once a day. 6. Camphor-Menthol Ointment Sig: One (1) Topical once a day. 7. Albuterol Sulfate 0.083 % Solution Sig: One (1) puff Inhalation every six (6) hours. 8. Promethazine HCl 12.5 mg Tablet Sig: One (1) Tablet PO four times a day as needed for nausea. Disp:*120 Tablet(s)* Refills:*2* 9. Toprol XL 200 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 10. Oxycodone HCl 5 mg Capsule Sig: [**12-4**] Capsules PO every six (6) hours as needed for headache. Disp:*24 Capsule(s)* Refills:*0* 11. lorazepam Sig: One (1) mg Sublingual every six (6) hours as needed for nausea. Disp:*120 tabs* Refills:*2* 12. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 14. Epoetin Alfa 4,000 unit/mL Solution Sig: 8000 (8000) units Injection QMOWEFR (Monday -Wednesday-Friday). 15. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 16. Levetiracetam 250 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 17. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection Q6H (every 6 hours): heparin flush for peritoneal dialysis. . Disp:*[**Numeric Identifier 108357**] units* Refills:*2* 18. Insulin Lispro (Human) 100 unit/mL Solution Sig: qs units Subcutaneous four times a day: Inject with meals and before bed according to sliding scale: BG 150-200 - 2 units, BG 201-250 - 4 units, BG 251-300 - 6 units, BG 301-350 - 8 units, BG 351-400 - 10 units. . Disp:*qs one month* Refills:*2* 19. prescription Syringes for humalog and lantus insulin injections qid. #qs one month. refills: 2. 20. Clonidine HCl 0.1 mg/24 hr Patch Weekly Sig: One (1) patch Transdermal once a week. Disp:*4 patches* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: Seizure NOS Right Frontal Lobe Lesion NOS GIB - Coffee Ground Emesis Clotted PD Catheter Diabetic Ketoacidosis Subdural Hematoma Urinary Retention Hyperkalemia Hyperphosphatemia Secondary/PMH: Insulin Dependent Diabetes Mellitus Retinopathy Neuropathy ESRD on Peritoneal [**Hospital **] Medical Non-Compliance Asthma Recurrent Pyelonephritis Atypical Chest Pain Gastroparesis Hypertension Gastritis/Esophagitis Chronic Lower Extremity Ulcers Chronic Diarrhea Recurrent MSSA Skin Abscesses Perianal Abscess Anemia Discharge Condition: Stable Discharge Instructions: If you experience any fevers, chills, increasing headache, neck stiffness, muscle weakness or loss of sensation, abdominal pain, or if your peritoneal dialysis fluid is not draining well you should call Dr. [**First Name (STitle) 805**] but if he is not available you should go to the emergency room. You were started on a new medication for seizure called keppra which you should take as prescribed. Also, please take your increased dose of Metoprolol XL once a day. Followup Instructions: You should follow-up with Dr. [**First Name (STitle) 805**] as you have contracted for on Thursday [**2-2**] at 1:00 p.m. If you cannot make this appointment you need to call [**Telephone/Fax (1) 5972**]. You should also followup with Dr. [**Last Name (STitle) **], your PCP, [**Name10 (NameIs) **] Wednesday, [**2-8**] at 2p.m. Please call [**Telephone/Fax (1) 250**] if you need to cancel. Please also follow up with Dr. [**Last Name (STitle) 978**] at the [**Last Name (un) **] Diabetes center on [**4-18**] at 12 p.m. Please call [**Telephone/Fax (1) 2384**] if you need to cancel. You also need to call Neurology [**Telephone/Fax (1) 44**] regarding your upcoming appointment on [**3-13**] with Dr. [**First Name4 (NamePattern1) 5627**] [**Last Name (NamePattern1) **]. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

[ "250.11", "707.8", "250.51", "362.01", "535.51", "788.20", "285.21", "276.1", "346.90", "250.61", "780.39", "403.91", "V15.81", "493.90", "432.1", "583.81", "996.73", "536.3", "337.1", "250.41", "698.9" ]

icd9cm

[ [ [] ] ]

[ "54.98", "03.31", "99.15", "38.93" ]

icd9pcs

[ [ [] ] ]

13369, 13375

6760, 10286

364, 485

13941, 13949

5193, 6737

14465, 15375

4204, 4238

10823, 13346

13396, 13920

10312, 10800

13973, 14442

4254, 5174

317, 326

513, 2380

2402, 3424

3440, 4188

10,352

103,647

26131

Discharge summary

report

Admission Date: [**2129-2-19**] Discharge Date: [**2129-2-21**] Date of Birth: [**2056-5-15**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6075**] Chief Complaint: Acute onset aphasia. Major Surgical or Invasive Procedure: N/A History of Present Illness: The pt is a 72 year-old woman with a history of hypertension, leukemia, breast and colon cancer, who was last seen well at 6pm on [**2-18**]. At ~6:30pm, one of her granddaughters went to her home to help her make dinner, and noticed that "she wasn't speaking right". Pt replied "Yes I know" to every question. Did not seem to be understanding what people were saying. No known headache, but Pt held her hand over her forehead. Concerned that this could be related to her diabetes (?low blood sugar), she was given juice. No improvement, EMS called at 7pm. Upon arrival to [**Hospital3 **] [**Name (NI) **], Pt vomited and had a seizure (?focal onset with head turn). Right sided weakness was noted after the seizure. She was loaded with Dilantin and intubated. Head CT revealed a large L parieto-occipital hemorrhage with surrounding edema. Pt received Decadron 10mg IV x1 and was transferred to [**Hospital1 18**] for neurosurgical evaluation. Past Medical History: -HTN - baseline SBP 140s, developed HTN at least 20 years ago -Leukemia - diagnosed 4 1/2 years ago -Colon CA - s/p resection -Breast CA - s/p mastectomy -NIDDM -s/p cholecystectomy Social History: Lives alone, is independent with ADLs. Family members live upstairs. No tobacco, EtOH, or illicit drug use. Family History: Noncontributory. Physical Exam: Afebrile HR 93 BP 129/38, 142/77 RR 16 O2sat 100% GEN Lying in bed, intubated, sedated HEENT NCAT, MMM, OP clear Chest CTAB CVS RRR, I/VI systolic murmur loudest @ LLSB ABD soft, NT, ND, +BS EXT no c/c/e, 2+ distal pulses, +venous stasis changes over LE Neuro MS: Sedated with propofol. Grimaces to sternal rub and moves L arm, but does not localize. Not following commands. No spontaneous eye opening. CN: PERRL 3 to 2mm bilaterally, does not blink to threat, +doll's eye reflex, +corneal reflexes bilaterally. +grimace to nasal tickle bilaterally. +gag, cough. Motor: normal bulk and tone; moves all extremities spontaneously L>R. Reflexes: |[**Hospital1 **] |tri |bra |pat |[**Doctor First Name **] |toe | L | 2 | 2 | 2 | 2 | 2 | dn | R | 2 | 2 | 2 | 2 | 2 | dn | [**Last Name (un) **]: Withdraws to noxious stim in all four extremities. Pertinent Results: [**2129-2-18**] 09:00PM BLOOD WBC-2.0* RBC-2.64* Hgb-11.3* Hct-31.3* MCV-119* MCH-42.6* MCHC-36.0* RDW-20.2* Plt Ct-314 [**2129-2-18**] 09:00PM BLOOD Neuts-74* Bands-0 Lymphs-21 Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2129-2-18**] 09:00PM BLOOD PT-14.0* PTT-21.1* INR(PT)-1.2* [**2129-2-18**] 09:00PM BLOOD Glucose-259* UreaN-57* Creat-1.5* Na-138 K-3.6 Cl-99 HCO3-23 AnGap-20 [**2129-2-19**] 01:56AM BLOOD Calcium-9.3 Phos-4.2 Mg-1.9 [**2129-2-19**] 01:56AM BLOOD Phenyto-17.2 [**2129-2-18**] 10:11PM BLOOD Type-ART Rates-10/ Tidal V-600 FiO2-100 pO2-466* pCO2-39 pH-7.43 calHCO3-27 Base XS-2 AADO2-222 REQ O2-44 Intubat-INTUBATED CT head ([**2129-2-18**]): Significant worsening compared to the outside hospital CT; while the left parietal hemorrhage appears roughly similar in size, the prominent hyperdense left subdural is new, and the amount of midline shift is much worse. Additionally, there is progression of the blurring of [**Doctor Last Name 352**]-white matter differentiation throughout the left hemisphere suggesting diffuse edema. Subfalcian herniation, and possible early uncal herniation. CT head ([**2129-2-19**]): Large left-sided intraparenchymal and extra-axial hemorrhage. Slightly increased degree of subfalcine and uncal herniation Brief Hospital Course: The patient was admitted to the neurology ICU. Neurosurgical consultation was obtained and she was deemed not to be a candidate for operative management. Serial CT scans of the head demonstrated worsening in terms of edema and herniation. Clinically, she steadily declined. A family meeting was held with the patient's next of [**Doctor First Name **]. It was decided by the patient's family that given the patient's poor prognosis, the focus of care should be her comfort. All medical interventions were discontinued except sedation and analgesia. The patient passed away at 5am on [**2129-2-21**]. Medications on Admission: Verapamil 240mg [**Hospital1 **] Hydroxyurea 500mg QD Lasix 80mg [**Hospital1 **] Glyburide 7.5mg QD KCL 10mEq QD Lisinopril 20mg QD Colchicine 0.6mg QD Iron QD Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Intracranial hemorrhage Discharge Condition: N/A Discharge Instructions: N/A Followup Instructions: N/A

[ "V10.3", "401.9", "208.90", "V10.05", "431", "250.00", "780.39" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

4779, 4788

3932, 4538

337, 342

4855, 4860

2640, 3909

4912, 4918

1666, 1684

4751, 4756

4809, 4834

4564, 4728

4884, 4889

1699, 2621

277, 299

370, 1318

1340, 1524

1540, 1650

18,353

160,915

52578

Discharge summary

report

Admission Date: [**2166-1-23**] Discharge Date: [**2166-3-7**] Date of Birth: [**2101-6-19**] Sex: M Service: SURGERY Allergies: Benadryl / Morphine / Ativan / Compazine Attending:[**First Name3 (LF) 1781**] Chief Complaint: Abdominal discomfort; non-healing Right 1st toe amputation site Major Surgical or Invasive Procedure: [**2166-1-31**]: Diagnostic right lower extremity arteriogram via antegrade right axillofemoral approach. Percutaneous balloon angioplasty of the posterior tibialis, tibioperoneal trunk and below-the-knee popliteal History of Present Illness: Mr. [**Name14 (STitle) 108560**] is a 64 year old male a complicated past medical history (including CAD/CHF/ESRD/PVD, among others) who presented to the ED on [**1-23**] with nausea and pressure in his abdomen/chest. The patient states that he was in his usual state of health until yesterday when he felt a little off - he cannot clarify further what was wrong. He awoke this morning and felt nauseated; had some dry heaves with spit production - no blood. Also felt a pressure on his chest and abdomen (he points to epigastrum and lower chest). Different from his pancreatitis pains. This pressure did not radiate anywhere and was not worsened by deep breathing or anything else. He does say that he has some SOB ("can't take a deep breath") but this is unrelated to pain. Reports a cough since this morning, productive of yellow sputum. Denies fevers/chills. In the ED, vitals were: 98.0, BP 140/90, HR 80, 94% on room air. Blood pressures were as high as 180s systolic in the ED. Was given: ceftriaxone 1g IV, azithromycin, [**Last Name (LF) 28920**], [**First Name3 (LF) **], reglan. On HOD #1 on the medicine floor, the patient received compazine and ativan approximately 45 minutes prior to having a change in mental status. The patient became increasing somnolent. BP and HR were stable and glucose 150's. An ABG was 7.35/59/238. EKG was unchanged. Last HD was [**2166-1-22**]. . In the MICU, patient was put on Bipap which he usually uses at home. Mental status cleared within 5 hours and was thought to be due to medications (ativan and compazine) he received on the floor. He was back to his baseline mental status and was transferred back to floor. . On admission to floor, patient was alert and oriented, asking for pain medication for his feet. He denied dizziness, headache, chest pain, sob, abdominal pain, mild nausea, no vomiting, constipation, no diarrhea. C/O B/L lower extremity pain. Past Medical History: 1. Coronary artery disease: Myocardial infarction in [**2155**], MQWMI in [**2160**]. Most recent cath, [**2163-10-18**]: LCx stenting; previous RCA stent patent at that time. 2. Nonischemic dilated cardiomyopathy; EF [**12-6**] 33%. EF [**2164-1-11**] to 25% 3. Diabetes greater than 20 years; with triopathy. 4. Hypertension. 5. End stage renal disease on hemodialysis, q. Monday, Wednesday and Friday via right arteriovenous fistula. 6. Hypothyroidism. 7. Chronic obstructive pulmonary disease. 8. Hepatitis C. 9. Chronic pancreatitis. 10. Peptic ulcer disease. 11. Right perinephric hematoma; status post embolization. 12. Obstructive sleep apnea on CPAP. 13. Ruptured right groin abscess; recurrent right groin abscess in [**2162-12-4**]. 14. Peripheral [**Year (4 digits) 1106**] disease. 15. Status post R PFA to BK [**Doctor Last Name **] bypasss graft with vein 16. Status post 2nd and 3rd toe amps 17. Status post left CFA to AK [**Doctor Last Name **] with PTFE 18. Status post L inguinal hernia repair 19. Status post umbilical hernia repair 20. Ischemic left foot 21. A - Fib Social History: Social: Lives in [**Location 686**] with wife, has older children tobacco: 1 ppd x 60 yrs. quit 3 months ago, no EtOH Family History: Non contributory Physical Exam: VS - T 97.7 HR 78 BP 138/60 RR 18 O2 98%RA GEN - awake and alert, NAD HEENT- atraumatic, anicteric, pupils 2 mm and reactive CV - RRR, S1, S2 , 3/6 systolic ejection murmur LUSB and apex, no radiation to carotids Lungs - CTAB ABD - soft, NT/ND, no masses EXT - Right 1 st toe amp site w/ decreased serosanguinous drainage (non-purulent), clean, intact, Left foot wound - healing, granulation tissue, no discharge or surrounding erythema PULSES: palpable R. ax-fem BPG, palp R. fem-[**Doctor Last Name **], palpable L. ax-fem BPG, dopplerable L. AKpop-PT [**Name (NI) **] angio w/palp L. fem-AKpop Pertinent Results: [**2166-1-23**] WBC-15.0* RBC-4.06* Hgb-11.9* Hct-37.3* Plt Ct-482* [**2166-3-3**] WBC-8.5 RBC-2.63* Hgb-8.2* Hct-25.3* Plt Ct-218 [**2166-1-23**] Neuts-78.1* Lymphs-12.9* Monos-3.9 Eos-4.1* Baso-1.0 [**2166-1-30**] Neuts-62.4 Lymphs-21.5 Monos-4.9 Eos-9.9* Baso-1.2 [**2166-1-23**] PT-12.5 PTT-30.6 INR(PT)-1.1 [**2166-2-24**] Glucose-75 UreaN-76* Creat-8.4*# Na-132* K-6.5* Cl-95* HCO3-22 [**2166-3-3**] Glucose-90 UreaN-63* Creat-6.9* Na-134 K-5.6* Cl-92* HCO3-30 [**2166-2-24**] Albumin-3.7 Calcium-8.1* Phos-4.6* Mg-2.4 [**2166-3-3**] Calcium-8.6 Phos-2.7 Mg-2.1 Imaging: [**2166-1-23**] 10PM CXR -diffuse interstitial pulmonary edema [**2166-1-23**] 10AM CXR - Likely multifocal pneumonia and mild congestive heart failure [**2166-1-23**] 8:30AM CXR - Bilateral patchy infiltrates likely consistent with multifocal pneumonia. [**2166-1-23**] CTA Abd/Pelvis - Reason: eval for aortic disection, mesenteric ischemia 1. Patchy consolidations at the lung bases along with a large hiatal hernia likely represents aspiration pneumonia. 2. No evidence of aortic dissection or mesenteric ischemia. 3. Unchanged appearance of left inguinal and umbilical hernias. 4. Cholelithiasis without acute cholecystitis. 5. Changed appearance of the femoral-femoral bypass graft of which only the left portion is visible without evidence of contrast within the graft. This patient had a bypass revision in this region. ? 6. Unchanged appearance of both kidneys with multiple cysts, likely representing lithium toxicity. 7. Polychamber cardiomegaly. [**2166-1-23**] CT HEAD - No intracranial hemorrhage or mass effect. Lateral ventricles are normal in size configuration and are unchanged from the prior examination. [**2166-1-28**] CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Reason: Assess for abscesses in abdomen IMPRESSION: 1. No evidence of intra-abdominal occult abscess. 2. Stable appearance to bilateral patchy basal lung consolidation. 3. Unchanged bowel containing left inguinal and umbilical hernias with no evidence of incarceration or obstruction. 4. Cholelithiasis without evidence of acute cholecystitis. 5. Unchanged bilateral cystic kidneys, as mentioned on prior reports may represent lithium toxicity RADIOLOGY [**2166-1-28**] 1:33 PM ART EXT SGL LEVEL Reason: assess w/metatarsal [**Hospital 108561**] [**Hospital 93**] MEDICAL CONDITION: 64 year old man with nonhealing R. great toe amp site, needs revision versus poss. TMA REASON FOR THIS EXAMINATION: assess w/metatarsal PVR's STUDY: Unilateral lower extremity arterial non-invasive at rest. REASON: Non-healing right great toe amputation site. FINDINGS: Single forefoot pulse volume recording was taken in the right lower extremity. There is a severely dampened waveform with approximately 5 mm of deflection. IMPRESSION: Significant right lower extremity arterial occlusive disease. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: WED [**2166-1-29**] 10:46 AM RADIOLOGY [**2166-1-29**] 1:05 PM ART DUP EXT LO UNI;F/U RIGHT Reason: Arterial duplex of RT profunda-[**Doctor Last Name **] bypass and RT BKpop stent [**Hospital 93**] MEDICAL CONDITION: 64 year old man with had right foot toe amp / non healing / Had PVRs on [**1-28**]- now requires duplex of RT profunda-[**Doctor Last Name **] bypass and RT BKpop stent. Patient is at dialysis [**1-29**] am. REASON FOR THIS EXAMINATION: Arterial duplex of RT profunda-[**Doctor Last Name **] bypass and RT BKpop stent-Evaluate for graft stenosis and ?stent occlusion. ARTERIAL DUPLEX LOWER EXTREMITY. REASON: Right foot gangrene patient status post bypass. FINDINGS: Duplex evaluation was performed of the right profunda-to-popliteal graft as well as the popliteal stent, peak systolic velocities in centimeters per seconds are as follows 37, 54, 68, 39 in native proximal vessel, proximal anastomosis, distal anastomosis, and native distal vessel respectively. Within the graft from proximal-to-distal, velocities are 56, 50, 54, 68. Within the popliteal artery stent, velocities are 35, 31, 51, 56. IMPRESSION: Widely patent right profunda to popliteal artery bypass graft as well as popliteal artery stent. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: [**Doctor First Name **] [**2166-1-30**] 1:18 PM . CHEST PORT. LINE PLACEMENT [**2166-1-30**] 12:02 PM 1. Radiopaque PICC wire positioned at cavoatrial junction. 2. Improving CHF. . RADIOLOGY [**2166-2-4**] 1:52 PM ART DUP EXT LO UNI;F/U; ART EXT SGL LEVEL Reason: RLE PVRs/seg pressures and RT profunda to [**Doctor Last Name **] bypass [**Hospital 93**] MEDICAL CONDITION: 64 year old man with nonhealing R. great toe amp site, needs revision versus poss. TMA s/p RT bypass, BK [**Doctor Last Name **] stent angioplasty and angioplasty of TPT and PT on [**1-31**] REASON FOR THIS EXAMINATION: RLE PVRs/seg pressures and RT profunda to [**Doctor Last Name **] bypass HISTORY: 64-year-old man with unhealing right great toe amputation site, status post right iliac to popliteal and profunda femoris to popliteal bypass grafts. RADIOLOGIST: This study was read by Dr. [**First Name (STitle) 4685**] [**Name (STitle) 4686**]. TECHNIQUE: Evaluation of bypass graft patency was done with spectral Doppler ultrasound. Additionally, pulse volume recordings were obtained in the right lower extremity. Both bypass grafts presented patent with a peak systolic velocity of 85 cm/sec in the mid iliac to popliteal PTFE graft, and with velocities ranging between 42 and 96 cm/sec in the right profunda femoris to popliteal bypass. PVRs present moderately decreased amplitudes at the ankle and metatarsal levels on the right. COMPARISON: No significant change as compared to Doppler and PVRs on [**2166-1-29**] and [**2166-1-28**]. IMPRESSION: Patent right lower extremity bypass grafts and decreased right ankle and metatarsal PVRs, not significantly changed from previous. . Cardiology Report ECHO Study Date of [**2166-2-7**] PATIENT/TEST INFORMATION: Indication: Probably vegitation found on tricuspid valve on TTE. Bacteremia with kiebasella, eval for endocarditis. BP (mm Hg): 172/77 HR (bpm): 81 Status: Inpatient Date/Time: [**2166-2-7**] at 16:32 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007W000-0:00 Test Location: West Cath/EP Lab Technical Quality: Adequate MEASUREMENTS: Left Ventricle - Ejection Fraction: 30% (nl >=55%) INTERPRETATION: Findings: LEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA. A mass/thrombus associated with a catheter/pacing wire in the RA or RV. PFO is present. LEFT VENTRICLE: Severely depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve leaflets. No AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Moderately thickened tricuspid valve leaflets. No mass or vegetation on tricuspid valve. Moderate [2+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**] throughout the procedure. Local anesthesia was provided by benzocaine topical spray. The patient was sedated for the TEE. Medications and dosages are listed above (see Test Information section). The posterior pharynx was anesthetized with 2% viscous lidocaine. No TEE related complications. Conclusions: 1. 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 small highly mobile fibrous material associated with a catheter is seen in the right atrium. A patent foramen ovale is present by color Doppler. 2.Overall left ventricular systolic function is severely depressed with globabl hypokinesis EF 30%. 3.Right ventricular chamber size and free wall motion are normal. 4.There are complex (>4mm) atheroma in the aortic arch and descending thoracic aorta. 5.There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. No aortic regurgitation is seen. 6.The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. 7.The tricuspid valve leaflets are moderately thickened. Moderate [2+] tricuspid regurgitation is seen. Impression: No tricuspid valve vegetation. There is fibrinous material associated with/attached to the catheter in the right atrium. Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD on [**2166-2-7**] 18:11. [**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. . RADIOLOGY [**2166-2-10**] 11:21 AM UNILAT UP EXT VEINS US RIGHT Reason: DVT vs. Fluid collection [**Hospital 93**] MEDICAL CONDITION: 64 year old man w/ R. arm dialysis fistula, R. ax to PFA-BK (vein graft) now s/p R1 ray amp REASON FOR THIS EXAMINATION: DVT vs. Fluid collection HISTORY: Right upper extremity swelling. Evaluate for deep venous thrombosis. COMPARISON: [**2166-1-8**]. RIGHT UPPER EXTREMITY ULTRASOUND: Right internal jugular, right subclavian, right axillary, right brachial, right basilic and right cephalic veins were evaluated with grayscale, color, and pulse Doppler imaging. Normal compressibility, color flow, waveforms, and augmentation were demonstrated in all these veins. No intraluminal thrombus was identified. IMPRESSION: No evidence of deep venous thrombosis in the right upper extremity. . RADIOLOGY [**2166-2-11**] 11:50 AM CHEST PORT. LINE PLACEMENT Reason: please check placement l bas picc for abx 60 cm call beeper [**Hospital 93**] MEDICAL CONDITION: 64 year old man with h/o ESRD on HD now SSCP and nausea, now with mental status changes, and desats in to 80s on 2L NC> REASON FOR THIS EXAMINATION: please check placement l bas picc for abx 60 cm call beeper [**10/2601**] with wet read asap thanks AP CHEST, 11:51 A.M., ON [**2-11**] HISTORY: End-stage renal disease with substernal chest pain and nausea. IMPRESSION: AP chest compared to [**1-23**] through 28: Moderate cardiomegaly and mediastinal [**Month (only) 1106**] engorgement are unchanged since [**1-30**]. Bilateral hilar enlargement is also chronic. Residual consolidation at the base of the right lung is stable, perhaps residual edema. Tip of a left PIC catheter projects over the mid SVC. Note is no pneumothorax or pleural effusion. Fullness in the mediastinum, particularly at the thoracic inlet to the right of the trachea is due at least in part to dilated head and neck vessels. The thyroid may also be enlarged. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**] Approved: WED [**2166-2-12**] 5:54 AM . RADIOLOGY [**2166-2-21**] 2:01 PM ART DUP EXT LO UNI;F/U BILAT Reason: [**Month/Day/Year **] PATH - ASSESS: B/L AX FEM, LEFT FEM AK - [**Doctor Last Name **], LEFT [**Hospital 93**] MEDICAL CONDITION: 64 year old man with REASON FOR THIS EXAMINATION: [**Hospital **] PATH - ASSESS: B/L AX FEM, LEFT FEM AK - [**Doctor Last Name **], LEFT AK [**Doctor Last Name **] - DP, RIGHT PROFUNDA TO BK [**Doctor Last Name **], NATIVE PT ARTERIAL STUDY. HISTORY: Bilateral ax-fem, left above knee [**Doctor Last Name **] to DP graft and right profunda to below knee [**Doctor Last Name **] graft. FINDINGS: Doppler evaluation demonstrates patency of both bilateral ax-fem bypass grafts. Velocities on the right range from 60-75 and those on the left are 68-58 cm. The right fem above knee [**Doctor Last Name **] graft demonstrates velocities ranging from 32 cm per second (distal anastomosis) to 86 cm/sec. At the proximal anastomosis, the peak systolic velocity is 46 cm/sec. The native right posterior tibial artery shows velocities ranging from 43-53 cm per second. On the left, the peak systolic velocity within the left fem to above knee [**Doctor Last Name **] graft is 48 cm/sec and that within the graft itself ranging from 18-45 cm/sec, the latter at the distal graft anastomosis. The left [**Doctor Last Name **] to posterior tibial graft shows velocities of between 125 and 31 cm/sec. At the distal anastomosis, the peak systolic velocity is 102 cm/sec and that within the native posterior tibial artery, 62 cm/sec second. Of note is a stent, which appears within the native left popliteal artery. IMPRESSION: Findings as stated above which indicate patency of all grafts interrogated. DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6888**] Approved: SAT [**2166-2-22**] 11:32 AM . EKG: NRS at 80 bpm; LAD; long PR (182ms) and long QTc (469ms); ST depression in V5. . PATHOLOGY: Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/cofc SPECIMEN SUBMITTED: PROXIMAL BONE 1ST METATARSAL, 1ST RAY AMPUTATION, (2). Procedure date Tissue received Report Date Diagnosed by [**2166-2-6**] [**2166-2-6**] [**2166-2-11**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/cma?????? Previous biopsies: [**-7/4883**] 1ST DIGIT, RIGHT FOOT, AND BONE FROM RIGHT FOOT (2). [**-7/3259**] GRAFT. [**Numeric Identifier 108562**] RT GROIN CLOT/FIBROSIS TISSUE. [**Numeric Identifier 108563**] LEFT FOOT DEBRIDEMENT. (and more) DIAGNOSIS A. Bone, proximal right 1st metatarsal: - Bone, articular cartilage and fibrous tissue. - Marrow shows focal sclerosis and acute hemorrhage. B. 1st ray amputation: - Ulcerated skin and subcutaneous tissue. - Scant bone and articular cartilage. Note: No osteomyelitis seen. Clinical: Non-healing right toe. Specimen submitted: 1. Right proximal 1st metatarsal bone. 2. Right 1st right amputation. Gross: The specimen is received fresh, in two parts, each labeled with the patient's name "[**Known firstname **] [**Known lastname 91245**]", and the medical record number. Part 1 is additionally labeled "proximal bone 1st metatarsal, right", and consists of multiple bone fragments, which are represented in A, following decalcification. Part 2 is additionally labeled "1st right amputation", and consists of an ellipse of ulcerated skin and granulation tissue, measuring 4 x 2 cm, and 0.5 cm in depth. Multiple bony fragments are detected in the specimen, and it is represented in B and C, following decalcification. . Microbiology: [**1-16**] right foot wound: klebsiella (esbl) sensitive to zosyn, meropenem, imipenem, unasyn and enterococcus sensitive to PCN, linezolid and ampicillin. . [**2166-1-23**] 10:40 am BLOOD CULTURE AEROBIC BOTTLE (Final [**2166-1-29**]): NO GROWTH. ANAEROBIC BOTTLE (Final [**2166-1-26**]): REPORTED BY PHONE TO [**Doctor Last Name **], [**2166-1-24**], 11:30AM. KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES. KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- R CEFUROXIME------------ =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- =>8 R MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ =>16 R . [**2166-2-6**] 11:10 am TISSUE PROXIMAL 1ST METATARSAL BONE RIGHT. GRAM STAIN (Final [**2166-2-6**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [**2166-2-10**]): KLEBSIELLA PNEUMONIAE. SPARSE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- =>64 R CEFEPIME-------------- 8 S CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 32 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- =>8 R MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ =>16 R ANAEROBIC CULTURE (Final [**2166-2-10**]): NO ANAEROBES ISOLATED. . [**2166-2-25**] 9:40 am SWAB R 1ST TOE AMP SITE. GRAM STAIN (Final [**2166-2-25**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2166-2-27**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH [**2166-1-28**] 10:12 am STOOL CONSISTENCY: LOOSE Source: Stool. OVA + PARASITES (Final [**2166-1-29**]): NO OVA AND PARASITES SEEN. CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2166-1-29**]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. Reference Range: Negative. . Blood Cultures on [**2166-1-23**], [**2166-1-24**], [**2166-1-26**], [**2166-1-26**], [**2166-1-28**] all were negative . OPERATIVE REPORT: POSTOPERATIVE DIAGNOSIS: Nonhealing right foot ulcer. OPERATION: Diagnostic right lower extremity arteriogram via antegrade right axillofemoral approach. Percutaneous balloon angioplasty of the posterior tibialis, tibioperoneal trunk and below-the-knee popliteal. CPT codes [**Numeric Identifier 4237**], [**Numeric Identifier 8881**], [**Numeric Identifier 8882**], [**Numeric Identifier 100842**], [**Numeric Identifier **]. PROCEDURE: With the patient supine on the cardiac catheterization table, after adequate induction of intravenous conscious sedation, the patient's right groin and right side of the abdomen were prepped and draped in the usual sterile fashion. We obtained access via an antegrade puncture through the distal third portion of the right axillofemoral bypass graft. This was done with a micropuncture kit. An 0.035 inch [**Location (un) **] wire was advanced into the distal portion of the graft and a 4-French sheath was placed. Serial multiplanar images with the fraction angiography were obtained of the right lower extremity showing multiple areas of stenoses within the proximal posterior tibialis, tibioperoneal trunk and the previously placed below-the-knee popliteal stent. For that reason we proceeded to exchange our wire for an 0.014 [**Location (un) **] core wire over which a Amphirion 3 x 40 mm balloon was placed. The wire was navigated across the tibial lesions and we proceeded to perform balloon angioplasty of the mid posterior tibialis, the proximal aspect of the posterior tibialis, the full length of the tibioperoneal trunk including the distal aspect of the below-the-knee popliteal stent. The completion arteriogram demonstrated a widely patent stent tibioperoneal trunk and posterior tibialis with preserved 2- vessel runoff down to the foot via a peroneal and posterior tibialis predominately. There was no evidence of significant residual stenoses or flow-limiting dissections. At this point, the wire and catheter were removed and the sheath secured in place for later removal once the ACT is subtherapeutic. The patient tolerated the procedure well. There were no complications. Dr. [**Last Name (STitle) **] was present throughout the procedure. ANGIOGRAPHIC FINDINGS: Patent distal right axillofemoral profunda bypass graft, the anastomoses of the PTFE axillofemoral to profunda to below-the-knee popliteal venous graft is widely patent. There is a widely patent previously placed below-the-knee popliteal stent. The trifurcation is severely diseased with an occluded anterior tibialis and a mildly diseased and small caliber proximal peroneal. The posterior tibialis is open with some mild to moderate stenosis proximally. The distal lower extremity revealed a focal area of stenosis of the mid posterior tibial with a widely patent peroneal. At the foot, the runoff is a given via mainly posterior tibialis, as well as the peroneal, with reconstitution of the distal anterior tibialis which is of the very small caliber and very calcified. The plantar lateral and medial branches are both present and we also see extensive distal plantar and digital branch of stenoses. We then performed successful percutaneous transluminal balloon angioplasty of the focal high-grade stenotic lesion within the mid right posterior tibialis as well as the proximal posterior tibialis. The tibioperoneal trunk and below-the-knee popliteal artery stent were also angioplastied with good results. Completion arteriogram demonstrated widely patent out flow via both posterior tibialis and peroneal. Brief Hospital Course: # PVD: significant vasculopath s/p multiple bypasses. Lactate wnl suggestive against ischemia. Recently admitted with ischemic gangrene of right first and fifth toes. h/o VRE infections. - meropenem started on [**1-24**] and continued until [**2166-3-7**] - RLE angiogram: Diagnostic right lower extremity arteriogram via antegrade right axillofemoral approach. Percutaneous balloon angioplasty of the posterior tibialis, tibioperoneal trunk and below-the-knee popliteal - wound care for right 1st toe consisted of adaptec, betadine swabs with DSD and kerlix; regranex, DSD and kerlix were used for left foot wound - pain controlled initially with IV dilauded but was then transitioned to dilaudid 2-4mg PO q4h prn # PNA/bacteremia: Comfortable without O2 requirement. Multifocal PNA on CXR and Klebsiella 1/4 bottles sensitive to meropenem. Afebrile and blood cultures NGTD since [**1-24**]. - appreciate ID recs, cont meropenem x 4 weeks / This was DC on DC . # Tricuspid endocarditis: diagnosed via ECHO on [**2166-1-28**]. Not hemodynamically significant and no evidence perivalvular extension. ?source = foot. - continue Meropenem per ID x 6 weeks then re-evaluate - if clinically worsens, consider CT [**Doctor First Name **] consult - appreciate [**Doctor First Name 1106**] surgery recs re: foot wounds - placed PICC line [**1-30**] - EKG qod to eval for conduction abnormalities . # Hyperkalemia: Increased since yesterday. No EKG changes or symptoms. - kayexalate today, recheck EKG - will correct at HD today - continue low K+ diet . # End stage renal disease: Continue HD MWF. Continue Sevelamer, Cinacalcet, Nephrocaps. Restarted phos binder. . # Nausea: Resolved. ?related to PNA. - [**Month/Year (2) **], maalox PRN; metoclopramide per home regimen . # CAD: No active issues. ROMI, chest pain free. - Continue [**Month/Year (2) **], statin, [**Month/Year (2) 4532**], ACEI (low dose) - not on BB for unclear reasons . # CHF: No active issues. EF 20%. Euvolemic. Cont ACEi. ?start BB. - daily weights, strict I/O's . # AFib: No active issues. Cont amiodarone; not on coumadin as h/o nephric bleed. . # Diabetes mellitus, type II: HISS, FS QID, diabetic diet . # Hypertension: better after HD, probably fluid overload was contributing on admission. cont ACEi. . # Hypothyroidism: Continue levothyroxine . # COPD/OSA: on CPAP at home but does not use --> d/c'd; nebs PRN . # Hepatitis C: Stable. Most recent viral load ([**1-3**]) was 623,000 IU/mL. ALT of 52 on admission. INR of 1.1; albumin 3.7. Liver appears normal on CT. . # Chronic pancreatitis: No active issues. Amylase mildy elevated with normal lipase. No evidence of pancreatitis on CT. . # Peptic ulcer disease: cont PPI. . # Increased Somnolence: resolved. likely due to medications ativan and compazine since the somnolence occured in close proximity to when he got the medication. cont to avoid benzo's/and other sedating medications. minimize narcotics. . Medications on Admission: MEDICATIONS: 1. Aspirin 81 mg daily 2. Clopidogrel 75 mg daily 3. Atorvastatin 10 mg daily 4. Lisinopril 2.5 mg daily 5. Amiodarone 200 mg daily 6. Sevelamer 800 mg TID 7. Cinacalcet 30 mg daily 8. B Complex-Vitamin C-Folic Acid 1 mg daily 9. Gabapentin 100 mg [**Hospital1 **] 10. Insulin sliding scale 11. Metoclopramide 5 mg QIDACHS 12. Levothyroxine 50 mcg daily 13. Citalopram 20 mg daily 14. Pantoprazole 40 mg daily 15. Zinc Sulfate 220 mg daily 16. Oxycodone-Acetaminophen 5-325 mg [**2-4**] Q4-6H PRN 17. Vancomycin 1 g QHD for 2 weeks (started [**1-17**]) Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 10 days. Disp:*40 Tablet(s)* Refills:*0* 11. Amiodarone 200 mg Tablet Sig: 1.25 Tablets PO DAILY (Daily). 12. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 13. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 14. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for SOB/wheezing. 15. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 16. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 17. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 20. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 21. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 22. Becaplermin 0.01 % Gel Sig: One (1) Appl Topical DAILY (Daily). Disp:*1 Becaplermin (Topical) 0.01 % Gel* Refills:*2* 23. Insulin If you were on insulin / please take your usual dosage Discharge Disposition: Home with Service Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Nonhealing right toe amputation site DM2 ESRD - HD Bactermia PNA Discharge Condition: Stable Discharge Instructions: Please take your medications as prescribed. Please call Dr. [**Name (NI) 22066**] office/return to [**Hospital1 18**] if you have persistent fever (Temp>101.5), increasing pain/redness/swelling/drainage from the surgical sites. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in 2 week Please call ([**Telephone/Fax (1) 1804**] for an appointment. Completed by:[**2166-3-7**]

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icd9cm

[ [ [] ] ]

[ "39.95", "77.48", "39.50", "00.42", "99.04", "88.72", "93.90", "84.11", "38.93", "86.28", "88.48" ]

icd9pcs

[ [ [] ] ]

30812, 30888

25267, 28205

363, 580

30997, 31006

4437, 6752

31283, 31437

3783, 3801

28821, 30789

15843, 15864

30909, 30976

28231, 28798

31030, 31260

10495, 13457

3816, 4418

260, 325

15893, 21229

608, 2519

13489, 13665

21265, 25244

2541, 3631

3647, 3767

27,201

146,240

33489

Discharge summary

report

Admission Date: [**2118-3-16**] Discharge Date: [**2118-3-31**] Date of Birth: [**2058-4-1**] Sex: M Service: NEUROSURGERY Allergies: Penicillin V Potassium / Bactrim / Ativan / Codeine / Levofloxacin Attending:[**First Name3 (LF) 1271**] Chief Complaint: consulted for large right frontal IPH Major Surgical or Invasive Procedure: Craniectomy for removal of large subdural intracranial hemorrhage. History of Present Illness: 59 year old male presented to [**Hospital 14663**] Hospital today with the worst headache of his life and left sided-weakness. He walked into the ER there and quickly decompensated. The patient required intubation because he became obtunded and his right pupil became unreactive. He was also posturing. The CT scan showed a large right IPH and SDH. He was given phosphenytoin and mannitol and med-flighted to [**Hospital1 18**]. Past Medical History: HIV on HAART Social History: homeless, living with family members Family History: NC Physical Exam: T:afebrile BP:150 systolic HR:82-96 O2Sat100% - vented Gen: intubated, posturing. (+) corneals bilaterally, no cough/gag HEENT: Pupils: Right - 5mm, non-reactive. Left 2-1mm Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Skin: The patient has scabs covering all surfaces of his extremities and torso. Neuro: Mental status: Patient is unresponsive and intubated. Cranial Nerves: I: Not tested II: Pupils: Right - 5mm, non-reactive. Left 2-1mm III-XII: unable to test Motor: The patient is decerebrate posturing with bilateral upper extremities. His lower extremities withdraw briskly to noxious stimuli. Sensation: withdraws to noxious Toes upgoing bilaterally Brief Hospital Course: 59 year old male presented to [**Hospital 14663**] Hospital on [**2118-3-16**] with the worst headache of his life and left sided-weakness. He walked into the ER there and quickly decompensated. The patient required intubation because he became obtunded and his right pupil became unreactive. He was also posturing. The CT scan showed a large right IPH and SDH. He was then transferred to our facility. Upon arrival to [**Hospital1 18**], he was determined to require emergent right hemicraniectomy for a large right frontal intracranial hemorrhage. On [**3-18**], his repeated CT scan was stable, with improved post-surgical changes. He did have an angiogram performed that identified an anterior communicating aneurysm (not related to the bleed). [**3-19**] he was extubated however required reintubation secondary to being unable to tolerate his secretions. He was then given repeated trials to wean off the vent but was unsuccessful. He was therefore taken for a PEG and trach on [**3-24**]. Afterwards he was successfully weaned off the vent. In the interim, the path report returned and it showed a likely GBM. This was discussed with the patient and his family with his permission. He was taken back to the OR on [**3-30**] for a flap replacement. He will follow-up with neurosurgery as an outpatient as well as for XRT. Medications on Admission: HIV cocktail Discharge Medications: 1. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 4. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation Q4H (every 4 hours). 5. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 6. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 9. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation Q4H (every 4 hours). 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 11. Senna 8.6 mg Capsule Sig: 1-2 Tablets PO BID (2 times a day) as needed. 12. Atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 15. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed. 16. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO three times a day. Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: 1) Large Rt. frontal intracranial hemorrhage, s/p Right hemicraniectomy and flap replacement 2) GBM 3) HIV Discharge Condition: Stable Discharge Instructions: ?????? Have a 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, excessive bending ?????? You may wash your hair only after staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: PLEASE RETURN TO THE OFFICE IN 10 DAYS FOR REMOVAL OF YOUR STAPLES/SUTURES PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.[**Last Name (STitle) 14074**] TO BE SEEN IN 4 WEEKS. YOU WILL NEED A CAT SCAN OF THE BRAIN Provider: [**Name10 (NameIs) 5005**] [**Last Name (NamePattern4) 5342**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2118-4-11**] 11:30. Located: [**Location (un) 858**] [**Hospital Ward Name 23**] Bldg. (Please call ([**Telephone/Fax (1) 27543**] if you need additional directions or need to change your appointment. [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]

[ "263.9", "518.81", "518.0", "437.3", "191.9", "432.1", "698.3", "728.87", "V60.0", "042", "331.4", "335.22" ]

icd9cm

[ [ [] ] ]

[ "43.11", "38.93", "96.04", "96.71", "87.03", "96.72", "88.41", "96.6", "31.1", "01.24", "99.77", "02.06" ]

icd9pcs

[ [ [] ] ]

4427, 4507

1786, 3120

369, 438

4658, 4667

5986, 6649

1002, 1006

3183, 4404

4528, 4637

3146, 3160

4691, 5963

1021, 1404

291, 331

466, 896

1475, 1762

1419, 1459

918, 932

948, 986

31,910

148,616

6198

Discharge summary

report

Admission Date: [**2109-4-18**] Discharge Date: [**2109-4-26**] Date of Birth: [**2029-10-16**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 663**] Chief Complaint: Altered mental status, loss of responsiveness Major Surgical or Invasive Procedure: None History of Present Illness: Dr. [**Known lastname **] is a 79 year old male with paroxysmal atrial fibrillation on warfarin, prior admissions for S. pneumo sepsis ([**1-5**]), stage I colon Ca s/p sigmoidectomy and hx of pulmonary fibrosis [**3-2**] amiodarone who was transferred from [**Hospital **] rehab for decreased responsiveness and sleepiness. . Patient continues to be drowsy and falls asleep frequently during the interview but is arousable. He remembers little about the past week, stating that he is "here to be evaluated for a lung transplant", but says he has been sleepier than usual over the past week. He denies dyspnea or PND at any time during the past week. He also reports a "bad cough" productive of whitish sputum without hemoptysis. He denies fevers or chills, nausea/vomiting, night sweats, myalgias or any chest pain or pleuritic chest pain with the cough. In addition, patient states that he received a flu shot this season, and denied any sick contacts with colds or influenza in the rehab. . He also says that since he stopped amiodarone 2 months ago "my atrial fibrillation has not been well controlled", but denies any symptoms from it such as lightheadedness/dizziness, chest pain or dyspnea. . Per NH notes, patient had "sundowning" for over 4 weeks with slight delirium and has been treated with risperidone increasing from 0.25mg to 1mg with no effect on his delirium. Apparently pt had been brought to [**Hospital1 18**] on [**4-15**] for head CT and chest CT/CTA for SOB before his current admission on [**4-27**]. . In the ED, patient was started on levo/flagyl for ?aspiration pneumonia, and also given 50mg metoprolol for rate control of his atrial fibrillation. He was given a trial of BIPAP which increased his O2 sat to 95% on 2L O2, but apparently did not decrease his hypercarbia/hypercapnia from pCO2 = 60. He was switched to 2L NC with continued O2 sat of 95%, and transferred to the floor. . Past Medical History: 1. Stage I T2M0 sigmoid colon adenocarcinoma, s/p lap [**Date Range 65**] ([**2109-2-25**]) 2. S. pneumoniae sepsis, seeded from septic wrist ([**2110-1-15**]) 3. Paroxsymal atrial fibrillation formerly on amiodarone, unable to maintain sinus even with DC cardioversion, so amiodarone was discontinued due to possible lung toxicity. Now on metoprolol+ diltiazem+digoxin and warfarin. 4. Amiodarone related pulmonary fibrosis 5. Spinal stenosis and sciatica 6. Low back pain - hx of disc herniation at age 35 with surgery in recent past. 7. Hx of melanoma on R chest s/p excision and extensive right axillary node dissection in [**2061**] 8. Glaucoma 9. Detached retina 10. Dysphagia of unclear etiology, s/p PEG [**1-27**] 11. Pacemaker ([**Company 1543**] EnPulse) 12. PPD positive status per PCP, [**Name10 (NameIs) **] unclear 13. Pseudogout (diagnosed on joint aspiration [**1-/2109**]) 14. EtOH abuse 15. MRSA infection of the R olecranon bursa with associated cellulitis ([**2105**]) 16. Recent hx of Pseudomonas UTI treated with 7 day course of cefepime (per NH records) . PAST SURGICAL HX: ================= 1. Laparoscopic sigmoid colectomy for colon adenocarcinoma with bladder injury, no evidence of metastasis, stage I T2N0 ([**2109-2-25**], Dr. [**Last Name (STitle) 1120**] 2. I+D of L Wrist abscess ([**2109-1-14**], Dr. [**Last Name (STitle) **] Social History: JOB: Former Chief of Anesthesia for over 20 years at the [**Hospital **] hospital. LIVING SITUATION: He currently lives by himself and is able to live independently. His wife died of PBC. His son, Chip, is a computer scientist who lives in [**Location **] and is his major support. He also has a daughter, age 40, who is a lawyer in [**Name (NI) 7349**]. ETOH: Has prior EtOH abuse issues per PCP, [**Name10 (NameIs) 24174**] to drinking "1 drink a night" 6 months ago, but stopped due to illness. TOBACCO: Quit smoking when he was 40 (~39 years ago), has 15 pack-year history prior. DRUGS: Denies any illicit drugs. Family History: Father died at age 70 of DM, CVA. Mother died at age 85 of CVA. Son and daughter are healthy, patient denies family hx of cancer. Physical Exam: VS: T:98.2 , BP: 101/65, HR:110, RR:28, O2:952L GEN: elderly man, sleepy, arousable, answers questions but falls asleep frequently during interview HEENT: NCAT, dry MM, clear OP, no exudates NECK: Supple, no LAD, no JVP CHEST: CTA bil CV: nml s1 s2 irregula, irregular no m/r/g ABD: soft, ntnd, G tube in place without surrounding edema or eythema EXT: no c/c/e 2+ DP pulses bilaterally NEURO: A+O to place and month, language is fluent but often falls asleep, strength 4+/5 LUE strength with 5/5 strength otherwise, sensation to light touch grossly intact, neg babinski Pertinent Results: Admission labs: [**2109-4-17**] 08:30PM WBC-11.3* RBC-4.71# HGB-13.5*# HCT-41.8# MCV-89# MCH-28.6# MCHC-32.3 RDW-14.9 [**2109-4-17**] 08:30PM NEUTS-77.8* LYMPHS-14.2* MONOS-5.5 EOS-2.4 BASOS-0.1 [**2109-4-17**] 08:30PM PLT COUNT-335 [**2109-4-17**] 08:30PM GLUCOSE-90 UREA N-22* CREAT-0.7 SODIUM-131* POTASSIUM-4.8 CHLORIDE-89* TOTAL CO2-39* ANION GAP-8 [**2109-4-17**] 08:30PM ALT(SGPT)-32 AST(SGOT)-30 LD(LDH)-238 CK(CPK)-21* ALK PHOS-165* AMYLASE-98 TOT BILI-0.3 [**2109-4-17**] 08:30PM LIPASE-41 [**2109-4-17**] 08:36PM LACTATE-0.9 [**2109-4-17**] 08:30PM PT-28.0* PTT-31.7 INR(PT)-2.8* Brief Hospital Course: A/P: 79 yo M with PMH of PAF, colon Ca s/p sigmoidectomy, amiorodarone lung toxicity presenting with increased somnolence and found to be hypercarbic on ABG. . #. Hypercarbic Resp Failure: With input from Pulmonology and Nephrology, pt was felt to have a primary resp acidosis secondary to oversedation from ripseridol and tramadol. His respiratory acidosis improved off sedating medications. In addition, pt has underlying intertitial lung disease from amiodarone, which appears improved on CTA. Pt was initially treated with levo/flagyl for question of aspiration pneumonia which has been discontinued as pt does not clinically appear to have a pneumonia. He continues to clinically improve off antibiotics. Pt still requires intermittent 1-2 L O2 by NC. Pt will follow up with pulmonary as an outpatient. . # MS changes: MS changes probably multifactorial from hypercapnea and oversedation from medications. Neurology was consulted. EEG was normal. They had also recommended LP; however, pt declined this procedure as his mental status improved. With his clinical improvement and lack of fever and other symptoms, deferring LP was not felt to be unreasonable. His mental status is now at/near baseline and he is currently alert and oriented x3. Pt is to follow up with Neurology at ECF. . # Paroxysmal A-fib: Pt was continued on coumadin, dilt, digoxin, and metoprolol. Patient was briefly in the MICU on [**4-20**] because of borderline hypotension and afib with RVR to 140s. He had missed several doses of nodal agents because PEG was clogged. His PEG tube is now functional. HR is now controlled in the 80-100. . # Transient hypotension: Patient was briefly in the MICU for hypotension, in setting of receiving diltiazem and lopressor to control his RVR. The hypotension had not responded to 1.5L of fluid boluses on the floor. He continued to receive fluids overnight and is now normotensive w/ systolics in 100s. He is off IVFs. . # Leukocytosis: This appears to be chronic, though source is unclear. . # Dysphagia: Pt has a PEG tube that was placed by IR 3 months ago. It had clogged on [**4-19**] but is now functioning. Speech and swallow evaluation, including video swallow, resulted in the following recommendations: 1. Suggest a PO diet of nectar thick liquids and soft consistency solids. 2. Take liquids by straw. Tuck your chin to your chest before you swallow. 3. Take [**4-2**] swallows for each bite and sip. 4. Follow each bite with a sip of liquid. 5. Pills crushed with purees. 6. Continue with supplemental nutrition via the feeding tube as needed. Consult nutrition for recommendations. . # Decubitus ulcers: He was evaluated by wound care nursing. Recommendations are: 1. Pressure redistribution per pressure ulcer guidelines 2. Turn and reposition q 2 hours and prn 3. Foam cushion to chair when sitting 4. Cleanse skin with gentle foam cleanser, pat dry, apply thin layer of critic aid with antifungal moisture barrier ointment. Reapply after every 3 rd cleansing. . # COMM: [**Name (NI) **]/HCP Chip - cell([**Telephone/Fax (1) 24175**] . # CODE STATUS: FULL . # DISPO: ECF Medications on Admission: 1. Albuterol sulfate 2.5mg/0.5ml soln 1 NEB QID 2. Ascorbic acid 500mg tab [**Hospital1 **] 3. Cyanocobalamin 500mcg tab DAILY 4. Digoxin 0.125mg tab qT/Th/S 5. Digoxin 0.25mg tab qSu/Mo/We/Fr 6. Diltiazem (Cardizem) 60mg q0600/1200/1800/2200, hold for SBP <95, HR <60 7. Guaifenesin 200mg PO TID 8. Ipratropium Bromide 0.02% soln NEB QID 9. Lansoprazole 30mg DAILY 10. Metoprolol Tartrate 50mg [**Hospital1 **], hold for SBP <95, HR <60 11. Miconazole Nitrate powder, to sacrum TID 12. Nystatin 10ml PO TID 13. Risperidone 1mg PO DAILY 14. Sodium Bicarbonate 8.4% vial 10cc with Lansoprazole VT DAILY 15. Thiamine 100mg tab VT DAILY 16. Timolol maleate 0.25% drops, 1 drop to each eye [**Hospital1 **] 17. Warfarin 2.5mg PO DAILY 18. Zinc sulfate 220mg capsule VT DAILY PRN Meds: 19. Acetaminophen Elixir 650mg/20ml VT Q4H:PRN 20. Albuterol Sulfate 2.5mg/0.5ml Soln NEB Q4H:PRN SOB, wheezing 21. Aquaphor healing ointment [**Hospital1 **]:PRN for dry skin 22. Ipratropium 0.02% soln Q4H:PRN for SOB, wheezing 23. Lactulose 20g/30ml cup VT DAILY:PRN constipation 24. Lidocaine patch 5% to back R Lumbar, max 12 hours TP DAILY:PRN pain 25. Miconazole nitrate Topical [**Hospital1 **]:PRN Rash 26. Miracle Cream (Bacitracin, Vit A&D, Zinc oxide ointment) Topical to sacrum TID:PRN rash 27. Risperidone 0.25mg PO BID:PRN confusion 28. Tramadol 50mg PO Q8H:PRN pain [**7-9**] max dose 300mg/day 29. Tramadol 25mg PO Q8H:PRN pain [**2-2**] max dose 300mg/day . Discharge Medications: 1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 2. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q4H (every 4 hours) as needed for wheezing/dyspnea. 3. Zinc Sulfate 220 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY (Daily). 4. Ascorbic Acid 90 mg/mL Drops [**Last Name (STitle) **]: Five Hundred Four (504) mg PO DAILY (Daily). 5. Thiamine HCl 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 6. Digoxin 50 mcg/mL Solution [**Last Name (STitle) **]: 0.125 mg PO DAILY (Daily). 7. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg PO BID (2 times a day). 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 9. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day) as needed. 10. Warfarin 2.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY16 (Once Daily at 16). 11. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as needed. 12. Diltiazem HCl 60 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID (4 times a day). 13. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Respiratory Failure Mental status changes Paroxysmal atrial fibrillation Transient hypotension Dysphagia Pressure ulcers Discharge Condition: Stable, A&Ox3 Discharge Instructions: You were admitted for increased somnolence. This is suspected to be due to the combination of risperidol and tramadol. Your somnolence has greatly improved. Neurology has been consulted. EEG was normal. You have declined to have a lumbar puncture; however, you are doing well clinically. Please continue to take your medications as prescribed. Please follow up with your physicians. Followup Instructions: Please follow up with your primary care provider [**Last Name (NamePattern4) **]. [**First Name (STitle) **] within 4 weeks. His clinic number is [**Telephone/Fax (1) 250**]. Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from Pulmonology regarding your amiodarone toxicity with 2 weeks. His clinic number is ([**Telephone/Fax (1) 513**]. Please also follow up with Neurology within 2 weeks. The clinic number is ([**Telephone/Fax (1) 2528**].

[ "458.29", "427.31", "E942.0", "V44.1", "E939.3", "707.03", "276.2", "515", "518.81", "E935.2", "V10.05", "292.85", "V58.61" ]

icd9cm

[ [ [] ] ]

[ "96.6" ]

icd9pcs

[ [ [] ] ]

11826, 11905

5717, 8848

361, 368

12070, 12086

5086, 5086

12523, 13020

4349, 4480

10354, 11803

11926, 12049

8874, 10331

12110, 12500

4495, 5067

276, 323

396, 2311

5102, 5694

2333, 3699

3715, 4333

4,459

194,222

51928

Discharge summary

report

Admission Date: [**2173-4-20**] Discharge Date: [**2173-5-4**] Date of Birth: [**2093-8-18**] Sex: F Service: NEUROSURGERY Allergies: Demerol / Floxin / Erythromycin Base / Codeine / Ciprofloxacin / Ceclor / Tetracycline / Diovan / Avelox Attending:[**First Name3 (LF) 2724**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: Ventriculostomy drain R occipital craniotomy w/evacuation History of Present Illness: 79 year-old woman washing up this am who called her daughter and stated that she was not feeling well. Her sister called his brother [**Name (NI) 107507**] on her, which she was still in the bathroom face flushed, diaphoretic, incoherent. EMS called in patient arrived to [**Hospital1 18**] with code stroke, her initial exam per neurology resident report was alert, following simple commands, left facial droop and an left drift, able lift bilateral lower extremities against gravity, and dysarthric. GCS 7 at arrival to ED. Head CT demonstrated R cerebellar hemorrhage. Pt electively intubated in the ED s/p these findings. Past Medical History: 1. TIA's in past: p/w slurred speech, dizziness, left facial droop-all in the setting of hyponatremia. 2. Congestive heart failure [**4-/2167**] with a normal echocardiogram in '[**68**]. 3. Hypertension. 4. Gastroesophageal reflux disease with hiatal hernia. 5. Diverticulosis. 6. Osteoporosis with multiple fractures. 7. Mitral valve prolapse. 8. Total abdominal hysterectomy. 9. Hyponatremia. 10. SIADH. 11. Multiple bouts of cystitis. 12. Migraine headaches Social History: She is married and lives with her husband (82) and son. She is ambulatory with a pronged cane at baseline. She has never smoked and does not drink alcohol. Family History: No family hx of stroke or ICH. Sister recently died of nasopharyngeal cancer. Physical Exam: Gen: intubated, unresponsive HEENT: no carotid bruits, no scleral hemorrhage, or icteria. Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. No C/C/E. Neuro: Intubated, unresponsive. Right Pupil 3mm to 2mm reactive, left pupil is nonreactive to light. Corneal reflexes and cough reflex are present. Right facial droop on rest No movement on the right upper extremity Withdraws on left upper extremity to noxious stimuli Triple flexion on bilateral lower extremities Pertinent Results: Head CT [**2173-4-20**]: A large, acute, mostly right cerebellar hemorrhage. Fourth ventricle is not identified concerning for a development of hydrocephalus. There is no evidence of hydrocephalus yet. Subdural hematoma along the left tentorium. Blood in the right sphenoid sinus. Head CT [**2173-4-22**]: Status post evacuation of cerebellar hemorrhage, with overall unchanged appearance of the brain with residual hemorrhage in posterior fossa and arund the ventricular catheter. Brief Hospital Course: Patient was seen by the stroke team initially and then by the neurosurgery team after she was diagnosed with a R cerebellar hemorrhage. A ventriculostomy drain was placed at the bedside and an MRI was performed which demonstrated a question of increased pressure and the risk of impending herniation. The patient was emergently consented via her family and taken to the operating room for an occipital craniotomy with evacuation of the hemorrhage. She was transferred intubated to the SICU where her blood pressure was controlled, neuro checks were performed and she was carefully monitored. She remained stable, however, was minimally responsive off sedation. POD1 she was noted to be in rate controlled atrial fibrillation and a cardiology consult was obtained. They recommended rate control with metoprolol and amiodarone for an attempt at conversion. Over the next few days, she was in and out of atrial fibrillation with normal blood pressures. At this time, her ventriculostomy drain was in place with normal ICPs. On POD 4 her ventriculostomy drain was d/ced without any complication. Over the next few days her mental status improved, she opened her eyes and did follow simple commands. Nutrition was maintained with tube feeds via a dobhoff tube. POD 8 a tracheostomy was placed at the bedside. Per her families' wishes, a PEG tube was deferred. She was weaned to trach mask and remained afebrile and stable. Patient at this point was in NSR and cardiology did recommend an amiodarone taper. Over the next few days, despite being afebrile, pt's WBC did continue to increase, peaking at 24,000. Pancultures were sent which were positive for Pseudomonas Aeruginosa in her blood and on her CVL catheter tip. She was started on Zosyn for Pseudomonas coverage. Her WBC did trend down, and she remained afebrile and stable. Prior to discharge, a postpyloric feeding tube was placed in interventional radiology and the patient was started on tube feeds. She was discharged to rehabilitation on POD 14 in stable condition. Medications on Admission: Inderal 10mg TID ASA 81mg qd Flonase Tylenol Miacalcin NSD Tylenol PRN Discharge Medications: 1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 2. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig: One (1) dose Nasal DAILY (Daily): alternate each nostril. 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) inj Injection [**Hospital1 **] (2 times a day). 4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 6. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 7. Pantoprazole 40 mg IV Q24H 8. Morphine Sulfate 2-4 mg IV Q4H:PRN 9. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO twice a day for 1 weeks: one week duration from [**Date range (1) 102994**]. Disp:*14 Tablet(s)* Refills:*0* 10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: this is maintenance dose and should start on [**5-9**]. Disp:*30 Tablet(s)* Refills:*2* 11. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: 4.5 Recon Solns Intravenous Q8H (every 8 hours) for 16 days. Disp:*216 Recon Soln(s)* Refills:*0* 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed). 14. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 15. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) for 7 days. 16. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): under breasts. 17. Diphenhydramine HCl 50 mg/mL Solution Sig: Twenty Five (25) mg Injection Q6H (every 6 hours) as needed. 18. HydrALAZINE HCl 10 mg IV Q6H:PRN SBP>140 19. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days. Discharge Disposition: Extended Care Facility: [**Hospital 100**] Rehab Facility Discharge Diagnosis: R cerebellar hemorrhage Discharge Condition: Stable Discharge Instructions: Please come to the emergency room if you have fever >101.4F, nausea or vomiting, shortness of breath, or persistent bleeding/swelling/redness from your surgical site. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 548**] in [**4-22**] weeks. Call his office at [**Telephone/Fax (1) 1669**] for an appointment.

[ "790.7", "486", "996.62", "E930.5", "401.9", "428.0", "431", "427.31", "348.4", "693.0", "253.6", "518.5", "041.7" ]

icd9cm

[ [ [] ] ]

[ "01.39", "96.6", "31.1", "02.39", "96.04", "96.72" ]

icd9pcs

[ [ [] ] ]

6926, 6986

2935, 4960

390, 450

7054, 7063

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7279, 7426

1784, 1865

5082, 6903

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4986, 5059

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1609, 1768

56,165

135,230

36224

Discharge summary

report

Admission Date: [**2179-7-3**] Discharge Date: [**2179-7-9**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 905**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname **] is an 89 year old male with past medical history of hyperlipidemia and pulmonary embolism who presented to [**Hospital1 **] [**Location (un) 620**] with shortness of breath. Of note, he was recently admitted to [**Hospital1 **] [**Location (un) 620**] from [**2179-6-20**] to [**2179-6-22**] after presenting with bradycardia from his nursing home. At that time he endorsed back pain, some wheezing, and dizziness. he was evaluated by pulmonary, and it was felt he likely had an upper respiratory tract infection. He received antibiotics (unknown which--discharge summary reports they were "broadened" when patient was febrile); he was eventually discharged on azithromycin. He returned to the [**Hospital1 **] [**Location (un) 620**] ED today due to continued respiratory symptoms and a few days of small-volume hemoptysis. CT scan chest today was remarkable for a cavitary left lung lesion. There is a question of TB as etiology since patient did report a positive PPD test when he was 12 and was never placed on prophylaxis. Patient transferred to [**Hospital1 18**] for further management. In the [**Hospital1 18**] ED, initial vital signs were: T 97.8 P 66 BP 130/71 R 18 O2 sat- 92% on 5L. Patient received dose of vanc and zosyn in the ED. Seen by IP in the ED- will be available if needed. Thoracics was also consulted in the ED. Given increased oxygen requirement and possible need for bronchoscopy, patient was admitted to the MICU team. On the floor, patient was doing well. Denied any shortness of breath, chest pain, dizziness. He did have a productive cough- no blood seen in sputum. Patient denies recent travel history, sick contacts, night sweats. He does report intentional weight loss via diet and exercise. Review of systems: (+) Per HPI- cough and shortness of breath (-) Denies fever, chills, night sweats, recent unintentional weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies 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: - Hyperlipidemia - BPH - History of pulmonary embolism - Hypertension - Gallstones - Cataracts Social History: Social History: [**Hospital3 **] home, fairly independent. Artillery division in WWII. Denies any recent travel history. Does have hx of positive PPD at age 12 that was never treated. - Tobacco: Denies - Alcohol: Denies - Illicits: Denies Family History: Notable for bladder cancer in his father and pancreatic cancer in mother. Physical Exam: General: Alert, oriented, no acute distress. Mild cough. Conversational with no difficulty speaking/breathing HEENT: Sclera anicteric, MMM, oropharynx clear. NC in place. Neck: supple, JVP not elevated, no LAD Lungs: Rhonchorous breath sounds 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 Pertinent Results: Admission Labs: [**2179-7-3**] 02:20PM WBC-9.7 RBC-4.96 HGB-14.8 HCT-45.2 MCV-91 MCH-29.8 MCHC-32.7 RDW-13.3 [**2179-7-3**] 02:20PM NEUTS-77.4* LYMPHS-15.0* MONOS-5.3 EOS-1.9 BASOS-0.4 [**2179-7-3**] 02:20PM PLT COUNT-296 [**2179-7-3**] 02:20PM PT-12.6 PTT-25.6 INR(PT)-1.1 [**2179-7-3**] 02:20PM GLUCOSE-59* UREA N-20 CREAT-1.1 SODIUM-141 POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-29 ANION GAP-13 [**2179-7-3**] 02:36PM LACTATE-2.3* [**2179-7-3**] 10:26PM PT-13.4 PTT-26.7 INR(PT)-1.1 [**2179-7-3**] 10:26PM PLT SMR-NORMAL PLT COUNT-262 Studies: OSH: CT Chest ([**7-3**])- 1. NEW BILATERAL LOWER LOBE PNEUMONIA COMPARED TO [**2179-6-21**] WITH LARGE CAVITARY LESION VERSUS LOCULATED HYDROPNEUMOTHORAX WITH AIR FLUID LEVEL EXTENDING OBLIQUELY ALONG THE COURSE OF THE MAJOR FISSURE ON THE LEFT. NO EVIDENCE OF PULMONARY EMBOLUS; A DIMINUTIVE VESSEL WITHIN THE AREA OF PNEUMONIA [**Month (only) **] REFLECT BASAL CONSTRUCTION OR COMPRESSION. BIBASILAR BRONCHIECTASIS WITH AREAS OF MUCUS PLUGGING, APPEARING NEW FROM THE PREVIOUS EXAMINATION. 2. PULMONARY ARTERY ENLARGEMENT CONSISTENT WITH PULMONARY ARTERY HYPERTENSION. AORTIC AND CORONARY ARTERY VASCULAR CALCIFICATIONS CONSISTENT WITH ATHEROMATOUS DISEASE. . EKG [**7-3**]: Sinus rhythm. Probable anterior wall myocardial infarction of indeterminate age. Diffuse T wave flattening which is non-specific. No previous tracing available for comparison. . CXR [**7-5**]: No substantial opacification in the lungs is left lower lobe with volume loss indicates this is largely atelectasis. A smaller concurrent pneumonia could be present there and in a small region of opacification projecting inferior to the minor fissure on the right. Small left pleural effusion is probably present, increased since the earlier study. Upper lungs clear. Heart size normal. CT chest [**2179-7-6**]: Left lower lobe pneumonia. Air collection with small amount of fluid paralleling the left major fissure just superior to the left lower lobe consolidation could be a loculated hydropneumothorax. There is no evident pneumothorax in the left apices or on the right side. Coronary calcifications. Hiatal hernia. Evidence of granulomatous infection in the liver and spleen. Brief Hospital Course: 89 year old male with h/o HL, HTN, and PE who presented to [**Hospital1 **] [**Location (un) 620**] with shortness of breath and was admitted to the MICU [**2179-7-3**] for a cavitary lung lesion and hypoxia, transferred to the floor [**2179-7-6**]. . #. Cavitary pneumonia: Patient admitted to the MICU for increased oxygen requirement and possibility of urgent bronchoscopy. He remained on oxygen throughout his stay in the ICU. He did have a few episodes of desaturation that each resolved with nebs and chest PT. He continued to have a productive cough with some blood streaking in his sputum. He was initially on vanc/zosyn but was eventually switched to unasyn for improved anaerobic coverage for his likely aspiration PNA. He was kept in respiratory isolation until he was ruled out for TB. He denied fevers, chills, weight loss (unintentional) and night sweats. He underwent repeat CT chest on [**2179-7-6**]. On [**7-8**], IV unasyn was discontinued and he was switched to PO augmentin. Patient is to complete a four week course of augmentin. A swallow eval was done with no acute concerns but do recommend diet with reflux precautions and possibly outpatient f/u for further assessment. Nebs were stopped [**7-8**] and oxygen was weaned. Patient was maintaining SpO2 > 94% with 3 L NC. Patient was discharged home with supplemental oxygen that should be weaned over the following month. Recommend follow up chest x-ray in [**6-22**] weeks to ensure resolution. . #. CAD: Continued his home statin. Aspirin was initially held due to recent hemoptysis but restarted at discharge. . #. Communication: Daughter [**Name (NI) **] [**Telephone/Fax (1) 82117**], and Son [**Telephone/Fax (1) 82118**] . #. Code status: Full (discussed with patient) . # Dispo: home to [**Hospital3 **] facility with home PT and VNA services Medications on Admission: Aspirin 81 mg daily Ranitidine 150 mg b.i.d. Folic acid 1 mg Simvastatin 20 mg daily Discharge Medications: 1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Amoxicillin-Pot Clavulanate 250-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 4 weeks. Disp:*84 Tablet(s)* Refills:*0* 6. Guaifenesin 400 mg Tablet Sig: One (1) Tablet PO three times a day as needed for cough for 4 weeks. Disp:*90 Tablet(s)* Refills:*0* 7. Supplemental Oxygen Please provide continuous supplemental oxygen [**1-17**] LPM via nasal cannula. Pulse dose for portability. Discharge Disposition: Home With Service Facility: [**Location (un) **] Home Health Care Discharge Diagnosis: Primary Diagnosis: Cavitary Pneumonia . Secondary Diagnosis: Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (rolling walker). Oxygen saturation with ambulation 90-95% on 3 L NC. Discharge Instructions: You were admitted to the hospital due to coughing up blood. Your oxygen level in your blood was also low. You were found to have a pneumonia and a cavitary lung lesion. You were treated with IV antibiotics and your coughing and oxygen levels improved. You were switched to oral antibiotics on discharge. You will continue to need supplemental oxygen over the next few weeks. Once your oxygen levels returned to [**Location 213**] you will be able to discontinue the supplemental oxygen. . The following changes were made to your home medications: 1) START Augmentin 1 tablet by mouth every 8 hours for 1 month. This is antibiotic to help treat your infection. 2) START Guaifenesin 1 tablet by mouth every 4 to 6 hours as needed for cough suppression. .. Followup Instructions: You have the following appointments scheduled: Department: [**Hospital **] HEALTHCARE OF [**Location (un) **] When: THURSDAY [**2179-7-22**] at 02:50 PM With: [**First Name11 (Name Pattern1) 20**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3070**] Building: [**Street Address(2) 8172**] ([**Location (un) 620**], MA) Ground Campus: OFF CAMPUS Best Parking: Parking on Site . Department: [**Hospital **] HEALTHCARE OF [**Location (un) **] When: TUESDAY [**2179-8-17**] at 10:40 AM With: [**First Name11 (Name Pattern1) 20**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3070**] Building: [**Street Address(2) 8172**] ([**Location (un) 620**], MA) Ground Campus: OFF CAMPUS Best Parking: Parking on Site [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

[ "V12.51", "600.00", "513.0", "786.3", "401.9", "494.0", "507.0", "511.89", "799.02" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8498, 8566

5832, 7672

279, 286

8684, 8684

3590, 3590

9700, 10632

2954, 3029

7807, 8475

8587, 8587

7698, 7784

8919, 9451

3044, 3571

9469, 9677

2099, 2560

220, 241

314, 2080

8648, 8663

3606, 5809

8606, 8627

8699, 8895

2582, 2678

2710, 2938

25,941

115,461

3798+55505

Discharge summary

report+addendum

Admission Date: [**2185-7-6**] Discharge Date: [**2185-7-15**] Date of Birth: [**2136-12-24**] Sex: F Service: CHIEF COMPLAINT: Fevers. HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old morbidly obese female with a past medical history significant for insulin-dependent diabetes mellitus complicated by severe gastroparesis (on intermittent total parenteral nutrition), coronary artery disease (status post coronary artery bypass graft in [**2179**]), sarcoidosis (status post tracheostomy), and multiple admissions for line an urinary tract infections (most recently for a Escherichia coli resistant emphysematous cystitis and Staphylococcus epidermidis line infection treated with an 8-week course of meropenem and linezolid) who presents with 24 hours of fevers, shaking chills, nausea, vomiting, shortness of breath, and complaints of foul-smelling urine. The patient was recently admitted to [**Hospital1 190**] from [**5-24**] to [**5-28**] for emphysematous cystitis with multiple drug resistant Escherichia coli. The patient was discharged to a rehabilitation facility and treated with an 8-week course of broad spectrum antibiotic of meropenem and linezolid with reported resolution of the urinary tract infection. The patient was recently discharged from rehabilitation to home; and while at home developed the acute onset of fevers to 103, associated with shaking chills, nausea, vomiting, and shortness of breath. The patient also notes a pustular discharge from her right upper extremity peripherally inserted central catheter line site through which she received total parenteral nutrition. The peripherally inserted central catheter line was placed during her prior hospitalization. In the Emergency Department, the patient was found febrile to 103.3 and hemodynamically unstable with a blood pressure of 86/39, heart rate was 119, and oxygen saturation was 100% on a 10-liter tracheal mask. While in the Emergency Department, the patient's blood pressure dropped to a systolic blood pressure in the 60s, and the patient was started on aggressive intravenous hydration as well as dopamine for blood pressure support. The peripherally inserted central catheter line site was noted to be markedly erythematous with pustular discharge. The peripherally inserted central catheter line was removed, and the patient was meropenem and linezolid empirically. An ultrasound of the right upper extremity demonstrated a thrombus of the distal right brachial vein; however, no abscess was noted. PAST MEDICAL HISTORY: 1. Type 1 diabetes mellitus diagnosed at the age of 16. 2. Morbid obesity. 3. History of emphysematous cystitis in [**2185-5-10**] with resistant Escherichia coli; treated with a course of meropenem. 4. History of vancomycin-resistant Staphylococcus epidermidis as well as methicillin-resistant Staphylococcus aureus. 5. History of sternotomy; status post osteomyelitis following coronary artery bypass graft in [**2179**]. 6. History of coronary artery disease; status post coronary artery bypass graft in [**2179**] (with left internal mammary artery to the left anterior descending artery, saphenous vein graft to the first obtuse marginal, and saphenous vein graft to second obtuse marginal) with an ejection fraction of 40% in [**2185-5-10**] (known to have reversible defects). 7. Hypertension. 8. Asthma. 9. History of sarcoidosis with upper airway obstruction leading to permanent tracheostomy and history of mucus plugging. 10. History of pleural effusions with atypical cells. 11. History of neurogenic bladder with urinary incontinence as well as retention. 12. History of mild chronic renal insufficiency with proteinuria. 13. History of depression. 14. History of severe gastroparesis; status post gastrojejunostomy tube placement in [**2184-12-10**] requiring intermittent total parenteral nutrition. 15. Status post cholecystectomy as well as appendectomy. 16. History of small-bowel obstruction; status post small-bowel resection. 17. Iron deficiency anemia. 18. History of peripheral neuropathy. 19. History of bilateral vitrectomy and multiple laser surgeries. ALLERGIES: Allergies included VANCOMYCIN (with a reaction of leukocytoclastic vasculitis), PAPER TAPE, and INTRAVENOUS DYE. MEDICATIONS ON ADMISSION: 1. Multivitamin one tablet p.o. every day. 2. Reglan 10 mg p.o. three times per day. 3. Zofran 8 mg p.o. four times per day as needed. 4. Compazine 10 mg p.o. four times per day as needed (for nausea). 5. Protonix 40 mg p.o. once per day. 6. Neurontin 300 mg p.o. q.a.m. and 300 mg p.o. at noon and 400 mg p.o. q.h.s. 7. Lopressor 25 mg p.o. twice per day. 8. Ultram 50 mg p.o. three times per day. 9. Darvocet N twice per day. 10. Cogentin 2 mg p.o. twice per day. 11. NPH 30 units subcutaneously q.a.m. and 20 units subcutaneously q.p.m. with sliding-scale prior to meals. SOCIAL HISTORY: The patient lives with a partner who is a nurse as well as the partner's mother. She denies current alcohol use and reports a distant history of tobacco use. FAMILY HISTORY: Family history is notable for diabetes mellitus, hypercholesterolemia, and coronary artery disease. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed temperature was 103.3, blood pressure was 79/33, heart rate was 99, respiratory rate was 25, and oxygen saturation was 100% on 10-liter tracheal mask. In general, the patient was a morbidly obese female who appeared older than her stated age, in mild distress. Head, eyes, ears, nose, and throat examination revealed normocephalic and atraumatic. Pupils were equal, round, and reactive to light and accommodation. Extraocular movements were intact bilaterally. Mucous membranes were dry. The oropharynx was clear. The neck was supple with no lymphadenopathy or jugular venous distention. Tracheostomy in place. The lungs were clear to auscultation bilaterally. No wheezes, rhonchi, or rales. Cardiovascular examination revealed tachycardic with a regular rhythm. Normal first heart sounds and second heart sounds. No murmurs, rubs, or gallops were appreciated. Abdominal examination revealed obese, soft, and nontender. Jejunostomy tube in place with foul-smelling discharge. Extremity examination revealed right upper extremity peripherally inserted central catheter site was indurated with erythema. No fluctuance; however, the presence of pustular discharge. The lower extremities were warm and well perfused with no evidence of edema. Neurologic examination revealed awake, alert and oriented times three with a nonfocal neurologic examination. NOTE: The remainder of this dictation including the hospital course will be dictated at a later date. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12974**], M.D. [**MD Number(1) 12975**] Dictated By:[**Name8 (MD) 4935**] MEDQUIST36 D: [**2185-7-15**] 11:05 T: [**2185-7-18**] 10:33 JOB#: [**Job Number 17051**] Name: [**Known lastname 2654**], [**Known firstname **] Unit No: [**Numeric Identifier 2655**] Admission Date: [**2185-7-6**] Discharge Date: [**2185-7-15**] Date of Birth: [**2136-12-24**] Sex: F Service: [**Company 112**] MEDICINE ADDENDUM: LABORATORY/RADIOLOGIC DATA ON ADMISSION: CBC was with a white blood cell count of 13.4, hematocrit 28.2, platelets 167,000. Chem-7: Sodium 134, potassium 4.2, chloride 98, bicarbonate 21, BUN 46, creatinine 2.1, previously 0.8 on [**2185-5-27**], and glucose of 252. Relevant radiologic data since the time of admission: Chest x-ray on [**2185-7-6**] was with linear opacities bilaterally in the lower lobes consistent with atelectasis, otherwise no evidence of consolidation. Ultrasound of the right upper extremity on [**2185-7-6**] was with evidence of thrombus in the right brachial vein. Microbiology data from the time of admission: Blood culture, PICC line catheter culture, and PICC site swab culture from [**2185-7-6**] was with evidence of methicillin-sensitive Staphylococcus aureus. Urine culture from [**2185-7-6**] was with levo-resistant E. coli. Surveillance blood cultures from [**2185-7-8**] were without growth at the time of dictation. Repeat urine surveillance urine culture from [**2185-7-8**] was also without growth. HOSPITAL COURSE: 1. INFECTIOUS DISEASE: The patient was started on empiric linazolid and meropenem for sepsis secondary to presumed PICC line infection. The patient's PICC line was removed on hospital day number one with initial blood culture, PICC line catheter culture, and PICC line site swab notable for growth of methicillin-sensitive Staphylococcus aureus. The patient's urine culture also from admission grew levofloxacin-resistant E. coli. Given the patient's history of multiple line infections with recent emphysematous cystitis, the Infectious Disease Service was consulted with recommendations to tailor the patient's antibiotic therapy to cefazolin for appropriate coverage of both E. coli UTI and methicillin-sensitive Staphylococcus aureus blood infection. The patient is to complete a five week course of cefazolin. The Surgical Service was also consulted to evaluate for potential abscess at the prior PICC line site in the right upper extremity. An ultrasound of the right upper extremity was without evidence of abscess. However, a right upper extremity brachial vein deep venous thrombosis was noted. On hospital day number four, the patient defervesced and was successfully weaned off of dopamine for blood pressure support. The patient has remained afebrile and hemodynamically stable throughout the remainder of the hospitalization. Surveillance urine culture as well as blood cultures are without growth. At the time of dictation, the patient's right upper extremity PICC line site remains without evidence of localized infection. A left midline was placed on [**2185-7-11**] for a prolonged course of antibiotics. 2. HEMATOLOGY: The patient was incidentally found to have a right upper extremity brachial vein deep venous thrombosis by ultrasound. Although clinically asymptomatic, the patient developed a transient right bundle branch block with tachypnea on hospital day number two in the setting of a right internal jugular line placement. The patient was ruled out for a myocardial infarction by three sets of cardiac enzymes and the right bundle branch block subsequently resolved. The transient bundle branch block was felt likely secondary to a pulmonary embolus secondary to right upper extremity deep venous thrombosis. The patient was started on heparin with the initiation of Coumadin and maintained with a therapeutic PTT until the patient's INR became therapeutic above 2.0. The patient will continue on a six month course of Coumadin for management of a DVT with potential PE. During the early part of the patient's hospitalization, the patient's hematocrit dropped from baseline 28-29 to a hematocrit of 24. The hematocrit drop was felt likely secondary to low-grade DIC in the setting of sepsis as well as aggressive IV hydration. The patient received 2 units of packed red blood cells and maintained a hematocrit greater than 28 during the remainder of the hospitalization without further need for a transfusion. 3. RENAL: The patient was noted to have acute renal failure with an anion gap acidosis in the setting of sepsis and hypotension. The patient's metabolic abnormalities and renal dysfunction rapidly resolved with IV hydration and blood pressure support. The patient's renal function remains at baseline at the time of dictation. 4. DIABETES MELLITUS: The patient remained n.p.o. in the early portion of the hospitalization with minimal insulin requirement. As the patient resumed oral intake, the patient's insulin requirements gradually increased to her baseline insulin requirement at the time of dictation. The patient will be discharged on her home regimen of NPH 30 units q.a.m. and 20 units q.p.m. with sliding scale premeal. 5. CARDIOLOGY: The patient has a known history of coronary artery disease, status post prior three vessel CABG in [**2179**]. As previously noted, the patient had a transient right bundle branch block without evidence of ischemia early in the hospitalization. The patient was continued on her outpatient regimen of aspirin and statin and as she became more hemodynamically stable, her beta blocker was resumed. No further conduction abnormalities were noted during the hospitalization. 6. GASTROINTESTINAL: The patient has a known history of severe gastroparesis requiring intermittent TPN during periods of acute illness. The patient also has a GJ tube in place, however, is unable to tolerate significant tube feeds secondary to nausea and vomiting. Early in the hospitalization, the patient was started on low-dose tube feeds with TPN via her right IJ central line. On transition to the medical floor, the patient's diet was progressively advanced and TPN discontinued. At the time of dictation, the patient was tolerating a full diabetic Heart Healthy Diet with standing Reglan and p.r.n. antiemetics as needed. 7. UROLOGY: The patient has a known history of neurogenic bladder with issues with urinary incontinence as well as retention. The patient has a recent history of emphysematous cystitis for which she has completed a full course of meropenem. The Urology Service was consulted during the hospitalization and reiterated the prior discharge plan of maintaining an indwelling Foley catheter with potential for intermittent catheterization as an outpatient. The patient was instructed to follow-up with urologist, Dr. [**Last Name (STitle) 2698**], in two weeks postdischarge. The patient will be discharged with VNA services to help maintain the indwelling Foley catheter and monitor surveillance urine cultures as per Infectious Disease recommendations. CONDITION ON DISCHARGE: Stable, afebrile, and hemodynamically stable, tolerating a full diet. DISCHARGE MEDICATIONS: 1. Coumadin 7.5 mg p.o. q.h.s. (to be dosed by INR). 2. Cefazolin 2 grams IV q. eight hours to complete a five week course (last day [**2185-8-15**]). 3. Neurontin 300 mg p.o. q.a.m., 300 mg p.o. q.p.m., 400 mg p.o. q.h.s. 4. Aspirin 325 mg p.o. q.d. 5. Lopressor 25 mg p.o. b.i.d. 6. Lipitor 10 mg p.o. q.d. 7. Reglan 10 mg p.o. q.i.d. 8. Iron sulfate 325 mg p.o. q.d. 9. Zofran 4 mg to 8 mg p.o. q. eight hours p.r.n. 10. Lansoprazole 30 mg p.o. q.d. 11. Fioricet one to two tablets p.o. q. six hours p.r.n. 12. Flovent 110 micrograms two puffs inhaled b.i.d. 13. Albuterol two puffs q. four to six hours p.r.n. 14. Atrovent two puffs q. six hours p.r.n. 15. Senna one tablet p.o. b.i.d. 16. Colace 100 mg p.o. b.i.d. 17. Magnesium oxide 400 mg p.o. t.i.d. DISCHARGE INSTRUCTIONS: The patient is to be discharged to home with VNA services for continued hemodynamic monitoring as well as medication teaching (IV antibiotics) on [**2185-7-15**], VNA will obtain blood work for repeat coagulations, potassium, and magnesium, as well as obtain urine specimen for surveillance urine culture. Infectious Disease recommended weekly surveillance urine cultures given that the patient is to be discharged with an indwelling Foley catheter. The patient was instructed to follow-up with her primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) 2656**], in three to four days postdischarge as well as urologist, Dr. [**Last Name (STitle) 2698**], in two weeks post discharge. The patient was instructed to return to the Emergency Department in case of recurrent fevers and/or intolerance of oral intact, DISCHARGE DIAGNOSIS: 1. Methicillin-sensitive Staphylococcus aureus line infection. 2. E. coli urinary tract infection. 3. History of emphysematous cystitis. 4. Insulin-dependent diabetes mellitus. 5. Neurogenic bladder with indwelling Foley. 6. Severe gastroparesis. 7. Peripheral neuropathy. 8. Coronary artery disease, status post CABG. 9. Obstructive sleep apnea. 10. Sarcoidosis, status post tracheostomy. 11. Migraine headaches. 12. Anemia. 13. Status post cholecystectomy. 14. Status post appendectomy. DR.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2699**] 12.317 Dictated By:[**Name8 (MD) 2285**] MEDQUIST36 D: [**2185-7-15**] 11:41 T: [**2185-7-15**] 12:26 JOB#: [**Job Number **]

[ "584.9", "286.6", "250.61", "599.0", "496", "038.11", "996.62", "444.21", "135" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

5109, 7344

14095, 14864

15752, 16481

4319, 4914

8388, 13976

14889, 15731

145, 154

183, 2536

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9,804

158,840

50701

Discharge summary

report

Admission Date: [**2136-8-31**] Discharge Date: [**2136-9-3**] Date of Birth: [**2090-9-11**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1377**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: Central line placement Arterial line Esophagoduodenoscopy History of Present Illness: 45 year old woman with alcoholic cirrhosis and grade 1 varices presented with hematemesis and bright red blood per rectum for one day. Initially able to relate history but became increasingly obtunded. Had hemoptysis and BRBPR. Hct found to be 8.5 and trended down to 4 over the next hour. Lactate found to be 22.7. Blood pressure remained stable. Pt was tachycardic to 100s. Pt intubated for airway protection given hemoptysis and mental status decline. Initial blood gas 6.91/25/511/9. Pt given 5 L NS and 6 units of pRBC and started on octreotide drip, also given . Hematocrit trended back up to 28, lactate to 13. Blood pressure remained stable and pt transferred to MICU. By this time pt still having bloody secretions but less profusely, BRBPR had resolved. Past Medical History: Liver cirrhosis secondary to EtOH, known grade I varices s/p banding in [**1-/2136**] H/o EtOH Abuse, with acute hepatitis [**6-/2134**] H/o pleural effusions believed secondary to liver disease Endometriosis Fibroids s/p hernia repair s/p c-section Social History: Lives at home with daughter, nephew, and [**Name2 (NI) 802**] in [**Name (NI) 669**]. Per OMR notes no recent EtOH use last drink in ? [**7-/2135**]--at that time 6-pack of beer for 3 consecutive weekends. Smokes 1 pack of cigarettes per week. Denies IVDU. Family History: Daughter and 4 brothers have anemia. Mother has colonic polyps. Father has CAD and diabetes. Physical Exam: VS: 97.7 P 102 BP 130-140/70-80 RR 17 O2 99% RA Vent settings: AC FIO2 100 (now to 40%) TV 500 RR 16 PEEP 5 Gen: Intubated, but appears alert, following commands, interactive. Eyes: Pale conjuctiva, mild icterus, PERRL, Mouth: MM pale , OP clear with some blood, thin bloody secretions on suction Chest: Scattered rhonchi CV: RRR, nl S1/S2 Abd: Soft, protuberant, nontender, mild distension, active BS. Liver palpated 4 cm below right costal margin. No splenomegaly. Ext: Normal distal pulses. No edema. Rectal: No frank blood. Neuro: Alert, follows commands and moving all extremities. Pertinent Results: [**2136-8-31**] liver ultrasound 1. No evidence of portal vein thrombosis. Slow flow in main and right portal veins. 2. No evidence of ascites. 3. Echogenic liver, consistent with known cirrhosis. 4. Stable cysts adjacent to the gallbladder and stable diffuse gallbladder wall thickening without other signs of cholecystitis. . EGD: small ulcer in the duodenum . FEMORAL [**Month/Day/Year **] US RIGHT PORT [**2136-9-1**] 3:28 PM IMPRESSION: Limited examination, but possible AV fistula is seen. Further evaluation with dynamic contrast enhanced CT scan is recommended. . Repeat femoral [**Month/Day/Year 1106**] u/s ([**2136-9-3**]): Nonocclusive thrombus in the CFV. Arteriovenous fistula between the common femoral artery and vein. . [**2136-8-31**] 04:35AM BLOOD WBC-22.4*# Hct-8.5*# Plt Ct-216# [**2136-8-31**] 06:45AM BLOOD WBC-15.9* RBC-3.14* Hgb-8.7* Hct-27.4*# MCV-87 MCH-27.7 MCHC-31.7 RDW-16.8* Plt Ct-140* [**2136-8-31**] 08:39AM BLOOD Hct-29.1* [**2136-8-31**] 02:16PM BLOOD Hct-25.0* [**2136-8-31**] 06:27PM BLOOD Hct-26.5* [**2136-8-31**] 10:14PM BLOOD WBC-12.5* RBC-3.15* Hgb-8.8* Hct-25.0* MCV-80*# MCH-27.9 MCHC-35.0# RDW-17.2* Plt Ct-71* [**2136-9-1**] 02:19AM BLOOD WBC-11.7* RBC-3.04* Hgb-9.0* Hct-25.0* MCV-82 MCH-29.8 MCHC-36.1* RDW-17.0* Plt Ct-76* [**2136-9-1**] 11:24AM BLOOD WBC-12.7* RBC-3.27* Hgb-9.7* Hct-27.2* MCV-83 MCH-29.8 MCHC-35.8* RDW-17.1* Plt Ct-70* [**2136-9-1**] 04:05PM BLOOD Hct-25.3* [**2136-9-1**] 08:09PM BLOOD Hct-24.3* [**2136-9-2**] 02:09AM BLOOD WBC-11.5* RBC-2.90* Hgb-8.6* Hct-24.3* MCV-84 MCH-29.6 MCHC-35.3* RDW-18.1* Plt Ct-69* [**2136-9-2**] 01:58PM BLOOD Hct-23.3* [**2136-9-2**] 10:37PM BLOOD Hct-25.1* [**2136-9-3**] 04:55AM BLOOD WBC-9.7 RBC-2.93* Hgb-8.5* Hct-24.8* MCV-85 MCH-29.2 MCHC-34.5 RDW-19.3* Plt Ct-59* [**2136-9-3**] 12:45PM BLOOD Hct-25.9* [**2136-8-31**] 04:35AM BLOOD PT-22.0* PTT-41.5* INR(PT)-2.1* [**2136-9-2**] 02:09AM BLOOD PT-15.3* PTT-37.6* INR(PT)-1.4* [**2136-8-31**] 04:35AM BLOOD Glucose-107* UreaN-22* Creat-1.5* Na-137 K-3.7 Cl-97 HCO3-LESS THAN [**2136-9-3**] 04:55AM BLOOD Glucose-85 UreaN-4* Creat-0.6 Na-134 K-3.3 Cl-107 HCO3-20* AnGap-10 [**2136-8-31**] 04:35AM BLOOD ALT-49* AST-134* CK(CPK)-217* AlkPhos-87 Amylase-117* TotBili-1.1 [**2136-9-3**] 04:55AM BLOOD ALT-157* AST-210* AlkPhos-99 TotBili-3.8* Brief Hospital Course: 45 year old woman with alcoholic liver cirrhosis with grade I esoph varices admitted with hematemesis, BRBPR likely seconday to UGI bleed with profound anemia and severe lactic acidosis. Intubated for airway protection, improved hematocrit status post 6 units of blood, hemodynamic status proved remarkably stable. Mental status appeared improved and active bleeding tapered off by arrival to MICU. Coagulopathy reversed with vitamin K and FFP. Pt underwent upper endoscopy which revealed gastritis and small ulcer in duodenum--no active bleeding. . On HD 2 pt was successfully extubated. Hct remained stable in mid-20's R femoral cordis was discontinued but with extensive bleeding noted. Distal pulses remained preserved, an ultrasound revealed possible AV fistula. [**Month/Day/Year **] surgery consult service examined film and believed there was no fistula but recommended repeat ultrasound. Repeat u/s revealed AV fistula. . ## GI bleed, from gastritis/duodenal ulcer seen on EGD on [**8-31**].--now appears resolved no banding done. Hemodynamicaly stable with hct now relatively stable. Needs f/u EGD in about 6 weeks. Scheduled. H. pylori was negative. . ## Liver disease, from EtOH cirrhosis. No evidence of portal vein thrombosis or ascites on U/S. Medications on Admission: Protonix 40 daily Iron 325 daily Discharge Medications: 1. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. Disp:*QS ML(s)* Refills:*0* 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:*2* 3. Iron (Ferrous Sulfate) 325 (65) mg Tablet Sig: One (1) Tablet PO once a day. 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 5. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO three times a day. 6. M-Vit Tablet Sig: One (1) Tablet PO once a day. Tablet(s) Discharge Disposition: Home Discharge Diagnosis: upper GI bleed AV fistula Discharge Condition: good Discharge Instructions: Please continue your home medications. Do not take aleve, motrin, midol, ibuprofen, naproxen, or any other NSAIDS. Come to the emergency room if you have any more blood in your vomit or stool. Do not drink alcohol. It is very important to continue your protonix. Followup Instructions: Provider: [**Name10 (NameIs) 6811**] STONE, RVT Date/Time:[**2136-9-12**] 2:00 Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB) Date/Time:[**2136-9-12**] 2:45 Provider: [**Name10 (NameIs) **] WEST,ROOM ONE GI ROOMS Date/Time:[**2136-10-16**] 9:00. Please do not eat or drink anything other than clear liquids prior to this visit. You will need someone to drive you home after this visit. . The office will call you with an appointment for a capsule endoscopy. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]

[ "785.59", "V18.2", "285.1", "532.00", "305.1", "998.11", "518.81", "456.1", "537.89", "276.2", "303.93", "998.6", "790.92", "571.2", "V18.0", "V17.3" ]

icd9cm

[ [ [] ] ]

[ "96.71", "99.04", "99.07", "45.13", "96.04" ]

icd9pcs

[ [ [] ] ]

6728, 6734

4782, 6052

323, 382

6804, 6811

2459, 4759

7122, 7801

1740, 1835

6135, 6705

6755, 6783

6078, 6112

6835, 7099

1850, 2440

275, 285

410, 1175

1197, 1449

1465, 1724

70,784

190,551

24175

Discharge summary

report

Admission Date: [**2105-8-5**] Discharge Date: [**2105-8-18**] Date of Birth: [**2038-3-29**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5569**] Chief Complaint: NASH Cirrhosis Major Surgical or Invasive Procedure: [**2105-8-5**] 1. Deceased donor liver transplant. 2. Removal of right ovarian mass History of Present Illness: 67yoF with h/o NASH cirrhosis complicated by diuretic refractory ascites and hepatic encephalopathy. Past Medical History: - NASH cirrhosis c/b ascites and hepatic encephalopathy - ARF - seasonal allergies - depression - HTN - GERD - Ovarian dermoid cyst - s/p CCY Social History: Widowed, currently lives with son. [**Name (NI) **] is 34 and works during the day, but would be willing to support her when sick. She also has two neighbors that check in on her daily. Retired factory worker. ETOH: social use, infrequent. She denies any tobacco or IVDA. Family History: Noncontributory, denies any history of liver disease. Physical Exam: Vitals: 98.1 , 64, 104/43, 18, 96% RA, 79 KG HEENT: NC/AT. MMM. no cervical or supraclavicular lymphadenopathy CV:RRR Lungs:CTAB Abdomen:soft, NT ND, no guarding Extremities: warm, well perfused, no edema. pulses intact bilat Neuro: AAO x 3 Labs:pH Na:136 K:3.7 Cl:98 Glu:171 freeCa:0.55 Lactate:3.4 Hgb:8.3 HCT:25 Imaging: CXR from [**2105-7-6**] - In comparison with the study of [**7-1**], there has been a substantial increase in the degree of right pleural effusion. Mild displacement of the heart and mediastinal structures is toward the left is again seen. The left lung is essentially clear. EKG: from [**2105-5-28**] - normal sinus rhythm Pertinent Results: [**2105-8-18**] 04:20AM BLOOD WBC-6.7 RBC-3.21* Hgb-10.2* Hct-27.7* MCV-86 MCH-31.6 MCHC-36.6* RDW-16.2* Plt Ct-156 [**2105-8-7**] 04:54PM BLOOD PT-11.9 PTT-27.8 INR(PT)-1.0 [**2105-8-5**] 12:30PM BLOOD Glucose-94 UreaN-36* Creat-2.0* Na-138 K-3.5 Cl-102 HCO3-26 AnGap-14 [**2105-8-17**] 04:30AM BLOOD Glucose-103* UreaN-42* Creat-1.8* Na-120* K-5.0 Cl-90* HCO3-25 AnGap-10 [**2105-8-18**] 04:20AM BLOOD Glucose-102* UreaN-41* Creat-1.7* Na-125* K-5.0 Cl-93* HCO3-24 AnGap-13 [**2105-8-5**] 12:30PM BLOOD ALT-27 AST-68* AlkPhos-111* TotBili-3.1* [**2105-8-18**] 04:20AM BLOOD ALT-29 AST-13 AlkPhos-82 TotBili-0.2 [**2105-8-18**] 04:20AM BLOOD tacroFK-6.5 Brief Hospital Course: On [**2105-8-5**], she underwent deceased donor liver transplant with removal of right ovarian mass. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Refer to operative note for details. Two JPs were placed. Postop, she had a large right pleural effusion that responded well to a chest tube. She went to the SICU for management. She required blood products to maintain hemostasis. She was extubated on [**8-6**]. LFTs increased as expected. Liver duplex the next day demonstrated patent vasculature, no biliary dilatation or fluid collections. JP fluid was non-bilious. LFTs trended down. Chest tube was removed on [**8-9**]. CXR post removal showed no pneumothorax. She was transferred out of the SICU. Mental status was notable for some confusion that resolved over several days. Diet was advanced and tolerated. JP drain outout was high requiring IV fluid replacements. Albumin was given. JP fluid became cloudy. Amylase, triglycerides (183)were not impressive. Cell count of the fluid was notable for wbc 750 with 1 poly. Repeat cell count of [**8-13**] had 650 wbc with 53% polys. On [**8-14**], wbc was 120 with 33% polys.Fluid culture isolated Proteus sensitive to Ceftrixone. IV Ceftriaxone was started on [**8-14**]. Fluid became less cloudy and JPs were removed/sutured. Sites remained dry. Ceftriaxone was stopped on [**8-18**]. Serum WBC was wnl and she remained afebrile. Immunosuppression consisted of Cellcept which was started preop. Postop, this continued. Steroids were given per protocol taper. Prograf was started on postop day 1. Doses were adjusted per trough levels. She became hyperkalemic and hyponatremic. Kayexalate was given. A Renal consult was obtained and diagnosed renal tubular acidosis induced by Tacrolimus. Serum sodium dropped as low as 20 on [**8-14**]. Florinef was started and sodium increased to 125. Potassium decreased to 5. She was instructed to maintain a 1 liter free water restriction and low potassium diet. Citalopram was stopped on [**8-18**] as this was suspected of possibly contributing to hyponatremia. Insulin was required for hyperglycemia due to steroid. [**Last Name (un) **] was consulted and added 75/25 insulin as well as Humalog sliding scale. She did well with insulin teaching and medication teaching. She was ready for discharge to home on [**8-18**] with instructions to get lab work at [**Company 5620**] on [**8-20**] in [**Location (un) 8973**]. VNA services were arranged to assist her at home. Medications on Admission: 1. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. propranolol 10 mg Tablet Sig: Two (2) Tablet PO TID 5. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID 6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY 8. loratadine 10 mg Tablet Sig: One (1) Tablet PO once daily 9. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID 10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY 11. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY 12. spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY 13. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY 14. calcium 500 mg Tablet Sig: One (1) Tablet PO twice a day. 15. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H Allergies: NKDA Discharge Medications: 1. prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily): follow printed taper schedule. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once a day. 3. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO 2X/WEEK (MO,TH). 9. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 1X/WEEK (FR). 10. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO 3X/WEEK ([**Doctor First Name **],TU,TH). Disp:*15 Tablet(s)* Refills:*2* 11. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily) as needed for sinus congestion. 12. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 13. 75/25 Sig: Ten (10) units once a day: Insulin. Disp:*1 bottle* Refills:*2* 14. insulin lispro 100 unit/mL Solution Sig: follow printed taper scale Subcutaneous four times a day. Disp:*1 bottle* Refills:*2* 15. Kayexalate Powder Sig: Four (4) teaspoons PO prn: high potassium level: as directed by the Transplant service. Discharge Disposition: Home With Service Facility: Southeastcoast Home Care Services Discharge Diagnosis: NASH cirrhosis ovarian mass s/p liver transplant R pleural effusion Proteus peritonitis hyponatremia tacrolimus induced RTA (renal tubular acidosis) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -You will be going home with [**Location (un) 6138**] VNA that has been arranged -Please call the Transplant Office [**Telephone/Fax (1) 673**] if you have any of the following: fever (temperature of 101 or greater), shaking chills, nausea, vomiting, inability to take any of your medications, jaundice, constipation/diarrhea, increased abdominal or incision pain, incision/JP insertion site appears red or has bleeding/drainage You will need to have blood drawn for lab monitoring every Monday and Thursday. -you may shower, but no tub baths/swimming -no driving while taking pain medication -You are on a 1 liter free water fluid restriction due to low blood sodium Followup Instructions: Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2105-8-24**] 11:40 Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2105-8-27**] 10:20 Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2105-9-3**] 2:50 Completed by:[**2105-8-19**]

[ "790.29", "E878.0", "220", "530.81", "E933.1", "588.89", "401.9", "998.11", "571.5", "997.39", "998.59", "276.1", "276.7", "567.22", "041.6", "E932.0", "511.89" ]

icd9cm

[ [ [] ] ]

[ "38.93", "00.93", "97.41", "34.04", "50.59", "65.29" ]

icd9pcs

[ [ [] ] ]

7502, 7566

2447, 4952

317, 411

7759, 7759

1768, 2424

8602, 9073

1018, 1073

6012, 7479

7587, 7738

4978, 5989

7910, 8579

1088, 1749

263, 279

439, 542

7774, 7886

564, 708

724, 1002

74,034

170,505

35801

Discharge summary

report

Admission Date: [**2180-11-14**] Discharge Date: [**2180-11-21**] Date of Birth: [**2127-1-21**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Vancomycin / Codeine / Cefuroxime Axetil / Percocet Attending:[**First Name3 (LF) 922**] Chief Complaint: Chest pain, transferred for cardiac catheterization Major Surgical or Invasive Procedure: [**2180-11-14**] Cardiac catheterization [**2180-11-17**] Three Vessel Coronary Artery Bypass Grafting utilizing the left internal mammary artery to left anterior descending, with saphenous vein grafts to obtuse marginal and right coronary artery History of Present Illness: 53 year old woman with HTN, hyperlipidemia, + tobacco, GERD and strong family history of CAD who presented to OSH ED this morning with 4 days of intermittent exertional chest pain and SOB. She describes the sensation as a tightness in her chest with SOB, but no sweating or nausea. She had CP radiating to her jaw 3 years prior which was attributed to GERD. She thus attributed this pain to GERD and had been taking any antacid in her house (she was out of nexium, but took other OTC meds which gave her diarrhea). She woke on day of presentation with severe chest tightness radiating to both arms; she called her husband to bring her to the [**Name (NI) **]. She had no personal h/o CAD or DM. EKG on presentation to OSH reportedly with no specific ischemic changes. Troponin was elevated to 0.52. She was started on heparin and integrillin gtts and was transferred to [**Hospital1 18**] for cardiac catheterization. Past Medical History: Hyperlipidemia Hypertension OSA GERD s/p "stretching of esophagus" - ?stricture dilation MRSA (furuncle on leg treated with abx) hypothyroidism s/p 3 c-sections s/p bilateral carpal tunnel releases s/p hysterectomy s/p tonsillectomy and wisdom teeth extraction lactose intolerance Social History: Social history is significant for the [**11-24**] ppd x 30 years with current tobacco use. There is no history of alcohol abuse. Family History: There is significant family history of premature coronary artery disease, her mother had her CABG at 57 and father at 63. Mother also has DM2. Physical Exam: Admission PE: VS - 173/98 67 16 Gen: WDWN middle aged 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: Habitus makes assessment difficult, Supple with JVP of 7 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi (anteriorly-on bed rest after sheath pull). Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits, bandage on right. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ Femoral 1+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 1+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [**2180-11-14**] 06:50PM BLOOD WBC-5.4 RBC-3.49* Hgb-10.8* Hct-30.3* MCV-87 MCH-31.1 MCHC-35.7* RDW-13.9 Plt Ct-239 [**2180-11-14**] 06:50PM BLOOD PT-13.4 PTT-41.6* INR(PT)-1.2* [**2180-11-14**] 06:50PM BLOOD Glucose-99 UreaN-9 Creat-0.9 Na-148* K-2.9* Cl-112* HCO3-29 AnGap-10 [**2180-11-14**] 06:50PM BLOOD ALT-10 AST-20 LD(LDH)-178 CK(CPK)-88 AlkPhos-76 TotBili-1.0 [**2180-11-14**] 06:50PM BLOOD CK-MB-NotDone cTropnT-0.07* [**2180-11-15**] 05:10AM BLOOD CK-MB-NotDone cTropnT-0.10* [**2180-11-14**] 06:50PM BLOOD %HbA1c-6.2* [**2180-11-14**] 06:50PM BLOOD Triglyc-196* HDL-28 CHOL/HD-4.5 LDLcalc-58 [**2180-11-14**] Cardiac Catheterization: 1. Selective coronary angiography of this right dominant system revealed left main plus 2 vessel obstructive coronary artery disease. The LMCA had a 40% stenosis distally. The LAD had a proximal tubular 80% stenosis. The LCX had a 50% ostial stenosis. The RCA had a long proximal 60-70% stenosis and a mid 80% stenosis. 2. Limited resting hemodynamics revealed elevated left sided filling pressures with a LVEDP of 22 mm Hg. Systemic arterial pressures were normal. Left ventriculography showed normal LV systolic function with an ejection fraction of 50% and mitral regurgitation only during VT. There was no gradient across the aortic valve on carefull pullback of the catheter from the left ventricle to the aorta. [**2180-11-15**] Echo: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%).There is no definite LV regional wall motion abnormality. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. [**2180-11-19**] 04:12AM BLOOD WBC-9.9 RBC-2.48* Hgb-7.6* Hct-21.5* MCV-87 MCH-30.7 MCHC-35.4* RDW-14.5 Plt Ct-139* [**2180-11-20**] 07:23AM BLOOD WBC-10.2 RBC-2.59* Hgb-8.1* Hct-22.4* MCV-86 MCH-31.1 MCHC-36.0* RDW-15.1 Plt Ct-157 [**2180-11-18**] 03:27AM BLOOD Glucose-118* UreaN-11 Creat-0.6 Na-137 K-3.8 Cl-105 HCO3-27 AnGap-9 [**2180-11-19**] 04:12AM BLOOD Glucose-127* UreaN-15 Creat-0.7 Na-135 K-4.1 Cl-102 HCO3-30 AnGap-7* [**2180-11-20**] 05:16AM BLOOD Glucose-106* UreaN-18 Creat-0.7 Na-137 K-3.8 Cl-102 HCO3-32 AnGap-7* [**2180-11-20**] 05:16AM BLOOD Albumin-2.8* Mg-2.0 Brief Hospital Course: Mrs. [**Known lastname 81429**] was admitted under cardiology with chest pain and non ST elevation myocardial infarction. She underwent cardiac catheterization which revealed severe three vessel coronary artery disease. Cardiac surgery was consulted and preoperative evaluation was performed. She remained pain free on Integrillin and Heparin. Workup was unremarkable and she was cleared for surgery. Surgery was delayed for several days given recent Plavix dose. On [**11-17**], Dr. [**Last Name (STitle) 914**] performed coronary artery bypass grafting. For surgical details, please see operative note. Given hospital stay was greater than 24 hours, Vancomycin was given for perioperative antibiotic coverage. Following the operation, she was brought to the CVICU for invasive monitoring. Within 24 hours, she awoke neurologically intact and was extubated without incident. She maintained stable hemodynamics and transferred to the SDU on postoperative day one. Chest tubes and pacing wires were removed without complication. She remained in a normal sinus rhythm as beta blockade was advanced as tolerated. She initially required blood transfusions for a hematocrit of 21, which stabilized by post-operative day three at 27. By post-operative day four she was ready for discharge to home. Medications on Admission: Lopressor 100 mg PO BID Nexium 40mg Daily Levothyroxine 75mcg Daily Lipitor 80 mg Daily Zirtec 10mg Daily HCTZ (not taking last several days) Potassium supplement (dose uncertain) Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 6. Nexium 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:*0* 7. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: [**11-24**] Tablets PO Q4H (every 4 hours) as needed. Disp:*45 Tablet(s)* Refills:*0* 8. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 14 days. Disp:*28 Tablet(s)* Refills:*0* 9. Potassium Chloride 20 mEq Packet Sig: One (1) PO Q12H (every 12 hours) for 14 days. Disp:*28 * Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] S region Discharge Diagnosis: Coronary artery disease - s/p CABG Recent Non ST Elevation Myocardial Infarction Hypertension Dyslipidemia History of MRSA GERD Discharge Condition: Good. Discharge Instructions: Take medications as directed on discharge instructions. Do not drive for 4 weeks. Do not lift more than 10 lbs. for 2 months. Shower daily, let water flow over wounds, pat dry with a towel. Do not use creams, lotions, or powders on wounds. Call our office for temp.>101.5, sternal drainage. Followup Instructions: Make an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 131**] for 1-2 weeks ([**Telephone/Fax (1) 81430**]. Make an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] for 2-3 weeks ([**Telephone/Fax (1) 25358**]. Make an appointment with Dr. [**Last Name (STitle) 914**] for 4-5 weeks ([**Telephone/Fax (1) 11763**]. If eye disturbances continue several weeks after surgery, make an appointment with opthomology at ([**Telephone/Fax (1) 18621**]. Completed by:[**2180-11-21**]

[ "327.23", "410.71", "530.81", "276.8", "305.1", "414.01", "285.9", "244.9", "V12.04", "273.8" ]

icd9cm

[ [ [] ] ]

[ "36.15", "88.56", "36.12", "39.61", "99.20", "88.53", "37.22", "99.04" ]

icd9pcs

[ [ [] ] ]

8544, 8624

5886, 7182

385, 634

8796, 8804

3169, 5863

9144, 9698

2056, 2201

7413, 8521

8645, 8775

7208, 7390

8828, 9121

2216, 3150

294, 347

662, 1590

1612, 1894

1910, 2040

13,714

130,005

51694

Discharge summary

report

Admission Date: [**2157-9-9**] Discharge Date: [**2157-9-16**] Date of Birth: [**2093-5-22**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 148**] Chief Complaint: Anemia Elevated INR Tachycardia Major Surgical or Invasive Procedure: PICC History of Present Illness: This is a 64 year old female s/p pancreatoduodenectomy [**8-10**]. She was discharged on [**2157-9-2**] on Coumadin and instructed to have her INR monitored with her PCP. [**Name10 (NameIs) **] presented for follow-up with her PCP and she was found to be tachycardic to the 140's and have an elevated INR to 21 and appear fatigued. Past Medical History: [**2157-8-25**] 1. Pylorus-preserving pancreaticoduodenectomy. 2. Open cholecystectomy. Afib on coumadin, CAD, HTN, hyperchol, DM (diet controlled), Arthritis, Gout, Cardiac Stent [**2148**] Social History: NC Family History: NC Physical Exam: VS: T 98.1, P 142, BP 108/66, %O2 Sat 98 Gen: Looks tired/fatigued. CV: regular tachycardia Cheat: Basilar fine crackles in her lungs Abd: soft, nontender, nondistended, healing scar - no signs of redness, infection. Ext: no edema Pertinent Results: RADIOLOGY Preliminary Report PICC LINE PLACMENT SCH [**2157-9-13**] 7:35 AM PICC LINE PLACMENT SCH Reason: needs TPN [**Hospital 93**] MEDICAL CONDITION: 64 year old woman with possible anastomotic leak REASON FOR THIS EXAMINATION: needs TPN INDICATION: 64-year-old female with possible anastomotic leak requiring TPN. RADIOLOGISTS: Doctors [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9035**] and [**First Name8 (NamePattern2) **] [**Doctor Last Name 380**]. Dr. [**Last Name (STitle) 380**], the attending radiologist was present and supervising throughout the entire procedure. PROCEDURE/FINDINGS: The patient was brought to the Radiology Suite and placed supine on the angiographic table. Following a preprocedure timeout including the patient's name and two patient identifiers, the left arm was sterilely prepped and draped. As no suitable veins were visible, ultrasound was used identified the left basilic vein, which was patent and compressible. Approximately 5 cc of 1% lidocaine were then applied for local anesthesia. A 21 gauge needle was then used to access the left basilic vein. Hard copy ultrasound images were obtained before and after venopuncture. A 0.018-inch guidewire was then threaded through the needle and the needle was exchanged for a 4 French micropuncture sheath. Guidewire was advanced into the SVC and based upon the markings on the wire, the PICC line was trimmed to a length of 40 cm. The PICC was then advanced over the wire and into the SVC under fluoroscopic guidance. The wire and peel-away sheath were removed. The catheter was flushed, capped, and heplocked. Finally, the catheter was statlocked in place and a sterile transparent dressing was applied. A final fluoroscopic image was taken demonstrating the tip of the PICC line in the distal SVC. IMPRESSION: Successful placement of a 5 French double lumen 40 cm PICC the left basilic vein with the tip in the distal SVC. The line is ready for use. DR. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] PreliminaryApproved: WED [**2157-9-14**] 11:25 AM Cardiology Report ECG Study Date of [**2157-9-9**] 6:04:56 PM Sinus tachycardia. Delayed R wave transition. Compared to the previous tracing of [**2157-8-27**] no diagnostic interim change. Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**] Intervals Axes Rate PR QRS QT/QTc P QRS T 127 122 86 288/363.42 52 -21 73 ([**-5/5080**]) RADIOLOGY Final Report CT HEAD W/O CONTRAST [**2157-9-9**] 7:17 PM CT HEAD W/O CONTRAST Reason: UNSTEADY GAIT, FEVER, TACHY, R/O BLEED [**Hospital 93**] MEDICAL CONDITION: 64 year old woman with inr at outside clinic of 8, possible unsteady gait over past few days, now with tachycardia and fever, no other symptoms REASON FOR THIS EXAMINATION: evaluate for bleed CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Elevated INR, recent Whipple. Unsteady gait. COMPARISON: None. TECHNIQUE: Non-contrast head CT. FINDINGS: No intra- or extra-axial hemorrhage is identified. There is no mass effect or shift of normally midline structures. The ventricles are normal in size and symmetric. The density of the brain parenchyma is within normal limits. The visualized paranasal sinuses and mastoid air cells are clear. Soft tissue structures appear unremarkable. IMPRESSION: No evidence of intracranial hemorrhage or mass effect. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 15097**] L. [**Doctor Last Name **] DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Approved: SAT [**2157-9-10**] 11:09 AM RADIOLOGY Final Report CHEST (PA & LAT) [**2157-9-9**] 7:32 PM CHEST (PA & LAT) Reason: evaluate for cardiopulm process: infection, etc [**Hospital 93**] MEDICAL CONDITION: 64 year old woman with fever, tachycardia, 2 weeks postop, inr 8 REASON FOR THIS EXAMINATION: evaluate for cardiopulm process: infection, etc HISTORY: Fever, tachycardia, two weeks post-op, INR 8, evaluate for cardiopulmonary process. CHEST, TWO VIEWS. There are slightly low inspiratory volumes. Heart size is at the upper limits of normal or minimally enlarged. No CHF or effusion is identified, although the posterior right costophrenic angle is blunted. There is some atelectasis at the right base and in the region of the cardiophrenic angle -- possibility of changes related to aspiration or early pneumonic infiltrate cannot be excluded. Unusual contour to the right upper ribcage is similar to that seen on [**2157-7-2**] and may represents sequela of prior trauma and/or some pleural thickening. IMPRESSION: Low inspiratory volumes. Right base atelectasis -- early infiltrate or aspiration cannot be excluded. No focal consolidation or mediastinal widening. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4343**] Approved: SAT [**2157-9-10**] 11:24 AM RADIOLOGY Final Report CT ABDOMEN W/O CONTRAST [**2157-9-9**] 9:49 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Reason: S/P WHIPPLE, FEVER, TACHYCARDIA Field of view: 42 [**Hospital 93**] MEDICAL CONDITION: 64 year old woman with INR of 21, s/p whipple on [**8-25**], fevers, tachycardia REASON FOR THIS EXAMINATION: evaluate for blood in abdomen, please use pancreas protocol CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 64-year-old status post Whipple on [**8-25**] with fevers, tachycardia and elevated INR, evaluate for hematoma. COMPARISON: CT abdomen of [**2157-4-7**]. TECHNIQUE: Axial MDCT images of the abdomen and pelvis with oral but without IV contrast per physician request with coronal and sagittal reformats. CT ABDOMEN WITHOUT IV CONTRAST: There is mild bibasilar opacities likely relating to either atelectasis. The liver is suboptimally evaluated without contrast. Patient is status post pyloric sparing Whipple procedure per the Op-note. There is marked wall thickening of a segment of the efferent loop anteriorly with prominent adjacent inflammatory change and foci of free air consistent with anastomotic dehiscence. There is no extravasation of oral contrast. Additionally, the pancreaticoduodenal anastomosis appears somewhat edematous with a small amount of fluid around it, though this may be within normal limits postoperatively. CT PELVIS WITH IV CONTRAST: The remainder of the abdomen and pelvis is suboptimally evaluated without IV contrast but no acute abnormalities are seen. IMPRESSION: 1) Evidence of anastamotic dehsiscence in the anterior abdomen with wall thickening and extensive inflammatory change and foci of extraluminal air surrounding an anterior portion of the efferent loop. No extravasation of oral contrast on this study. 2) Minimally dilated and edematous appearance at the pancreaticojejunal anastomosis with surrounding stranding and fluid. This may be within normal limits considering the recent postoperative status. 3 No evidence of intra-abdominal hematoma. Findings discussed after the study with the covering surgical team and in the morning with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 21884**] Approved: SAT [**2157-9-10**] 9:38 AM Brief Hospital Course: She was admitted to [**Hospital1 18**] with a HCT of 28.4 that dropped to 22 and an INR that was 21.8 then dropped to 1.8 after 2 Units of FFP. She received 2 Units of PRBC and was sent to the ICU for monitoring. LFT's were all WNL. A CT showed evidence of anastomotic dehiscence in the anterior abdomen with wall thickening and extensive inflammatory change and foci of extraluminal air surrounding an anterior portion of the efferent loop. She was made NPO and was receiving IV fluids. She received a fluid bolus for a low urine output. She was started on IV Levo/Flagyl. These will be continued at the rehab facility. She was transferred to the floor and monitored closely and had serial abdominal exams. She was clinically stable. She continued to have some mild abdominal pain that was controlled with Morphine and then she was eventually switched to a Fentanyl patch and PO Percocet. A PICC line was placed and she was started on TPN. She continued to be NPO and will remain so until her follow-up appointment. She was seen and examined by PT and was ambulating using a walker and supervision. Medications on Admission: Reglan, ASA, Allopurinol 100', Colchicine 0.6', Metoprolol 100', Metformin 500', Rosuvastatin 5', Percocet, Colace, Senna, Dilt 120SR", Coumadin 5', Protonix 40' Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 3. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO BID (2 times a day). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 5. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): See sliding scale. 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 9. Levofloxacin in D5W 500 mg/100 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 2 weeks. 10. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: One (1) Intravenous three times a day. 11. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 12. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours). 13. Outpatient Lab Work Chem 10 twice weekly while on TPN. Adjust TPN accordingly 14. TPN See TPN order Discharge Disposition: Extended Care Facility: [**Hospital 1263**] Hospital Transitional Care Unit - [**Location (un) 686**] Discharge Diagnosis: Anemia Tachycardia Elevated INR Discharge Condition: Good Discharge Instructions: * Increasing pain * Fever (>101.5 F) * Inability to eat or persistent vomiting * Inability to pass gas or stool * Increasing shortness of breath * Chest pain Please resume all of your regular medications and take any new medications as ordered. Continue to walk several times per day. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. Call [**Telephone/Fax (1) 2833**] to schedule an appointment. You will need a Abd CT scan prior to your appointment. Please let the receptionist know this when scheduling your appointment. . Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 902**] Date/Time:[**2157-9-19**] 11:00 Completed by:[**2157-9-16**]

[ "785.0", "790.92", "401.9", "285.8", "997.4", "783.0", "427.31", "272.0", "716.90", "274.9", "250.00", "V58.61", "V45.89" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.04", "99.15" ]

icd9pcs

[ [ [] ] ]

11514, 11618

8880, 9985

344, 351

11694, 11701

1237, 1361

12037, 12452

964, 968

10197, 11491

6583, 6664

11639, 11673

10011, 10174

11725, 12014

983, 1215

273, 306

6693, 8857

379, 712

734, 927

943, 948

78,336

186,636

40316

Discharge summary

report

Admission Date: [**2168-11-3**] Discharge Date: [**2168-11-11**] Date of Birth: [**2088-8-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7055**] Chief Complaint: Atrial fibrillation refractory to cardioversion Major Surgical or Invasive Procedure: none History of Present Illness: 80yo M with history of longstanding CAD (s/p triple bypass 19yrs ago), EF of 15-20%, DMII, paroxismal AF (s/p multiple cardioversion, most recent one [**11-2**]) transferred from [**Hospital1 4494**] for ablation. . The patient was last discharged s/p cardioversion on [**10-26**]. He felt well for several days, then began to feel dizzy (his usual afib symptoms, he feels well while not in afib all the time). He also felt short of breath. He decided to visit Dr. [**First Name (STitle) 7756**] who admitted him to [**Hospital3 3765**] for cardioversion. . At [**Hospital3 3765**] Vitals were 190/88 P 100 RR 26 T-97.6 - 80% RA HE was given Lasix 80 yesterday, 40 today and diuresed 1 Liter. He was placed on Oxygen, and also given dobutamine. Cardioversion was completed but ultimately failed and he was transferred to [**Hospital1 18**] for possible ablation as well as diuresis. . Of note, On last admission to [**Hospital1 18**] the patient was in severe biventricular failure and was diuresed, started on Dofetilide for 3 days, and then was cardioverted into sinus rhythm with DDD pacing. He was sent home on Dofetilide 125 mcg b.i.d. in addition to his heart failure regime. The plan then was if he goes back into Afib to bring him in and to ablate him as there is no more pharmacologic options. . On review of systems, He denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains,hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations. . On admission to the floor the vitals were:Afebrile- 112/60 - HR 85 (paced) 97% on 4Liters Past Medical History: CHF (chronic systolic) CABG (triple, 19yrs ago) AFib s/p AV nodal ablation and BiV pacer in [**2162**] maintained NSR on amio until last year when he developed pulmonary fibrosis so off amio and now recurrent AF episodes associated with CHF exacerbations DM2 CRI (baseline creatinine 3) followed by nephrologist at [**Hospital1 **] . Cervical Fusion COPD HL Gout GERD h/o prostate CA Social History: Married. 2 children 1 daughter died. -[**Name2 (NI) 1139**] history: quit 40yrs ago, 30 pack years -ETOH: rare -Illicit drugs: denies . Family History: Father MI at 64, Mother MI at 72. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: On admission: WDWN Caucasian male in mild respiratory distress. Oriented x3. Mood, affect appropriate. Talking in full sentences. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: JVP at 11 CM CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. LUNGS: unlabored respirations, no accessory muscle use. Crackles [**12-5**] of the way up. Otherwise clear, no wheezes. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: Cool. No c/c. Trace pedal edema b/l. No femoral bruits. SKIN: No stasis dermatitis, ulcers, or xanthomas. Well-healed midline sternal incision; L saphenous vein harvest scar x2 PULSES: Right: Carotid 2+ Femoral 1+ DP palp Left: Carotid 2+ Femoral 1+ DP palp On discharge: Gen: A/O, NAD HEENT: JVD 1/3 up CV: RRR, no M/R/G RESP: CTAB post ABD: NT, ND, pos BS EXTR: no edema, feet warm, pulses palp NEURO: A/O, better comprehension of medical condition Pertinent Results: [**2168-11-3**] 08:40PM PT-36.4* PTT-34.6 INR(PT)-3.7* [**2168-11-3**] 08:40PM PLT COUNT-264# [**2168-11-3**] 08:40PM WBC-5.8 RBC-3.59* HGB-10.7* HCT-32.2* MCV-90 MCH-29.7 MCHC-33.1 RDW-19.3* [**2168-11-3**] 08:40PM CALCIUM-9.0 PHOSPHATE-4.3 MAGNESIUM-2.3 [**2168-11-3**] 08:40PM estGFR-Using this [**2168-11-3**] 08:40PM GLUCOSE-101* UREA N-38* CREAT-2.5* SODIUM-137 POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-25 ANION GAP-15 [**2168-11-9**] 05:12AM BLOOD WBC-5.6 RBC-3.93* Hgb-11.7* Hct-35.4* MCV-90 MCH-29.8 MCHC-33.0 RDW-17.9* Plt Ct-287 [**2168-11-9**] 05:12AM BLOOD Glucose-132* UreaN-85* Creat-3.4* Na-136 K-3.5 Cl-92* HCO3-30 AnGap-18 [**2168-11-6**] 05:55AM BLOOD ALT-21 AST-29 AlkPhos-91 TotBili-0.6 [**2168-11-9**] 05:12AM BLOOD Calcium-9.6 Phos-4.7* Mg-2.6 CXR [**11-6**]:In comparison with the study of [**11-5**], there is no displacement of the leads of the pacer-defibrillator device. Again, there is globular enlargement of the cardiac silhouette in a patient with previous CABG and clips in the thyroid region. However, no evidence of vascular congestion, pleural effusion, or acute focal pneumonia. Liver ultrasound [**11-9**]: Done to rule out gallstones as a cause for substernal right-sided intermitten pain that is relieved with NSAIDs on [**2168-11-9**]. Brief Hospital Course: # Afib: The patient was admitted in Afib with ventricular pacing which likely exacerbates his CHF symptoms On [**10-25**] he undervent DCCV (converted, then reverted to afib, and spontaneously reverted back to sinus), and was sent home on dofetilide and now represents in Afib. His home warfarin dose was 6mg. He was admitted to [**Hospital1 **] for the same symptoms, in afib and cardioversion there failed. He was on dobutamine drip while there. On admission, he was weaned off of dobutamine and rate controled with metoprolol. He was aggressively diuresed and his symptoms of shortness of breath improved. He converted from atrial fibrillation to sinus rythm spontaneously on Sunday [**11-5**]. Thus, the plan for ablation was first delayed and then cancelled, given that this intervention unlikely to benefit the patient at this time. We continued him on warfarin and checked his INR daily with dose adjustments. We also continued him on Dofetilide (we was briefly switched to quinidine, but then placed back since he converted). A discussion of home milronone was entertained, this was discussed with Dr. [**First Name (STitle) 437**] who recommended against milrinone or metolazone at home (would dry him out too much), but if he comes back with another decompensated event, would consider home IV therapy. He was given close follow up with his outpatient cardiologist. . # CAD: s/p CABG [**76**] yrs ago. no s/s of ACS during admission. We continued his home plavix, simvastatin, and metoprolol was increased to 100 daily. His imdur ws discontinued due to fear of hypotension. He was also given potassium supplementation with his Lasix dose of 120mg twice daily. . # Systoloc Heart Failure: Pt is followed by Dr. [**First Name (STitle) 437**] from heart failure clinic. His last echo showed LVEF of 15-20%. He has a restrictive filling pattern. We continued his home medications. We managed his CHF with diureses and fluid restriction, as well as medically as above (see Afib). . # CKI: Baseline creatinine 3, stage III, Patient's creatinine initially increased to 3.6 and trended down with diuresis. We renally dosed his medications. He was also given potassium supplementation with his Lasix dose of 120mg twice daily. . # DM: Patient was given his home insulin and was covered with insulin sliding scale as well. His glucose was monitored with fingersticks. He was sent home with his usual 70-30 insulin with fingerstick sclae. . # COPD: We continued home Advair and he maintained his pO2 above 90 during his stay and was weaned off of oxygen, which he required on admission. . # Gout: continued allopurinol, but we stopped his colchicine. Medications on Admission: 1. Welchol (colesevelam) 25 [**1-6**] daily 2. Ranitidine 150 daily 3. Amitrlyptiline 50 daily 4. Metoprolol 50 daily 5. Lasix 40 3 tabs 2 times a day = 120mg [**Hospital1 **] 6. Dofetilide 125 [**Hospital1 **] 7. Allopurinol 100 daily 8. Colchicine 0.6 daily 9. Isosorbide Mononitrate 30 daily 10. Novolog 70/30 17U morning and evening 11. Lactulose 10 [**Hospital1 **] 12. Plavix 75 Daily 13. Warfarin as needed 14. Simvastatin 40 15. Colace PRN 16. Perdiem Discharge Medications: 1. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* 2. Outpatient Lab Work Please check INR, chem-7 on [**2168-11-13**] and call results to Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] W. at [**Telephone/Fax (1) 88463**] 3. Advair Diskus 500-50 mcg/dose Disk with Device Sig: One (1) disk Inhalation twice a day. 4. lactulose 10 gram/15 mL Syrup Sig: Ten (10) ML PO twice a day. 5. metoprolol succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 6. WelChol 625 mg Tablet Sig: One (1) Tablet PO twice a day. 7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO at bedtime. 9. warfarin 6 mg Tablet Sig: One (1) Tablet PO once a day. 10. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 15. insulin NPH & regular human 100 unit/mL (70-30) Suspension Sig: Ten (10) units Subcutaneous twice a day: Please titrate your insulin at home as you normally do. 16. furosemide 80 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 17. dofetilide 125 mcg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Atrial Fibrillation Acute on Chronic Systolic Congestive Heart Failure Acute on chronic Kidney Injury 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 39852**], You have been admitted to our hospital in order to have your heart procedure to help control your heart rate better. You had an acute exacerbation of your congestive heart failure and required milrinone and lasix infusions to get off the extra fluid. Your weight at discharge is 171 pounds, you should stay at this weight from now on. You will need to follow a low salt diet, information regarding this was discussed with you and written information was provided. You will see Dr. [**Last Name (STitle) **] on [**11-17**] in [**Location (un) 1514**] to discuss further options for the atrial fibrillation. Weigh yourself every morning, call Dr. [**First Name (STitle) 7756**] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. The following changes have been made to your medications: 1. Decrease the furosemide (lasix) to 120 mg daily instead of twice daily 2. Increase Metoprolol to 100mg daily 3. Discontinue Imdur because your blood pressure was low 4. Stop taking colchicine until your kidney function improves 5. Start taking potassium daily, we have had to give you this in the hospital. Followup Instructions: Department: CARDIOLOGY, DR [**Last Name (STitle) **] When: THURSDAY [**2168-11-17**] at 4:40 PM . Name: [**Last Name (LF) **],[**First Name3 (LF) **] W. Location: [**Location (un) 2274**]-[**Location (un) **] Address: [**Hospital Ward Name **] EXTENSION, [**Location (un) **],[**Numeric Identifier 15215**] Phone: [**Telephone/Fax (1) 28262**] When: Thursday, [**11-17**], 1:30PM . Name: [**Last Name (LF) **],[**Name8 (MD) 20**] MD/ Cardiology Address: 131 ORNAC, JCB #650, [**Location (un) **],[**Numeric Identifier 17125**] Phone: [**Telephone/Fax (1) 71179**] When: Tuesday, [**11-29**], 1:30PM . Name: PRICE, [**Doctor First Name **] Address: [**Street Address(2) 88464**], [**Location (un) **],[**Numeric Identifier 17125**] Phone: [**Telephone/Fax (1) 88465**] When: Wednesday, [**2169-12-14**]:15PM

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icd9cm

[ [ [] ] ]

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icd9pcs

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10144, 10193

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364, 370

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153,314

1182

Discharge summary

report

Admission Date: [**2103-5-2**] Discharge Date: [**2103-5-9**] Date of Birth: [**2023-7-2**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5755**] Chief Complaint: hyponatremia: transfer from OSH Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a 79 yo m with head and neck cancer s/p treatment with radiation/chemo who presents with hyponatremia. He is tranferred from [**Hospital **] hospital with hyponatremia. He was originally seen at oncologists office on [**5-1**] where na was found to be 119. Last evening patient's sodium was 116 with no confusion. He was then given 3% NS with na remaining 115. He was then transferred for further workup. . Of note, Pt recently recieved amoxicillin for increased mucous (started on friday) after which he began to have diarrhea as well as increased residuals on sat. . In our ED, Na was 117, hypertonic saline was stopped and patient was given 250cc of ns. Repeat NA was 117. Pt rec'd levofloxacin for concern of pna on RUL on cxr. . Additionally, no acute neurological events were witnessed by medical staff such as seizures, acute delerium etc. . He denies f/c/n/v/headache/dizziness. Past Medical History: throat ca dx [**12-31**]- poorly differentiated ca, s/p erbotox and xrt CABG [**2-26**], 4V (echo [**4-28**]: nl ef) HTN Atrial fibrillation - on sotalol s/p cardioversion- discussed with Dr. [**Last Name (STitle) 7516**] his PCP who reports that he was very difficult to rate control and would like us to hold off on stopping sotalol unless necessary. vision loss s/p L carotid endartectomy Social History: lives in [**Location **] with wife married 51 [**Name2 (NI) 1686**], previously an investment banker, no etoh, tobacco currently, had 100 pack years of tobacco then switch to pipe 30 years ago until [**2100**]. Family History: NC Physical Exam: T 99.6 BP 156/84 P 86 O2 98% GEN: alert, oriented, visible weaping areas in neck area, No resp distress HEENT: radiation lesions, bloody, dry mmm, increased oral secretions Lungs: cta x 2 Heart: s1 s2 no m/r/g Abd: soft nt/nd Gtube in place Ext: no c/c/e Neuro: AOx3, motor strength 5/5, sensory [**4-28**] Pertinent Results: [**2103-5-2**] 10:08AM WBC-2.9* RBC-4.11* HGB-11.7* HCT-35.4* MCV-86 MCH-28.4 MCHC-33.0 RDW-17.8* [**2103-5-2**] 10:08AM NEUTS-74.1* LYMPHS-9.4* MONOS-15.5* EOS-0.7 BASOS-0.3 [**2103-5-2**] 10:08AM PLT COUNT-366 [**2103-5-2**] 11:20AM PT-18.0* PTT-33.7 INR(PT)-1.7* . IRON 16, TIBC 173, FERRITIN 48, FOLATE 14.6, B12 1347 . [**2103-5-2**] 10:08AM GLUCOSE-79 UREA N-13 CREAT-0.6 SODIUM-117* POTASSIUM-4.0 CHLORIDE-82* TOTAL CO2-28 ANION GAP-11 ALT 51, AST 27 . [**2103-5-2**] 10:05AM LACTATE-0.8 NA+-118* K+-4.2 . TSH 1.6 . [**2103-5-2**] 11:20AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017 [**2103-5-2**] 11:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG . [**2103-5-2**] 11:20 am URINE Site: CATHETER **FINAL REPORT [**2103-5-3**]** URINE CULTURE (Final [**2103-5-3**]): NO GROWTH. . [**2103-5-2**] BLOOD CX: NEGATIVE . EKG: QTC 407 Normal sinus rhythm. Delayed R wave transition. No previous tracing available for comparison. . CXR [**2103-5-2**]: AP UPRIGHT CHEST: Sternal closure devices and mediastinal clips are seen suggestive of prior CABG. The thoracic aorta is tortuous and the cardiac silhouette is enlarged with a left ventricular configuration. There is increased interstitial opacity in the right upper lobe. There is tracheal deviation to the left. Pulmonary vascularity is within normal limits. No pleural effusions are seen; there is some pleural abnormality - thickening versus fluid - on the left. IMPRESSION: 1. Increased interstitial markings with some confluent areas in the right upper lobe; the sharp demarcation of this area is consistent with prior radiation therapy, but superimposed infection cannot be excluded. 2. Tracheal deviation to the left suggestive of a right superior mediastinal mass. Comparison to prior studies is recommended, or alternatively a chest CT for further evaluation. Findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], and additional history of throat cancer with prior radiation therapy was obtained. . CXR [**2103-5-7**]: A left-sided PICC catheter extends into the internal jugular vein with distal tip not visualized. A dense opacity projecting over the right apex may be slightly increased in density when compared to initial radiographic assessment and may reflect radiation changes. More subtle left apical opacity is unchanged. Increased opacity noted at the right base may reflect asymmetric edema versus developing consolidatopn/atelectasis and left-side pleural effusion has slightly increased in size from most recent radiograph. No evidence of pneumothorax or pulmonary edema. IMPRESSION: 1. Biapical opacity, right > left, with apparent increase on the right compared to recent CXRs. Although possibly due to evolving post- XRT changes given history of recent XRT therapy, correlation with portal suggested as well as comparison to outside studies would be helpful to exclude an acute infection such as TB developing in an area of radiation treatment. 2. Malpositioned left-sided PICC catheter. This finding was discussed with IV nursing shortly after exam acquisition. 3. Increased left-sided pleural effusion and slight worsening right effusion and adjacent basilar opacity. . NON-CONTRAST HEAD CT [**2103-5-6**]: No mass lesion, shift of normal midline structures, hydrocephalus, or major vascular territorial infarct is seen. There is a small hypodense area within the left temporal lobe measuring 10 x 6 mm which is best seen on series 5, image 14. This most likely represents an area of old lacunar infarct. The density values of the remainder of brain parenchyma is within normal limits. The [**Doctor Last Name 352**]-white matter differentiation is well preserved. The bone windows and soft tissue structures are normal. The maxillary, ethmoid, frontal, and sphenoid sinuses are clear. IMPRESSION: The study was severely limited due to the patient motion. However, there is a hypodense area within the left temporal lobe measuring 10 x 6 mm which most likely represents an old lacunar infarct. However, if acute infarct is clinically suspected, consider MR [**First Name (Titles) 151**] [**Last Name (Titles) 3631**] . . MR HEAD W/ AND W/O CONTRAST [**2103-5-7**]: There is no slow [**Month/Day/Year 3631**] to indicate an acute infarct. There is no midline shift, mass effect or hydrocephalus. The [**Doctor Last Name 352**]-white matter differentiation is preserved. There are sulcal and ventricular prominence due to generalized brain atrophy. There is fluid in the mastoid sinus air cells bilaterally, a finding that could be consistent with acute mastoiditis in the correct clinical setting. No enhancing abnormalities are noted. IMPRESSION: No evidence of an acute infarct or enhancing abnormality. Mild amounts of chronic microvascular ischemic change. Fluid in the mastoid sinus air cells bilaterally could be consistent with acute mastoiditis in the correct clinical setting. . EEG [**2103-5-6**]: FINDINGS: BACKGROUND: During wakefulness, a 10 Hz alpha frequency posterior dominant rhythm was seen bilaterally. One instance of body jerking was noted by the technologist which did not have any electrographic correlate. There were occasional faster activity primarily in the temporal regions bilaterally, which correlated with mouth movements, most likely due to muscle artifacts. HYPERVENTILATION: Contraindicated due to abnormal cardiac rhythmic. INTERMITTENT PHOTIC STIMULATION: Could not be performed as this was a portable study. SLEEP: The patient progressed from wakefulness to drowsiness and stage II sleep. CARDIAC MONITOR: There were occasional premature beats and the average heart rate was 78 bpm. IMPRESSION: This is a normal routine EEG in the waking and sleeping states. No focal or epileptiform features were seen. Occasional mouth movements in sleep were seen with associated movement and muscle artifacts. Brief Hospital Course: # Hyponatremia: Initially, placed on 3% saline infusion with improvement in sodium to 120s. Then changed to NS with full correction into low 130s. This response consitent with hypovolemic hyponatremia likely from N/V/D, as well as from extensive airway secretions/insensible losses. His sodium has remained stable without further NS boluses. Renal was consulted during this admission. . # Delirium: Confusion and alertness has improved considerably, however patient still has difficulty with place and is often forgetful. I suspect this was precipitated by his severe hyponatremia. LFTs, electrolytes, TFT, infectious work-up, head CT, and head MRI were all unrevealing for an alternative etiology. . # Acute unresponsiveness: In the context of his delirium, patient had an episode of unresponsiveness with stable vital signs, concerning for possible seizure. EEG shows no evidence of epileptiform activity. Neurology was consulted and followed along. Given findings on CT, patient underwent a brain MRI which showed only an old, small stroke. The episode may have been precipitated by a TIA given his history of carotid disease. Thus, he will undergo and MRA of the neck to evaluate his carotids. In the meantime, he is on anticoagulation, a statin, and we are controlling his blood pressure. Telemetry x 24 hours unremarkable. . # Radiation dermatitis: Involves face, neck, chest, mouth. Seen by wound care. Wound care recs included on page 1. Skin appears to be improving without evidence of bacterial superinfection. . # Oral Secretions: Also likely due to radiation injury. Seen by radiation oncology who recommended mucomyst and expectorant which improved secretions. He also received a total of 5 days of levofloxacin for a possible underlying bacterial infection. . # Right upper extremity swelling: Suspect underlying DVT versus thrombophlebitis. Recommend warm packs and elevation. Patient is on coumadin for his afib and is being bridged with lovenox, given this finding. . # Atrial fibrillation: Rate was controlled on his home sotalol. He is anticoagulated with lovenox until his coumadin is therapeutic. His dose of coumadin is slowly being increased due to failure of the INR to increase (1.4 on day of discharge). . # Abnormal CXR: Mild cough. Low grade temps (99.7). Concerning for early radiation pneumonitis. Rad onc clarified that indeed involved portions of the lung were in the fields. However, they would not recommend corticosteroids unless patient develops hypoxia or worsening symptoms. No history of TB exposure or positive PPD. . # Anemia: Folate and B12 within normal limits but iron studies suggest iron deficiency. He was started on a liquid supplement. Hematocrit has been stable at 30-32. . # Head and neck cancer: S/p xrt and chemo. Will need outpatient follow-up with Dr.[**Doctor Last Name 7517**] from medical oncology and Dr. [**First Name (STitle) 7518**] from radiation oncology. . # Dispo: patient discharged to [**Hospital **] rehab . # full code . # communication: wife, [**Name (NI) **], [**Telephone/Fax (1) 7519**] . # access: left midline (initial PICC in right IJ so converted to midline) - can be d/c if you are able to get labs . # PPX: aspiration and fall precautions, anticoagulated, on H2B Medications on Admission: Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Coumadin Procrit qweek Discharge Medications: 1. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Coumadin 4 mg Tablet Sig: Two (2) Tablet PO once a day: PLEASE MONITOR INR DAILY AND ADJUST DOSE AS NEEDED (GOAL [**1-27**]). 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Enoxaparin 100 mg/mL Syringe Sig: One Hundred (100) MG Subcutaneous Q12H (every 12 hours). 8. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) INJECTION Injection QMOWEFR (Monday -Wednesday-Friday). 9. Mineral Oil-Hydrophil Petrolat Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): to face, lips, neck, and upper back. 10. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every 6 hours): Give through G-tube . 11. Acetylcysteine 10 % (100 mg/mL) Solution Sig: 200-400 mg Miscellaneous Q6H (every 6 hours): swish and suction for thinning of oral secretions . 12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for SBP<100 . 13. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day): SWISH AND SUCTION . 14. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Five (5) mL PO DAILY (Daily) for 3 months. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: primary: hypovolemic hyponatremia delirium right upper extremity swelling, suspect DVT radiation dermatitis abnormal CXR, possibly consistent with radiation pneumonitis secondary: atrial fibrillation head and neck cancer of unknown primary chronic anemia Discharge Condition: good: stable on room air, afebrile, still forgetful Discharge Instructions: Please monitor for temperature > 100.5, shortness of breath, worsening cough, worsening mental status, or other concerning symptoms. Followup Instructions: Please follow-up with Dr. [**First Name4 (NamePattern1) 3403**] [**Last Name (NamePattern1) **] on [**5-17**], 3:45 PM. Location: [**Street Address(2) 7520**], Wellseley. Phone: ([**Telephone/Fax (1) 7521**] Please follow-up for an MRA of your neck to rule out carotid artery disease on [**2103-5-16**] at 8:30 PM at [**Hospital1 18**] [**Hospital Ward Name **], basement level. Phone: [**Telephone/Fax (1) 327**] Dr.[**Last Name (STitle) 7522**] office will be contacting you at [**Name (NI) **] with a follow-up appointment. If you do not hear from them within 1 week, please call to clarify your appointment time. Phone: [**Telephone/Fax (1) 7523**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

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1458

Discharge summary

report

Admission Date: [**2105-1-22**] Discharge Date: [**2105-1-31**] Date of Birth: [**2041-5-18**] Sex: M Service: SURGERY Allergies: Neurontin / Beta-Blockers (Beta-Adrenergic Blocking Agts) / Ace Inhibitors Attending:[**Known firstname 148**] Chief Complaint: pancreatic head mass, failure to thrive, chronic abdominal pain Major Surgical or Invasive Procedure: Exploratory laparotomy, intraoperative ultrasound, J tube placement, take back for bleeding at mesentery History of Present Illness: This 63-year-old Chef has been relatively healthy with the exception of chronic migraines and back pain, and hypertension. He has suffered from other pain problems such as knee pain and neck spondylosis over time. He has had a history of asthma and melanoma as well. Most notably, however, is that he had a distal gastrectomy with Billroth II reconstruction in [**2094**] for peptic ulcer disease. He has also had a cholecystectomy in the past as well as a melanoma excision. His [**Last Name 3545**] problem is that of an unrelenting epigastric pain diagnosed as chronic pancreatitis elsewhere. This has been going on since [**Month (only) **]. Apparently, he has had an endoscopic ultrasound evaluation by Dr. [**Last Name (STitle) 8671**] at which time he felt the distal pancreas accessible through the stomach showed evidence of chronic pancreatitis. Subsequent to that, he was referred to Dr. [**Last Name (STitle) **] for another endoscopic ultrasound and [**Male First Name (un) **] was unable to access the pancreatic head due to the Billroth II reconstruction again. A CT scan has been performed and this shows a hypodensity in the posterior pancreatic head which is worrisome for either a malignancy or a focal pancreatitis problem. I will note that there is no evidence of ductal dilation of either his bile duct or pancreas duct, however, and the rest of his pancreas tissue looks normal to me. There is no evidence of a distinct pancreatitis sequelae or destruction. Currently, he is at his wits end with his progressive abdominal pain, which has been with him since [**Month (only) **]. It is epigastric and does not radiate to the back. It is worse after eating. He has nausea and vomiting with this. He has lost 30 pounds over this time. He is on a fentanyl patch at this point for pain. He has no distinct history of current alcohol abuse. He said he did drink some alcohol, but not had abusive levels in the past. He stopped years ago when he felt that alcohol was not a good interaction with his pain pills used for treatment of his migraines and other back pain problems. Past Medical History: PMH: migraines, back pain L5 fx, Gastric ulcer, HTN, BPH, knee pain, Asthma, h/o melenoma, neck spondylosis PSH: Antrectomy with BII in [**2094**], Tonsillectomy, Melanoma excision, open CCY Social History: previous EtOH but not abused. Family History: nc Physical Exam: In office with Dr. [**Last Name (STitle) **]: his abdomen is soft but tender in the epigastric region and he has some left lower quadrant tenderness as well. He has a well-healed right subcostal incision, which crosses the midline. Rectal exam was deferred. There is no evidence of any hernias or masses in his inguinal exam. The rest of physical exam is relatively normal. Pertinent Results: CTAP: 1. Ill-defined hypoenhancing heterogeneous area in the pancreatic head. Given the lack of pancreatic or biliary ductal dilatation findings could represent focal pancreatitis; however, a neoplastic process cannot be excluded. Therefore further evaluation with MRI is recommended. 2. Multiple hypodensities in the kidneys bilaterally which are too small to characterize. There may be a thin septation within a cystic lesion in the upper pole of the right kidney and attention to this area on the MRI is recommended. Brief Hospital Course: Mr. [**Known lastname 8672**] presented to [**Hospital1 18**] for operative exploration and possible Whipple due to considerable concern of a pancreatic head mass associated with chronic abdominal pain. In the OR, a bilateral subcostal incision was made as well as adhesiolysis to free the bowels. After performing a [**Doctor Last Name **] maneuver, no mass was felt in the pancreas. A curious, plump-looking lymph node was biopsied. On frozen section, foreign body giant cell reaction but no evidence of malignancy or other process. Intraoperative ultrasound was performed as well which showed absolutely no abnormalities of pancreatic parenchyma. The pancreatic head was devoid of any masses. The pancreatic duct and bile duct were normal. Dr. [**Last Name (STitle) **] was contact[**Name (NI) **] and it was collectively decided to place a feeding jejunostomy tube to allow enteral feedings and the patient was closed. Approximately 7 hours postoperatively, the patient showed signs of hypovolemia, with falling urine output and hematocrit. Thus, he was taken back to the OR emergently whereupon a bleeding vessel was found and ligated. After hemostasis was achieved, the patient's BP and urine output rose accordingly. Because of the large amount of blood loss, the patient was taken to the surgical ICU postoperatively. There, serial hcts were checked to ensure stability as well as intensive monitoring of hemodynamics and urine output. In total, the patient received 7 units of packed red blood cells and 1 unit of fresh frozen plasma. As his condition improved, his NG tube was discontinued and he was started on tube feeds as his bowel function returned. He was seen by the Chronic Pain Service and was given a regimen on which he could go home. His condition slowly improved and his diet was advanced as appropriate. On the floor he remained stable and he was ultimately discharged afebrile, with stable hemodynamics, urinating on his own, tolerating a regular diet supplemented with jejunal feedings. He will follow up with Dr. [**Last Name (STitle) **] in clinic. Medications on Admission: albuterol 2 puffs prn, amlodipine 10', Celebrex 100", fentanyl patch, finasteride 5', flunisolide, fluticasone, HCTZ 25', Hydromophrine prn pain, viokase, losartan 100', minoxidil 30', Asmanex, omeprazole 20', percocet, protonix, pravastin 10', prchlorperazine 10', ranitidine 150', sucralfate 1g", terazosin 2', topamax 100', vitamin B, Calcium, Coenzyme, triazolam, IRon, Loratadine, magnesium, MVI, omega, zinc Discharge Medications: 1. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 2. Acetaminophen 160 mg/5 mL Solution Sig: Fifteen (15) mL PO Q6H (every 6 hours) as needed for pain for 10 days. Disp:*500 mL* Refills:*0* 3. Topiramate 100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Amlodipine 2.5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 6. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Minoxidil 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 9. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 10. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for headach. 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation for 10 days. Disp:*20 Capsule(s)* Refills:*0* 13. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain for 10 days. Disp:*50 Tablet(s)* Refills:*0* 14. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed for nausea for 1 months. Disp:*50 Tablet(s)* Refills:*1* 15. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day for 1 months. Disp:*60 Tablet(s)* Refills:*1* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: chronic pancreatitis mass at head of pancreas on CT scan failure to thrive chronic abdominal pain Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: Please return to the ED if you... *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. 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: Please follow up with in the pain center with the following appointments: Provider: [**Name10 (NameIs) 8673**] [**Last Name (NamePattern4) 8674**], MD Phone:[**Telephone/Fax (1) 1652**] Date/Time:[**2105-2-18**] 2:10 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 1652**] Date/Time:[**2105-2-19**] 11:00 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2105-3-30**] 4:30 Please call the [**Hospital **] Clinic at [**Telephone/Fax (1) 3681**] to set up follow up for your tube feeds and discuss changes in your tube feed requirements.

[ "998.11", "568.0", "577.1" ]

icd9cm

[ [ [] ] ]

[ "54.12", "40.11", "96.6", "46.39", "54.59" ]

icd9pcs

[ [ [] ] ]

7905, 7980

3885, 5964

396, 503

8122, 8122

3340, 3862

10313, 11025

2922, 2926

6428, 7882

8001, 8101

5990, 6405

8267, 9782

9798, 10290

2941, 3321

293, 358

531, 2644

8136, 8243

2666, 2859

2875, 2906

27,957

104,695

14894

Discharge summary

report

Admission Date: [**2102-8-18**] Discharge Date: [**2102-8-20**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 106**] Chief Complaint: respiratory distress Major Surgical or Invasive Procedure: Cardiac catherization. History of Present Illness: [**Age over 90 **] year-old woman with a history of HTN who is now transferred to the CCU with respiratory distress. She initially presented to the ED on [**2102-8-18**] with one day of chest pain; she wsa found to have a-fib with RVR to the 120s in the ED and was thought to have ST elevations in V2-V4 so she was taken urgently to the cath lab. At cath, she was found to have mild 3-vessel disease and no intervention was performed. Her pre- and post-catheterization labs were notable for a creatinine of 2.2 (baseline unknown). She was given a total of 3 L of IV fluids today due to her elevated creatinine and urine electrolytes consistent with prerenal azotemia; she reportedly put out only about 300cc of urine to this throughout the day. . Cardiac review of systems cannot be obtained at this time due to respiratory distress and acuit of the situation. Past Medical History: ypertension . Cardiac Risk Factors: Hypertension . Cardiac History: Percutaneous coronary intervention, on [**2102-8-18**] anatomy as follows: Selective coronary angiography of this co-dominant system demonstrates moderate three vessel coronary artery disease. The LMCA has 30% proximal stenosis. The LAD has moderate luminal irregularities with serial 40% elsions and mid vessle 50% stenosis. The mLCx artery has 50% stenosis with streaming artifact. The LPLV has 70% stenosis. The pRCA has 60% stenosis with 50% stenosis in the mid vessel. Limited resting hemodynamic measurement reveals normal central aortic pressure of 122/79mmHg. Social History: Social history is significant for the absence of current tobacco use (quit 20 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: VS: T 96.1, BP 110/75, HR 110, RR 36, O2 % unable to check with pulse oximeter (PaO2 117 on 4L n.c.) Gen: Elderly hispanic woman in respiratory distress, answering questions appropriately HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa; dry mucous membranes. Neck: Supple with JVP of 12 cm. CV: PMI located in 5th intercostal space, midclavicular line. Tachycardic, normal S1, S2. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were markedly labored, with accessory muscle use. Crackles were noted throughout both lung fields. Abd: Soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: Modertaley cool with mild cyanosis. No clubbing or edema. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; trace DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; trace DP Pertinent Results: [**2102-8-18**] 05:45PM BLOOD WBC-9.4 RBC-3.83* Hgb-12.2 Hct-36.9 MCV-96 MCH-31.9 MCHC-33.2 RDW-14.4 Plt Ct-230 [**2102-8-20**] 06:48AM BLOOD WBC-10.2 RBC-3.24* Hgb-10.2* Hct-32.6* MCV-101* MCH-31.6 MCHC-31.4 RDW-14.8 Plt Ct-152 [**2102-8-18**] 05:45PM BLOOD Neuts-87.1* Bands-0 Lymphs-7.6* Monos-4.3 Eos-0.7 Baso-0.3 [**2102-8-20**] 06:48AM BLOOD Neuts-87* Bands-1 Lymphs-10* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2102-8-20**] 12:01AM BLOOD Fibrino-90* [**2102-8-20**] 06:48AM BLOOD FDP-320-640* [**2102-8-20**] 04:00AM BLOOD Glucose-197* UreaN-64* Creat-2.2* Na-143 K-4.1 Cl-99 HCO3-11* AnGap-37* [**2102-8-19**] 09:10PM BLOOD ALT-113* AST-152* LD(LDH)-833* AlkPhos-237* Amylase-134* TotBili-2.1* [**2102-8-18**] 05:45PM BLOOD cTropnT-0.10* [**2102-8-19**] 09:10PM BLOOD CK-MB-7 cTropnT-0.11* [**2102-8-20**] 04:00AM BLOOD CK-MB-9 cTropnT-0.09* [**2102-8-18**] 05:45PM BLOOD Calcium-9.4 Phos-4.4 Mg-2.3 [**2102-8-20**] 04:00AM BLOOD Albumin-2.5* Calcium-6.9* Phos-7.9* Mg-2.4 [**2102-8-19**] 05:45AM BLOOD Triglyc-47 HDL-60 CHOL/HD-1.9 LDLcalc-45 [**2102-8-20**] 04:00AM BLOOD Hapto-168 [**2102-8-18**] 05:50PM BLOOD Comment-GREEN TOP [**2102-8-19**] 09:29PM BLOOD Type-ART pO2-255* pCO2-19* pH-7.24* calTCO2-9* Base XS--17 [**2102-8-20**] 12:45AM BLOOD Type-ART pO2-554* pCO2-27* pH-7.08* calTCO2-8* Base XS--21 [**2102-8-20**] 02:02AM BLOOD Type-ART pO2-264* pCO2-26* pH-7.18* calTCO2-10* Base XS--17 -ASSIST/CON Intubat-INTUBATED [**2102-8-20**] 04:08AM BLOOD Type-ART pO2-156* pCO2-29* pH-7.25* calTCO2-13* Base XS--12 [**2102-8-20**] 07:21AM BLOOD Type-ART Temp-36.7 FiO2-40 pO2-154* pCO2-29* pH-7.33* calTCO2-16* Base XS--9 Intubat-INTUBATED [**2102-8-19**] 08:38PM BLOOD Lactate-14.9* K-4.6 [**2102-8-20**] 12:45AM BLOOD Lactate-16.3* [**2102-8-20**] 07:21AM BLOOD Glucose-235* Lactate-11.4* Brief Hospital Course: Patient had a cardiac catherization without finding occlusive disease. She tolerated the procedure well. One day following, the patient was [**Last Name (un) 4662**] the CCU in respiratory distress. Patient was intubated, and ventilation was stabilized. She had a progressive lactic acidosis. She eventually had a cardiac arrested and was unsucessfully coded. On autopsy, patient was found to have multiple thrombosis, including large pumonary embolisms. Medications on Admission: aspirin 325mg daily pantoprazole 40mg daily metoprolol 12.5mg [**Hospital1 **] Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Cardiopulmonary collapse Discharge Condition: Expired

[ "276.2", "414.01", "584.9", "995.93", "427.31", "038.9", "585.9", "410.71" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "37.22", "88.52", "38.93", "88.55" ]

icd9pcs

[ [ [] ] ]

5535, 5544

4914, 5376

282, 307

5612, 5622

3075, 4888

2017, 2099

5506, 5512

5565, 5591

5402, 5483

2114, 3056

222, 244

335, 1198

1220, 1858

1874, 2001

41,143

112,156

35097

Discharge summary

report

Admission Date: [**2132-10-18**] Discharge Date: [**2132-10-28**] Service: MEDICINE Allergies: Keflex / Ambien Attending:[**First Name3 (LF) 2901**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: 83M with PVD s/p balloon angioplasty to both legs presents with increasing shortness of breath, bilateral leg swelling x2 weeks, and substernal chest pain this evening lasting at least 20 minutes. Chest pain occured while he was getting into bed; he thought it was indigestion and took a tylenol for it, with eventual resolution in He recently had a toe amputation 1 week ago [**3-8**] arterial insufficiency and has been relatively less mobile during this time. He developed some dyspnea with the CP today and then presented to [**Hospital3 **]. There, CXR showed pulm edema, also had an elevated BNP and TnI. D-dimer was also elevated at 393. Lidocaine was started for VT and he was transferred to [**Hospital1 18**]. . In the [**Hospital1 18**] ED, afebrile, pulse 80s, BP 100s/60s, RR 28, Sat 80%RA, 100% NRB. Started heparin gtt, ASA, and given lasix 20mg IV. Past Medical History: Hypertension Peripheral Vascular Disease Hip replacement in [**2130**] L toe osteomyelitis leading to partial amputation one week ago Social History: Lives with wife; has two grown children. Prior smoker, quit many years ago. No alcohol. Family History: Son w/ CAD at young age Physical Exam: VS:108/62, 82, 22, 96%RA HEENT: MMM, No appreciable JVD Heart: RRR, III/VI SEM at URSB Lungs: Decreased breath sounds in the bases, mild crackles to midlung, no wheezes, mild rhonchi in L midlung. Abdomen: Soft, NT, ND, BS+, No HSM Ext: Partially amputated L second toe w/ 2 sutures in place. No LE edema. Pedal pulses dopplerable. Radial pulses 2+ and equal. Neuro: A/OX3, CNII-XII grossly intact w/ slight facial droop to R. Pertinent Results: [**2132-10-18**] echo The left atrium is moderately dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 10-20mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is severe global left ventricular hypokinesis (LVEF = 25 -30%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular cavity is markedly dilated with mild global free wall hypokinesis. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (area 1.2cm2). The mitral valve leaflets are mildly thickened. The mitral valve leaflets are elongated. Mild to moderate ([**2-6**]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. [**2132-10-18**] LE doppler: No e/o DVT [**2132-10-18**] CXR EMI-UPRIGHT VIEWS OF THE CHEST AT 12:10 A.M.: There are moderate bilateral pleural effusions, with associated atelectasis. Pulmonary vasculature appears slightly engorged, and increased opacity at both lung bases likely reflect mild pulmonary edema. The heart is enlarged. There is no hilar or mediastinal enlargement. There is no pneumothorax. Soft tissue and bony structures are notable for convex leftward curvature of the upper spine, but are otherwise unremarkable. IMPRESSION: Moderate bilateral pleural effusions, enlarged heart and mild pulmonary edema. Brief Hospital Course: 83M with PVD, HTN, history of tobacco, presents with CHF and NSTEMI; hihg-risk features in this patient include the presence of chest pain at rest, positive biomarkers, CHF signs/symptoms, and patient already on ASA. . # CAD/Ischemia: NSTEMI in pt with existing CAD-risk equivalent. High risk feature of CHF. Pt. had indigestion on the day after admission which responded to 2 sublingual nitroglycerin was not associated w/ ECG changes and did not return. Pt. was initially scheduled for catheterization, but was unable to lay flat for procedure due to orthopnea. It was decided that pt. would be high risk for cath and may require intubation from which he would be a very difficult wean. It was determined that given his history of severe PVD he likely has 3vd without a single intervenable culprit lesion and that he would be a very poor candidate for CABG given his debilitated state. He will f/u with cardiologist as an outpt. for possible future catheterization when he is more able to lay flat. His medical regimen was optimized w/ ASA, plavix, BB, ACEI and he was diuresed several liters after which his orthopnea significantly improved. CT coronaries was considered but decided against because either result (3vd vs. single lesion) would require a catheterization for confirmation. . # PUMP: LVEF is 25% with moderate AS (1.2cm2), mild-to-moderate MR, and severe TR. Pt. appeared severely volume overloaded on presentation and could not be cathed secondary to orthopnea. He was diuresed several liters with furosemide and acetazolamide and his oxygen requirement and orthopnea decreased progressively with diuresis. . #Hypercarbia: pt. was noted to have a compensated respiratory acidosis in addition to his initial hypoxia. This was not entirely explained by his pulmonary edema as CO2 is soluble in water. His mental status improved with diuresis, and an ABG was not rechecked after he improved but it is likely that his lungs were stiff from edema fluid increasing the difficulty of breathing and thus causing him to hypoventilate. . # Rhythm: afib, new diagnosis, was started on warfarin, metoprolol for rate control. Pt. had no episodes of RVR. . #HTN: Pt. was initiated on several new antihypertensive medications and for most of his admission his BP was normal to low. He had several episodes of SBP in high 70's, usually in the afternoons when sitting up in the chair during which he mentated appropriately and produced significant UOP. He was also noted to be orthostatic by PT. He had been taking midodrine at home but we did not restart this as he has known PVD and now CAD w/ low EF. We decreased his diuresis and encouraged PO intake as he appeared dry on exam. . # elevated D-dimer: PE was not very high on the differential as pt. was short of breath and hypoxic but clearly in florid heart failure. Pt. was r/o for DVT/PE w/ LE dopplers . # Depression: continued home duloxetine 30mg daily and trazodone 50mg QHS. . # Macrocytic anemia: Pt. was on B12, thiamine, folate supplementation. TSH normal. Vitamin B12 and folate studies were pending on d/c. . # Code: full . Medications on Admission: lisinopril 20mg daily ASA 81mg daily lasix 20mg daily duloxetine 30mg daily trazodone 50mg QHS thiamine folic acid MVI Vit C Vit B12 Discharge Medications: 1. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 10. Cyanocobalamin 250 mcg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 12. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 14. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 15. Famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day. 16. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) vial Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 17. Ipratropium Bromide 0.02 % Solution Sig: One (1) vial Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 18. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily). 19. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 20. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 21. Outpatient Lab Work INR on [**2132-10-31**] , results to be sent to Dr. [**Last Name (STitle) **] rehab. 22. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital 1263**] Hospital Transitional Care Unit - [**Location (un) 686**] Discharge Diagnosis: Ischemic Coronary Artery Disease s/p Non ST Elevation Myocardial Infarction. Acute Systolic Congestive Heart Failure Atrial Fibrillation Anemia Peripheral Vascular disease s/p PCI x2 Osteomyelitis s/p amputation of left second toe Hypertension Discharge Condition: stable. Discharge Instructions: You were admitted because you had a heart attack and because your body was overloaded with fluid making it difficult for you to breath. We increased your medicines in order to protect your heart. We considered doing a cardiac catheterization to evaluate your cardiac vessels more precisely but because you looked very ill we decided to try and maximize medical therapy first. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 2 liters Followup Instructions: Cardiology: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD/ Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] Phone: [**Telephone/Fax (1) 62**] Date/Time: Tuesday [**11-11**] at 3:20pm. . Vascular Surgery: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 80155**], MD [**Apartment Address(1) 67514**], [**Hospital1 **], [**Numeric Identifier **] Phone: ([**Telephone/Fax (1) 80156**] [**10-30**] at 11:45pm. . Sleep study: Please discuss this with your primary care doctor, Dr. [**Last Name (STitle) **]. . Primary Care: Please make an appt to see Dr. [**Last Name (STitle) **] in your home after you return. Please have your INR drawn on [**2132-10-31**] and results sent to Physician on site at rehabilitation center. . You should have a podiatrist see you at the rehabilitation center [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**] Completed by:[**2132-10-28**]

[ "281.9", "599.7", "V15.82", "V58.61", "410.71", "867.0", "428.0", "493.20", "V64.1", "V49.72", "428.21", "715.36", "401.9", "V17.3", "276.2", "424.2", "440.20", "E928.9", "311", "396.2", "427.31", "276.3" ]

icd9cm

[ [ [] ] ]

[ "99.20" ]

icd9pcs

[ [ [] ] ]

9065, 9169

3742, 6837

236, 243

9457, 9467

1902, 3719

10022, 11028

1415, 1440

7020, 9042

9190, 9436

6863, 6997

9491, 9999

1455, 1883

186, 198

271, 1137

1159, 1294

1310, 1399

83,034

167,891

37580

Discharge summary

report

Admission Date: [**2122-11-4**] Discharge Date: [**2122-11-11**] Date of Birth: [**2097-1-19**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3043**] Chief Complaint: Cough and dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: 25 yo F with cough, SOB for two weeks. She reports that she went to her PCP's office approximately 2 weeks ago when the SOB and cough started and was told she had bronchitis and placed on inhalers and Zpack, which did not improve her symptoms. She then returned to her PCP's office on Wednesday [**11-4**] for continued SOB, at that time PCP sent her to [**Hospital 1562**] hospital for evaluation, where she was found to have positive d-dimer and subsequent CTA showing bilateral PE. Patient reports that she had bloody sputum approximately two weeks ago, has also had bloody sputum past 2 days. Sputum clear other than blood. Reports that she also had an episode of lower chest/epigastric pain approximately 1 week ago in the late evening when lying in bed, [**10-3**] pain, improved with Tylenol, which she attributed to GERD as had previously had spicy meal earlier in the day. Received vancomycin/lovenox (1mg/kg at ~5pm), patient reports received 2 shots in abdomen. Vancomycin because of ?PNA on chest CT. Denies fevers/chills/nightsweats. Reports that she had an episode in [**Month (only) **] of increased leg pain, went to PCP who sent her for ultrasound, per patient she recieved ultrasound and then heard nothing. When went to ED in [**Hospital1 1562**] today told that she had had a clot in her leg on previous ultrasound. In [**Hospital1 18**] ED Patient was given nothing. Vitals: T98 HR101 BP123/77 RR22 O2sat 15L NRB 96% Review of systems: (+) One episode post-tussive emesis on tuesday night (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: Asthma Hypothyroidism Shingles PNA in [**2115**] GERD Obesity Taking birth control (Trispritec?) until last sunday when she ran out. Social History: EtoH 2-3 beers approx 2-3 times/month, Tobacco quit approximately 1 week ago, 6 mos smoked approximately 9 cigs/month (only when out with friends). [**Name2 (NI) **] drug abuse. Lives with mother, works as a bank teller/[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 233**] consultant Family History: Positive for multiple family members ([**Name2 (NI) 12232**], aunts) with blood clots, all venous. Reports one cousin recently hospitalized. Doesn't know full details. Also grandmother with breast CA. Physical Exam: Vitals: T:95.5 BP:121/80 P:96 R: 29 O2:94% nonrebreather General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PEERRL 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, obese, 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: WBC count 16.8 with 74% neutrophils, bicarb 17, normal PT, PTT and INR, proBNP:5050, troponin normal <0.01. Of note sample lipemic. DISCHARGE LABS: [**2122-11-11**] 06:59AM BLOOD WBC-9.7 RBC-4.54 Hgb-13.4 Hct-40.6 MCV-89 MCH-29.4 MCHC-32.9 RDW-14.4 Plt Ct-227 [**2122-11-11**] 06:59AM BLOOD Plt Ct-227 [**2122-11-11**] 06:59AM BLOOD Glucose-84 UreaN-11 Creat-0.9 Na-137 K-4.2 Cl-104 HCO3-27 AnGap-10 [**2122-11-5**] 04:28PM BLOOD Fibrino-300 MICRO: Urine Cultures: No Growth To Date STUDIES: BILAT LOWER EXT VEINS [**2122-11-5**]: No evidence of deep vein thrombosis in either leg. ECHO: Severe pulmonary hypertension (~[**1-27**] systemic). Dilated right ventricle with mild systolic dysfunction and pressure overload. Preserved left ventricular systolic function. Moderate tricuspid regurgitation. No intracardiac shunting seen. CXR: There is a right upper lobe relatively peripheral opacity that might represent a pulmonary infarct giving the history of pulmonary embolism although infectious process cannot be excluded and comparison with outside chest CT is recommended. The rest of the lungs are unremarkable except for left upper paramediastinal opacity most likely representing atelectasis. There is no pleural effusion and there is no pneumothorax. The heart size is top normal although might be exaggerated by the study technique and the low lung volumes. EKG: Sinus tachycardia @ 110. Diffuse non-diagnostic repolarization abnormalities. No previous tracing available for comparison. Brief Hospital Course: 1. Bilateral Pulmonary Emboli: Patient initially evaluated at [**Hospital 1562**] Hospital where she was found to have positive D-dimer; CT scan done showed bilateral PEs. Patient recieved Lovenox at approximately 5pm on [**2122-11-4**]. Lysis was deferred because she was hemodynamically stable and there was no evidence of either significant clot on LE ultrasound or PFO or significant right heart strain on TTE. Patient was put on a IV heparin drip in the unit rather than Lovenox due to her body habitus. Warfarin was started with a goal INR of [**1-27**]. She was kept on a heparin drip until her INR was therapeutic. She was discharged on 5mg Warfarin daily with instructions to have her INR checked on Friday, [**11-13**] (2 days after discharge) and to have her primary care physician follow up on her anticoagulation. The cause of her pulmonary emboli were not clear, but her risk factors included family history of blood clots (cousin), recent oral contraceptive use, and smoking. While lower extremity U/S during this admission showed no evidence of DVTs, per report there was some evidence of a small DVT on previous LE U/S at an OSH a few months prior to the current admission. Further work up of potential coagulopathies was differed to after discharge given her current clot burden. 2. Respiratory Failure: Patient was initially admitted to the MICU on a non-rebreather with respiratory failure due to her pulmonary emboli. PNA was considered to be unlikely given her lack of fevers, lack of crackles on exam, and lack of clear evidence of PNA on imaging. Asthma was also considered unlikely given her lack of wheezing. She was given nebulizer treatments to help with subjective shortness of breath and cough. She was then successfully weaned to room air and remained stable, without labored breathing or other signs of respiratory distress, and saturating > 95% on room air for the remainder of her hospitalization. 3. Hypothyroidism: Patient was admitted with PMH of hypothyroidism but with current and recent non-compliance on levothyroxine and uncertainty about her current dose. Her primary care physician was [**Name (NI) 653**] and she was started on her previous dose of 50mcg daily. A TSH was checked and was normal but was considered unlikely to be accurate given her current medical state. This issue should be followed up as an outpatient. 4. GERD: Patient was continued on Omeprazole. 5. FOLLOW-UP: Patient should have her INR followed regularly and her Coumadin adjusted accordingly. Medications on Admission: levothyroxine - not taking PPI - not taking OCP - was taking until 1 month prior to admission when ran out Albuterol inhaler (has not needed since [**2117**] until recent episode) Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough. 4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Coumadin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day: Please have your INR checked on Friday, [**11-13**], and then followed up by your primary care provider. [**Name Initial (NameIs) **]:*60 Tablet(s)* Refills:*2* 6. Outpatient Lab Work Bloodwork: PT/INR, PTT, hematocrit. Please have these labs checked on Friday, [**11-13**], and have your primary care provider follow up on the results. Discharge Disposition: Home Discharge Diagnosis: PRIMARY: 1. Pulmonary Embolism SECONDARY: 1. Hypothyroidism 2. Obesity Discharge Condition: stable, tolerating food without difficulty, breathing comfortably on room air Discharge Instructions: It was a pleasure taking care of you during your admission at [**Hospital1 69**]. You were admitted for a pulmonary embolism. While you were here you were treated with blood thinners. We also restarted your levothyroxine while you were here. While you were here we started you on a blood thinner called Warfarin (also sometimes called Coumadin). This medication needs to be monitored regularly using a blood test called an INR. Please continue to take this medication exactly as prescribed. Please have your INR checked on Friday, [**11-13**]. We are providing you with a prescription to have this labwork drawn. Please contact your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 84337**], and arrange to have them follow up on the result of this lab. Her office can be reached at [**Telephone/Fax (1) 23860**]. Please arrange to have your INR checked regularly by your primary care physician and your Warfarin dose adjusted accordingly. When you meet with your primary care physician you should discuss plans to further evaluate the reasons why this pulmonary embolism developed. There are a range of factors that can contribute to the likelihood of these occuring, including genetic factors, use of contraceptive medications, and smoking. We did not change any of your other medications while you were here. Please continue to take all of your previous medications exactly as prescribed. Please call your physician or go to the emergency room if you experience any of the following: worsening chest pain, shortness of breath, nausea, bloody vomiting, blood diarrhea, any loss of consciousness, fevers, chills, or other concerning symptoms. Followup Instructions: 1. Have your INR checked on Friday, [**2122-11-13**]. Your primary care provider can assist you in finding a lab where you can have this drawn. 2. Primary Care Appointment: Dr. [**Last Name (STitle) 84337**], Monday, [**2122-11-23**] at 2:15PM, [**Telephone/Fax (1) 23860**]. Please make sure to discuss plans for having your INR followed and your Coumadin adjusted.

[ "V58.69", "493.90", "416.0", "V18.3", "415.19", "429.9", "288.60", "786.3", "278.01", "V12.51", "V58.61", "518.81", "530.81", "244.9", "305.1" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8563, 8569

5049, 7568

334, 341

8685, 8765

3506, 3506

10491, 10862

2740, 2942

7798, 8540

8590, 8664

7594, 7775

8789, 10468

3671, 5026

2957, 3487

1830, 2250

277, 296

369, 1811

3522, 3655

2272, 2407

2423, 2724

28,180

101,813

33694

Discharge summary

report

Admission Date: [**2112-3-30**] Discharge Date: [**2112-5-10**] Date of Birth: [**2030-4-22**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1481**] Chief Complaint: sepsis Major Surgical or Invasive Procedure: trach fluid collection aspiration fistula intubation multiple wound debridements History of Present Illness: This is an 81 year old male who was transferred from an OSH on [**2112-3-30**], POD 15 from a left colectomy for a lower GI bleed. (8 units of RBC transfused). On POD 8, the patient had an anastamotic leak and underwent a Hartmann's procedure with creation of an ascending colostomy. His post operative course was subsequently complicated by acute renal failure, small peripheral pulmonary emboli, HIT positivity on argatroban, and atrial fibrillation a\on an amiodarone drip. Past Medical History: HTN, hyperlipidemia, EF 60%, DM2 diet controlled, history of throat cancer s/p resection + xrt '[**89**], s/p empyema w/ CT drainage, legally blind right eye secondary to injury Social History: widowed, lives alone independently Family History: noncontributory Physical Exam: ON ADMISSION VS- T 98.6, P 61, BP 120/40, RR 18, O2 97% on ventillator Gen- NAD, intubated, sedated Heart- irregularly irregular Lungs- coarse rhonchi throughout Abdomen- soft, diffusley tender to palpationmidline incision with necrotic edges, ostomy pink with green stool Extremities- 2+ edema b/l Pertinent Results: [**2112-3-30**] 11:55PM TYPE-ART PO2-95 PCO2-50* PH-7.30* TOTAL CO2-26 BASE XS--1 [**2112-3-30**] 11:17PM URINE HOURS-RANDOM CREAT-97 SODIUM-39 [**2112-3-30**] 11:17PM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.018 [**2112-3-30**] 11:17PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-SM [**2112-3-30**] 11:17PM URINE RBC-[**6-7**]* WBC-[**3-2**] BACTERIA-MOD YEAST-NONE EPI-0 [**2112-3-30**] 11:17PM URINE GRANULAR-<1 HYALINE-0-2 [**2112-3-30**] 11:12PM TYPE-ART PO2-86 PCO2-54* PH-7.26* TOTAL CO2-25 BASE XS--3 [**2112-3-30**] 10:04PM TYPE-ART PO2-105 PCO2-56* PH-7.25* TOTAL CO2-26 BASE XS--3 [**2112-3-30**] 10:04PM LACTATE-2.0 [**2112-3-30**] 10:04PM freeCa-1.05* [**2112-3-30**] 09:54PM GLUCOSE-135* UREA N-63* CREAT-2.6* SODIUM-139 POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-21* ANION GAP-18 [**2112-3-30**] 09:54PM CALCIUM-7.5* PHOSPHATE-2.8 MAGNESIUM-2.1 [**2112-3-30**] 09:54PM WBC-22.1* RBC-3.15* HGB-9.4* HCT-28.9* MCV-92 MCH-29.7 MCHC-32.4 RDW-16.0* [**2112-3-30**] 09:54PM NEUTS-83* BANDS-3 LYMPHS-5* MONOS-2 EOS-3 BASOS-1 ATYPS-0 METAS-2* MYELOS-1* NUC RBCS-1* [**2112-3-30**] 09:54PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL [**2112-3-30**] 09:54PM PLT SMR-LOW PLT COUNT-104* [**2112-3-30**] 09:54PM PT-38.5* PTT-100.0* INR(PT)-4.2* Brief Hospital Course: Briefly, Mr. [**Known lastname 77982**] was transferred to [**Hospital1 18**] from [**Hospital1 **] on [**2112-3-30**] after subtotal colectomy for LGIB requiring a massive transfusion of 8u pRBC. His [**Hospital 18**] hospital course is broken down by systems: Neuro He was intermittently sedated with fentanyl and propofol. His sedation was weaned to prn dilaudid and oxycodone liquid. Pain gradually became a nonissue. He should not require pain medication even for VAC changes. He was seen by neurology for dystonia, who recommended an MRI of the brain whcih showed an acute left parietal subcortical infarct. The neurologist felt that coumadinizing him with a goal INR 2.5- 3.5 would be best to prevent another stroke. The etiology of his stoke is presumed cardiac given his atrial fibrillation. His cognition gradually improved throughout his hospital course, as did his dystonia, for which he is on cogentin per neurology. At present, he is alert and can communicate effectovely. Cards On admission, Mr. [**Known lastname 77982**] had afib with RVR for which he was on an amiodarone gtt. He was evaluated by cardiology and weaned off amiodarone. After amiodarone was weaned, his rhythm was intermittently in and out of afib. He eventually stabilized on PO lopressor and PO amiodarone. In addition, he was intermittently on and off pressors, including levophed and pitressin. Eventually he stabilized and has been off of all pressors for over 2 weeks prior to discharge. Pulm The patient had a tracheostomy. He was gradually weaned on the ventillator. Eventually he was weaned to trach collar, which he has been tolerating for over 2 weeks. On [**5-4**], he did tolerate a Passy-muir valve trial. He requires supervision with the PM valve, because he desaturates. He does require suctioning intermittently. FEN/GI Tube feeds via Dobhoff, TPN, ostomy, serial abdominal debridements [**4-4**], [**4-8**], and abdominal VAC [**4-12**], 16, 17, 20, 24, 26 and Q 3 days thereafter. Last VAC change was [**2112-5-8**]. His abdominal wound has been healing very well with a VAC dressing. It is granulating nicely. There had been a fistulous connection between the ostomy and the wound. This has since closed off after a few vicryl sutures were placed at the bedside. He was seen and evaluated by plastic surgery who recommended outpatient skin grafting. He has been tolerating tube feeds at goal for over 2 weeks prior to discharge and his ostomy is productive. He gets his tube feeds via a Dobhoff. We did not feel that a PEG was a good idea in him beacause of his anatomy. He was hypernatremic to 153 at a maximum, but he did respond to free water boluses and his sodium has since stabilized. We have since decreased his free water boluses. GU He developed ARF and started hemodialysis at the referring institution x3 days. Daily CVVH was started at [**Hospital1 18**] via R fem HD catheter, and he was weaned off CVVH, intermittently on lasix, and he now makes appropriate urine output without any assistance. His azotemia gradually cleared. Withing the past week, we have started gradual diuresis to make him about a liter negative daily. His weights have been retruning to baseline of 98 kg. H Mr. [**Known lastname 77982**] was found to have small peripheral PEs and HIT at the referring institution, and was continued on an argatroban gtt. Eventually he was transitioned off the argatroban to coumadin. He was found to be HIT negative by seratonin release assay. He is currently on coumadin, goal INR 2.5- 3.5. ID The patient had a long and complicated infectious disease course. Meropenem ([**4-16**]) and vancomycin ([**4-17**]) for MRSA PNA, fluconazole for [**Female First Name (un) **] torulopsis in the urine and sputum [**4-19**], flagyl empircally for C. diff (although he never tested positive) [**4-20**] Cultures include Klebsiella in blood at OSH [**3-31**] Wound cx: [**Female First Name (un) **], klebs [**4-3**] Sputum: budding yeast, GNR, MRSA [**4-10**] Sputum: sparse klebs [**Last Name (un) 36**] to cipro/bactrim [**4-14**] Sputum: MRSA, Klebs [**4-17**] sputum: MRSA, 2+budding yeast, sparse GNR [**4-20**] sputum: MRSA and 1+budding yeast Eventually, all antiobiotics were stopped on [**2112-5-4**]. Endo Mr. [**Known lastname 77982**] was kept on a strict insulin sliding scale to keep his sugars within a tight range. Medications on Admission: lisinipril 20', acebutolol 400', allopurinol 300', lipitor 10', ASA 325', MVI Discharge Medications: 1. Maalox 200-200-20 mg/5 mL Suspension [**Known lastname **]: One (1) ML PO TID (3 times a day) as needed for constipation. 2. Artificial Tear with Lanolin 0.1-0.1 % Ointment [**Known lastname **]: One (1) Appl Ophthalmic PRN (as needed). 3. Polyvinyl Alcohol 1.4 % Drops [**Known lastname **]: One (1) Drop Ophthalmic PRN (as needed). 4. Docusate Sodium 50 mg/5 mL Liquid [**Known lastname **]: One (1) PO BID (2 times a day). 5. Oxycodone 5 mg/5 mL Solution [**Known lastname **]: One (1) PO every eight (8) hours as needed for pain. 6. Acetaminophen 325 mg Tablet [**Known lastname **]: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 8. Zinc Sulfate 220 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY (Daily). 9. Allopurinol 100 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO DAILY (Daily). 10. Benztropine 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 11. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 12. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day). 13. Warfarin 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO ONCE (Once) for 1 doses: check daily INR. 14. Furosemide 10 mg/mL Solution [**Last Name (STitle) **]: One (1) Injection [**Hospital1 **] (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital1 685**]- [**Location (un) **] Discharge Diagnosis: LGIB s/p colectomy anastomotic leak s/p exlap, Hartmann's renal failure pulmonary emboli sepsis rapid atrial fibrillation large abdominal wound dystonia CVA Discharge Condition: good Discharge Instructions: Please call or come to the ED with any fevers > 101, nausea, vomiting, abdominal pain, purulence from wounds, oliguria, hypotension, rapid atrail fibrillation, or any other worrisome issues. Please continue all medications as directed. Activity as tolerated. Followup Instructions: Please call the office of Dr. [**Last Name (STitle) **] to schedule a follow-up appointment ([**Telephone/Fax (1) 1483**] Completed by:[**2112-5-9**]

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icd9cm

[ [ [] ] ]

[ "31.1", "96.6", "93.90", "38.91", "38.95", "99.15", "54.91", "86.28", "96.07", "93.57", "96.72", "39.95" ]

icd9pcs

[ [ [] ] ]

8989, 9057

2951, 7344

321, 403

9258, 9265

1531, 2928

9574, 9726

1180, 1197

7472, 8966

9078, 9237

7370, 7449

9289, 9551

1212, 1512

275, 283

431, 911

933, 1112

1128, 1164

32,247

113,222

15732

Discharge summary

report

Admission Date: [**2122-9-22**] Discharge Date: [**2122-9-29**] Date of Birth: [**2059-1-8**] Sex: F Service: MEDICINE Allergies: Percocet / Motrin / Nsaids / Aspirin / Dilantin / Ativan Attending:[**First Name3 (LF) 1973**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Intubation History of Present Illness: 63F with multiple medical problems and multiple admissions for altered mental status presenting with abdominal pain and altered mental status. Ms. [**Known lastname **] [**Last Name (Titles) 1834**] exploratory laparotomy on [**2122-9-11**] and was found to have benign cecal pneumatosis. The patient presents now for progressive confusion and decreased mental acuity. The family is not available to discuss their concerns and the patient complains of unchanged abdominal pain. In the ED her vitals were 98.2 99 123/39 17 99%RA. FSG was 86 on arrival. Exam showed A+O x 1. Labs were c/w ESRD, with AG acidosis, but no hyperkalemia. Neurology was consulted given the AMS, and felt it was due to a toxic-metabolic encephalopathy and not a central insult or seizure. CXR was unrevealing except for LLL atelectasis. No urine able to be obtained but blood cultures were sent. A CT head was negative. A CT abdomen and pelvis was obtained which showed no acute process or abscess, but a small hematoma/stranding in the anterior subcutaneous tissues and likely also left rectus, c/w recent surgery. Her HR did increase to the 140s in the ED, responded to IV labetolol, but pressure dropped. This responded to IVF. She was given 250mg of levetiracetam and admitted to medicine for further workup of AMS and correction of electrolytes. Past Medical History: PMH: 1. Multiple admission with altered MS recently ([**10-13**]) - with recent extensive neurological workup revealing multifocal etiology likely due to HD fluid/electrolyte shifts, ? uremia prior to HD, also component of vascular dementia. Started on [**Month/Year (2) 13401**] [**9-14**]. 2. Diabetes mellitus. 3 End-stage renal disease secondary to diabetes mellitus s/p failed dual extended-criteria donor renal transplant (BK virus nephropathy) 4. Hemodialysis. 5. Hypertension. 6. Hyperlipidemia. 7. Thrombosis of bilateral IVJ (catheter placement)-- DVT associated with HD catheter RUE on anticoagulation (Coumadin) --balloon angioplasty performed [**1-13**]. 8. Osteoarthritis. 9. PER OMR NOTES (?) - Arthritis of the left knee at age nine, treated with ACTH resulting in secondary [**Location (un) **]. She was diagnosed with rheumatic fever. 10. h/o Trach and PEG [**1-13**] (reversed [**2-13**]). 11. h/o L tension pneumothorax [**2-7**] intubation . Past Surgical History: 1. Kidney transplant in [**2119**] b/l in RLQ 2. Left arm AV fistula for dialysis. 3. Removal of remnant of AV fistula, left arm. 4. Catheter placement for hemodialysis. 5. Low back surgery (unspecified) Social History: The patient smokes half a pack of cigarettes a day for the last 20 years. She does not drink alcohol or has ever experienced with recreational drugs, has no tattoos. The patient has had transfusions in [**2119**] and [**2120**]. The patient is a homemaker. The patient has experienced economic problems lately. . Family History: Family History: From prior d/c summary Mother and sister with diabetic mellitus. Kidney failure in mother, sister Physical Exam: On admission to ICU PE: intubated, sedated, NAD VS: T 98.0 BP 157/64--> 80s/40s with propofol HR 96 RR 12, 100% AC 100% 500 x 20 5 General: intubated, sedated HEENT: tongue is swollen and protruding from her mouth, blood visible around ET tube, lips swollen. L pupil briskly reactive to light from 3 mm --> 1 mm; R pupil is sluggish, 3 mm --> 2 mm. anicteric . NECK: no JVD, supple CV: +s1s2 RRR 2/6 systolic murmur, no R/G. +L.sided tunnel cath no erythema, C/D/I, currently accessed/receiveing IVF. PULM: CTA B/L ABD: +bs, midline inscision c/d/i, staples in place, soft, ND. EXT: no C/C/edema 2+pulses b/l NEURO: intubated/sedated. moves all 4. Pertinent Results: Admission labs: [**2122-9-21**] 04:00PM PLT COUNT-415 [**2122-9-21**] 04:00PM NEUTS-67.4 LYMPHS-20.1 MONOS-9.8 EOS-2.6 BASOS-0.1 [**2122-9-21**] 04:00PM WBC-8.3 RBC-2.72* HGB-9.1* HCT-27.7* MCV-102* MCH-33.3* MCHC-32.7 RDW-16.1* [**2122-9-21**] 04:00PM ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG [**2122-9-21**] 04:00PM CALCIUM-9.7 PHOSPHATE-8.0*# MAGNESIUM-2.5 [**2122-9-21**] 04:00PM GLUCOSE-58* UREA N-49* CREAT-13.8*# SODIUM-136 POTASSIUM-6.8* CHLORIDE-99 TOTAL CO2-21* ANION GAP-23* [**2122-9-21**] 04:09PM LACTATE-1.4 K+-4.6 [**2122-9-21**] 05:24PM PT-18.3* PTT-29.2 INR(PT)-1.7* [**2122-9-22**] 06:50AM PLT COUNT-421 [**2122-9-22**] 06:50AM WBC-8.5 RBC-2.83* HGB-9.2* HCT-29.4* MCV-104* MCH-32.7* MCHC-31.4 RDW-15.5 [**9-21**] CT ABD/PELVIS: no acute process, diverticulosis, extensive atherosclerotic changes, left anterior subcutaneous tissue stranding with hematoma-post surgical, extensive collateral circulation, suggestive of an upper extremity thrombus. CT HEAD (noncontrast) [**9-21**]: no acute intracranial process, multiple lacunar infarcts, chronic small vessel ischemic disease (unchanged) EEG: This is an abnormal 24-hour video EEG telemetry in the waking and sleeping states due to the occasional left mid-temporal sharp waves suggestive of a potential focus of epileptogenesis. In addition, there were bursts of generalized delta frequency slowing suggestive of midline subcortical dysfunction. Nonetheless, there were no electrographic seizures and no pushbutton activations noted. [**2122-9-29**] 01:30PM BLOOD WBC-6.4 RBC-3.28* Hgb-10.9* Hct-33.7* MCV-103* MCH-33.3* MCHC-32.4 RDW-16.6* Plt Ct-470* [**2122-9-29**] 01:30PM BLOOD Plt Ct-470* [**2122-9-29**] 01:30PM BLOOD PT-27.6* PTT-131.8* INR(PT)-2.8* [**2122-9-29**] 01:30PM BLOOD Glucose-134* UreaN-36* Creat-9.5*# Na-136 K-3.7 Cl-97 HCO3-26 AnGap-17 [**2122-9-29**] 01:30PM BLOOD Calcium-8.6 Phos-5.8* Mg-2.2 Brief Hospital Course: 1. Altered mental status/seizure/intubation: most likely etiology is multiple missed hemodialysis sessions/uremia. It is possible the Tylenol with codeine she was taking for post operative pain control contributed. The morning following admission she had an episode of decreased responsiveness, clonic jerks, lip smacking and hand automatisms. She was evaluated by neurology and was given Ativan and Depakote for complex partial seizure. Approximately 1 hour after this she became unresponsive and her tongue was swollen. She was intubated for airway protection due to angioedema. Her mental status normalized (thought to be related to post-ictal state and medications), EEG was negative for status epilepticus, head CT and toxicology screens were negative. The patient required daily dialysis from [**Date range (3) 45315**] and her mental status normalized and was stable for several days at discharge. 2. Angioedema/respiratory failure: Her tongue was noted to be swollen prior to the administration of Depakote during suctioning prior to intubation. The angioedema seemed to correlate with the Ativan administration. There is a report of angioedema in the past, attributed to Dilantin--but she received Ativan at that time as well. She was treated for 24 hours with steroids with remarkable improvement. Her lisinopril was also discontinued. Her intubation was for airway protection in the setting of altered mental status and angioedema. She had persistent apneic episodes on the ventilator and never developed a cuff leak. She has presumed tracheal stenosis from prior tracheostomy. She was successfully extubated in the presence of anesthesia on [**2122-9-25**]. It is recommended she have an outpatient sleep study to evaluate for obstructive sleep apnea as well as an outpatient allergy evaluation. 3. Seizures: The patient suffered a partial complex seizure on the morning after admission. The neurology team followed the patient throughout her admission. She was initially loaded with depakote, however, this was then tapered off and her [**Date Range 13401**] dosing was increased to 500 mg twice daily and an additional dose following hemodialysis. She will follow up with Neurology as an outpatient. 4. ESRD on HD: She missed two outpatient HD sessions prior to admission. She was dialyzed daily in the MICU from [**Date range (1) 45316**] then returned to her scheduled of T/T/Saturday. 5. Atrial fibrillation: Rate control with metoprolol. She had a single episode of RVR in the ED prior to admission which responded to labetalol, otherwise, she was effectively rate controlled. Her INR was subtherapeutic at admission, but was therapeutic at discharge. Her INR will need to be followed in rehabilitation and outpatient monitoring set up prior to discharge home. 6. Abdominal Pain: likely post operative, waxed and waned on this admission. At the time of discharge, the pain was controlled by Tylenol. Her staples were removed by the surgical team during this hospitalization. She had increased discharge from her abdominal wound noted on [**2122-9-28**]. The surgery team evaluated and felt the wound was healing well and there was no evidence of a wound infection. They recommended daily dry dressing changes. 7. Benign Hypertension: continued on amlodipine and metoprolol. Lisinopril discontinued in the setting of angioedema and not restarted. The amlodipine was started in its place. Her blood pressure ranged 110-140s/50-70s prior to discharge. 8. Disposition: the patient was discharged to a rehabilitation facility. She will benefit from a home safety evaluation and visiting nurses to evaluate medication understanding/compliance. She requires INR monitoring. As an outpatient, she should have an allergy evaluation for the recurrent angioedema as well as a sleep study to evaluate sleep apnea. Medications on Admission: MEDS: 1. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr [**Date Range **]: One (1) Tablet Sustained Release 24 hr PO once a day. 2. Atorvastatin 20 mg Tablet [**Date Range **]: One (1) Tablet PO once a day. 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Date Range **]: One (1) Cap PO DAILY (Daily). 4. Cinacalcet 90 mg Tablet [**Date Range **]: One (1) Tablet PO once a day. 5. Sertraline 100 mg Tablet [**Date Range **]: One (1) Tablet PO once a day. 6. Lisinopril 5 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 7. Acetaminophen-Codeine 300-30 mg Tablet [**Date Range **]: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 8. Warfarin 1 mg Tablet [**Date Range **]: Two (2) Tablet PO once a day: Please restart [**2122-9-18**]. Do NOT dose on [**9-17**]. 9. Levetiracetam 250 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO twice a day: Started with previous admission 10. Levetiracetam 250 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO following HD. Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO TID (3 times a day). 2. Atorvastatin 20 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Month/Year (2) **]: One (1) Cap PO DAILY (Daily). 4. Cinacalcet 30 mg Tablet [**Month/Year (2) **]: Three (3) Tablet PO DAILY (Daily). 5. Sertraline 100 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 6. Warfarin 1 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 7. Levetiracetam 500 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a day). 8. Levetiracetam 500 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO HD PROTOCOL (HD Protochol). 9. Amlodipine 5 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO DAILY (Daily). 10. Acetaminophen 500 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO Q6H (every 6 hours) as needed: not to exceed 4 grams/24 hours. Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: Primary: Altered mental status Uremia Angioedema Respiratory failure Complex partial seizure Secondary Hypertension End stage renal disease on hemodialysis Atrial fibrillation Seizure Disorder Failed renal transplant X 2 Hyperlipidemia Discharge Condition: At mental status baseline, pain controlled, tolerating diet Discharge Instructions: You were admitted with confusion in the setting of missed hemodialysis sessions. In the hospital, you had a seizure and a reaction to a medication which caused your tongue to swell and necessitated a breathing tube. You had several daily dialysis sessions and your confusion resolved. You had abdominal pain which was controlled with Tylenol. Surgery evaluated your wound and thought you were healing well. You are being discharged to a rehabilitation facility to regain your strength after the long hospitalization. Followup Instructions: Please call your primary provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 45317**] for an appointment within 1 week of rehabilitation discharge. Surgery Follow Up: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2122-10-16**] 2:00 Neurology Follow Up: Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 540**] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2122-11-10**] 4:30 Renal Transplant Appointment: Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2123-1-15**] 9:00 Completed by:[**2122-9-29**]

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icd9cm

[ [ [] ] ]

[ "96.71", "96.04", "38.93", "39.95", "89.14" ]

icd9pcs

[ [ [] ] ]

11908, 11981

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338, 350

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78,504

101,658

40647

Discharge summary

report

Admission Date: [**2169-6-26**] Discharge Date: [**2169-6-30**] Date of Birth: [**2143-4-5**] Sex: F Service: MEDICINE Allergies: Penicillins / morphine / Codeine Attending:[**First Name3 (LF) 2195**] Chief Complaint: Abdominal pain, hyperglycemia Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname 9625**] is a 26F with a history of type I diabetes complicated by chronic gastroparesis and prior DKA (last episode [**5-/2169**]) who presents with a ~4 day history of uncontrolled sugars, abdominal pain, and malaise. She states that her symptoms began on Thursday, when she noticed that her fingerstick values were getting very high. Since that time, she reports that her lowest FS were in the 300s, and many were > 400 (in the early part of the month, she estimates that average readings were in the 160s). She takes 36 units Lantus QHS and [**10-26**] untis of Novolog per day with her sliding scale. States that she has been compliant with fingersticks and insulin administration. Took 16 units of insulin (Novolog) prior to coming to ED at 11:00 AM today. . She has chronic gastroparesis and is never fully pain-free, but notes that her abdominal pain is worse than baseline and different from her standard pain. She feels bloated. This pain does not feel like her prior episodes of kidney stones. In the ED, she reported vomiting 5-10 times daily, but on the floor reports that N/V have not been severe and that she feels that she has been keeping down fluids adequately. She has poor appetite and did not eat solid food today but was able to keep down food yesterday. However, she has had "no energy" and was in bed most of the day yesterday, which she states is very unusual for her. Denies diarrhea but does suffer from chronic problems with constipation. She does report that she has had on-and-off chills and drenching nightsweats two of the last four nights to the point that her boyfriend has had to wake her because the sheets were wet. She does not own a thermometer so did not take her temperature. She has not had SOB or URI symptoms, and though she does report some dysuria she states that this is usual for her and unchanged from her baseline. She reports several prior UTI which have caused "kidney infections" and states that she has been hospitalized for treatment multiple times. She does not currently have flank pain but does report that she had some mild right flank pain on Saturday. Also reports feeling "out of it" like she's drunk, though has not had any alcohol. . In the ED, initial vs were: T 98.1, HR 102, BP 125/82, RR 16, O2 sat 100%. Patient was given IV cipro x 400 mg for possible UTI, at least one liter IVF, started on an insulin gtt, dilaudid 1 mg IV, and IV Zofran. . On the floor, she reports abdominal pain is [**8-16**] severity. Also states that she is hungry and would like to eat, feels that she could tolerate food at this time. . Review of sytems: (+) Per HPI. Also reports recent episode of leg swelling in feet and ankles one week ago, now largely resolved. (-) Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. No recent change in bowel or bladder habits. Denied arthralgias or myalgias. Past Medical History: - Type I diabetes complicated by gastroparesis and prior DKA, diagnosed age 2 - GERD - Anxiety - Cholecystectomy Social History: Lived in [**Location **] with her aunt and uncle until recently, when she moved in with her boyfriend in [**Name (NI) 86**]. She does not work (disabled). She denies cigarette use but occasionally smokes marijuana (none in past few weeks). Does not drink alcohol. No other recreational drug use. Family History: Paternal grandfather had [**Name2 (NI) 499**] cancer. Maternal grandmother had breast cancer. Per notes, her mother is deceased from heroin overdose and her father was murdered by her step mother. She has one brother and one sister who are alive and healthy. Physical Exam: Physical on Arrival to [**Hospital Unit Name 153**] Vitals: T:97.6 BP:104/73 P:98 R: 14 O2: 97% on RA General: Alert, oriented, appears comfortable in bed from doorway though reports [**8-16**] pain HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD, MMM Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Back: No vertebral body, SI or CVA tenderness Abdomen: Soft, diffusely tender to palpation but worse in RLQ, non-distended, bowel sounds present, + rebound tenderness but no guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Labs on Admission: [**2169-6-26**] 12:10PM lucose-671* UreaN-14 Creat-0.7 Na-129* K-5.3* Cl-90* HCO3-24 AnGap-20 WBC-5.8 RBC-4.61 Hgb-12.6 Hct-39.0 MCV-85 Plt Ct-324 Neuts-65.9 Lymphs-29.1 Monos-2.5 Eos-1.7 Baso-0.8 ALT-19 AST-23 LD(LDH)-140 AlkPhos-177* Amylase-44 TotBili-0.2 Lipase-22 Calcium-9.1 Phos-4.1 Mg-1.7 Acetone-NEG Osmolal-285 HCG-<5 URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.016 URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-1000 Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD URINE RBC-1 WBC-9* Bacteri-NONE Yeast-NONE Epi-<1 Microbiology: [**2169-6-26**] - URINE CULTURE: E. coli sensitive to Cipro Brief Hospital Course: 26 F with type I diabetes presenting with anion gap acidosis and + ketones in urine. # DKA. Patient's 2nd DKA in 1 month. Last HgbA1C 8.4. Trigger thought likely to be her underlying UTI given her symptoms, + UA, and + UCx growing E. coli. Prior notes also suggested possible problem with compliance with her insulin and her uncle has raised concern that she may on occasion have intentionally elevated her blood glucose in order to be treated in the hospital with narcotic pain medication. Per her last D/C summary, she was scheduled to see a new PCP, [**Name10 (NameIs) **] missed the appointment and has yet to reschedule. Patient was transitioned to D5 and subcutaneous glargine soon after arriving the ICU. Her BS improved significantly with taking in po. Her anion gap closed. [**Last Name (un) **] followed her throughout her hospitalization, and she was discharged on an adjusted sliding scale and Lantus 23u in the evening. # ABDOMINAL PAIN: Initially thought to have rebound tenderness and RLQ pain, concerning for appendicitis and other intra-abdominal pathology (no ovarian cyst, but has prominent right ovary). Her presentation is nearly identical to that at her prior admission in [**Month (only) 116**], at which time she underwent CT abdomen/pelvis which was unrevealing. Given her young age and desire to minimize radiation exposure, patient had serial abdominal exam. She did not have persistent nausea or vomiting and she reported being able to pass gas and tolerate food intake. She was given IV dilaudid, which was transitioned to her home regimen of PO Oxycodone. She was given a prescription for several days worth of Oxycodone and instructed to follow-up with her new PCP. # URINARY TRACT INFECTION: U/A is mildly positive with 9 WBC, + LE, and also + UCx. Patient states that she has chronic dysuria, frequent UTI's, and that she has had multiple prior hospitalization for pyelonephritis and two prior episodes of kidney stones. She was started on ciprofloxacin and discharged to complete a total of 7 days. # ANXIETY: Per patient, prescriptions had previously been given by her PCP prior to moving to [**Location (un) 86**]. Per last discharge summary, attempts were made to contact a pharmacy and her prior PCP, [**Name10 (NameIs) **] no record of prescriptions could be obtained. She was continued on her home medications and no prescriptions were given at discharge. Contact: HCP is uncle [**Name (NI) **] [**Name (NI) 9625**] [**Telephone/Fax (1) 88920**]. Boyfriend with whom she lives is second emergency contact at [**Telephone/Fax (1) 88922**]. Medications on Admission: - Zoloft 100 mg PO daily (this is dose per recent D/C summary; patient reported 400 mg daily) - Buspar 20 mg PO BID - Clonazepam 2 mg PO TID - Hydroxyzine 50 mg QID - Trazadone 50 mg [**1-8**] tab qHS for insomnia - Omeprazole 40 mg PO BID (this is dose per patient report; D/C summary had 20 mg PO daily) - Novolog insulin sliding scale - Lantus 36 units SC QHS - oxycodone 5 mg 1-2 tabs po q4h prn for pain Discharge Disposition: Home Discharge Diagnosis: Diabetic ketoacidosis Urinary tract infection Discharge Condition: Mental Status: Clear and coherent. Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with diabetic ketoacidosis and a urinary tract infection. You were treated with antibiotics and an insulin infusion. You tolerated a regular diet prior to discharge. Your blood sugars will continue to be adjusted by your [**Last Name (un) **] doctors. Please call them with any questions or concerns regarding your blood sugars or your insulin dosage. You will need to complete a course of Ciprofloxacin as an outpatient; a prescription for this medicaiton is provided. Followup Instructions: Please follow-up with Dr.[**Last Name (STitle) 32886**] on [**7-4**] at 2pm at the [**Last Name (un) **] Diabetes Center. You are also scheduled for the following appointment with your new PCP, [**Last Name (NamePattern4) **].[**First Name (STitle) **]: Department: [**Hospital3 249**] When: WEDNESDAY [**2169-7-5**] at 3:00 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 815**], MD [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "536.3", "300.00", "530.81", "250.63", "V58.67", "250.13", "041.4", "599.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8507, 8513

5449, 8048

322, 328

8603, 8603

4787, 4792

9318, 9887

3781, 4041

8534, 8582

8074, 8484

8789, 9295

4056, 4768

253, 284

2978, 3316

356, 2960

4806, 5426

8653, 8765

3338, 3452

3468, 3765

9,434

131,818

14757

Discharge summary

report

Admission Date: [**2127-2-21**] Discharge Date: [**2127-3-7**] Date of Birth: [**2052-8-6**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 41017**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: 73-year-old male with a history of CAD, status post CABG and AVR presents with 1 week of acute dyspnea in the setting of progressive DOE X 3-4yrs. Cardiac evaluation yielded three vessel disease and AS, status post AVR/CABG in [**6-19**]. Since then has had persistent DOE. States that becomes SOB after 600 yrds walking or with walking up any incline. +PND. Sleeps on 2 pillows. Admitted last month after 1 wk of CP--> stress test showed large reversible defect. He was then admitted for cath which showed diffuse disease with patent LIMA and occluded SVG-PDA. Patient was taken for 2nd cath to complete possible intervention but procedure aborted due to TIA. Sent home after short CCU stay. His first cardiac cath of the aforementioned yielded: PCWP 12, PA 28/12, RV 27/7, RA 6, CO 5.5, PVR 116. Since that admission, the patient had ongoingdyspnea and has been worked up for dyspnea by CT scans x2 at NEBH which showed pleural plaques and LLL mass vs. rounded atelectasis. Also had low prob V/Q scan. PFTs at NEBH in [**12-21**]: FEV1 55%, FVC55%, Ratio 66%, TLC 56%(?), RV 60%, DLCO 44%. Pt states that he has been more short of breath over the last 1 month. Started on bronchodilators last week and Singulair. DOE has progressed and is now with minimal exertion. Cough productive of occ white sputum for last 1 wk. No F/C. Also has been wheezing for week prior to admission as well. Past Medical History: 1. CAD s/p CABG as above, c/b ascending aorta aneurysm 2. s/p AVR 3. HTN 4. CRI 5. s/p pacer 6. s/p AAA repair ??????01 7. AF ?????? s/p cardioversion ??????03 8. hypothyroid 9. carotid stenosis 10. kyphosis Social History: Retired electrician. Quit smoking in [**2090**]. Asbestos exposure in submarines 50 yrs ago. Family History: n/c Physical Exam: Vitals: 97.6 130/70 106 20 90%2L Gen: NAD HEENT: OP clear Neck: JVP 5cm Lungs: B/L exp wheeze throughout. No crackles/rhonchi. No dullness to perc Heart: Reg tachy. +[**3-23**] HSM. Loud s2. Abd: +BS. S. NT/ND Extr: Tr LE edema. No clubbing. No cyanosis Neuro: No gross deficit Pertinent Results: _ _ _ ________________________________________________________________ Cardiac Cath [**2126-1-22**]: 1. Three vessel coronary artery disease. 2. Normal diastolic ventricular function. LMCA had mild disease. pLAD was 100% occluded LCx was patent with mild/moderate disease pRCA was 100% filled via collaterals from the Lcx. patent LIMA-> LAD graft SVG-PDA was ostially occluded SVG-> D1 was not visualized normal left and right-sided filling pressures (RVEDP 7mmHg, LVEDP 12mmHg, PA mean 20mmHg, PCWP 12mmHg mean) (CO 5.36 l/min). _ _ _ _ ________________________________________________________________ RECENT ETT MIBI (per Dr. [**Last Name (STitle) **]: w/ no frank ischemia _ _ _ _ ________________________________________________________________ CXR [**2127-2-21**]: Small b/l effusions. Retrocardiac infiltrate. Widened mediastinum. Flat hemidiaphragms on lateral. _ _ _ _ ________________________________________________________________ Chest CT: from NEBH ([**2-3**]): Findings suspicious for a mass of the left lung base. Further evaluation is recommended with the means of a routine chest CT. _ _ _ _ _ ________________________________________________________________ Chest CT from NEBH ([**2-5**]): Calcified pleural plaques compatible with previous asbestos exposure. Lower lobe densities,left greater than right, compatible with rounded atelectasis. Ascending aortic aneurysm and possible focal aneurysm of the aortic arch as above described. _ _ _ _ _ _ ________________________________________________________________ PFTs ([**12-21**]): FVC 55% predicted, FEV1 55% predicted, FEV1/FVC 66% predicted DLCO: 44%, TLC 56%(?), RV 60% _ _ _ _ _ ________________________________________________________________ V/Q Scan ([**12-21**]): low prob _ _ _ _ _ ________________________________________________________________ CT chest [**2127-2-23**]: percardial effusion ?subacute/chronic hemorrhage, no active bleeding, saccular aortic arch aneurysm, w/ focal pouching into thrombosed portion, infrarenal AAA _ _ _ _ _ _ ________________________________________________________________ Echo [**2127-2-24**]: normal chamber sizes, ascending aorta moderately dilated, no pericardial effusion, moderately thickened MV, EF 75% _ _ _ _ _ _ ________________________________________________________________ CT ABDOMEN W/O CONTRAST [**2127-2-27**] : Large new bilateral retroperitoneal hematomas since the prior study, also a small anterior rectus sheath hematoma. Given the bilaterality, and lack of evidence of hematoma surrounding the aortic aneurysm, the appearance is most consistent with spontaneous retroperitoneal hemorrhages. _ _ _ _ _ ________________________________________________________________ CT CHEST/ABDOMEN/PELVIS W/O CONTRAST [**2127-3-4**]: Intrathoracic lymphadenopathy of undetermined significance, unchanged from previous. An anterior pericardial collection as described, unchanged from previous. Left-sided aneurysm or pseudoaneurysm in the thoracic aorta, unchanged from previous. Pleural plaques, unchanged from previous. Bilateral retroperitoneal hemorrhage with hematoma formation, slightly decreased from previous. No evidence of new disease or acute intraabdominal pathology. Infrarenal abdominal aortic aneurysm. _ _ _ _ _ ________________________________________________________________ PFTs ([**2127-3-6**]): (NOTE: STUDY OBTAINED ON 10MG PREDNISONE TAPER) FVC 2.02 (49%), FEV1 1.38 (51%), FEV1/FVC 68, TLC 3.1 (46%), RV 1.02 (40%), DsbHb 11.7 (48%), d/VA 3.86 (107%). Post bronchodilator 8% change in FEV1, 7% change in FVC _ _ _ _ _ ________________________________________________________________ [**2127-2-21**] 05:50PM CK(CPK)-426* [**2127-2-21**] 05:50PM CK-MB-6 [**2127-2-21**] 05:50PM cTropnT-<0.01 [**2127-2-21**] 07:40AM GLUCOSE-170* UREA N-48* CREAT-2.7* SODIUM-139 POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-23 ANION GAP-18 [**2127-2-21**] 07:40AM CK(CPK)-151 [**2127-2-21**] 07:40AM CK-MB-4 cTropnT-<0.01 [**2127-2-21**] 07:40AM TOT PROT-7.4 [**2127-2-21**] 07:40AM WBC-11.0 RBC-4.40* HGB-13.5* HCT-40.5 MCV-92 MCH-30.7 MCHC-33.4 RDW-13.0 [**2127-2-21**] 07:40AM NEUTS-91.3* LYMPHS-6.4* MONOS-0.8* EOS-1.0 BASOS-0.5 [**2127-2-21**] 07:40AM PLT COUNT-243 [**2127-2-21**] 02:45AM POTASSIUM-4.5 [**2127-2-21**] 01:30AM GLUCOSE-116* UREA N-46* CREAT-2.4* SODIUM-136 POTASSIUM-7.6* CHLORIDE-102 TOTAL CO2-25 ANION GAP-17 [**2127-2-21**] 01:30AM CK(CPK)-200* [**2127-2-21**] 01:30AM NEUTS-69 BANDS-0 LYMPHS-7* MONOS-7 EOS-17* BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2127-2-21**] 01:30AM PLT COUNT-239 [**2127-2-21**] 01:30AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ [**2127-2-21**] 01:30AM PT-13.0 PTT-23.0 INR(PT)-1.1 Brief Hospital Course: 74yo M w/ CAD s/p CABG/bioprosthetic AVR c/b stable ascending aortic aneurysm, preserved LV sytolic function, aflutter, h/o heart block s/p PPM, with chronic dyspnea on exertion since CABG [**6-19**], subacutely worse in months leading up to admission with outpatient worku-up yielding restrictive PFTs, pleural plaques, eosiniphilia, and a LLL mass. Now presents after galloping progression of DOE with associated cough, profound wheeze, and hypoxia w/ exertion. _ _ _ _ _ _ _ _ _ ________________________________________________________________ ## From a Respiratory Standpoint: - Probable Asthma - Restrictive Lung Disease (Pleural Asbestos-related Plaques) - LLL mass Pulmonary consultation was sought on admission. Clinical presention was most notable for bronchospastic disease. He was treated w/ steroids (intially solumedrol, then prednisone taper), bronhcodilators. Advair was initiated. Probable asthma w/ a contribution from restrictive lung disease was likely mediating his progressive dyspnea. Occult cardiac ischemia was not evident via serial cardiac enzymes and EKGs. Contribution from diastolic HF in the setting of aflutter may have also contributed in small part to the presentation. At the conclusion of his hospital course the patient had PFTs (see above) which confirmed restrictive disease likely on the basis of pleural asbestos-related plaques. This is the likely diagnosis when taken in concert with his 2 Chest CT scans that did NOT show parenchymal changes consistent with interstitial disease. During the PFTs, there was still a component of bronchospasm given wheeze/response to steroids. Bronchodilator challenge showed FVC improvement though not diagnostic of asthma as this study was done on 10mg of Prednisone. At discharge he was able to ambulate down the hallways with Oxygen saturation > 90% on room air. Moderate exertion up and down stairs yielded desaturations to 83% on room air. Given a DLCO >10, it is hopeful that these episodic desaturations may improve, however he will need to have close pulmonary follow up of his restrictive lung disease as that component cannot fully be assessed in the context of his comorbidities this admit. He was therefore discharged with home oxygen to use to with exertion. Patient was also treated empirically for atypical PNA vs AECB with Levoquin. Additional pulmonary studies such as ANCA, IgE levels for ABPA, glactomannans, sputum Cx were non-diagnostic. Patient should follow up with outpatient pulm rehab as well as outpatient pulmonologist at NEBH ([**Telephone/Fax (1) 39803**] Dr. [**First Name4 (NamePattern1) 4134**] [**Last Name (NamePattern1) 3647**]. Will need follow up of pleural dz and LLL mass. _ _ _ _ _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ ## Rapid AFlutter ## RP bleed (on heparin) ## Blood Loss Anemia [**Hospital **] hospital course was complicated by rapid atrial flutter likely exacerbated by beta agonism from nebulizers. He was rate controlled with dilt gtt and anticoagulated with heparin gtt in anticipation of TEE/DCCV. Prior to the procedure, the patient experienced significant abdominal/pelvic pain with coincidal hypotension, hypothermia, and a 7 point hemotocrit drop. Urgent CT scan yielded retroperitoneal bleed (report above) that was felt to be spontaneous. The integrity of his known AAA (s/p repair) was assess by Vascular surgical consultants who felt there was no acute surgical intervention necessary for either the RP bleed or the stable appearing AAA (not felt to be source of bleed). Cardiac Surgery felt the ascending aortic aneurysm was stable as compared with previous scans (likely old organized extra-thoracic fluid from prior AVR/CABG in [**6-19**]) and not active at this time. Patient was volume rescusitated in the MICU receiving 5 Units PRBC and 8 Liters Normal Saline. Given mild muscle stranding noted on CT, the ICU team empirically treated for potential bacterial superinfection along a hemotoma site w/ Vancomycin. Culture data eventually returned no growth, patient remained afebrile, and antibiotics were d/c'd after 7 days noting as well that sepsis was unlikely a contributor to the decompensation. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ ## Rapid AFlutter ## CAD Patient was transferred back to the cardiac floor where the diltiazem gtt was weaned off and he was diuresed (volume overloaded from rescusitation). A flutter rate was controlled with oral CCB. He had been orally digoxin loaded in the ICU and then maintained on 0.125 daily. Anticoagulation was deferred in view of recent bleed. Rhythm control (DCCV vs Flutter ablation) was deferred in view of relative [**Name (NI) 43419**] to peri-procedure anti-coagulation. _ _ _ _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ ## Ascending Aortic Aneurysm 6.5cm w/ intramural thrombus. no flap or dissection. Focal outpouching unchanged. Likely old organized extra-aortic fluid related to AVR/CABG ([**2124-7-11**]) rather than intramural thrombus. Dr. [**Last Name (STitle) **] is aware of the findings and is following serial CT scans as outpatient. _ _ _ _ _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ ## AAA s/p repair 6 years ago. Follow up as per Dr. [**Last Name (STitle) **]. Vascular Staff consulted during admission was Dr. [**Last Name (STitle) 1391**]. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ ## Code: Full Medications on Admission: asa, plavix, synthroid, lopressor, folate, lipitor, hydralazine, combivent, singulair Discharge Medications: 1. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*60 Disk with Device(s)* Refills:*2* 4. Atrovent 18 mcg/Actuation Aerosol Sig: Two (2) Inhalation every six (6) hours. Disp:*1 mdi* Refills:*6* 5. Albuterol 90 mcg/Actuation Aerosol Sig: [**1-19**] Inhalation every 4-6 hours as needed. Disp:*1 mdi* Refills:*1* 6. Home Supplemental Oxygen, 2Liters Nasal Canula Continuously 7. Outpatient Pulmonary Rehabilitation 8. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 9. 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* 10. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Disp:*30 Tablet(s)* Refills:*2* 11. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. Disp:*3 Tablet(s)* Refills:*0* 13. Cardizem CD 360 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO once a day. Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary 1. Probable Asthma Exacerbation 2. Restrictive Lung Disease ([**2-19**] Pleural Disease from prior Asbestos) 3. Bilateral Massive Retroperitoneal Bleed 4. Atrial Flutter 5. Blood Loss Anemia Secondary CAD s/p CABG S/p tissue AVR HTN CRI PVD s/p AAA repair Carotid stenosis Hypothyroidism Discharge Condition: Home O2 provided for use with exertion (83% RA with stairwell), though > 90% RA with rest and ambulation down hallways Discharge Instructions: You were treated for your shortness of breath. This was likely due to asthma and some restrictive lung disease. Continue to take the steroid (prednisone) as directed and the inhalers. You will be discharged with home oxygen. Please use 2 liters of oxygen via the nasal canula with any moderate exertion (for example ascending stairs) or at any point you are feeling short of breath. Please take the mediations as prescribed. Many alteration were made to her previous regimen in order to reflect the changes consequent to this admission. You will be on a baby aspirin a day. Dr. [**Last Name (STitle) 11679**] recommended you not take Plavix for now and readress this with Dr. [**Last Name (STitle) **] on Wed. Dr.[**Name (NI) 5452**] office should be in contact with you on [**Name (NI) 766**] in order for you to see him next wedsday. Contact his office if you do not hear from him. Dr. [**Last Name (STitle) **] wanted you to follow up with Dr. [**First Name4 (NamePattern1) 4134**] [**Last Name (NamePattern1) 3647**] who is a pulmonologist. Call for appointment at ([**Telephone/Fax (1) 1504**]. Th[**Last Name (STitle) 43420**]rysm in your chest will need to be further evaluated and possibly surgically repaired. Dr. [**Last Name (STitle) **] will advise you as to the best timing to see Dr. [**Last Name (Prefixes) **] at his clinic. Please call your doctor or go to the ER if you develop: * any signs of bleeding * uncontrolled shortness of breath * chest pain * dizziness * any worrisome symptoms Followup Instructions: DR. [**Last Name (STitle) **] next Wed Dr. [**First Name4 (NamePattern1) 4134**] [**Last Name (NamePattern1) 3647**] (pulmonologist). Call for appointment at ([**Telephone/Fax (1) 1504**]. Completed by:[**2127-3-7**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

14410, 14416

7239, 12826

322, 328

14756, 14877

2451, 7216

16442, 16661

2119, 2124

12962, 14387

14437, 14735

12852, 12939

14901, 16419

2139, 2432

275, 284

356, 1760

1782, 1991

2007, 2103

31,922

199,465

32075

Discharge summary

report

Admission Date: [**2155-9-13**] Discharge Date: [**2155-9-22**] Date of Birth: [**2110-2-10**] Sex: M Service: NEUROLOGY Allergies: Penicillins Attending:[**First Name3 (LF) 618**] Chief Complaint: CC: called by ER to eval HA, LP at OSH with blood, no xanthochromia Major Surgical or Invasive Procedure: cerebral angiogram lumbar puncture History of Present Illness: HPI: 45M with complaints of "migraines" for past 6 months, worse over last 1 month, presented to [**Location (un) 47**] ED after he had "worst HA of my life" and subjective fever to 104 at home. Some episodic nausea at home over past month. He was tapped at OSH (reportedly high tap at L1-2) with 34,000 RBC's in one tube and 18,000 RBC's in another. WBC's 36 and 17 respectively. No xanthochromia. CT scan at OSH neg for bleed. Fever to 101 noted there. c/o mild blurred vision. Pt was loaded with Dilantin and transferred here to [**Hospital1 18**] ED. Pt denies drug or tobacco use, +coffee daily that sometimes improves the HA. HA now [**7-11**], described as being all over, dull pain, improved with Dilaudid at OSH. Mild blurred vision, no current nausea. Past Medical History: PMHx: Migraines, back pain Social History: Social Hx: denies tobacco, ETOH, or drug use. Family History: Family Hx: No FH of stroke or aneurysms Physical Exam: ON arrival PHYSICAL EXAM: T: 98.9 BP: 112/74 HR: 73 R: 20 99% RA Gen: lying in dark room, eyes closed Lungs: CTAB Cardiac: RRR Abd: Soft, NT, BS+ Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4 to 3 mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**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 [**4-5**] throughout. No pronator drift Sensation: Intact to light touch Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements On discharge ********* Pertinent Results: [**2155-9-13**] 10:20AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015 [**2155-9-13**] 10:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2155-9-13**] 09:14AM LACTATE-0.8 [**2155-9-13**] 08:50AM GLUCOSE-117* UREA N-11 CREAT-0.8 SODIUM-140 POTASSIUM-3.7 CHLORIDE-108 TOTAL CO2-21* ANION GAP-15 [**2155-9-13**] 08:50AM WBC-9.1 RBC-4.22* HGB-14.0 HCT-39.8* MCV-94 MCH-33.1* MCHC-35.0 RDW-12.8 [**2155-9-13**] 08:50AM NEUTS-85.1* LYMPHS-11.5* MONOS-2.8 EOS-0.5 BASOS-0.1 [**2155-9-13**] 08:50AM PLT COUNT-202 [**2155-9-13**] 06:50AM PT-11.8 PTT-23.4 INR(PT)-1.0 RADIOLOGY Preliminary Report MR HEAD W & W/O CONTRAST [**2155-9-14**] 4:33 PM MR HEAD W & W/O CONTRAST Reason: brain MRI +/- gado to rule out tumor Contrast: MAGNEVIST [**Hospital 93**] MEDICAL CONDITION: 45 year old man with ? SAH REASON FOR THIS EXAMINATION: brain MRI +/- gado to rule out tumor CONTRAINDICATIONS for IV CONTRAST: None. EXAM: MRI of the brain. CLINICAL INFORMATION: Patient with question of rule out tumor. TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion axial images obtained before gadolinium. T1 axial and coronal images obtained following gadolinium. FINDINGS: Diffusion images demonstrate no evidence of acute infarct. The ventricles and extraaxial spaces are normal in size without midline shift, mass effect, or hydrocephalus. There are no focal signal abnormalities within the brain. Following gadolinium, no evidence of abnormal parenchymal, vascular, or meningeal enhancement identified. At the left infratemporal region, an irregular area of T1 and T2 hyperintensity identified which appears to be fat within the skull base bones. This is an incidental finding. IMPRESSION: No significant abnormalities detected on MRI of the brain with and without gadolinium. DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**] RADIOLOGY Preliminary Report CTA HEAD W&W/O C & RECONS [**2155-9-13**] 9:27 AM CTA HEAD W&W/O C & RECONS Reason: please eval for source of SAH Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 45M tx from [**Location (un) 47**] with fever, ?SAH. Pt with hx migraines, worse over last mo, yesterday with worst HA of life, fever to 104. Seen at [**Location (un) 47**], CT head neg, LP with Tube 1: 18,000 RBC, Tube 4 with 34,000 RBC. No xanthrochromia. Pt given IV fosphenytoin, dilaudid. REASON FOR THIS EXAMINATION: please eval for source of SAH CONTRAINDICATIONS for IV CONTRAST: None. CLINICAL INFORMATION: Patient with question of subarachnoid hemorrhage. Patient had migraines with positive LP and fever of 104 degrees. TECHNIQUE: Axial images of the head were obtained before contrast. Following this, contrast-enhanced CT angiography of the head was obtained using departmental protocol. 3D reformatted images were acquired. FINDINGS HEAD CT: Head CT demonstrates normal ventricles and extraaxial spaces without midline shift, mass effect, hydrocephalus, or hemorrhage. IMPRESSION: Normal head CT without contrast. CT ANGIOGRAPHY OF THE HEAD: CT angiography of the head demonstrates normal appearances of the arteries of anterior and posterior circulation. No evidence of vascular occlusion, stenosis, or an aneurysm identified. IMPRESSION: Normal CTA of the head. DR. [**First Name (STitle) 18394**] [**Name (STitle) 18395**] DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**] MR [**Name13 (STitle) 430**] with and without contrast [**2155-9-14**]: IMPRESSION: No significant abnormalities detected on MRI of the brain with and without gadolinium. At the left infratemporal region, an irregular area of T1 and T2 hyperintensity identified which appears to be fat within the skull base bones. This is an incidental finding. MR of the cervical, thoracic, and lumbar spine w/ and without contrast on [**2155-9-15**]: IMPRESSION: 1. Enhancement and T2 hyperintensity of the prevertebral space of the cervical spine extending from C2 to the C5 level which is concerning for cellulitis/phlegmon. No discrete fluid collections concerning for abscesses are seen. Less likely possibility is calcific tendinitis of the longus [**Last Name (un) **] muscle. 2. No enhancing masses or obvious vascular lesions of the cord or spine. 3. Mild canal stenosis due to degenerative changes at C6/7. 4. Mild degenerative changes of the lower lumbar spine with epidural lipomatosis of the lower lumbar spine as described above. Portable CXR [**2155-9-16**]: IMPRESSION: No evidence of pneumonia or any other major cardiovascular abnormality on single-view chest examination with patient in semi-erect position. LE U/S [**2155-9-16**]: Negative for DVT. Renal U/S [**2155-9-16**]: IMPRESSION: Horseshoe kidney. No ultrasonographic findings to suggest pyelonephritis; however, normal ultrasound does not rule out this entity. Tagged WBC scan [**2155-9-19**]: Normal Brief Hospital Course: The patient was originally admitted to the Neurosurgery service for management of a subarachnoid hemorrhage. Neither subarachnoid blood nor a vascular anomaly was not seen on the MRI imaging of the entire neuroaxis. The patient had a post lumbar puncture headache from the outside hospital. It was ultimately felt that the patient's months long headache course was likely related to analgesia rebound phenomenon - taking too many pain medications and requiring more and more to quell the headaches as the tissues that respond to the medications learn to require more and more of them. Over the course of the admission the patient's headache substantially resolved such that by 5th day he was sitting up in bed without the orthostatic headache. Nortryptiline was started to prevent headaches. Fioricet, tylenol, ibuprofen and hydromorphone were used PRN to help with headaches. The patient developped a fever of 102.6 on the fourth day of admission. He had a positive UA. He was started on a course of ciprofloxacin. The official read of the C-spine MRI suggested a retropharyngeal phlegmon. The infectious disease service was consulted and a recommended tagged white blood cell scan that was normal. Because sampling/biopsy could not be performed on the retropharyngeal collection, the decision was made to give the patient 6 weeks of antibiotics for broad-spectrium coverage to continue until the end of Novemeber: vancomycin 1 g IV q 12 hrs, ciprofloxacin 500 mg po q 12, and flagyl 500 mg po q 8 hrs. With this regimen on board, the patient defervesced and was stable. A PICC was placed so that he could continue home infusions of vancomycin. His headache was intermittent but notably improved by day of discharge. The patient was advised to gradually reduce his analgesic regimen as an outpatient with the hope that nortriptyline would continue to provide effectie prophylaxis. We suggested that he would eventually taken fioricet no more than three times per week by four weeks after discharge. He has follow up with ID, who will follow weekly CBC, BUN, Cr, LFTs and vancomycin troughs while on therapy. Medications on Admission: Medications prior to admission: ? Tramadol, Valium, pt does not remember other pain meds Discharge Medications: 1. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous every twelve (12) hours for 6 weeks: Please continue from [**9-19**] through [**2155-10-31**]. Disp:*qs Supply sufficient for 6 weeks* Refills:*0* 2. Outpatient Lab Work Weekly CBC, BUN, Cr, LFTs, vanco trough while receiving vancomycin Please fax all results weekly to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] in Infectious Disease at ([**Telephone/Fax (1) 6313**] 3. Outpatient Physical Therapy Lower back pain with radiculopathy from disc - needs physical therapy 4. PICC LINE CARE Please flush picc line as appropriate per [**Hospital1 **] protocol 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 7. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for headache: Within four weeks, you should limit your Fioricet use to LESS THAN THREE TIMES PER WEEK. Please decrease your dose appropriately to achieve this goal. Disp:*90 Tablet(s)* Refills:*0* 8. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime): take this every night. Disp:*30 Capsule(s)* Refills:*2* 9. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain: take for back pain. 10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for take for 6 weeks; last day is [**10-31**] weeks. Disp:*77 Tablet(s)* Refills:*0* 11. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane every four (4) hours as needed for pain: for sore throat. Disp:*30 Lozenge(s)* Refills:*0* 12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for take for 6 weeks - last dose is [**10-31**] weeks. Disp:*116 Tablet(s)* Refills:*0* 13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed: per protocol. Discharge Disposition: Home With Service Facility: [**Hospital 5065**] Healthcare Discharge Diagnosis: Headache. UTI and retropharngeal collection Discharge Condition: Vital signs stable. The patient has no objective neurological deficit. Discharge Instructions: Please take your medications as prescribed. Please follow up with the appointments documented below. Please come back to the hospital if you should have severe headache, blurry vision, nausea, vomiting, severe light sensitivity or any other concerning neurological symptoms. You should gradually reduce your intake of fiorcet, such that in four weeks, you will be taking fioricet no more than three times per week. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 68568**], your PCP in the next 2 weeks and share with him the plan that we made for you regarding the pain medication. 1-[**Telephone/Fax (1) 5835**]. Please make a follow up appointment with Dr. [**Last Name (STitle) 6383**] in the [**Hospital 878**] clinic in the next 2 months. The number is ([**Telephone/Fax (1) 12196**]. You have a follow up appointment set up with Infectious Disease: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2155-10-17**] 10:00 [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

[ "599.0", "346.90", "349.0", "780.6", "276.8", "478.24" ]

icd9cm

[ [ [] ] ]

[ "38.93", "88.41", "03.31", "38.91" ]

icd9pcs

[ [ [] ] ]

11865, 11926

7504, 9632

341, 377

12014, 12087

2439, 3273

12552, 13213

1308, 1350

9772, 11842

4641, 4935

11947, 11993

9658, 9658

12111, 12529

1392, 1529

9690, 9749

233, 303

4964, 5391

405, 1175

1713, 2420

5401, 7481

1544, 1697

1197, 1228

1244, 1292

29,330

152,522

34153

Discharge summary

report

Admission Date: [**2144-6-24**] Discharge Date: [**2144-6-26**] Date of Birth: [**2071-7-8**] Sex: M Service: MEDICINE Allergies: Codeine / Ace Inhibitors Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Cardiac arrest Major Surgical or Invasive Procedure: endotracheal intubation History of Present Illness: HPI: 72 yo M with PMH of CAD and h/o CABG, CHF (EF 55% in [**10-3**]), hx of AS/AI, CKD (baseline Cr 1.6), COPD and atrial fibrillation (on coumadin) here for push enteroscopy/ colonoscopy for evaluation of GI bleed. Procedure today went smoothly and was notable for multiple small AVMs s/p thermal ablation. Patient received ~1100cc of NS during the procedure and propafol sedation. While in the recover area, he was getting ready to go home 2 hrs post procedure, when he developed productive cough and later respiratory distress. At that time he was given 40mg lasix, 4mg zofran, 25mg demerol (for shaking) and 5mg lopressor for tachycardia, rate 120s. A code blue was called and he was intubated and transiently lost a pulse. One round of CPR was performed with 1 mg of epinephrine. Intubation was notable for bloody secretions at this time. He also had a tachyarrhythmia to the epinephrine which lasted only a short time. He never lost a pulse again and he maintained his blood pressure and was transferred to the ICU for further care. Past Medical History: (history taken from records patient had with him from [**State 108**]) -CAD s/p CABG in '[**28**] -CHF diastolic with valvular abnormalities: Mild-Moderate AI; AS, mean gradiet >16; Trace MR- other notes say moderate to severe MR; Mod TR -atrial fibrillation on coumadin -Sick Sinus syndrome -HTN -Hyperlipidemia -Thoracic aortic aneurysm 5.2 cm -Myelodysplastic syndrome- transfusion dependent -COPD- FEV1 47% -Iron deficiency anemia -Barrett's esophagus -Angiodysplasia Social History: married. Pediatrician who was [**Male First Name (un) **] of a medical school. Family History: NC Physical Exam: VS: T 99.3 BP 97/46 HR 97 RR 26 with O2 sat 100% on PS 8/5 FIO2 40% GEN: NAD intubated and sedated HEENT: small pupils but reactive to light and symmetric. MMM LUNGS: crackles bilaterally throughout lung fields CV: very distant heart sounds, but sounds regular. can not appreciate murmur at this time ABD: +BS, soft, obese, non-tender EXT: 2+ edema on LLE with scar from vein graft and trace to 1+ on RLE (chronic per old notes) Pertinent Results: [**2144-6-24**] 01:51PM WBC-3.5* RBC-4.26* HGB-10.6* HCT-35.4* MCV-83 MCH-24.8* MCHC-29.8* RDW-15.5 [**2144-6-24**] 01:51PM NEUTS-69 BANDS-11* LYMPHS-14* MONOS-3 EOS-3 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2144-6-24**] 01:51PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL BURR-OCCASIONAL [**2144-6-24**] 01:51PM PLT COUNT-137* [**2144-6-24**] 01:51PM PT-14.9* PTT-23.3 INR(PT)-1.3* [**2144-6-24**] 01:51PM GLUCOSE-155* UREA N-21* CREAT-1.6* SODIUM-140 POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-26 ANION GAP-12 [**2144-6-24**] 01:51PM CK(CPK)-54 [**2144-6-24**] 01:51PM CK-MB-4 cTropnT-<0.01 [**2144-6-24**] 02:59PM TYPE-ART PO2-108* PCO2-49* PH-7.35 TOTAL CO2-28 BASE XS-0 [**2144-6-24**] 02:59PM LACTATE-1.9 [**2144-6-24**] 05:37PM URINE RBC-93* WBC-4 BACTERIA-FEW YEAST-NONE EPI-<1 [**2144-6-24**] 05:37PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2144-6-24**] 05:37PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.010 [**2144-6-24**] 08:53PM HCT-31.7* [**2144-6-24**] 08:53PM UREA N-24* CREAT-2.0* POTASSIUM-4.4 [**2144-6-24**] 08:53PM MAGNESIUM-2.1 [**2144-6-25**] 04:17AM BLOOD CK(CPK)-613* [**2144-6-25**] 04:17AM BLOOD CK-MB-6 cTropnT-0.02* [**2144-6-25**] 06:34PM BLOOD CK(CPK)-567* [**2144-6-25**] 06:34PM BLOOD CK-MB-4 cTropnT-0.01 [**2144-6-26**] 05:09AM BLOOD WBC-5.3 RBC-3.79* Hgb-9.5* Hct-30.2* MCV-80* MCH-25.1* MCHC-31.5 RDW-14.4 Plt Ct-112* [**2144-6-26**] 05:09AM BLOOD Plt Ct-112* [**2144-6-26**] 05:09AM BLOOD PT-14.5* PTT-30.0 INR(PT)-1.3* [**2144-6-26**] 05:09AM BLOOD Glucose-110* UreaN-35* Creat-2.5* Na-135 K-4.5 Cl-101 HCO3-27 AnGap-12 [**6-26**] 2pm Cr 2.4 . [**6-24**] CXR As compared to the previous radiograph, the retrocardiac atelectasis has slightly increased. The left-sided parenchymal opacity is unchanged in extent, the pre-existing air bronchograms are less appreciable than before. The extent of interstitial fluid accumulation at the right lung base seems to increase, as expressed by subtle thickening of the peribronchial interstitium. Minimal left-sided pleural effusion, no newly occurred focal parenchymal opacities. The size of the cardiac silhouette is unchanged. . TTE [**6-24**] Results Measurements Normal Range Left Atrium - Long Axis Dimension: *4.8 cm <= 4.0 cm Left Atrium - Four Chamber Length: *8.0 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.7 m/s Right Atrium - Four Chamber Length: *7.2 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.5 cm Left Ventricle - Fractional Shortening: 0.30 >= 0.29 Left Ventricle - Ejection Fraction: 50% >= 55% Left Ventricle - Lateral Peak E': 0.10 m/s > 0.08 m/s Left Ventricle - Septal Peak E': *0.07 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 12 < 15 Aorta - Sinus Level: 3.6 cm <= 3.6 cm Aorta - Ascending: *4.1 cm <= 3.4 cm Aortic Valve - Peak Velocity: *3.0 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *37 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 24 mm Hg Mitral Valve - E Wave: 1.0 m/sec Mitral Valve - E Wave deceleration time: 210 ms 140-250 ms TR Gradient (+ RA = PASP): 23 mm Hg <= 25 mm Hg Pulmonic Valve - Peak Velocity: 1.3 m/sec <= 1.5 m/sec Findings pt intubated on vent. LEFT ATRIUM: Marked LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Low normal LVEF. No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. RV function depressed. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Moderately dilated ascending aorta. Focal calcifications in ascending aorta. AORTIC VALVE: Moderately thickened aortic valve leaflets. Mild AS (AoVA 1.2-1.9cm2). Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Mild thickening of mitral valve chordae. Calcified tips of papillary muscles. No MS. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Normal tricuspid valve supporting structures. No TS. Mild to moderate [[**1-29**]+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. 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. Suboptimal image quality - poor subcostal views. Suboptimal image quality - ventilator. Conclusions The left atrium is markedly dilated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). There is no ventricular septal defect. Right ventricular chamber size is normal. with significantly depressed free wall contractility. The ascending aorta is moderately dilated. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. . [**6-25**] LENI FINDINGS: [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**] of bilateral common femoral, superficial femoral, and popliteal veins were performed. There was normal compressibility, flow, and augmentation. IMPRESSION: No evidence of DVT. . [**6-25**] CXR SINGLE SUPINE RADIOGRAPH OF THE CHEST, BEDSIDE: There is interval worsening of the diffuse left lung airspace opacity with new areas of opacification in the right mid and lower lobes. There is a small left pleural effusion. The right costophrenic angle is excluded from the field of view however there is no gross right pleural effusion. The cardiomediastinal silhouette is unchanged. Endotracheal tube is terminating 4 cm above the carina. NG tube is extending below the diaphragm and out of the field of view. IMPRESSION: Interval worsening of the diffuse airspace opacity indicating worsening pulmonary edema. . [**6-26**] CXR Mild-to-moderate cardiomegaly is stable. A small pleural effusion is stable. Unilateral airspace disease in the left lung has started to regress. The right lung is clear. No right pleural effusion is seen. Multiple large sternotomy wires are noted with no complications. IMPRESSION: 1. Slowly regressing unilateral airspace disease in the left lung. 2. Stable small left pleural effusion and mild-to-moderate cardiomegaly. . Brief Hospital Course: 72 yo M with PMH of CAD s/p CABG, atrial fibrillation, diastolic dysfunction, COPD here for evaluation of GI bleed who developed respiratory distress requiring intubation along with cardiac arrest following enteroscopy. . # Acute Respiratory Failure: Pt underwent an enteroscopy and colonoscopy for recurrent GI bleeding, following the procedure the patient developed acute respiratory distress requiring intubation. CXR consistent with pulmonary edema with possible aspiration. The patient required intubation overnight, respiratory status quickly improved following diuresis. He was extubated on [**6-25**] and was sating well on room air. The patient received one dose of vancomycin and cefepime after spiking a fever following intubation with a question of aspiration on CXR. Vanc/cefepime was tapered to levaquin on [**6-25**]. Antibiotics were discontined on [**6-25**] as pt became afebrile and was without evidence of infiltrate on CXR. The etiology of his event is unclear. [**Name2 (NI) **] was felt likely to have had pulmonary edema in the setting of receiving ~1.5L IVF during the procedure. Precipitant for episode is unclear, possibly tachycardia causing flash pulm edema, preload falling following sedation from procedure. He had no witnessed aspiration event. Cardiac enzymes negative for AMI. PE considered as the pt had evidence of new RV dysfunction of TTE. He was unable to undergo CTA given ARF. LENI negative for evidence of DVT. . # Cardiac Arrest - Immediately following the patient's intubation he was found to have lost a pulse and Code Blue was called. He received CPR and was given epinephrine. The patient regained a pulse. Upon arrival of the ICU team the patient was in Afib w/ RVR with a palpable pulse. He had a brief run of VT with pulse and stable BP which broke within seconds without intervention. He remained with a stable BP and pulse and was transferred to the ICU. The patient has no further events on telemetry. He was weaned from mechanical ventilation as above. CE were negative. A TTE was performed which demonstrated slightly reduced EF of 55% but new RV dysfunction from prior [**2143**] TTE. The inciting event for arrest is unclear at this time. The patient should undergo further ischemic workup upon discharge. He was continued on aspirin. BB held given a history of SSS and bradycardia. . #. Acute on chronic diastolic CHF - TTE demonstrated stable EF 55% with mild AS (AoVA 1.2-1.9cm2). The patient was diuresed as above. He is on [**First Name8 (NamePattern2) **] [**Last Name (un) **] at home however this was held as pt developed ARF. . #. Acute on Chronic Renal Failure: Following his arrest the patient was found to have a Cr of 1.6. He was given a single dose of IV lasix for acute respiratory decompensation and diuresed 1L. His Cr bumped to 2.0 then to a peak to 2.7. Further diuresis was held and Cr trended down to 2.4 prior to discharge. Urine electrolytes were sent and Furea was 21% consistent with prerenal etiology. Cozaar was held. The patient will follow up with PCP for further monitoring. . # History of chronic GI bleed: The patient presented for colonoscopy and enteroscopy to evaluate GI bleeding. He was found to have AVMs throughout GI tract. He also had a gastric polyps removed and underwent AVM cauderizations. He had no evidence of bleeding during his hospitalization. . # CAD s/p CABG: CE negative for new AMI. He was restarted on aspirin and imdur. Given unclear etiology of arrest and new RV dysfunction the patient should undergo further ischemic workup as outpatient. . # Atrial fibrillation: Pt well rate controlled without intervention. He was off coumadin given GI procedure but this was restarted on day of discharge. No BB added given history of SSS. . # AAA: stable per OSH records stable at 5.3cm. . # Myelodysplastic syndrome: transfusion dependent. HCT stable currently. Medications on Admission: -Glimepiride (Amaril) 1mg daily -Doxazosin 6 mg qHS -Pepcid 20 qHS -Combivent 2 puffs [**Hospital1 **] -Imdur 90mg [**Hospital1 **] -Losartan 100mg daily -Lovastatin 60 qHS -Prilosec 20mg daily -Coumadin 5mg daily except Friday 2.5 mg daily (holding for GI procedure) -ASA 81mg daily (holding for GI procedure) -colace 100mg qhs Discharge Medications: 1. Lovastatin 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 2. Doxazosin 4 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) Inhalation twice a day. 5. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day. 6. Multivitamin Capsule Sig: One (1) Capsule PO once a day. 7. Glimepiride 1 mg Tablet Sig: One (1) Tablet PO once a day. 8. Imdur 30 mg Tablet Sustained Release 24 hr Sig: As directed Tablet Sustained Release 24 hr PO three times a day: Take 60mg in the morning and the evening and 30mg in the afternoon. 9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 10. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Cardiac Arrest 2. Respiratory Failure 3. Pulmonary Edema 4. Acute on Chronic Renal Failure Discharge Condition: Clinically Improved, ambulating without assistance, afebrile, sating well on room air Discharge Instructions: You were admitted after suffering a cardiac arrest and respiratory failure following your endoscopy procedure. You were briefly intubated for excess fluid in your lungs. You had an Echo which showed new right ventricular dysfunction. Your cardiac enzymes have been negative. You should follow up with your outpatient cardiologist for further workup of possible ischemic heart disease. Your outpatient cardiologist Dr. [**Last Name (STitle) 78728**] has been contact[**Name (NI) **] about your hospital stay and your should follow up with him next week for further management. . You should continue to hold your medication Cozaar until your creatinine is rechecked by your PCP next week. . You should restart your coumadin at your home dose. . The remainder of your medications have not changed. . Please return if you experience any signs of bleeding. You should also return if you develop chest pain, shortness of breath or fever. Followup Instructions: Please follow up with your Primary Care Physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 78728**] on Monday or Tuesday of next week. Please call [**Telephone/Fax (1) 78729**] to make an appointment. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "V45.81", "E849.7", "427.31", "511.9", "518.5", "280.9", "585.9", "496", "E879.8", "414.00", "211.1", "424.1", "530.85", "569.85", "427.5", "997.1", "441.2", "428.0", "584.9", "428.33", "403.90", "238.75" ]

icd9cm

[ [ [] ] ]

[ "45.16", "99.60", "45.43", "43.41", "96.07", "88.72", "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

14430, 14436

9353, 13221

306, 331

14583, 14671

2477, 9330

15651, 16005

2008, 2012

13601, 14407

14457, 14562

13247, 13578

14695, 15628

2027, 2458

252, 268

359, 1400

1422, 1896

1912, 1992

29,152

187,285

50173

Discharge summary

report

Admission Date: [**2123-8-6**] Discharge Date: [**2123-8-15**] Date of Birth: [**2068-2-21**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: cc:[**CC Contact Info **] Major Surgical or Invasive Procedure: Left upper bronchial artery embolization Flexible Bronchoscopy X 4 Left Subclavian central line History of Present Illness: HPI: Patient is a 55yo gentleman with pulmonary thromboembolic disease who is on chronic anticoagulation who presents with hemoptysis in the setting of a supertherapeutic INR to 3.3. Patient has a h/o massive PE, s/p IVC filter as well as chronic thrmobotic events. He has pulmonary htn and RV failure secondary to the thrombotic events. He started coughing blood 2 days prior to admission. He reports that it got worse on day of admission and was 1/2-1cup full in total. Of note he also has a left upper lobe cavitarious lesion, suspcious for aspergilloma noted on Pet in [**4-24**]. He reported sweats and blurry vision and recent diarrhea. He denies pain, chest pain, sob, blood in his stools, change in urinary habits. . In the ED his VS were HR 100s, BP 112/70, 97% on 8LNC. He had a CTA which showed new ground glass opacities surrounding the cavitary lesion. His labs were significant for INR of 3.3. He was seen by his primary pulmonologist ([**Doctor Last Name 575**]) and Angio and consented for possible intervention. He received 4 bags FFP and sent to the ICU for management. On admission, impression was for supratherapeutic INR leading to bleed into cavitary lung lesion. Patient received a further 2 bags of FFP with improvement in his INR to 2.2. Hematorcrit was stable during his stay. Sarted on voriconazole and ceftazidime (later stopped ceftaz) for treatment of pneumonia/lung lesion. Patient was deemed stable for transfer to the floor, w/ plan for bronchoscopy +/- ablation by pulmonary/angio. Past Medical History: b/l PE w/ saddle embolism in [**2113**]. s/p ICU admission and thrombolysis at that time. Had IVC filter placed, maintained w/ goal INR [**3-21**] since that time. Pulmonary hypertension secondary to pulmonary thrombolic disease RV dysfunction LUL cavitary lesion -> ? aspergilloma Social History: Social Hx: Lives with fiance. No children. Custodian at middle school. 1.5 ppd x 20yrs. Social Etoh 3drinks/day. Family History: No family h/o cancer or clotting/bleeding disorders. Physical Exam: PE: VS: T99.6 HR 115, BP 120/80 RR 22 99% on RA General: Middle aged man in NAD, speaks easily and comfortably HEENT: NCAT, PERRL, EOMI, OP clear Chest: decreased BS bilaterally left worse than right, no crackles Cardiac: tachy, RV heave, no m/r/g Abd: +BS, soft, NTND, no pulsatile mass noted Ext: 2+ pulses, no edema, no clubbing. Pertinent Results: [**2123-8-6**] 01:25PM BLOOD WBC-4.7 RBC-4.56* Hgb-14.7 Hct-44.4 MCV-98 MCH-32.3* MCHC-33.1 RDW-15.4 Plt Ct-195 [**2123-8-6**] 11:45PM BLOOD WBC-8.5# RBC-3.86* Hgb-12.8* Hct-36.7* MCV-95 MCH-33.1* MCHC-34.8 RDW-15.8* Plt Ct-137* [**2123-8-6**] 01:25PM BLOOD Neuts-55.7 Lymphs-33.6 Monos-6.1 Eos-3.4 Baso-1.2 [**2123-8-6**] 01:25PM BLOOD PT-31.1* PTT-34.8 INR(PT)-3.3* [**2123-8-6**] 01:25PM BLOOD Glucose-98 UreaN-13 Creat-1.1 Na-133 K-9.0* Cl-100 HCO3-21* AnGap-21* [**2123-8-6**] 11:45PM BLOOD ALT-21 AST-26 LD(LDH)-225 AlkPhos-282* TotBili-1.4 [**2123-8-6**] 11:45PM BLOOD Albumin-4.4 Calcium-9.5 Phos-2.5* Mg-1.9 [**2123-8-9**] 04:38AM BLOOD Type-ART Temp-35.7 Tidal V-500 PEEP-5 FiO2-50 pO2-71* pCO2-45 pH-7.37 calTCO2-27 Base XS-0 -ASSIST/CON Intubat-INTUBATED [**2123-8-6**] 06:06PM BLOOD Lactate-2.1* . . CTA CHEST ([**2123-8-6**]) IMPRESSION: 1. Chronic calcified pulmonary embolism involving the distal left main pulmonary artery with filling defects within the upper lobe and lower lobe segmental branches. Marked enlargement of the pulmonary arterial tree, likely related to underlying pulmonary hypertension. 2. Left upper lobe cavitary lesion containing low-attenuation material with "air cresent" appearance which may indicate saprophytic colonization, ie. mycetoma ("aspergilloma"). This may relate to the surrounding patchy ground- glass opacity in the left upper lobe worrisome for alveolar hemorrhage from a bronchial arterial source, in this context. 3. Stable left lower lobe pleural-based mass. 4. Stable ground-glass opacities in the right lung, likely related to altered "mosaic perfusion" from chronic pulmonary emboli history. 5. Small pericardial effusion. Enlarged right heart, likely related to chronic PE history. . . PULMONARY ARTERIOGRAM / EMBOLIZATION NOTE IMPRESSION: 1. Left bronchial arteriogram demonstrates vascular cavitary lesion in the left upper lobe, with apparent communication of the left bronchial artery with a branch of the left pulmonary artery. 2. Successful left bronchial artery embolization with Embosphere particles until stasis was achieved. 3. The case was discussed with Dr. [**Last Name (STitle) **] the attending of the medical team involved in the care of the patient prior to embolization and a possibility of infarction of a portion of the lung due to communication with the branch of the pulmonary artery and proximal partially occlusive chronic thrombus in the pulmonary artery was also discussed and the decision was made to go ahead with embolization as the risk of bleeding was very high. . . CARDIAC ECHO ([**2123-8-9**]) Conclusions: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Regional and global left ventricular wall motion are normal. (LVEF>55%). No masses or thrombi are seen in the left ventricle. The right ventricular free wall is hypertrophied. The right ventricular cavity is markedly dilated with severe global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The tricuspid valve leaflets are mildly thickened. There is severe pulmonary artery systolic hypertension. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. The main pulmonary artery is markedly dilated. There is a small to moderate sized circumferential pericardial effusion without evidence for hemodynamic compromise. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. Compared with the prior study (images reviewed) of [**2123-6-28**], the pericardial effusion is larger and the estimated pulmonary artery systolic pressure is much higher. Right venticul cavity size and free wall motion are similar. . CHEST X-RAY ([**2123-8-13**]) COMPARISON: [**2123-8-13**]. The endotracheal tube, nasogastric tube and the left subclavian central line are unchanged in position. Cardiomegaly and marked enlargement of pulmonary arteries is unchanged. There has been no significant interval change in diffuse patchy consolidations throughout the right hemithorax as well as patchy consolidations in the left upper lobe which may represent pulmonary hemorrhage versus pneumonia/aspiration. A small left pleural effusion is unchanged. There is no pneumothorax. No other significant interval changes are noted. IMPRESSION: No significant interval change in bilateral patchy consolidation and small left pleural effusion . Brief Hospital Course: MICU Course: Patient was admitted to MICU on [**2123-8-6**] for observation due to concerning history of chronic pulmonary emboli and new onset hemoptysis. He was observed for two days in the MICU during which he was stable and did not require any interventions. He was transfered to the floor on [**2123-8-8**] where he began having hemoptysis once again and had to be transfered to the MICU for stabilization. A right mainstem intubation was attempted by anesthesia in an attempt to tamponade left lung, but this was not possible due to a very low carina. Emergent bedside bronchoscopy was performed where ballon tamponade of the entire left lung was achieved. Patient was taken to OR on [**2123-8-9**] by interventional radionlogy, who was able to embolize blood supply to myecetoma, the known source of bleeding. During the procedure, it was determined that possibly due to the chronic emboli, bronchial and pulmonary circuits had coalesced and dual blood supply did not exist. Due to the life threatening hemorrhage into his lung however, it was decided to risk left upper lobe ischemia and arterial supply was embolized. Patient remained intubated and had several bedside flexible bronchoscopies to evacuate endobronchial thrombi with good improvement in gas exchange. INR remained elevated and was reversed with FFP with a goal below 2.0 in order to minimize residual low grade bleeding present. Patient however remained dependant on mechanical ventilation and began to develop hypotension. Sputum cultures isolated enterobacter and staph species and wide spectrum antibiotics were added in addition to pre-existing empiric coverage. . Patient continued to have increasing O2 requirements and began to experience profound hypotension. Pressors were initiated on [**2123-8-14**] and he was quickly maximized on Levophed, Vasopressin and Neosynephrine with very limited results. A short trial of inhaled nitric oxide was also attempted for known severe pulmonary hypertension, with no clinically apparent results. Family was contact[**Name (NI) **] regarding severity of his clinical situation and came in overnight. After condition continued to deteriorate and hypotension persisted in spite of above measures, family decided to pursue comfort care measures only. Patient deteriorated within minutes of discontinuation of pressors and was pronounced dead at 5:40am of [**2123-8-15**]. . Medications on Admission: Coumadin 7.5 3xweek, 5mg 4xweek, Qmo INR checks HCTZ 12.5 QAM Nifedical XL 30mg QAM Protonix 40mg QAM Spiriva 1 cap QAM Revatio 20 TID (not taking - no insurance approval) Discharge Medications: Not applicable Discharge Disposition: Expired Discharge Diagnosis: Patient deceased Discharge Condition: Patient deceased Discharge Instructions: Patient deceased Followup Instructions: Patient deceased

[ "458.9", "V58.61", "584.9", "416.8", "286.9", "518.81", "117.3", "V12.51", "786.3" ]

icd9cm

[ [ [] ] ]

[ "33.22", "96.72", "96.04", "38.93", "39.79" ]

icd9pcs

[ [ [] ] ]

10373, 10382

7715, 10111

339, 436

10442, 10460

2871, 7692

10525, 10544

2448, 2502

10334, 10350

10403, 10421

10137, 10311

10484, 10502

2517, 2852

275, 301

464, 1993

2015, 2301

2317, 2432

4,708

114,761

54120

Discharge summary

report

Admission Date: [**2145-7-7**] Discharge Date: [**2145-7-10**] Date of Birth: [**2066-8-23**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 1377**] Chief Complaint: hematemesis Major Surgical or Invasive Procedure: Esophagoduodenoscopy. History of Present Illness: 78 year-old man with history of DM2, NASH/cirrhosis, known esophogeal varices, and no prior GI bleeds presents with coffee ground emesis. Per his son, he has been doing well and was in his USOH until this morning when, after taking his medications with some tomato juice, he had sudden onset of coffee-ground emesis with dark blood. EMS was called and he was brought to the ED. Upon arrival, initial VS were 98.5 115/52 85 20 98%RA and had repeated episode of coffee-ground emesis. An NG lavage was performed and after aspiration of coffee grounds and dark red blood, his gastric contents cleared with 500cc NS. He was also noted to have a melanotic bowel movement. He was started on an octreotide and PPI drip and given 2L IVF and ciprofloxacin 400 mg IV x 1. Because his initial K+ was 6.7, he was also given calcium gluconate, insulin, and dextrose. Liver was consulted and he was admited for urgent scoping. He remained hemodynamically stable while in the ED. . On arrival to the MICU, his VS remained stable and he was comfortable with no complaints. Recent history is notable for the absence of fevers, chills, sick contacts, nausea, vomiting, diarrhea, CP, and SOB. . While in the ICU, he had an EGD that showed some esophageal varices. Three bands were placed during the scope. He never received a transfusion. He had some melena during the day, but again, his Hct stayed stable around 27-28. His IV PPI was switched from a gtt to [**Hospital1 **], his diet was advanced. He was never hemodynamically unstable. . Currently, he is feeling well. He continues to have some melena. He is tolerating a real diet now, no nausea or vomitting or abdominal pain. He does not feel lightheaded or dizzy when sitting up of transferring from the bed to the commode. . Past Medical History: 1. DM type 2 2. HTN 3. NASH: cirrhosis c/b mild encephalopathy and ascites 4. h/o nonocclusive portal vein thrombosis: [**2137**] 5. Esophogeal varices (grade 2, last EGD [**6-2**]) 6. dCHF (LVEF 55% IN [**12-4**]) 7. Depression 8. Obesity/OSA: not on CPAP 9. Diastolic CHF, LVEF >70% 2/06 10. Wenckebach AV block s/p pacemaker 11. Hypercholesterolemia 12. s/p laminectomy L3-L4, L4-L5, L5-S1 and exploration of the left L5-S1 disc space on [**2142-1-16**] by Dr [**Last Name (STitle) 739**] for treatment of lumbar stenosis with radiculopathy 13. Psoriasis Social History: Retired sixth grade teacher. Lives with his wife and son. Smoked 2ppd, quit 8 years ago per his report; has at least a 100 pack-year history. Previously a social drinker, no alcohol use since diagnosed with NASH. Family History: No history of liver disease of blood clotting or bleeding diathesis. Physical Exam: T 98.6, BP 133/43, HR 90 (paced), R 19, 92% on RA Gen: NAD HEENT: anicteric, EOMI, PERRL, OP clear w/ dry MM, no JVD CV: reg s1/S2, [**1-1**] SM Pulm: symmetric to percussion, soft expiratory wheezes b/l, some mild bibasilar crakcles Abd: obese, +BS, soft, non-tender, ND; no spider angiomas or caput medusae Ext: warm, 2+ DP B/L, 2+ LE edema b/l Neuro: a/o x 3, CN 2-12 intact, [**3-30**] UE/LE strength . Pertinent Results: EKG [**2145-7-7**]: ventricularly paced, rate 83 bpm . CXR [**2145-7-7**] (my read): poor quality study, poor inspiratory effort, no clear infiltrates . EGD [**2145-7-7**]: Esophagus: Protruding Lesions 3 cords of grade II varices were seen starting at 30 cm from the incisors in the gastroesophageal junction and lower third of the esophagus. No blood in esophagus or stomach or duodenum. Two red linear erosions on one varix. 3 bands were successfully placed. . Stomach: Mucosa: Granularity, erythema, congestion, petechiae and nodularity of the mucosa were noted in the fundus and stomach body. These findings are compatible with moderate portal hypertensive gastropathy. . Duodenum: Normal duodenum. . Impression: Varices at the gastroesophageal junction and lower third of the esophagus (ligation); Granularity, erythema, congestion, petechiae and nodularity in the fundus and stomach body compatible with moderate portal hypertensive gastropathy; Otherwise normal EGD to second part of the duodenum . ADMISSION LABS: [**2145-7-7**] 02:45PM BLOOD WBC-7.8 RBC-3.46* Hgb-10.8* Hct-34.1* MCV-99* MCH-31.2 MCHC-31.6 RDW-13.8 Plt Ct-152 [**2145-7-7**] 02:45PM BLOOD Neuts-89* Bands-0 Lymphs-6* Monos-3 Eos-1 Baso-1 Atyps-0 Metas-0 Myelos-0 [**2145-7-7**] 02:45PM BLOOD PT-16.1* PTT-23.4 INR(PT)-1.4* [**2145-7-7**] 02:45PM BLOOD Glucose-252* UreaN-64* Creat-1.6* Na-137 K-6.7* Cl-105 HCO3-27 AnGap-12 [**2145-7-7**] 02:45PM BLOOD ALT-37 AST-58* AlkPhos-134* TotBili-1.0 [**2145-7-7**] 07:20PM BLOOD Calcium-9.1 Phos-2.5* Mg-1.8 [**2145-7-7**] 02:39PM BLOOD K-6.2* [**2145-7-7**] 02:39PM BLOOD Hgb-11.7* calcHCT-35 DISCHARGE LABS: [**2145-7-10**] 07:40AM BLOOD WBC-6.1 RBC-3.02* Hgb-9.4* Hct-29.9* MCV-99* MCH-31.3 MCHC-31.6 RDW-14.3 Plt Ct-120* [**2145-7-10**] 07:40AM BLOOD PT-15.5* PTT-29.2 INR(PT)-1.4* [**2145-7-10**] 07:40AM BLOOD ALT-30 AST-34 LD(LDH)-243 AlkPhos-95 TotBili-1.0 [**2145-7-10**] 07:40AM BLOOD Albumin-3.3* Calcium-8.7 Phos-3.5 Mg-1.7 Brief Hospital Course: 75 year-old man with history of DM2, NASH/cirrhosis, known esophogeal varices, and no prior GI bleeds presents with coffee ground emesis on [**7-7**], admitted to MICU for management of upper GI bleed, s/p scope with 3 bands placed. Hemodynamically stable with no hct drops. . # GI bleed: Likely source of bleeding is esophogeal varices or portal gastropathy though no active bleeding seen on endoscopy. Status post ligation of varices with evidence of some erosion. Hematocrit is stable at 29 down from baseline of 40 with no evidence of continued blood loss. No evidence of significant coagulopathy. Patient did not need blood transfusion. He was initially placed on octriotide drip which was D/c post banding. Patient has done well and is stable to go home. He will need a repeat EGD in 4 weeks to check on the varices -Cipro 500mg twice daily until [**2145-7-11**] for SBP ppx due to GI bleed for total of 5 days -Sulcralfate 1gm four times per day until [**2145-7-19**] -Started on pantoprazole 40mg twice daily -stopped ASA because of the bleeding . # NASH/cirrhosis: He is followed by Dr. [**Last Name (STitle) 497**]. He has esophogeal varices as described above. No evidence of encephalopathy. - restarted lasix on day prior to discharge at 80mg Qday since pt c/o SOB when walking to the bathroom - Holding spironolactone for now, would restart once creat started to trend down. He was sent home on Aldactone 100 mg Qday. - continue rifaxamin . # Chronic kidney disease: sl increase in Creatinine to 1.9 from his baseline of 1.6. He will need to have outpatient follow-up. - renally dose meds - renal diet - restarted the lasix and on spirolactone as noted above . # Diastolic heart failure: Appears well compensated currently though reports dyspnea on exertion at home. He had improving pleural effusions on cxray. Initially holding lasix and spirolactone due to increase in creatine which was restarted prior to him being discharge. Continue on lasix 80mg Qday and spirolactone 100mg Qday as noted above. . # Hyperkalemia: Had potassium of 6.7 on presentation and history of modestly elevated potassium, with multiple measurements > 6. No EKG changes and s/p calcium gluconate/insuline in ED. Has improved s/p kayexcelate, unclear why so high as no new renal failure. K was 4.4 at time of discharge. . . # DM type 2: controlled w/ lantus and insulin sliding scale. - insulin SS - holding aspirin in setting of bleed, would not restart for a while as is only preventative and does not have known CAD. . # FEN: on regular diabetic diet tolerating well . # Prophylaxis: pneumoboots, PPI . # CODE: Full code, discussed with patient . # Communication: Son, [**Name (NI) **] [**Name (NI) 58007**] [**Telephone/Fax (1) 110922**] (h) . Medications on Admission: Medications at home: Aldactone 100mg po daily Insulin: Lantus 32u sq at bedtime; regular insulin sliding scale Lasix 80 mg po qd Paroxetine 20mg po daily Welchol 625mg tabs, 3 tablets [**Hospital1 **] ?Ranitidine 150mg po [**Hospital1 **] Vitamin D 1000u qd Aspirin 81 po daily Rifaxamin 600 mg [**Hospital1 **] . Medications on Transfer: Octreotide gtt Protonix 40 mg IV BID Sulcralfate 1 gm PO QID Cipro 400 mg IV q12hr Rifaximin 600 mg [**Hospital1 **] Insulin sliding scale Paroxetine 20 mg daily * holding aspirin, aldactone, lasix for now . Discharge Medications: 1. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day) for 9 days: until [**7-19**]. Disp:*36 Tablet(s)* Refills:*0* 2. Rifaximin 200 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 3. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 days: until [**7-11**]. Disp:*3 Tablet(s)* Refills:*0* 6. Lantus 100 unit/mL Cartridge Sig: Thirty Two (32) units Subcutaneous at bedtime. 7. Insulin Regular Human 100 unit/mL Cartridge Sig: As directed Injection four times a day: Per sliding scale. 8. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day. 9. Aldactone 100 mg Tablet Sig: One (1) Tablet PO once a day. 10. WelChol 625 mg Tablet Sig: Three (3) Tablet PO twice a day. 11. Vitamin D-3 400 unit Tablet Sig: Two (2) Tablet PO once a day. Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Primary: UGI bleed esophageal varices NASH cirrhosis Secondary: Diastolic CHF HTN DM type II Discharge Condition: Vitals stable, no further bleeding. Discharge Instructions: You were admitted to [**Hospital1 18**] for coffee ground emesis. You had an endoscopy where they banded 3 of your esophageal varices. We also started you on some medications to proctect you from further bleeding or having an infection. You did well and did not need to have a blood transfusion. We have made the following changes to your medications: -Cipro 500mg twice daily until [**2145-7-11**] -Sulcralfate 1gm four times per day until [**2145-7-19**] -Started on pantoprazole 40mg twice daily -stopped ASA because of the bleeding Please make sure to follow-up with your doctor's appointments as listed below. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Call your doctor or come to the emergency room if you vomit any coffee ground fluid, if you have tar black stools or bloody stools, chesp pain, worsening shortness of breath, temperature > 101.3, chills, or for any other concerns: Followup Instructions: Follow-up with your PCP in the next 1-2 weeks. Please keep the following appointment: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2145-8-13**] 3:40 You will also need a repeat EGD in 4 weeks to check on the varices. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]

[ "571.8", "V45.01", "428.32", "585.9", "571.5", "456.20", "276.7", "696.1", "428.0", "250.00", "403.90", "V15.82" ]

icd9cm

[ [ [] ] ]

[ "42.33" ]

icd9pcs

[ [ [] ] ]

9821, 9896

5420, 8162

284, 308

10034, 10072

3439, 4446

11070, 11503

2927, 2997

8759, 9798

9917, 10013

8188, 8188

10096, 10420

5070, 5397

8209, 8502

3012, 3420

10449, 11047

233, 246

336, 2100

4462, 5054

8527, 8736

2122, 2681

2697, 2911

76,930

139,955

34113

Discharge summary

report

Admission Date: [**2108-2-28**] Discharge Date: [**2108-3-8**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7333**] Chief Complaint: cardiac arrest Major Surgical or Invasive Procedure: PEG, Trach, IR PICC line placeemnt History of Present Illness: Mr. [**Known lastname 19371**] is a [**Age over 90 **] yo man with DM2, h/o aortic valve replacement (St. [**Male First Name (un) 923**]), PAD s/p bypass surgery and recurrent LE ulcers who presented to the ED after a cardiac arrest. . Per the family, the pt was eating some pureed foods and complaining of having a choking sensation. The pt's caretaker was on the phone with the pt's primary care doctor when he stopped breathing. The caretaker called EMS, and they arrived within 5 minutes. He was pulseless and apneic, and CPR was started. He received epinephrine and atropine, and his rhythm allegedly converted to PEA. He continued to receive CPR, and an additional round of epinep2hrine and atropine were given, and he had ROSC. His rhythm was atrial fibrillation with RVR in the 130s. . In the ED, he received vancomycin, pip-tazo, 2.5L NS, midazolam, fentanyl, norepinephrine and was started on the Arctic Sun therapeutic hypothermia protocol. Of note, he has been on oral antibiotics for at least the last 3 weeks, most recently a 2-week course of TMP/SMX Past Medical History: Type II Diabetes with neuropathy Coronary artery disease Aortic valve disease, s/p [**Male First Name (un) 1291**] St. [**Male First Name (un) 923**], anticoagulated Chronic systolic CHF Peripheral arterial disease s/p unsuccessful right fem-[**Doctor Last Name **] bypass ([**6-6**]) Chronic bilateral foot disease Anemia Social History: Widowed Lives at home with 24hr [**Location (un) **] care aid s/p discharge from [**Hospital 100**] rehab this month Daughter very active in patient's care - Shisa [**Telephone/Fax (1) 78656**] Denies tobacco or ETOH use Family History: Father died @ 84yrs Mother died @64 complications of DM and CAD Physical Exam: GENERAL: Elderly man, sedated, intubated HEENT: NCAT. Sclera anicteric. NECK: JVP of 8 cm. CARDIAC: II/VI systolic murmur heard best at RUSB, otherwise distant heart sounds LUNGS: slight bilateral ronchi, no wheeze or rales anteriorly ABDOMEN: Soft, NABS EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. NEURO: R pupil 5 mm and fixed, L pupil 3mm and fixed; no corneal reflex; full neuro exam limited by sedation PULSES: Right: Carotid 2+ Femoral 2+ DP dopplerable Left: Carotid 2+ Femoral 2+ DP dopplerable Pertinent Results: [**2108-2-28**] 10:40AM BLOOD WBC-14.1* RBC-3.72* Hgb-9.5* Hct-30.5* MCV-82 MCH-25.5* MCHC-31.1 RDW-15.4 Plt Ct-280 [**2108-2-28**] 06:12PM BLOOD WBC-15.6* RBC-3.84* Hgb-9.6* Hct-31.2* MCV-81* MCH-25.1* MCHC-31.0 RDW-15.0 Plt Ct-288 [**2108-2-29**] 04:05AM BLOOD WBC-11.0 RBC-3.48* Hgb-9.2* Hct-27.3* MCV-78* MCH-26.3* MCHC-33.7 RDW-15.8* Plt Ct-269 [**2108-2-29**] 01:29PM BLOOD Hct-25.5* [**2108-3-1**] 04:30AM BLOOD WBC-11.5* RBC-3.42* Hgb-8.7* Hct-26.6* MCV-78* MCH-25.3* MCHC-32.5 RDW-16.1* Plt Ct-253 [**2108-3-2**] 04:25AM BLOOD WBC-9.9 RBC-3.18* Hgb-8.0* Hct-24.7* MCV-78* MCH-25.1* MCHC-32.3 RDW-16.4* Plt Ct-264 [**2108-3-3**] 04:08AM BLOOD WBC-10.9 RBC-3.28* Hgb-8.3* Hct-26.0* MCV-79* MCH-25.5* MCHC-32.1 RDW-16.1* Plt Ct-267 [**2108-2-28**] 10:00PM BLOOD PT-23.0* PTT-42.0* INR(PT)-2.2* [**2108-2-29**] 10:27PM BLOOD PT-17.2* PTT-66.9* INR(PT)-1.6* [**2108-3-2**] 04:25AM BLOOD PT-24.8* PTT-100.5* INR(PT)-2.4* [**2108-3-3**] 04:51AM BLOOD PT-31.3* PTT-130.0* INR(PT)-3.2* [**2108-3-4**] 01:43AM BLOOD PT-30.9* PTT-88.7* INR(PT)-3.2* [**2108-3-5**] 05:00AM BLOOD PT-26.2* PTT-55.7* INR(PT)-2.6* [**2108-3-6**] 04:29AM BLOOD PT-18.7* PTT-32.4 INR(PT)-1.7* [**2108-2-28**] 10:40AM BLOOD Glucose-93 UreaN-66* Creat-2.1* Na-138 K-6.4* Cl-105 HCO3-20* AnGap-19 [**2108-2-28**] 06:12PM BLOOD Glucose-105 UreaN-67* Creat-1.9* Na-137 K-5.8* Cl-105 HCO3-23 AnGap-15 [**2108-2-28**] 10:00PM BLOOD K-5.9* [**2108-2-29**] 04:05AM BLOOD Glucose-84 UreaN-71* Creat-2.0* Na-138 K-5.6* Cl-106 HCO3-23 AnGap-15 [**2108-3-1**] 04:30AM BLOOD Glucose-40* UreaN-73* Creat-2.2* Na-140 K-4.0 Cl-108 HCO3-23 AnGap-13 [**2108-3-2**] 04:25AM BLOOD Glucose-0* UreaN-84* Creat-2.6* Na-139 K-4.6 Cl-106 HCO3-24 AnGap-14 [**2108-3-3**] 04:08AM BLOOD Glucose-75 UreaN-83* Creat-2.8* Na-142 K-3.8 Cl-107 HCO3-25 AnGap-14 [**2108-3-4**] 01:43AM BLOOD Glucose-101 UreaN-85* Creat-2.8* Na-140 K-4.1 Cl-107 HCO3-25 AnGap-12 [**2108-3-5**] 05:00AM BLOOD Glucose-172* UreaN-85* Creat-2.6* Na-139 K-4.3 Cl-106 HCO3-28 AnGap-9 [**2108-2-28**] 10:40AM BLOOD ALT-54* AST-79* CK(CPK)-68 AlkPhos-120* Amylase-30 TotBili-0.3 [**2108-2-28**] 06:12PM BLOOD CK(CPK)-226* [**2108-2-29**] 04:05AM BLOOD ALT-51* AST-65* LD(LDH)-359* AlkPhos-108 TotBili-0.5 [**2108-2-29**] 05:28PM BLOOD ALT-47* AST-55* AlkPhos-98 TotBili-0.3 [**2108-2-28**] 10:40AM BLOOD cTropnT-0.04* [**2108-2-28**] 06:12PM BLOOD CK-MB-13* MB Indx-5.8 cTropnT-0.07* [**2108-2-28**] 06:12PM BLOOD Calcium-7.7* Phos-4.7*# Mg-2.7* [**2108-3-5**] 05:00AM BLOOD Calcium-7.6* Phos-4.1 Mg-2.7* STUDIES: CT HEAD [**2108-2-28**]: Small vessel ischemic disease and global parenchymal atrophy. No evidence of hemorrhage, edema, mass effect, or acute large vascular territorial infarction. TTE [**2108-2-28**]: 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 severely depressed (LVEF= 20-30 %) secondary to extensive akinesis involving the apex and anterior septum; there is severe hypkinesis of the anterior free wall, inferior septum, and inferior free wall. The basal half of the posterior and lateral walls contracts normally. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size is normal. with depressed free wall contractility. The aortic root is mildly dilated at the sinus level. A bileaflet aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. Impression: extensive anteroseptal-apical myocardial infarct of unknown acuity; inferior hypokinesis; findings consistent with multivessel obstructive coronary [**Last Name (un) **] disease EEG [**2108-3-5**]: This telemetry captured no pushbutton activations. Throughout the recording, the background was one of burst suppression alternating between frequent sharp generalized triphasic waves at a maximum frequency of 2 Hz to a more suppressed pattern of suppression of the background for periods of up to eight seconds alternating with bursts of low amplitude activity. In the recent past those triphasic appearing waves probably represent short electrographic seizures. Brief Hospital Course: In brief this is a [**Age over 90 **] yo man with DM2, PAD who presented with asystolic cardiac arrest. # Asystolic arrest: Most likely respiratory arrest. Initially started on cooling protocol but this was stopped for elevated INR. Since admission he remained nonresponsive with fixed and dilated pupils. He was intubated and remained so for the duration of the hospitalization. Daily spontaneous breathing trials were negative. Trach was placed and his care was transitioned to a ventilatory rehab facitlity. # Hypotension: he was noted to be hypotensive in the ED and was given IVF and started on pressor support with norepinephrine. He was waned of this medication and was able to mantain his BP. An ECHO was obtained showing EF20% hypokinetic LV and PCWP elevated. This is suggestive of systolic sysfunction and suggest a cardiac etiology of hypotension. He was gradually weaned off pressors and maintained a normal BP (90-120 systolic) for several days. His tamsulosin was held. # Coagulopathy: Likely [**1-2**] combination of warfarin and recent antibiotic use. No evidence of DIC. This was reversed with vitamin K and FFP. He was then placed on hep gtt when his inr was subtherapeutic. After the trach and peg he was restarted on coumadin. He will be bridged back onto coumadin at the ventilatory rehab center in [**1-3**] days. Goal INR 2.5-3.5. # h/o [**Date Range 1291**]: on heparin ggt for thrombus ppx. Transition to warfarin with heparin bridge for 2 days at INR>2.5. # Neurological disturbances: As noted he was unrespionsive to verbal and painfull comands. Initially his pupils were fixed and dilated. He was placed on EEG and a head CT showed small vessel ischemic disease and global parenchymal atrophy. No evidence of hemorrhage, edema, mass effect, or acute large vascular territorial infarction. His EEG identified foci of seizure activity, which occurred with concurrent uncontrolled muscle movement suggesting a seizure. Neurology followed the paitent. He was started on Keppra and this was uptitrated to effect (i.e absence of seizure activity on exam and EEG). During his stay he exbited some change in neuro exam, in that he was minimally responsive to pain and pupils more reactive. However this was very short lasted (one day) and subsequently he was again nonresponsive. # Acute renal failure: Initially he was noted to have an elevated creatinine of 2.1 from 1.o in recent months. Also this was associated with oligouria. This improved with pressure support and diuresis, suggestive that the renal failure was related to decreased forward cardiac output. # Longitudinal care: Palliative care consult obtained and several meettings were held with family members and spiritual leader. Decision to mantain ventilatory support unless evidence of worsening multiple organ failure. # Foot Ulceration: Noted severe ulcers on right foot, consistent with prior documented note by vascular surgery (tendons exposed). Continued wound care. # Nutritional support: provided through tube feeds during his hospitalization. PEG tube placed for future support. # Complicated UTI: on cefpodoxime (h/o proteus and enterococcus in urine sensitive to CTX - not cipro). End date [**2108-3-11**]. # Access: PICC was placed for administration of IV medications. # Indwelling devices: Trach, PEG, PICC Medications on Admission: Acetaminophen prn Bisacodyl prn Oxycodone prn Glyburide 2.5 mg daily Docusate prn Duloxetine 30 mg daily Tramadol 25 mg prn Tamsulosin 0.4 mg qhs Warfarin Discharge Medications: 1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 2. Cefpodoxime 100 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q24H (every 24 hours) for 8 days. 3. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2 times a day). 4. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day) as needed. 5. Keppra 750 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day. 6. Insulin Lispro 100 unit/mL Solution [**Last Name (STitle) **]: AS DIR Subcutaneous ASDIR (AS DIRECTED). 7. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral Solution [**Last Name (STitle) **]: AS DIR Intravenous ASDIR (AS DIRECTED): Goal PTT 50-80. 8. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Last Name (STitle) **]: [**12-2**] Drops Ophthalmic PRN (as needed). 9. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment [**Month/Day (2) **]: One (1) Appl Ophthalmic PRN (as needed). 10. Warfarin 2.5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Once Daily at 4 PM. 11. Keppra 750 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Cardiac Arrest Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital because your heart stopped beating. You were rescucitated. You had a tube placed in your throat to help you keep breathing. You are now on the machine to keep you breathing. You also had a tube placed in your stomach to feed you. Medication Changes: START: Cefpodoxime (last dose [**2108-3-15**]) START: Keppra 750mg twice daily START: Lansoprazole 30mg daily STOP: Glyburide STOP: Duloxetine STOP: Tramadol and oxycodone STOP: Tamsulosin Followup Instructions: None Completed by:[**2108-3-9**]

[ "780.01", "428.22", "799.1", "428.0", "707.03", "440.23", "276.7", "250.70", "E930.8", "286.9", "780.39", "V12.04", "584.9", "752.61", "518.81", "357.2", "E934.2", "V46.11", "V43.3", "414.01", "348.1", "707.15", "285.9", "427.31", "427.5", "V58.61", "250.80", "250.60", "599.0", "707.22", "443.81" ]

icd9cm

[ [ [] ] ]

[ "43.11", "57.94", "45.13", "31.1", "89.19", "38.93", "96.72", "96.6" ]

icd9pcs

[ [ [] ] ]

12003, 12074

7246, 10569

276, 312

12133, 12142

2667, 7223

12665, 12700

2009, 2074

10774, 11980

12095, 12112

10595, 10751

12166, 12431

2089, 2648

12451, 12642

222, 238

340, 1408

1430, 1754

1770, 1993

48,692

111,495

41313

Discharge summary

report

Admission Date: [**2195-3-20**] Discharge Date: [**2195-3-31**] Date of Birth: [**2141-1-15**] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 949**] Chief Complaint: AMS Major Surgical or Invasive Procedure: Paracentesis History of Present Illness: 54 year old male with PMH significant for HIV (on HARRT, last CD4 629), ESLD, HCV cirrhosis presents from clinic w/ AMS. . History taken from wife. Over 7-10 days, pt has been ill w/ nausea, vomiting and diarrhea. Wife thinks he's had at least 3 loose BM daily. He has had intermittent emesis, that she believes is non-bloody, non-biliary. He has had worsening abdominal distension as well, w/ very poor po intake. He was also complaining of abdominal pain. She did not take his temp, but states that he "felt hot." Per wife, pt drinking ETOH up until 2 months ago, very heavily ~ 1pint of vodka and 4-5 beers nightly. He has a h/o ivdu (heroin) but hasn't used in 2 years. . Pt was referred to Dr. [**Last Name (STitle) 497**] by his PCP. [**Name10 (NameIs) **] exam he was found to be very altered and he was referred to the ED. . In the ED, VS were T 99.0, HR 94, BP 151/95, RR 20, O2 97%. On exam, he had + asterixis, AMS, +abd distention/TTP. RUQ US showed patent portal vein, cirrhotic liver with perihepatic ascites (not seen in other quadrants), and GB sludge but no signs of cholecystitis. CT head showed no acute intracranial process. His labs were notable for a Na 127, K 5.4, Cr 1.5, t bili 25.3, ALT 212, AST 473, alb 2.6, INR 3.6, wbc 13.7, hct 35.7, plt 149. He was seen by hepatology. He received lactulose, ceftriaxone, albumin, and an amp of D5. He did not get paracentesis b/c of INR. 2 units of ffps started. He was subsequently transferred to the ICU . In the ICU, he was continued on ceftriaxone and lactulose. He was also started on D5NS for hyponatremia/hypoglycemia. For his coagulopathy, he received FFP as well as IV vitamin K. IR-guided paracentesis was performed performed but did not show any signs of SBP, but this was in the setting of having received IV antibiotics. . Review of systems: unable to obtain as pt altered. (+) 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: HIV on HARRT HCV cirrhosis Polysubstance abuse Social History: - Tobacco: "heavy" [**Last Name (LF) 1818**], [**First Name3 (LF) **] wife - Alcohol: 1pint of vodka and 4-5 beers nightly last drank 2 mo ago - Illicits: h/o ivdu (heroin), last used (per wife) ~ 2 yrs ago Family History: Unable to obtain Physical Exam: Admission Exam: General: Thin appearing male, jaundice HEENT: Sclera icteric, dry MM, oropharynx clear Neck: supple, JVP elevated above mandible, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Tachy, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Distended, tense, minimally ttp, no spider angiomata GU: no foley Ext: warm, well perfused, 2+ pulses, no edema Neuro: Oriented to self, able to state that he at [**Hospital3 **] Deaconness. States the year is [**2195**] initially, then [**2194**], but cannot state the month. Pertinent Results: Admission Labs: [**2195-3-20**] 11:20AM PLT COUNT-149* [**2195-3-20**] 11:20AM NEUTS-69.5 LYMPHS-24.4 MONOS-5.7 EOS-0.1 BASOS-0.3 [**2195-3-20**] 11:20AM WBC-13.7* RBC-3.43* HGB-12.6* HCT-35.7* MCV-104* MCH-36.7* MCHC-35.2* RDW-16.2* [**2195-3-20**] 11:20AM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2195-3-20**] 11:20AM AFP-29.0* [**2195-3-20**] 11:20AM ALBUMIN-2.6* [**2195-3-20**] 11:20AM LIPASE-42 [**2195-3-20**] 11:20AM ALT(SGPT)-212* AST(SGOT)-473* ALK PHOS-250* TOT BILI-25.3* DIR BILI-15.0* INDIR BIL-10.3 [**2195-3-20**] 11:20AM estGFR-Using this [**2195-3-20**] 11:20AM GLUCOSE-48* UREA N-16 CREAT-1.5* SODIUM-127* POTASSIUM-5.4* CHLORIDE-97 TOTAL CO2-24 ANION GAP-11 [**2195-3-20**] 12:41PM PT-35.3* PTT-43.1* INR(PT)-3.6* [**2195-3-20**] 03:00PM AMMONIA-115* [**2195-3-20**] 10:22PM PT-40.3* PTT-46.2* INR(PT)-4.2* [**2195-3-20**] 10:22PM PLT COUNT-119* [**2195-3-20**] 10:22PM WBC-10.1 RBC-2.86* HGB-10.6* HCT-30.0* MCV-105* MCH-37.0* MCHC-35.3* RDW-16.2* [**2195-3-20**] 10:22PM ETHANOL-NEG [**2195-3-20**] 10:22PM CALCIUM-8.7 PHOSPHATE-2.0* MAGNESIUM-2.5 [**2195-3-20**] 10:22PM GLUCOSE-64* UREA N-14 CREAT-1.2 SODIUM-130* POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-26 ANION GAP-7* [**2195-3-20**] 11:30PM URINE MUCOUS-RARE [**2195-3-20**] 11:30PM URINE HYALINE-4* [**2195-3-20**] 11:30PM URINE RBC-1 WBC-3 BACTERIA-FEW YEAST-NONE EPI-<1 [**2195-3-20**] 11:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-LG UROBILNGN-4* PH-5.5 LEUK-NEG [**2195-3-20**] 11:30PM URINE COLOR-DkAmb APPEAR-Hazy SP [**Last Name (un) 155**]-1.012 [**2195-3-20**] 11:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-POS [**2195-3-20**] 11:30PM URINE OSMOLAL-389 [**2195-3-20**] 11:30PM URINE HOURS-RANDOM UREA N-578 CREAT-98 SODIUM-26 POTASSIUM-34 CHLORIDE-27 [**2195-3-21**] 15:05 ASCITES WBC RBC Polys Lymphs Monos Mesothe Macroph 171* 93* 41* 6* 7* 3* 43* PERITONEAL FLUID TotPro Glucose Creat LD(LDH) Amylase 0.5 77 0.9 38 15 TotBili Albumin 2.3 LESS THAN 1 Discharge labs: [**2195-3-31**] 05:30AM BLOOD WBC-7.6 RBC-2.62* Hgb-9.8* Hct-28.6* MCV-109* MCH-37.5* MCHC-34.3 RDW-16.8* Plt Ct-76* [**2195-3-25**] 05:00AM BLOOD WBC-10.9 Lymph-33 Abs [**Last Name (un) **]-3597 CD3%-95 Abs CD3-3408* CD4%-30 Abs CD4-1095 CD8%-56 Abs CD8-[**2200**]* CD4/CD8-0.5* [**2195-3-31**] 05:30AM BLOOD Glucose-99 UreaN-8 Creat-0.8 Na-134 K-3.7 Cl-103 HCO3-25 AnGap-10 [**2195-3-31**] 05:30AM BLOOD ALT-88* AST-179* AlkPhos-156* TotBili-21.7* [**2195-3-21**] 01:45PM BLOOD calTIBC-129* Ferritn-1686* TRF-99* [**2195-3-21**] 05:25AM BLOOD VitB12-GREATER TH Folate-9.0 [**2195-3-22**] 07:30AM BLOOD Cortsol-6.7 [**2195-3-21**] 01:45PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE IgM HBc-NEGATIVE [**2195-3-21**] 01:45PM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:40 [**2195-3-20**] 11:20AM BLOOD AFP-29.0* [**2195-3-21**] 01:45PM BLOOD IgG-2387* Test Result Reference Range/Units HCV GENOTYPE, LIPA 1a [**2195-3-24**] 06:25 CA [**02**]-9 Test Result Reference Range/Units CA [**02**]-9 14 <37 U/mL Microbiology: [**2195-3-20**] Blood cultures x 2 NEGATIVE [**2195-3-20**] MRSA Screen NEGATIVE [**2195-3-20**] VRE Screen NEGATIVE [**2195-3-20**] Urine Culture NEGATIVE [**2195-3-20**] C. Diff Toxin NEGATIVE [**2195-3-21**] HCV Viral Load 2,260 IU/mL. [**2195-3-21**] 3:05 pm PERITONEAL FLUID PERITONEAL FLUID. **FINAL REPORT [**2195-3-27**]** GRAM STAIN (Final [**2195-3-21**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2195-3-24**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2195-3-27**]): NO GROWTH. [**2195-3-25**] RPR NONREACTIVE [**2195-3-25**] 11:40 am IMMUNOLOGY HIV-1 RNA is not detected. [**2195-3-31**] 12:20 pm URINE Source: CVS. **FINAL REPORT [**2195-4-3**]** URINE CULTURE (Final [**2195-4-3**]): ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. YEAST. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 1 S Imaging: CT HEAD NON-CON [**2195-3-20**]: Some motion through the inferior most images. Otherwise, no evidence of acute intracranial process. Please note that MRI is more sensitive in detecting small intracranial lesions. RUQ ULTRASOUND [**2195-3-20**]: 1. Doppler assessment of the main portal vein and their branches shows patency and hepatopetal flow. 2. Cirrhotic liver and ascites. 3. Distended gallbladder with sludge without gallbladder wall edema or pericholecystic fluid. Cholecystitis cannot be entirely excluded based on this study, if there is high clinical concern. If high clinical concern for cholecystitis, could further evaluate with a HIDA scan. CHEST XR [**2195-3-20**]: Small bilateral effusions with associated atelectasis. Mild pulmonary edema PELVIS (AP ONLY) Study Date of [**2195-3-23**] 10:38 PM FINDINGS: There is an apparent urinary catheter in the urethra and bladder. The tip of this is not well visualized. No metallic radiopaque foreign body is seen. No bone lesion or fracture is seen. - LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of [**2195-3-25**] 1:57 PM ABDOMINAL ULTRASOUND: Again noted is a heterogeneous nodular shrunken liver consistent with a known history of cirrhosis. The largest hypovascular nodule noted on MRI in segment2 was poorly seen despite multiple attempts at positioning at visualizing this segment of the liver. The lesion within segment [**Doctor First Name 690**] next to the gallbladder is slightly hypoechoic in comparison to the surrounding parenchyma measuring 2.5 x 2.5 x 3.8 cm and is in close proximity to the main hepatic artery and the main portal vein. The other peripheral lesion within segment VI, abutting the hepatorenal space is also seen and hypoechoic in comparison to the surrounding parenchyma measuring 2.1 x 2.6 x 3.7 cm. One additional echogenic nodule within segment VII/VIII is noted with no clear correlate on the MRI, measuring 7 x 11 x 14 mm. The other lesions within segment V on the MRI are not clearly seen. Moderate amount of ascites remains. IMPRESSION: 1. Unchanged appearance to known cirrhotic liver. The segment [**Doctor First Name 690**] and segment VI lesions are son[**Name (NI) 5326**] visible and could be attempted for percutaneous biopsy. The lesion locations would make the procedure technically challenging and high risk given the proximity to surrounding vessels, gallbladder and kidney. The segment II and V lesions are not clearly seen. A moderate amount of ascites persists and a paracentesis would have to be done prior to the procedure to minimize any risk of capsular bleeding. 2. 1 cm hyperechoic nodule, likely within segment VII or VIII without clear MRI correlate. - CT ABD W&W/O C Study Date of [**2195-3-30**] 3:26 PM IMPRESSION: 1. Four lesions displaying mild arterial enhancement and washout meet imaging criteria for HCC within segment V/VIII (one lesion), segment VI (two lesions), and segment [**Doctor First Name 690**] (one lesion). None is greater then 3 cm. 2. Two lesions within segment II display only washout but without increased arterial enhancement. The smaller more posterior lesion is more concerning as it shows washout to surrounding liver on portal and delayed venous phases with a more vague larger anterior lesion of uncertain significance only seen on most delayed phase. Both are hyperdense on non-contrast CT. Additional small segment VIII lesion also only seen on most delayed images without arterial enhancement. These may represent dysplastic nodules or hypovascular HCC's. 3. Known cirrhotic-appearing liver with sequelae of portal hypertension including abdominal/esophageal varices and splenomegaly as well as mild-to-moderate amount of ascites. Edema within the large bowel presumably related to congestive enteropathy. 4. Biliary sludge and gallstones as seen on prior MRI. Small pancreatic head cyst is of doubtful significance for this patient and can be watched on future exams. 5. Small left pleural effusion. Brief Hospital Course: 54 year old male with PMH significant for HIV (on HARRT, last CD4 629), ESLD, HCV cirrhosis w/ possible left lobe liver cancer, who was being admitted to the ICU w/ AMS # Cirrhosis: The patient has known Hepatitis C, both by history as well as by viral load in hospital, as well as a reported heavy history of EToH use. On admission, given reported episodes of fevers at home as well as abdominal pain, there was serious concern for SBP, and the patient was started on empiric antibiotics with ceftrixaone. RUQ U/S showed a cirrhotic liver and ascities, but without evidence of cholecystitis or PVT. Additionally, there was no evidence of GI bleed. Subsequent diagnostic tap did not reveal any evidence of SBP, however, as noted above, this was in the setting of having already received antibiotics. The patient completed a course of Ceftrixaone for presumed SBP, and subsequently started SBP prophylaxis with Cipro. The patient underwent an MRCP secondary to concerns from patient's PCP about [**Name Initial (PRE) **] possible liver lesions. MRCP discovered five liver lesions of various sizes, detailed in the results section of this report. Two of these lesions were amenable to biopsy, but given the patient's history, multiple lesions, and potential complications of biopsy, the patient in consultation with physicians here elected not to performed the biopsy, as the results were felt to be almost certain to reveal malignancy (perhaps HCC versus cholangiocarcinoma) that would not be amenable to treatment; the patient indicated he did not want to know if this were the case. Palliative care was consulted, and provided counseling regarding resources for palliative care. The patient was made DNR/DNI. A repeat triphasic CT confirmed that the pattern of filling of the lesions in the liver was consistent with HCC. Prior to discharge, the patient received a therapeutic tap and was discharged on 20 mg of Furosemide as well as 50 mg Spironolactone. # AMS: On admission, the patient was noted to be altered. AMS was felt to be secondary to decompensated liver failure as well as a component of SBP. Some of the patient's alteration in mental status was also presumed to medication effect, and initially the patient's home dose of methadone was decreased; however, this was up-titrated back to his home dose on discharge. The patient also received hepatic encephalopathy prophylaxis with lactulose and rifaximin. On discharge, the patient was noted to be AAOx3, follwoing commands, and conversant, and without any asterixis (he had had very prominent asterixis on admission). # HIV: The patient's HAART therapy was discontinued in house secondary to concerns for liver toxicity, specifically from abacavir. On discharge, the patient was noted to have a CD4 count in in the 1000s, with an undetectable viral load. HAART therapy was not restarted on discharge, and was deferred to the outpatient setting. The ID team indicated that the patient's HAART could safely be restarted once the LFTs were less than 2 x the ULN. # HTN: The patient's amlodipine and lisinopril on hold given initially the concern for the patient's illness in the setting of presumed infection; he was not restarted on these medications upon discharge as he had been normotensive in house. # EtOH Abuse: Per wife's report, the patient has not had alcohol in over two months. Patient did not exhibit any signs/symptoms of withdrawal, and was discharged from the hospital on a multivitamin. # Renal Insufficiency: The patient's creatinine appeared to normalize over the course of his admission with albumin and IV fluid. # HypoNa: The patient was noted to be hyponatremic on admission, likely secondary to dehydration, which resolved with hydration. # Hypoglycemia: The patient on inital admission to ICU was noted to be hypoglycemic requiring a D5W gtt. This hypoglycemia was presumed secondary to acute infection with SBP; the patient remained normoglycemic throughout the remainder of his admission. An AM cortisol was sent off to rule out adrenal insuffiency as a cause of hypoglycemia, but AM cortisol was within normal limits. # Chest Pain: Not currently bothersome to patient. However, he does describe a long history of intermittent chest pressure with may require outpatient follow-up. Medications on Admission: Home meds (confirmed with girlfriend who read off of pill bottles) -Epzicom 1 tab q day -Prezista 800 mg daily -Norvir 100 mg softgel 1 q day -Lisinopril 10 mg daily -Ondansetron 4 mg 1 tab up to TID -Omeprazole-20 mg [**Hospital1 **] -Fluoxetine 10 mg daily -amlodipine 5 mg daily -ibuprofen 800 mg 3x daily Discharge Medications: 1. fluoxetine 10 mg Capsule Sig: One (1) Capsule PO once a day. 2. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 3. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO three times a day as needed for nausea. 4. lactulose 10 gram/15 mL Solution Sig: Thirty (30) ml PO three times a day. Disp:*1 quantity sufficient* Refills:*2* 5. rifaximin 550 mg Tablet Sig: One (1) Tablet PO twice a day: Please take this medication for hepatic encephalopathy prophylaxis. Disp:*60 Tablet(s)* Refills:*2* 6. multivitamin Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 7. methadone 10 mg Tablet Sig: Fifteen (15) Tablet PO once a day. 8. Cipro 250 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 9. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. methadone 10 mg Tablet Sig: Fifteen (15) Tablet PO DAILY (Daily). 11. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital6 **] Discharge Diagnosis: Primary Diagnosis: - Spontaneous Bacterial Peritonitis Secondary Diagnosis: - Multiple Liver Lesions 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: Mr. [**Last Name (Titles) 13309**], it was a pleasure taking care of you in the hospital. You were admitted to the hospital because you had been having some abdominal pain and had some alteration in your mental status. After performing some images, we believes that you had an infection in the fluid which had accumulated in your abdomen, and treated you with an appropriate course of antibotics. When you finished these antibiotics, we started you on an antibiotic you will need to take indefinitely to prevent you from getting another infection. Our HIV specialists saw you and indicated that your current liver disease made it very dangerous for you to continue taking your HIV medications, all of which have been stopped. You should not restart these medications until you have consulted with your HIV physician and your provider [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 66037**]. We also performed some imaging of your liver; your primary physician had noted that one of the lobes of your liver had a lesion on it. When we took more pictures of of your liver, we saw that your liver had five different lesions on it. After discussions with you, you elected not to have us perform a biopsy. We got a CT scan which showed that this is likely to be liver cancer, however after discussion with you we decided that treating it would likely not make your life better and potentially make it worse. When you leave the hospital: - STOP Epzicom 1 tab DAILY (discuss with your primary care doctor when and if to restart this) - STOP Prezista 800 mg DAILY (discuss with your primary care doctor when and if to restart this) - STOP Norvir 100 mg DAILY (discuss with your primary care doctor when and if to restart this) - STOP Lisinopril 10 mg daily (discuss with your primary care doctor when and if to restart this) - STOP Amlodipine 5 mg daily (discuss with your primary care doctor when and if to restart this) - STOP Ibuprofen 800 mg 3x daily - START Furosemide 40 mg Daily (this is for the fluid in your abdomen and legs) - START Spironolactone 100 mg Daily (this is for the fluid in in your abdomen and legs) - START Ciprofloxacin 250 mg Daily (you will need this to prevent you from getting infections in the future) - START Lactulose 30 ml three times a day; take this as needed in order to have 3 bowel movements a day - START rifaximin 550 mg Tablet twice a day - START multivitamin Daily We did not make any other changes to your medications, so please continue to take them as you normally have been. Followup Instructions: Name: PA- [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 66037**] Location: [**Hospital1 **] FAMILY HEALTH CENTER Address: [**Street Address(2) **], [**Hospital1 **],[**Numeric Identifier 66038**] Phone: [**Telephone/Fax (1) 66039**] Appointment: Wednesday [**2195-4-1**] 2:30pm Department: LIVER CENTER When: FRIDAY [**2195-4-17**] at 3:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

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Discharge summary

report

Admission Date: [**2198-10-16**] Discharge Date: [**2198-10-22**] Date of Birth: [**2124-1-13**] Sex: M Service: MEDICINE Allergies: Hydrochlorothiazide Attending:[**First Name3 (LF) 2167**] Chief Complaint: Syncope Major Surgical or Invasive Procedure: EGD History of Present Illness: 74yo gentleman with h/o DM, HTN, CAD s/p recent CABG [**9-10**], and AFib on amiodarone (not on coumadin) presented to the ED with an episode of syncope, of note the patient was recently discharged ([**10-14**]) from [**Hospital1 18**] for an upper GI bleed. The patient reports that one day prior to admission he suddenly fell to the ground while standing in front of the mirror. The patient was unclear regarding the duration (perhaps 30mins?), but did not recall any preceding symptoms or events. Denied CP, palpitations, aura, loss of bowel or bladder. The patient also reports he cut his toe nail after he fall, which was why he initially came to the ED. The patient reports he had some black stools initially upon discharge home, but that they were improved from previously and more greenish in color. No other GI compliants. . Pt was recently admitted ([**10-4**]) to the [**Hospital1 18**] ICU for an upper GI bleed and received a total of 10U pRBC during the admission. Inital Hct was 25.4. The patient underwent upper endoscopy, which showed esophagitis, non-bleeding gastric and duodenal ulcers. Esophageal brushings showed [**Female First Name (un) **] non-invasive and the patient was started on Nystatin. The patient had continued GI bleed and scoped an additional three times. The patient was found to be H. pylori positive and was started on Flagyl 500mg PO TID and claritromycin 500mg PO Q12H. Additionally, the patient underwent thermal therapy and endovascular clipping with EGD at multiple sites as these gastric ulcers were later found to be bleeding. At the time of discharge, the patient was tolerating regular PO diet and the Hct was stable (30.8). . In the ED his vitals were T:97.8 BP:130/58 HR:70 SAT: 100% 2L, 98% RA. FS 37-45 and given D50. Pt had his toenail removed and given cipro 400mg and flagyl 500mg given concern for stool contact with open wound. He was also given 40mg IV protonix, GI consulted, and transferred to the ICU. BM in ED - greenish stool that was guaic positive. Past Medical History: CAD s/p CABG on [**9-/2198**]: LIMA to LAD, SVG to DIAG, SVG to OM, SVG to PDA DM HTN PVD AFib with RVR 2 weeks after CABG, on amiodarone CKD baseline Cr 3.0-3.7 Anemia baseline Hct 24-29 Admission [**Date range (1) 33626**]: Right LE cellulitis at vein harvest site, Cx grew Pseudomonas, on cipro and linezolid until [**10/2198**] Hyperlipidemia s/p L CEA [**9-10**] Gangrene of L foot (tips of 4th and 5th digits) Gout Osteoarthritis Cataracts Social History: Quite smoking in [**2182**]. No alcohol in last month but prior to that was 2 drinks one night per week. Lives alone in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. Uses a walker. He had a VNA coming every other day. Family History: Father died of a stroke, mother died of blood clot. Physical Exam: Tmax: 36.9 ??????C (98.5 ??????F) Tcurrent: 36.8 ??????C (98.3 ??????F) HR: 75 (68 - 82) bpm BP: 92/54(63) {92/49(59) - 122/72(77)} mmHg RR: 19 (12 - 22) insp/min SpO2: 100% Gen: NAD/ Comfortable HEENT: AT/NC, PERRLA, EOMI, anicteric, MMM, no exudates no rhinorrhea/ discharge, no sinus tenderness, upper and lower dentures in place NECK: supple, trachea midline, no LAD, no thyromegaly LUNG: CTA-B/L, no R/R/W CV: S1&S2, RRR, no R/G/M, distant heart sounds Carotid: no bruits ABD: Soft/+BS/ NT/ ND/no rebound/ no guarding/ no hepatomegaly/ no splenomegaly EXT: dusky toes, esp 4th and 5th toes on the left though sensation intact. toes cool to touch. +2 edema lower ext diminished distal pulses. Right first digit nail removed. Dressing C/I/D Dressing on right calf c/i/d SKIN: eccymosis on ext NEURO: AAOx3 CN II-XII grossly intact and non-focal b/l 5/5 strength in upper and lower ext b/l Diminished sensation in lower ext Reflexes [**2-5**] brachioradialis, biceps, triceps, patellar, Achilles Pertinent Results: [**2198-10-17**] 10:32AM BLOOD Hct-27.5* [**2198-10-17**] 04:18AM BLOOD WBC-12.2* RBC-3.19* Hgb-9.8* Hct-27.6* MCV-87 MCH-30.8 MCHC-35.5* RDW-14.3 Plt Ct-70* [**2198-10-17**] 04:18AM BLOOD Glucose-70 UreaN-74* Creat-3.8* Na-148* K-3.3 Cl-120* HCO3-14* AnGap-17 [**2198-10-17**] 01:32AM BLOOD CK(CPK)-249* [**2198-10-16**] 04:55PM BLOOD CK-MB-7 cTropnT-0.03* [**2198-10-17**] 01:32AM BLOOD CK-MB-8 cTropnT-0.03* [**2198-10-17**] 09:35AM BLOOD CK-MB-PND cTropnT-PND [**2198-10-17**] 04:18AM BLOOD Calcium-8.0* Phos-4.8* Mg-2.2 [**2198-10-16**] 11:08PM BLOOD Type-ART Temp-36.9 pO2-96 pCO2-26* pH-7.37 calTCO2-16* Base XS--8 [**2198-10-16**] 05:01PM BLOOD Glucose-136* Lactate-4.4* K-3.9 [**2198-10-16**] 08:30PM BLOOD Lactate-3.8* [**2198-10-16**] 11:08PM BLOOD Lactate-3.1* CXR: no acute pathology . IMAGING: FINDINGS: There is no acute intracranial hemorrhage, shift of normally midline structures, or evidence of acute major vascular territorial infarction. Mild prominence of the bifrontal subdural spaces likely represents to a component of atrophy. Mild- to- moderate periventricular and subcortical white matter hypointensity represents small vessel ischemic changes. There is evidence of a small prior left parietal lobe infarct. Atherosclerotic calcification of the cavernous carotid arteries is noted bilaterally. The surrounding osseous structures are unremarkable without evidence for fracture. Mild bilateral ethmoid and maxillary sinus mucosal thickening is noted. IMPRESSION: No acute intracranial hemorrhage or edema. . THREE VIEWS OF THE RIGHT FOOT: No fracture or dislocation is identified. Degenerative changes are most pronounced involving the first IP and MTP joints with joint space narrowing, subchondral sclerosis, and osteophyte formation. Alignment is anatomic. Soft tissue swelling is seen involving the first toe diffusely, but most prominent medial to the first MTP joint. No radiopaque foreign bodies are identified. Vascular calcifications are noted. IMPRESSION: No fracture or dislocation. . Endoscopy Esophagus: Normal esophagus. Stomach: Mucosa: Erythema and friability of the mucosa with contact bleeding were noted in the antrum. Excavated Lesions Multiple erosions were noted in the stomach body. A single non-bleeding ulcer with clean basis was found in the stomach body. Duodenum: Mucosa: Scarring of the mucosa was noted in the duodenal bulb. Impression: Scarring in the duodenal bulb Erythema and friability in the antrum Erosions in the stomach body Ulcer in the stomach body Otherwise normal EGD to jejunum Brief Hospital Course: 74 yo M with DM, HTN, CAD s/p CABG recently in [**9-10**] with subsequent a-fib with recent admission for upper GI bleed who presented with syncope, hypoglycemia and acute blood loss. Pt admitted to ICU initially late evening [**10-16**] for concern for acute GIB with decreased Hct to 24.5 and received 2u pRBC. . # Upper GI Bleed with known gastric/duodenal ulcers - After transfer to the medical service, the patient underwent EGD on [**10-18**] that revealed a single non-bleeding ulcer with clean basis in the stomach, erythema and friability in the antrum and erosions in the stomach body and scarring in the duodenal bulb. The next morning, the patient was noted to have a hb drop of 1 point over 24 hours and then subsequently had two reported large melanotic bowel movements throughout the day, and developed SVT to the 140s. The patient was aggressively fluid resuscitated and trasnfused 2 units PRBC. He did not have any further drops in his hematocrit and did not require further transfusions. He was continued on pantoprazole and carafate and will need to follow up as an outpatient. . # Syncope: Pt with concerning episode of syncope PTA given recent GI bleeds. His EKGs were unchanged. He was monitored on telemetry. He had no further episodes. . # Hypoglycemia/Diabetes II, controlled, without complications: Pt with low FS in ED and initially on the floor. Pt on glipizide at home. Likely [**2-3**] decreased po intake in the setting of glipizide with impaired renal clearance. The glipizide was held as an inpatient, and then patient was told to restart at a once daily dose at home once he was taking consistent pos. . # Anion Gap Acidosis: Pt with ABG 7.37/26/96/16 and lacate eventually trended down. Likely [**2-3**] lactic acidosis from GI bleed or possibly mesenteric ischemia and uremia from renal failure. No evidence of active infection. . #Transaminitis: Pt with elevated LFTs on admit, likely related to hypotension. No evidence of hepatitis. His LFTs improved by time of discharge. . # Chronic Renal Insufficiency, IV: Baseline Cr 3.0-3.7, Pt around baseline. Likely mutifactorial given hx of DM and hypertension. Additionally, pt has PVD, carotid stenosis, CAD. . # Hypernatremia: Resolved. . # CAD s/p recent CABG: currently ASx. His metoprolol and simvastatin were held transiently, and restarted on the floor when he was medically stable. . # Paroxysmal atrial fibrillation: Currently in sinus and rate controlled. He was continued on amiodarone, and his dose of metoprolol was doubled to 25 mg twice daily for better rate control. . # H. pylori: He finished his treatment course while in the hospital. . # Toe Nail Extraction: pt toe nail cut during fall. X-ray no acute fracture or dislocation. He was continued on local wound care. He received a short course of ciprofloxacin/metronidazole. Medications on Admission: 1. Allopurinol 100 mg PO EVERY OTHER DAY (Every Other Day). 2. Simvastatin 40 mg Two (2) Tablet PO DAILY 3. Amiodarone 200 mg One (1) Tablet PO DAILY (Daily): take two tablets daily until [**10-19**], and then one tablet daily thereafter. 4. Acetaminophen 500 mg Two (2) Tablet PO Q8H as needed for pain. 5. Sucralfate 1 gram One Tablet PO QID (4 times a day). 6. Metoprolol Tartrate 25 mg 0.5 Tablet PO BID 8. Prochlorperazine Maleate 10 mg (1) Tablet PO Q6H prn 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) 1 tab PO twice a day. 10. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Metronidazole 500 mg One (1) Tablet PO TID until [**10-23**] 12. Clarithromycin 250 mg Two (2) Tablet PO Q12H until [**10-23**] 13. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO twice a day: Swish and swallow. Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 5. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day. 6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO BID (2 times a day). 7. Pantoprazole 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: 1. GI bleeding 2. Atrial fibrillation 3. CAD s/p CABG 4. Hypertension 5. Diabetes mellitus 6. Hypernatremia 7. Hypoglycemia 8. Syncope Discharge Condition: Stable Discharge Instructions: You were admitted with bleeding from your GI tract. This resolved. If you develop fevers, chills, nausea, vomiting, or black stools, please call your primary care doctor or go to the emergency room. . Drink plenty of water, at least 1 liter/day to keep your sodium levels normal. . Today you will finish your treatment for H. pylori infection and you will not need to take any more antibiotics at home. . When you first came in, your blood sugars were low. You should take 1 tablet of glipizide ONE TIME A DAY for now instead of TWICE A DAY, and then monitor your blood sugars. . Your dose of METOPROLOL was increased to 25 MG twice a daily. Followup Instructions: Please follow up with your primary care doctor. [**First Name (Titles) 6**] [**Last Name (Titles) 648**] was made for you. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2198-10-29**] 11:15. At that time you should have another chemistry panel checked to evaluate your high sodium levels. Provider: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2198-10-23**] 1:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1241**] Date/Time:[**2198-10-24**] 2:00

[ "276.2", "250.80", "414.00", "578.9", "584.9", "276.0", "V45.81", "585.4", "041.86", "427.31", "285.1", "403.90" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

11129, 11187

6764, 9602

290, 296

11366, 11375

4185, 6741

12066, 12748

3096, 3149

10479, 11106

11208, 11345

9628, 10456

11399, 12043

3164, 4166

243, 252

324, 2352

2374, 2823

2839, 3080

29,503

154,874

32512

Discharge summary

report

Admission Date: [**2134-12-24**] Discharge Date: [**2134-12-31**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2160**] Chief Complaint: fever and respiratory distress Major Surgical or Invasive Procedure: none History of Present Illness: This is a [**Age over 90 **] year old demented latvian-speaking woman who lives at [**Hospital **] Healthcare Center. On [**12-21**], she was noted to have cough, wheezing, hoarseness, and temp of 101.4. She was started on levaquin, flagyl, and nebulizers for possible aspiration pneumonia. She had a fever to 100.9 the next day. On [**12-23**], her creatinine was noted to be up to 1.3 from 0.7 with poor PO intake. On [**12-24**], she had another temp to 101.4 was more short of breath with respiratory distress. She received nebs and tylenol, and was transferred the [**Hospital1 18**] ED. In the ED, she was noted to be in respiratory disress, satting 99% on a nonrebreather. She was given nebulizers and put on noninvasive mask ventilation. She had a temp of 99.8 but stable blood pressure. She was given 750 mg levofloxacin, 1 gram of ceftazadime. She was given PR aspirin for a slightly elevated CK and troponin. She weaned from mask ventilation and put on 2L NC, but admitted to the MICU for close observation. ROS: Unobtainable due to dementia (confused even with russian interpreter in ED) Past Medical History: DM II last A1C 7 in [**7-23**] pneumonia dementia hep c left BKA [**2067**]'s hypothyroidism frequent falls Right foot neuropathic pain HTN CAD s/p MI EF 35-40% hyperlipidemia transaminitis DJD anemia constipation Social History: Lives in [**Location **] at [**Hospital **] health center. She is incontinent of bowel and bladder but able to feed herself. Dependant on ADL's Family History: Unable to assess given dementia Physical Exam: T97.6 P94 BP 138/69 R24 Sat 93% 2L NC Gen: alert, peaceful and verbal but not understandable HEENT: PERRLA. Mucous membranes dry Nodes: no cervical LAD Resp: wheezes in all areas, with CV: RRR nl s1s2 no MGR Abd: soft, nontender, no organomegaly Ext: left leg s/p BKA, stump healed. right leg intact with minimal edema and intact DP pulse. Neuro: not oriented. Able to move all extremities Pertinent Results: [**2134-12-30**] 09:50AM BLOOD WBC-9.8 RBC-3.10* Hgb-9.1* Hct-28.6* MCV-92 MCH-29.4 MCHC-31.9 RDW-14.3 Plt Ct-386 [**2134-12-27**] 09:35AM BLOOD WBC-11.6* RBC-3.54* Hgb-10.4* Hct-32.5* MCV-92 MCH-29.4 MCHC-32.1 RDW-14.4 Plt Ct-465* [**2134-12-24**] 06:48PM BLOOD WBC-10.8 RBC-3.41* Hgb-10.1* Hct-30.4* MCV-89 MCH-29.6 MCHC-33.2 RDW-14.6 Plt Ct-290 [**2134-12-24**] 06:48PM BLOOD Neuts-81.3* Lymphs-13.2* Monos-4.4 Eos-1.0 Baso-0.1 [**2134-12-24**] 06:48PM BLOOD Ret Aut-1.2 [**2134-12-30**] 09:50AM BLOOD Glucose-134* UreaN-42* Creat-0.9 Na-143 K-4.3 Cl-106 HCO3-30 AnGap-11 [**2134-12-24**] 06:48PM BLOOD Glucose-147* UreaN-59* Creat-1.3* Na-138 K-5.2* Cl-105 HCO3-24 AnGap-14 [**2134-12-25**] 04:14PM BLOOD CK(CPK)-331* [**2134-12-25**] 01:20AM BLOOD ALT-21 AST-34 LD(LDH)-262* CK(CPK)-359* AlkPhos-51 Amylase-29 TotBili-0.3 [**2134-12-25**] 01:20AM BLOOD Lipase-15 [**2134-12-24**] 06:48PM BLOOD CK-MB-5 cTropnT-0.02* proBNP-[**Numeric Identifier 43273**]* [**2134-12-25**] 01:20AM BLOOD CK-MB-7 cTropnT-<0.01 [**2134-12-25**] 04:14PM BLOOD CK-MB-8 cTropnT-<0.01 [**2134-12-30**] 09:50AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.8 [**2134-12-25**] 01:20AM BLOOD Albumin-3.1* Calcium-9.8 Phos-3.2 Mg-2.0 Iron-21* [**2134-12-25**] 01:20AM BLOOD calTIBC-244* VitB12-419 Folate-GREATER TH Ferritn-235* TRF-188* [**2134-12-25**] 01:55AM BLOOD Type-ART pO2-80* pCO2-37 pH-7.45 calTCO2-27 Base XS-1 Intubat-NOT INTUBA [**2134-12-25**] 01:55AM BLOOD Lactate-1.3 K-4.7 [**2134-12-24**] 08:30PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019 [**2134-12-24**] 08:30PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2134-12-24**] 08:30PM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2 RenalEp-0-2 [**2134-12-25**] 3:34 am Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal aspirate. Rapid Respiratory Viral Antigen Test (Final [**2134-12-25**]): Respiratory viral antigens not detected. CULTURE CONFIRMATION PENDING. SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3 INFLUENZA A,B AND RSV. This kit is not FDA approved for direct detection of parainfluenza virus in specimens; interpret parainfluenza results with caution. VIRAL CULTURE (Preliminary): No Virus isolated so far Blood cultures - no growth. ECHO: Conclusions The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the basal half of the inferior and inferolateral walls and distal septum and apex. The remaining segments contract normally (LVEF = 35 %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild to moderate ([**1-19**]+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal cavity size with regional left ventricular systolic dysfunction c/w multivessel CAD. Mild-moderate mitral regurgitation. Thickened mitral and aortic valves but without discrete vegetation identified. CLINICAL IMPLICATIONS: Based on [**2134**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. CHEST RADIOGRAPH Comparison to [**2134-12-25**]. The preexisting radiographic alterations are unchanged, no newly appeared alterations. IMPRESSION: Unchanged radiographic appearance as compared to [**2134-12-25**]. Cardiology Report ECG Study Date of [**2134-12-25**] 1:25:20 AM Sinus rhythm. Right axis deviation. SI-Q3-T3 pattern. Low njormal voltage in limb and precordial leads. Right bundle-branch block. Compared to the previous tracing of [**2134-12-24**] no significant change. Read by: [**Last Name (LF) **],[**First Name3 (LF) **] I. Intervals Axes Rate PR QRS QT/QTc P QRS T 93 174 114 392/449 84 142 -5 CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN Reason: ? CHF [**Hospital 93**] MEDICAL CONDITION: [**Age over 90 **] year old woman with pna, o2 req, now inc wheeze REASON FOR THIS EXAMINATION: ? CHF Chest radiograph comparison to [**2134-12-25**], at 5:58 a.m. The radiographic appearance is virtually unchanged. Both lungs show relatively [**Name2 (NI) 15410**] opacities with air bronchograms. The opacities show no major progression. Slight bilateral pleural effusions that are limited to the costophrenic sinuses. No newly appeared lung opacities. Slightly enlarged cardiac silhouettes with aortic calcification. IMPRESSION: No relevant progression of the preexisting intrathoracic process. FRONTAL CHEST RADIOGRAPH: This examination is limited. There is elevation of the left hemidiaphragm and possible left retrocardiac opacity. Perihilar haziness and increased interstitial markings likely represent an element of pulmonary edema. There are small bilateral pleural effusions. More confluent alveolar opacity in the right upper lobe likely represents superimposed infection. There is diffuse osteopenia. IMPRESSION: Mild CHF and likely superimposed right upper and left lower lobe pneumonia. Brief Hospital Course: Hypoxia, dyspnea was likely an combination of acute on chronic systolic heart failure and bilobar pneumonia. Influenza and respiratory viral cultures negative. Treated with antibiotics, nebulizers, oxygen, aggressive pulmonary care with improvement. Also diuresed for CHF. The patient's overall clinical condition improved and she was discharged to NH to complete a total of 10 day course of antibiotics - levofloxacin. Lasix, lisinopril and atenolol were continued for CHF. Aspirin started. Dementia - per son, she is dependant on [**Name (NI) 5669**], however recognizes his and his wife. On the floor, the son was not in the hospital so it was unable to assess if the patient's mental state was at baseline. However, she was eating appropriately with RN assistance and was known to be dependent on ADL's. We attempted talking with her with Russian interpretor, but she either did not seem to understand the language or could not comprehend due to dementia. Language line could not provide a Latvian interpretor and at their recommendation lithuanian interpretor was [**Name (NI) 653**], however the response from the patient was same a above. Diabetes mellitus type 2 - avandia was held given acute CHF and mildly elevated troponin. Glyburide was continued. Chronic hepatitis C - no acute events noted. Ensure was given to address poor oral intake. Hypothyroidism - continued on synthroid Neuropathy - continued on neurontin Anemia - consistent with iron deficiency anemia and anemia of chronic disease. Oral ferrous sulfate is started Contact is son [**Name (NI) **] [**Name (NI) 75834**] - [**Telephone/Fax (1) 75835**]. He was [**Telephone/Fax (1) 653**] on phone with updates about patient's condition. Patient is DNR/DNI (confirmed with [**Doctor Last Name **]) Medications on Admission: duonebs Q4H levaquin 500 qd (start [**12-21**]) flagyl 250 TID x 10 days (start [**12-21**]), increased to 500 TID [**12-24**] lactinex 30 po Q meal avandia 4 mg po qd insulin sliding scale glyburide 5 mg po qam atenolol 12.5 mg po qd multivitamin colace levothyroxine 37.5 po qd senna 2 qhs neurontin 300 po qhs tylenol prn Discharge Medications: 1. Levothyroxine 25 mcg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 3. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. DuoNeb 0.5-2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation every four (4) hours. 9. Multivitamin Capsule Sig: One (1) Capsule PO once a day. 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation every 6-8 hours as needed for shortness of breath or wheezing. 12. Oxygen by nasal canula [**2-20**] lit/min to keen O2 saturation > 92% 13. Insulin sliding scale as per recommendation at NH 14. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO every 48 hours for 4 days. 15. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day: Do not take within 2 hours of the levothyroxine . 16. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital1 2670**] - [**Location (un) **] Discharge Diagnosis: acute on chronic systolic heart failure Community acquired pneumonia Dementia Diabetes mellitus type 2 Chronic hepatitis C Discharge Condition: stable, on room air Discharge Instructions: You were hospitalized for difficulty breathing, probably because of a combination of heart failure and pneumonia. Your breathing has improved in the hospital gradually, but still oxygen is needed. Please call your primary care physician with concerns and questions, and return to the emergency department with fever, chills, mental status change, difficulty breathing, chest pain or other alarming symptoms. Followup Instructions: Physician at nursing home to follow, please evaluate within [**1-19**] days of return to nursing home.

[ "584.9", "V49.75", "414.01", "428.0", "507.0", "244.9", "294.8", "280.9", "428.23", "263.9", "070.54", "250.00", "401.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11183, 11253

7725, 9506

295, 301

11420, 11442

2307, 5614

11900, 12006

1848, 1881

9883, 11160

6596, 6663

11274, 11399

9532, 9860

11466, 11877

1896, 2288

5637, 6559

225, 257

6692, 7702

329, 1433

1455, 1671

1687, 1832

14,008

173,497

8305

Discharge summary

report

Admission Date: [**2136-1-31**] Discharge Date: [**2136-2-5**] Date of Birth: [**2059-5-6**] Sex: F Service: ORTHOPAEDICS Allergies: Strawberry / Shellfish Attending:[**First Name3 (LF) 64**] Chief Complaint: Progressive left-sided hip pain with activity Major Surgical or Invasive Procedure: Left total hip replacement History of Present Illness: Ms. [**Known lastname 3549**] is a 76 y/o female with osteoarthritis and progressive left-sided hip pain who presents today for definitive treatment. Past Medical History: Chronic obstructive pulmonary disease Coronary artery disease s/p cardiac catheterization s/p CABG [**2128**] Chronic renal insufficiency (Cr 1.9-2.2) Right total hip replacement [**7-18**] Social History: Non-contributory Family History: Non-contributory Physical Exam: On discharge: Afebrile, All vital signs stable General: Alert and oriented, No acute distress Extremities: left lower Weight bearing: partial weight bearing Incision: no swelling/erythema/drainage Dressing: clean/dry/intact Extensor/flexor hallicus longus intact Sensation intact to light touch Neurovascular intact Capillary refill brisk 2+ pulse Pertinent Results: [**2136-2-3**] 10:20AM BLOOD WBC-9.9 RBC-3.34* Hgb-10.1* Hct-29.7* MCV-89 MCH-30.3 MCHC-34.2 RDW-15.2 Plt Ct-213 [**2136-2-3**] 10:20AM BLOOD Plt Ct-213 [**2136-2-2**] 07:10AM BLOOD Glucose-109* UreaN-31* Creat-1.7* Na-133 K-4.7 Cl-102 HCO3-20* AnGap-16 [**2136-2-2**] 07:10AM BLOOD Calcium-9.1 Phos-2.5* Mg-2.0 [**2136-1-31**] 08:15PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.016 URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG URINE RBC-3* WBC-0 Bacteri-NONE Yeast-NONE Epi-0 [**2136-2-2**] 10:41 AM HIP UNILAT MIN 2 VIEWS LEFT FINDINGS: Comparison to [**2135-1-31**]. Postoperative changes status post placement of a left total hip replacement with noncemented acetabular component fixed with two screws and a cemented femoral stem are noted. Gas is seen in the soft tissues. Clips are seen along the skin laterally. There is also a right total hip prosthesis with noncemented acetabular component fixed with one screw and a noncemented femoral stem, incompletely evaluated on the current study. Degenerative changes of the lower lumbar spine are seen. There is vascular calcification. A calcified structure in the pelvis may represent a calcified fibroid. No hardware-related complication of periprosthetic lucency is seen. IMPRESSION: Bilateral total hip prostheses without evidence of hardware-related complication. Brief Hospital Course: Ms. [**Known lastname 3549**] was admitted to [**Hospital1 18**] on [**2136-1-31**] for an elective left total hip replacement. Pre-operatively, she was consented, prepped, and brought down to the operating room for surgery. Intra-operatively, she was closely monitored and remained hemodynamically stable. She tolerated the procedure well without any difficulty or complication. Post-operatively, she was transferred to the PACU and floor for further recovery. On the floor,she remained hemodynamically stable with her pain controlled. She progressed with physical therapy to improve her strength and mobility. She continues to make steady progress without any incidents. She was discharged in stable condition. Medications on Admission: 1. Cartia XT 180mg daily 2. HCTZ 25mg daily 3. Lisinopril 10mg 4. Vytorin [**11-3**] 5. ASA 81mg (off prior to [**Doctor First Name **].) 6. Calcium 1mg daily 7. Lorazepam 1mg daily 8. Combivent 2-3 puffs prn 9. Alphagan 0.15% 1 drop each eye [**Hospital1 **] 10. Tylenol prn 11. Travatan 0.004% 1 drop qhs 12. Hydrocodone/APAP 5/500 q4-6hours prn 13. Metoprolol 25mg [**Hospital1 **] 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. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 8. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-17**] Puffs Inhalation Q6H (every 6 hours) as needed. 9. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 10. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q24H (every 24 hours). 11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Discharge Disposition: Extended Care Facility: Life Care Center of [**Location 15289**] Discharge Diagnosis: Osteoarthritis Discharge Condition: Stable Discharge Instructions: Keep the incision/dressing clean and dry. You may apply a dry sterile dressing as needed for drainage or comfort. If you have any increased redness, swelling, pain, drainage, shortness of breath, or a temperature >101.5, please call your doctor or go to the emergency room for evaluation. You may bear weight on your left leg. Resume all of your home medication prior to admission and take all medication as prescribed by your doctor. Continue your Lovenox injections as prescribed to help prevent blood clots. Feel free to call our office with any questions or concerns. Physical Therapy: Activity: as tolerated Left lower extremity: partial weight bearing Treatments Frequency: Your skin staples may be removed 2 weeks after your surgery. Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2136-2-17**] 1:00 Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2136-4-19**] 10:00 Provider: [**First Name11 (Name Pattern1) 2389**] [**Last Name (NamePattern1) 2390**], MD Phone:[**0-0-**] Date/Time:[**2136-4-19**] 2:30 Please call Dr [**Last Name (STitle) **] office at ([**Telephone/Fax (1) 2007**]. Schedule an appointment for two weeks. Completed by:[**2136-2-4**]

[ "403.90", "V45.81", "V10.11", "715.35", "496", "414.00", "530.81", "585.9" ]

icd9cm

[ [ [] ] ]

[ "81.51" ]

icd9pcs

[ [ [] ] ]

5129, 5196

2655, 3370

329, 358

5255, 5264

1223, 2632

6055, 6573

802, 820

3806, 5106

5217, 5234

3396, 3783

5288, 5860

835, 835

5878, 5947

5969, 6032

850, 1204

244, 291

386, 538

560, 752

768, 786

80,920

175,602

6503

Discharge summary

report

Admission Date: [**2131-5-29**] Discharge Date: [**2131-6-5**] Date of Birth: [**2054-4-10**] Sex: M Service: SURGERY Allergies: Optiray 300 / Iodine Attending:[**First Name3 (LF) 2597**] Chief Complaint: Thoracic Aortic Anuerysm Major Surgical or Invasive Procedure: Stent graft repair of the descending thoracic aortic aneurysm with 2 [**Doctor Last Name 4726**] TAG endoprostheses: The first one is reference number [**Serial Number 24968**], lot or batch code number [**Serial Number 24969**]. The second one is catalog number [**Serial Number 24970**], lot or batch code number [**Serial Number 24971**]. Left carotid subclavian bypass graft with 8-mm [**Doctor Last Name 4726**]-Tex graft. History of Present Illness: This 77-year-old gentleman is undergoing endovascular repair of a descending thoracic aortic aneurysm. It will be necessary to cover the left subclavian artery with a device in order to obtain adequate proximal seal and he has previously had an infrarenal aortic aneurysm repair and a lowered thoracoabdominal aneurysm repair. He is undergoing carotid subclavian bypass to decrease the chances of paraplegia with the other procedure. Past Medical History: CAD, HTN, MI, Bladder CA, GERD PSH: s/p CCY, cataract, CABG, AAA repair '[**15**], prostatectomy, hernia Social History: Pos hx smoking / quit [**2104**] Pos alcohol 2 per day Family History: Non contributary Physical Exam: PE: AFVSS NEURO: PERRL / EOMI MAE equally Answers simple commands Neg pronator drift Sensation intact to ST 2 plus DTR Neg Babinski HEENT: NCAT Neg lesions nares, oral pharnyx, auditory Supple / FAROM neg lyphandopathy, supra clavicular nodes LUNGS: CTA b/l CARDIAC: RRR without murmers ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness EXT: rle - palp fem, [**Doctor Last Name **], pt, dp lle - palp fem, [**Doctor Last Name **], pt, dp Pertinent Results: Wet Read Audit # 1 PXDb SUN [**2131-6-3**] 9:05 PM New LLL opacity, could be a combination of effusion, atelectasis and pneumonia. Clear right lung. Stable post surgical changes, Intervale extubation and removal of the NG tube [**2131-6-4**] 06:05AM BLOOD WBC-7.4 RBC-3.15* Hgb-9.2* Hct-27.7* MCV-88 MCH-29.3 MCHC-33.4 RDW-14.4 Plt Ct-181 [**2131-6-3**] 04:00AM BLOOD PT-12.7 PTT-34.4 INR(PT)-1.1 [**2131-6-4**] 06:05AM BLOOD Glucose-98 UreaN-25* Creat-1.7* Na-141 K-4.6 Cl-109* HCO3-24 AnGap-13 [**2131-6-4**] 06:05AM BLOOD Calcium-8.3* Phos-2.1* Mg-2.0 [**2131-6-3**] 06:17PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007 URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG URINE RBC-0-2 WBC-[**4-5**] Bacteri-FEW Yeast-NONE Epi-0-2 TransE-0-2 Brief Hospital Course: Mr. [**Known lastname **],[**Known firstname 24972**] was admitted on [**5-29**] with TAA. He agreed to have an elective surgery. Pre-operatively, she/he was consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were obtained, all other preperations were made. This is joint operation with Dr [**Last Name (STitle) 914**] for Cardiac Surgery. It was decided that she would undergo a TAG with left subclavian to carotid artery BPG. Pt with Lumbar drain. He was admitted the night before because of his CRF with a baseline creatinine of 1.7. On DC his creatinine is 1.6, He was prehydrated with PO mucomyst and IV Sodium Bicarbonate. He was prepped, and brought down to the operating room for surgery. Intra-operatively, he was closely monitored and remained hemodynamically stable. He tolerated the procedure well without any difficulty or complication. Post-operatively, he was transferred to the CVICU for further stabilization and monitoring. POD # 1 He was immediatly extubated. He did recieve post operative PO Mucomyst and IV Sodium Bicarbonante. HCT on arrival stable. Creatinine was stable. His neo was weaned. Pt kept bedrest. POD # 2 Lumbar drain removed, remained neurologically intact. SBP remained high treated with IV hydralazine. Foley remained in place with good urine output. 02 weaned to 2L. Treated with humulog SSI. Good pain control. Encouraged IS support. Transfered to the VICU. While in the VICU he recieved monitered care. When stable he was delined. His diet was advanced. A PT consult was obtained. POD # 3 PT consulted. Cleared PT for home without serivices. Pt went into rapid Afib to 130's. Hemodynamically stable without sequele. Lopressor did not work, Started on Dilt drip. Pt r/o for MI. POD # 4 Converted to NSR, Dilt drip weaned. Recieved Lasix for fluid overload. Had good responce with adaquate uop. He was stabalized from the acute setting of post operative care, he was transfered to floor status POD # 5 febrile, pan cultured. CXR shows LLL PNA, cx'x negative. PO levoquin started. Creat stable. Pt stable for DC On the floor, he remained hemodynamically stable with his pain controlled. He progressed with physical therapy to improve her strength and mobility. He continues to make steady progress without any incidents. He was discharged home in stable condition. To note his coumadin was started on DC. His PCP to [**Name9 (PRE) **] INR in the usual manner. Medications on Admission: ASA 81, lipitor 20, Coreg 3.125, coumadin 2.5 6d/wk, 3 1d/wk, diovan 80, MVI Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for fever: prn. 7. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed: prn. Disp:*30 Tablet(s)* Refills:*0* 9. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 10. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-2**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. Disp:*1 Polyvinyl Alcohol-Povidone (Ophthalmic) 1.4-0.6 %* Refills:*0* 11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain for 10 days: prn. Disp:*30 Tablet(s)* Refills:*0* 12. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: Have your INR checked in the usual manner. Goal INR is [**3-6**]. Discharge Disposition: Home Discharge Diagnosis: Descending thoracic aortic aneurysm Pneumonia LLL Afib PMH: CAD, HTN, MI, Bladder ca, GERD . PSH: Thoracoabdominal AAA repair c supraceliac clamp [**2127-11-26**], s/p CCY, cataract, CABG, AAA repair '[**15**], prostatectomy, hernia Discharge Condition: Good Discharge Instructions: Division of Vascular and Endovascular Surgery Endovascular Thoraic Aortic Aneurysm (TAA) Discharge Instructions, with Subclavian Artery to Carotid BPG Medications: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? Do not stop Aspirin unless your Vascular Surgeon instructs you to do so. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [**3-6**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications ?????? Call and schedule an appointment to be seen in [**5-7**] weeks for post procedure check and CTA What to report to office: ?????? Numbness, coldness or pain in lower and or upper extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or incision) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2131-7-2**] 1:20 Call Dr[**Name (NI) 9379**] office ([**Telephone/Fax (1) 1504**]. Schedule an appointment for 4 weeks. You may need a CTA. This is a CAT Scan with contrast. Let the receptionist know that you had a TAG (thoracic aortic graft stent placement). Also let the receptionist know that you have renal failure. You may need to be hydrated with a special medication before you get the CAT Scan. His office will arrange the follow-up and the CAT scan if you need. Completed by:[**2131-6-5**]

[ "585.9", "433.10", "E878.2", "403.90", "444.0", "441.7", "V02.61", "518.5", "V44.6", "427.31", "V58.61", "997.1", "V10.51", "562.10", "412", "V10.46", "V45.81", "V45.79", "530.81" ]

icd9cm

[ [ [] ] ]

[ "39.71", "39.22", "39.73" ]

icd9pcs

[ [ [] ] ]

6603, 6609

2781, 5202

304, 736

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1934, 2758

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240, 266

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1222, 1331

1347, 1404

26,027

127,906

7487

Discharge summary

report

Admission Date: [**2204-12-11**] Discharge Date: [**2204-12-12**] Date of Birth: [**2166-7-13**] Sex: M Service: MEDICINE Allergies: Gabapentin / Trazodone / Codeine Attending:[**First Name3 (LF) 8404**] Chief Complaint: EtOH Withdrawal Major Surgical or Invasive Procedure: None History of Present Illness: 38 M with h/o epilepsy, alcoholism, alcohol withdrawal seizures, and delirium tremens (per pt report). Last drink noon on [**12-11**]. Drinks [**1-14**] gallon alcohol daily. Ran out of money so presented to the emergency department. Reports seizure prior to arrival. Does not recall any of the specifics surronding the seizure though he states that he fell to the ground. He does not remember hitting his head. No one witnessed the event. He was not incontinent to bowel or bladder. Not currently taking any medications for seizures. Reports having [**2-15**] three seizures each month. Denies drinking anti-freeze or anything other than vodka. . In the ED. Initial vitals, 98.5 116 148/97 18 100%. Lab data revealed bicarb of 21 and anion gap of 22. No Imaging. 40mg IV valium and 2 mg IV ativan yet continues to be tremulous and tachycardic (over 3 hours). Given banana bag x one. NS running. Possible scabies. Vitals prior to transfer while patient is walking BP: 200/90 HR: 162 RR: 23 02sat: 98%. . In the ICU the patient is AOx3 and continues to be tremulous Past Medical History: -Small SDH [**4-/2204**] -Alcohol Abuse and polysubstance abuse -Alcohol withdrawal seizure -Epilepsy, since age 14 -Migraines -Bipolar Disorder -Low back pain -Multiple psychiatric hospitalization at [**Hospital1 18**] and [**Doctor First Name 1191**] among others. Per [**Doctor First Name **], multiple suicide attempts and psychiatric hospitalizations -MVA s/p chest tube placement in '[**00**] -In past notes in [**Name (NI) **], pt was also noted to have PTSD, impulse d/o, rage d/o and antisocial personality d/o Family History: Patient is adopted. Physical Exam: VS: Temp: 100.3 BP:150/58 HR:109 RR: 15 O2sat 98% GEN: pleasant, disheveled, tremulous HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: Bilateral Wheezes, No evidence of respiratory distress CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: multiple maculopapular lesions with evidence of excoriations. Multiple lesions on hand appear serpentine in nature. NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. Tremulous. Pertinent Results: Labs on Admission: [**2204-12-12**] 05:05AM BLOOD WBC-8.1# RBC-3.32* Hgb-10.7* Hct-32.0* MCV-96 MCH-32.1* MCHC-33.3 RDW-15.5 Plt Ct-249 [**2204-12-12**] 05:05AM BLOOD Glucose-83 UreaN-11 Creat-0.5 Na-135 K-3.3 Cl-102 HCO3-22 AnGap-14 [**2204-12-12**] 05:05AM BLOOD ALT-23 AST-51* AlkPhos-89 TotBili-0.7 [**2204-12-11**] 07:00PM BLOOD ASA-NEG Ethanol-317* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Brief Hospital Course: 38 M with h/o epilepsy, alcoholism, alcohol withdrawal seizures, and delirium tremens (per pt report) who presents in alcohol withdrawal requesting treatment. . 1. EtOH Withdrawal: Patient presented to the emergency department requesting detox. His last drink was approx 6 hours prior to arrival. He typically drinks [**1-14**] gallon on Vodka daily. His EtOH level on arrival was 317. Tox screen was otherwise negative. Patient became increasingly hypertensive, tachycardic, and tremulous. He was given Ativan 2mg IV and Valium for a total of 40mg IV over 3 hours though he continued to show signs of withdrawal. He was admitted to the ICU Continues and required approx 200mg of Valium over 6 hour period to control his symptoms of withdrawal. He was given a banana bag and started on Thiamine, Folate, and MVT. The morning after discharge the patient left AMA. . 2. Anion Gap Acidosis: Likely starvation versus alcoholic ketoacidosis. Resolved after two liters of IVF. . 3. H/0 Epilepsy: No longer on meds. Reports seizure prior to presentation. Not clear if this was a alcohol withdrawal seizure. Patient was monitored on seizure precautions. AED were not restarted prior to presentation. . 4. Scabies: Patient with evidence of scabies on exam. Contact precautions applied. Treated with both Permethrin and Ivermectin x one. Bendaryl and Sarna as needed for itching. Medications on Admission: None Discharge Medications: Pt encouraged to take Multivitamin, Folate, Thiamine Discharge Disposition: Home Discharge Diagnosis: EtOH Withdrawal Alcoholism Hx of Seizure disorder Discharge Condition: Stable, Ambulatory Discharge Instructions: Pt left AMA. Followup Instructions: Pt encouraged to follow up with primary care physician and discuss alcoholism and options for detox. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 8405**]

[ "303.01", "291.81", "724.2", "296.80", "276.2", "133.0", "345.90" ]

icd9cm

[ [ [] ] ]

[ "94.62" ]

icd9pcs

[ [ [] ] ]

4615, 4621

3112, 4483

311, 317

4714, 4734

2685, 2690

4795, 4990

1973, 1994

4538, 4592

4642, 4693

4509, 4515

4758, 4772

2009, 2666

256, 273

345, 1414

2704, 3089

1436, 1957

29,275

123,851

32006+32007+57776

Discharge summary

report+report+addendum

Admission Date: [**2154-9-1**] Discharge Date: [**2154-9-6**] Date of Birth: [**2113-7-31**] Sex: M Service: PSYCHIATRY Allergies: Penicillins Attending:[**First Name3 (LF) 2448**] Chief Complaint: "I am waiting for the [**Hospital1 1474**] police" Major Surgical or Invasive Procedure: none History of Present Illness: 41 yo male with schizoaffective disorder s/p serious SA via Excedrin OD earlier in [**Month (only) **] with subsequent 2 week hospitalization at [**Hospital1 1774**] (including ICU stay with intubation, subsequent VAP)transferred from medicine for further evaluation and stabilization. Pt was discharged from [**Hospital1 1774**] to [**Hospital1 36497**] but stayed only one day as he was sent to [**Hospital1 18**] for evaluation of diaphoresis and tachycardia. Past Medical History: - s/p SA via Excedrin OD -GERD -OSA on CPAP 11/5 -bipolar disorder with psychotic features versus schizoaffective, characterized by history of psychosis many years ago; more recently, per Dr [**Name (NI) 12982**], pt's decompensations characterized by depression and delusional thinking -recently stable on Abilify, Depakote, and Ativan; previous trials of clozaril -[**9-16**] past hospitalizations, last many years ago -one previous SA by OD on ASA -no SIB -GERD -OSA (on CPAP) Social History: -born in [**Location (un) 8985**], close with parents, school through high school, worked most recently as [**Doctor Last Name **] driver for [**Hospital3 **] facility -wife and two daughters, ages 4 and 10, denies marital strife -minimal debt, lives in section 8 housing Family History: no known substance abuse Pts wife with bipolar disorder, daughter with bipolar disorder, other daugher with ADD Physical Exam: please see resident exam Pertinent Results: [**2154-9-1**] 06:30PM TSH-6.4* [**2154-9-1**] 06:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2154-9-1**] 06:15AM GLUCOSE-97 UREA N-16 CREAT-1.0 SODIUM-141 POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-28 ANION GAP-15 [**2154-9-1**] 06:15AM CK(CPK)-76 [**2154-9-1**] 06:15AM LIPASE-115* [**2154-9-1**] 06:15AM WBC-9.4 RBC-4.12* HGB-12.2* HCT-36.8* MCV-89 MCH-29.6 MCHC-33.2 RDW-15.3 [**2154-9-1**] 06:15AM PLT COUNT-586* [**2154-8-31**] 07:00AM GLUCOSE-98 UREA N-15 CREAT-1.1 SODIUM-142 POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-30 ANION GAP-12 [**2154-8-31**] 07:00AM WBC-9.8 RBC-4.12* HGB-12.1* HCT-36.7* MCV-89 MCH-29.3 MCHC-32.9 RDW-15.2 [**2154-8-31**] 07:00AM PLT COUNT-647* Brief Hospital Course: Pt accepted as transfer from medicine for further evalution of his mood disorder and psychiatric stabilization s/p Tylenol OD. On [**9-6**], pt had episode concerning for seizure, and was transferred to medicine for further evaluation. Medications on Admission: please see OMR Discharge Medications: please see POE Discharge Disposition: Extended Care Facility: Medical Service [**Hospital1 18**] Discharge Diagnosis: Axis I - Axis II - deferred Axis III - rule out seizure disorder, recent Tylenol overdose, Obstructive sleep apnea, Gastrointestinal reflux disease Discharge Condition: pt transferred to medicine Discharge Instructions: pt transferred to medicine Followup Instructions: pt transferred to medicine [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2461**] Completed by:[**2155-12-25**] Admission Date: [**2154-9-6**] Discharge Date: [**2154-9-9**] Date of Birth: [**2113-7-31**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2297**] Chief Complaint: recent hospitalization with exedrin OD presents from psych S/P possible seizure event. Major Surgical or Invasive Procedure: none History of Present Illness: 41 yo male w/ hx of bipolar d/o, schizoaffective d/o admitted to [**Hospital1 **] 4 following recent suicide attempt (excedrin OD). Patient had been hospitalized in the MICU at [**Hospital1 1774**] following ingestion. He received NAC and LFTs normalized. On [**8-27**] patient was transferred to [**Hospital1 **] (inpatient psychiatry) and continues to have chills, sweats and an elevated WBC. (11.9). Pt had been afebrile, denies cough, SOB, N/V, abdominal pain, headache or urinary frequency/dysuria. . Pt was initially admitted to the medical service for workup of leukocytosis and mental status changes. Psychiatry and neurology were consulted. Pt's infectious workup has been completely negative thus far including negative blood cultures, urine cx and LP. Pt has ongoing language difficulties and memory problems. Pt was transferred to the pyschiatry inpatient service for ongoing depression and suicidal ideation. Evaluated by Med consult on [**9-3**] for ongoing increased WBC which resolved on recheck and low grade fevers (99s). Seen on [**9-6**] am for L sided CP, EKG done and during this time developed movemments suggestive of seizure with head turned to right, eyes closed, muscle rigidity, and non-rhythmic leg and arm movements. CP was felt to be consistent with GERD. Neuro did EEG which was negative for epileptiform and felt that it was a pseudoseizure. Code blue called at 6:30pm and MICU team responded. Apparently, patient stood up with food tray, made rhythmic arm movements, got down to all fours, then laid down with rhythmic movments and rigidity. This was followed by a period of decreased responsiveness. He received 6mg total Ativan IM. Vitals during were BP of 149/70, HR in 100s, O2sat of 100% on NRB and FS of 170. No head trauma was noted during this event. He was then transferred to the MICU for further care. Past Medical History: -Bipolar vs. Schizoaffective d/o with depression and delusional thinking -Many past psych hospitalizations and on previous SA by OD on ASA -GERD -OSA on CPAP 11/5 Social History: Pt is currently living in an apt in [**Location (un) 8985**] with his wife and children. Pt last worked as a [**Doctor Last Name **] driver 2 years ago. Pt reports history of alcohol abuse but states he has been sober for more than 10 years. He denies any abuse of other illicit substances or abuse of prescription medications. Denies any history of withdrawal seizures. Family History: Pts wife with bipolar disorder, daughter with bipolar disorder, other daugher with ADD . Physical Exam: PE: 99.1 80 139/86 RR 12 98% on RA Gen: sleepy but arousable, AOx3 HEENT: PERRL, EOMI, MMM CV: RRR, no MRGs appreciated Resp: CTAB Abd: soft, NT/ND, +BS, no HSM or masses appreciated Ext: no cyanosis, no edema Pertinent Results: [**2154-9-7**] 02:49AM BLOOD WBC-8.3 RBC-3.82* Hgb-11.2* Hct-33.9* MCV-89 MCH-29.3 MCHC-33.1 RDW-15.4 Plt Ct-352 [**2154-9-6**] 06:25PM BLOOD Neuts-65.4 Lymphs-28.7 Monos-5.4 Eos-0.3 Baso-0.1 [**2154-9-7**] 02:49AM BLOOD Plt Ct-352 [**2154-9-6**] 06:25PM BLOOD PT-12.8 PTT-23.4 INR(PT)-1.1 [**2154-9-7**] 02:49AM BLOOD ESR-PND [**2154-9-7**] 02:49AM BLOOD Glucose-103 UreaN-10 Creat-1.0 Na-139 K-3.5 Cl-104 HCO3-26 AnGap-13 [**2154-9-7**] 02:49AM BLOOD CK(CPK)-161 [**2154-9-6**] 06:25PM BLOOD ALT-15 AST-15 LD(LDH)-176 AlkPhos-43 Amylase-50 TotBili-0.3 [**2154-9-6**] 05:41PM BLOOD ALT-17 AST-19 LD(LDH)-234 CK(CPK)-201* AlkPhos-52 TotBili-0.3 [**2154-9-6**] 11:00AM BLOOD ALT-16 AST-14 CK(CPK)-152 AlkPhos-43 Amylase-42 TotBili-0.4 [**2154-9-6**] 06:25PM BLOOD Lipase-45 [**2154-9-7**] 02:49AM BLOOD CK-MB-4 cTropnT-0.01 [**2154-9-6**] 05:41PM BLOOD CK-MB-4 cTropnT-<0.01 [**2154-9-6**] 11:00AM BLOOD CK-MB-4 cTropnT-<0.01 [**2154-9-7**] 02:49AM BLOOD Calcium-9.0 Phos-4.9* Mg-2.4 [**2154-9-6**] 06:25PM BLOOD TSH-3.6 [**2154-9-6**] 05:41PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . EEG: IMPRESSION: This is a normal EEG in the awake state. Note is incidentally made of rapid eye blinking; no evidence of an epileptic or seizure correlate was seen with this. INTERPRETED BY: [**Last Name (LF) **],[**First Name3 (LF) 7495**] B. . RADIOLOGY Final Report CT HEAD W/O CONTRAST FINDINGS: There is no evidence of intracranial hemorrhage, mass effect, or shift of normally midline structures. [**Doctor Last Name **]-white matter differentiation is preserved. There is no acute major vascular territorial infarction. The ventricles are normal in size and symmetric. There is complete opacification of the left maxillary sinus and moderate opacification of the ethmoid sinuses as demonstrated on prior MRI. IMPRESSION: No evidence of intracranial hemorrhage or mass effect. Maxillary and ethmoid sinus disease. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10270**] DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**] Brief Hospital Course: A/P: 41 yo male with hx of bipolar/schizoaffective d/o with recent hospitalization with exedrin OD presents from psych S/P possible seizure event. Neurology feels they are consistent with pseudoseizures. . # Seizures - Felt likely to be pseudoseizures with negative EEG and presentation very atypical. Reassuring with negative LP during this admission. - EEG done and shows no evidence of focal seizure activity or abnormal brain wave activity - CT head done and shows no evidence of bleed, shift, or mass -> wnl - Complete infectious work up with blood/urine cx and CXR -> negative to date - Neuro consult following -> and feel pt. presenting pseudoseizure activity . # Hx of elevated WBC and low grade fevers. Not currently present. - Infectious work-up negative to date - Seen by the [**Female First Name (un) 1634**] med consult as well -> no leukocytosis on repeat labs and no true fevers - Culture if spikes - No need for further LP as already done this admission and pt. with no additional complaints . # Psych-Well controlled with no SI/HI now. Will need sitter has hx of SI. - Con't clozaril 50mg PO QHS. - Psych consult -> eval this morning ([**2154-9-7**]) and note indicates that once pt. has been cleared by MICU team (and he has been) he is safe for transfer back to [**Hospital1 **] 4. . # CP - Felt to be non-cardiac, related to GERD. EKG with no ischemic changes. - three sets of cardiac enzymes negative - Maalox PRN . # FEN - Cardiac Diet . # Access - PIV x2 . # Proph - Hep SC TID . # Code - Full Code . # Contact - [**Telephone/Fax (1) 74974**] [**Name (NI) **] (Wife) . # Dispo - Pt. has been cleared medically by primary team in ICU and psych resident has evaluated patient and deemed him appropriate for transfer back to [**Hospital1 **] 4. Medications on Admission: Medications on Tx: Clozaril 50mg PO QHS Haldol 5mg IM/IV PRN agitation Cogentin 1mg IM/IV PRN with haldol Colace 100mg PO BID [**Name (NI) 10687**] PRN MOM PRN Discharge Medications: 1. [**Name (NI) 10687**] 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Haloperidol 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for agitation. 4. Benztropine 1 mg Tablet Sig: One (1) Tablet PO PRN (as needed). 5. Clozapine 25 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 8. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 9. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 10. Lorazepam 1 mg IV Q4H:PRN Seizure >2min Discharge Disposition: Extended Care Discharge Diagnosis: - pseudoseizure - GERD - history of Bipolar vs. Schizoaffective d/o with depression and delusional thinking - Many past psych hospitalizations and on previous SA by OD on ASA -OSA on CPAP 11/5 Discharge Condition: good Discharge Instructions: - you may eat - you may shower - you will be transferred to [**Hospital1 **] 4 - an inpatient psych facility - to continue your psych care - [**Name8 (MD) 138**] MD or return to ED if T>101.5, chills, nausea, vomiting, chest pain, shortness of breath, seizure like activity, or any other concern Followup Instructions: - you will need to follow-up with your primary care physician within one week of your discharge from [**Hospital1 **] 4 Name: [**Known lastname 12345**],[**Known firstname **] Unit No: [**Numeric Identifier 12346**] Admission Date: [**2154-9-6**] Discharge Date: [**2154-9-9**] Date of Birth: [**2113-7-31**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 8964**] Addendum: Pt. was called out to [**Hospital1 **] 4. At approx 1452 started his shaking. Patient was tremulous in bilateral upper extremities, eyes closed tightly, and rolling head from side to side. This lasted about 10 min and pt. received 2mg ativan. Through much discussion with psych and neurology it was decided to place the patient on 24 hour eeg monitoring. At this point the pt. no longer needed IUC level care and was called out to the floor. . Just prior to transfer at approx 2200 the pt. began getting violent with the nursing staff and sitter. He was throwing punches and refusing to cooperate with having anyone touch him or his bed. He said he was refusing to leave the MICU - wanting his wishes respected of 'sleeping in this bed, taking his medication, and be awoken at 7:07 and greeted by his doctors. When the patient was told he no longer had critical care issues requiring an ICU bed (2214) -> he rolled his head back, shut his eyes, and began bilateral upper extremity shaking. . He was then transferred to the medicine service where he had a 24 hour EEG monitor placed. No seizure activity was recorded corresponding to patient's shaking episodes. He received Ativan for his shaking episodes. Neurology was consulted and felt that the patient most likely had pseudoseizures. . [**Name (NI) **] wife called the medicine team multiple times, with threats of "filing a report" against the medical team. She stated that she was afraid that her husband would be attacked by another patient despite multiple reiterations that her husband had a one-to-one sitter and therefore was unlikely to be attacked by a patient or staff. . Patient was felt to be safe to transfer back to psychiatry without any active medical issues. Discharge Disposition: Extended Care [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8968**] MD, [**MD Number(3) 8969**] Completed by:[**2154-9-9**]

[ "473.9", "V11.3", "327.23", "530.81", "300.11", "295.70", "296.80", "V17.0" ]

icd9cm

[ [ [] ] ]

[ "89.19", "89.14" ]

icd9pcs

[ [ [] ] ]

14471, 14643

8789, 10556

3762, 3768

11894, 11901

6575, 8766

12245, 14448

6238, 6329

10767, 11619

11678, 11873

10582, 10744

11925, 12222

6344, 6556

3636, 3724

3796, 5646

5668, 5833

5849, 6222

32,303

142,036

20989

Discharge summary

report

Admission Date: [**2168-9-15**] Discharge Date: [**2168-9-20**] Date of Birth: [**2117-4-25**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7223**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac catheterization and coronary stenting History of Present Illness: 51 y/o obese M w/ significant PMH of sleep apnea, HTN, CAD, s/p recent inferior STEMI, catheterization w/no [**First Name3 (LF) **], discharged on cardiac cocktail of Asprin, Plavix, B-blocker and statin 2 days ago from [**Hospital1 18**], was admitted to [**Location (un) 620**] early this morning with chest pain. Chest pain characterized as constant, substernal tightness, [**4-5**] with radiation to R & L arm with associated symptoms of diaphoresis. No SOB, palpitations or lightheadness. Reports compliance to prescribed meds with no recreational or OTC drug use. Vitals in [**Location (un) 620**] ER T 99.5, P 78, BP 156/69, RR 16, SaO2 92 on 3L. EKG noted for Hyperacute T waves in anterolateral leads. Given 2 units of SL Nitro for relief and started on Heparin, [**Location (un) **] and Lopressor and home dose of plavix 75mg. Then transferred to [**Hospital1 18**] for cardiac catheterization . In [**Hospital1 18**] cath lab, pt's LAD was noted to have diffuse disease with mid vessel thrombosis and distal stenosis of 90%. Following distal LAD taxus [**Hospital1 **], the proximal LAD sufferd a spiral dissection [**1-29**] guide-wire retraction. Pt then recieved a combination of BM & taxus stents throughout LAD with a final count of 6, over an extended Flouro course > 100 mins. Following procedure, patient noted to have large L-sided hematoma [**1-29**] to catheterization (Hct dropped from 40-36). . During prior admission at [**Hospital1 18**] ([**Date range (1) 55766**]) Pt was found to have Inferior STEMI, Cathed, no significant occlusion was noted, however procedure complicated by an iatrogenic proximal RCA dissection. Althought, ultimaltly, no significant disturbance in RCA Flow, no stents were placed. [**Hospital 1094**] hospital course also complicated by coffee ground emesis of unknown etiology that resolved w/ cessation of integralin and heparin. He was eval. by GI, who felt intervention was not indicated. Pt also suffered multiple episodes of hypotension that responded adequately to fluid and hypoxia that improved with an O2 facemask at 10L. . On review of symptoms, pt (+) for orthopnea of 3 pillows, PND when off CPAP, sleeps on back w/ no preference of position. He denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: HTN, dx 6 y/a, on b-blocker Diastolic CHF, (possible HOCM) dx 6 y/a, on lasix Asthma, on singular and antihistamine Chronic back pain BPH Obstructive sleep apnea, dx 6 y/a, on home CPAP congenital mild mental retardation? (per PCP) COPD per PCP, [**Name10 (NameIs) **] [**Name11 (NameIs) 11149**] available, also has elements of restrictive disease secondary to obesity cerebral palsy depression, on celexa s/p MVA in [**2161**]--c/b heart failure and mechanical ventilation **unclear if pt has h/o murmur--PCP describes [**Name9 (PRE) 1105**]/VI systolic murmur at base on some visit notes back to [**2165**], but no murmur noted on PCP's exam [**2168-6-26**] Social History: - Currently No Tobacco or Alcohol use, quit both 20yrs ago - Prior use: Tobacco (24 pack years), Alcohol (max: 1 case(24 beers), or liter of vodka per day for 12 years) - Lives in [**Location 620**] w/ brother and brother's partner - Exercise: minimal - Employment: adult care worker in [**Location (un) 620**] at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Workshop Family History: - Mother: aortic aneurysm died in 50s - Father: [**Name (NI) 19917**] Disease, aortic anuerysm w/ clips, quadruple bypass surgery > 50, alive in 80s Physical Exam: VS: T 98.3 , BP 110/71 , HR 72, RR 14, O2 94% on Gen: obese middle aged male in with labored resp on oxygen mask. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: Sclera anicteric. EOMI with resting nystamus, weak palpebral muscles. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple, unable to appreciate JVP CV: RR with early systolic murmur best heard in R 2nd intercostal space. Chest: rotund chest wall, with no apparent scoliosis or kyphosis. scattered crackles & wheezes Abd: Obese, soft, NTND, No HSM, tenderness in L lower quadrent, with no rebound tenderness, rigidity or fluid wave. Left groin Hematoma (6x4 cm), 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; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: EKG (following cath) -Rate 80, NSR, artifact in baseline, resolution of hyperacute T waves . CT CHEST [**2168-9-12**] 1. No central pulmonary embolism or aortic dissection detected. 2. Near-complete collapse of the left lower lobe and atelectasis at the right lung base above elevated right hemidiaphragm. There is a probable small amount of mucus in the left mainstem pulmonary bronchus. No definite endobronchial lesions detected. Correlate clinically and with follow up or bronchoscopic evaluation if clinically indicated. 3. Enlarged main pulmonary artery consistent with pulmonary artery hypertension. 4. Cardiomegaly 5. Small pericardial effusion. . Trans-Thoracic Echo on [**2168-9-13**] demonstrated: -IMPRESSION: Focused study for patent foramen ovale: No ASD/PFO present via color Doppler, or saline administration. Moderate pericarial effusion located posterior to the inferolateral wall. Mild resting [**Year (4 digits) 55767**] gradient that increases with Valsalva manuever. Mild MV leaflet thicking w/ [**Male First Name (un) **], no MR. [**Name14 (STitle) 55768**] with the prior study (images reviewed) of [**2168-9-7**], [**Year (4 digits) 55767**] gradient is lower and pericardial effusion is new. . TTE [**2168-9-7**] The left atrium is moderately dilated. The left atrium is elongated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is basal to mid inferior hypokinesis (the remaining segmetns are hyperdynamic). The overall left ventricular systolic function is preserved (LVEF>55%). There is a severe resting left ventricular outflow tract obstruction. No mid-cavitary gradient is identified. There is no ventricular septal defect. The remaining left ventricular segments contract normally. Right ventricular chamber size and free wall motion are normal. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is systolic anterior motion of the mitral valve leaflets. Moderate to severe (3+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. . IMPRESSION: Small pericardial effusion without tamponade. LVH with valvular [**Male First Name (un) **] and severe, rtesting [**Male First Name (un) 55767**] obstruction c/w hypertrophic/obstructive cardiomyopathy. Moderate to severe mitral regurgitaiton. . CARDIAC CATH ([**2168-9-6**]) for Inferior STEMI - 1. Coronary artery disease involving non-dominant RCA, likely proximal LPDA stenosis, and possible OM and mid LAD mild stenoses. - 2. Iatrogenic dissection of the non-dominant RCA without compromise of the lumen or flow with possible distal emobolization or additional dissection in AM1. - 3. Severe left ventricular diastolic heart failure. . CARDIAC CATH ([**2168-9-15**]) for Anterolateral Hyperacute T waves pending . LABORATORY DATA: . [**2168-9-15**] - 10:19AM----CK: 794 MB: 50 MBI: 6.3 Trop-T: 1.14 01:33PM----CK: 1556 MB: 105 MBI: 6.7 Trop-T: 7.9 . [**2168-9-15**] Na 139 Cl 98 BUN 7 Glu 160 AGap=9 K 3.9 CO2 36 Cr 0.6 estGFR: >75 Ca: 8.6 Mg: 2.3 P: 3.4 . WBC 10.3 N:89.2 L:7.0 M:3.2 E:0.5 Bas:0.1 HGB 12.4 HCT 36.8 PLT 240 PT: 27.1 PTT: 79.6 INR: 2.8 Brief Hospital Course: 51M with h/o sleep apnea on home O2, recent CCU admission for inferior STEMI c/b iatrogenic RCA dissection readmitted with recurrent chest pain, s/p LAD stenting c/b dissection . Ischemia: STEMI on [**9-6**] with cath complicated by RCA dissection. He had a recath on [**9-15**] with LAD dissection for which he was stented with Taxus stents x 2 and one bare metal [**Month/Year (2) **] all to LAD. Two days later, on [**9-17**], pt had CP and new TWI in V2-6, so had emergent repeat cath which showed stable dissection of LMCA and otherwise patent flow. He was continued on [**Month/Year (2) **] 325, Lipitor 80mg, Plavix 150, BB was titrated up to Toprol 150 on discharge. . CHF: Chronic, diastolic CHF with possible hypertrophic obstructive cardiomyopathy, preserved systolic function (EF 50-55%) w/ systolic anterior motion of MV, 2+ MR [**First Name (Titles) **] [**Last Name (Titles) 55767**] peak gradient of 60mmHg. He was treated with BB and discharged with cardiac MR for further w/u for possible HOCM. . Rhythm: 30-40 beats of non-sustained Ventricular Tachycardia on his previous admission. Electrophysiology was consulted at the time, and advised that the patient have a Lifewatch monitor upon discharge. The patient had no further episodes of VTach on this admission. He was discharged with a cardiac monitor. . Sleep Apnea: [**1-29**] intrinsic lung dieseae: COPD, and restrictive disease from obesity and cerebral palsy, he was continued on inhalers and started on CPAP. Medications on Admission: Plavix 25 Atorovastin 80 Furosemide 20 Toprol XL 50 Singular Celexa [**Doctor First Name **] [**Doctor First Name **] 325 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: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 5. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 7. Montelukast 10 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 8. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Coronary artery disease Discharge Condition: Stable Discharge Instructions: You were admitted with chest pain. You had a cardiac catheterization and had stents to your coronary arteries. You were also started on medications for your heart. Please resume all of your medications as directed. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet If you have any of the following symptoms, you should return to the ED or see your PCP: [**Name10 (NameIs) **] pain, difficulty breathing, palpitations, or any other serious concerns. Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 20111**] & DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2168-9-20**] 10:45 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD Phone:[**Telephone/Fax (1) 2386**] Date/Time:[**2168-10-10**] 9:20 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2168-12-13**] 1:00 You will be contact[**Name (NI) **] at home for your heart monitor. Completed by:[**2168-11-14**]

[ "V45.82", "401.9", "410.42", "427.0", "428.0", "327.23", "278.00", "600.00", "343.9", "425.4", "428.30", "998.12", "414.01", "311", "493.20", "998.2" ]

icd9cm

[ [ [] ] ]

[ "36.06", "36.07", "88.56", "00.66", "00.40", "37.22", "00.46" ]

icd9pcs

[ [ [] ] ]

11103, 11161

8506, 10001

326, 373

11237, 11246

5142, 8483

11798, 12378

4045, 4196

10174, 11080

11182, 11216

10027, 10151

11270, 11775

4211, 5123

276, 288

401, 2937

2959, 3622

3638, 4029

7,686

166,575

20663

Discharge summary

report

Admission Date: [**2134-4-1**] Discharge Date: [**2134-4-14**] Date of Birth: [**2099-2-7**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 13735**] Chief Complaint: Here for decadron tx for resistent AIDS-related lymphoma. Major Surgical or Invasive Procedure: None. History of Present Illness: 35yoM with HIV/AIDS, recently started on HAART, and an aggressive high-grade AIDS-related Burkitt's-like lymphoma (initially presented with a RLQ mass). His tumor has spread to the leptomeninges, and the Pt. has been treated with CODOX-MTX (s/p 2 cycles) alternating with IVAC (s/p 2 cycles). He has had fevers, dehydration, and was found to be orthostatic, anemic and thrombocytopenic. He was admitted for further workup of failure to thrive, including r/o infection (given severe immunocompromise), and possible bm bx to r/o marrow infiltration by tumor. ROS: recent epistaxis, denies fevers, chills, or sweats, no CP, SOB, or nausea. Past Medical History: 1) HIV+: diagnosed [**2123**], started HAART in [**2134-3-3**] 2) AIDS-related Burkitt's-like lymphoma: Diagnosed [**10/2133**] after sx of fever/night sweats and RLQ abd pain CT with large mass medial to the right psoas encasing the right external iliac artery with surrounding adenopathy bx confirmed the diagnosis of AIDS-related Burkitt's-like lymphoma. ChemoRx: 2 cycles CODOX-M + 2 cycles IVAC ([**10-5**] to present) 3) PPD positive at 10 y/o, s/p one year of INH. No pulmonary activity per report. Social History: Pt. has a Master's degree in art, retired teacher at [**Hospital 12706**]. Currently unemployed, lives with his partner, [**Name (NI) **]. Former smoker [**2-1**] ppd x 18 years, minimal current alcohol use. No history IVDA. Family History: GGF with lymphoma. GF with prostate cancer. Parents and brother are alive and healthy. Physical Exam: VS: 97.8 | 121 | 131/73 | 19 | 93% on 4LNC gen: ill-appearing, anxious, NAD, resting in bed. HEENT: PERRL and A, EOM intact, OP clear, dry MM, no JVD, no carotid bruit. neck: no masses, no LAD. CV: RRR, nl s1s2, no murmurs. chest: CTA b/l, no crackles or wheezes. abd: soft, nt/nd, +bs, + hepatomegaly. extr: warm well perfused, 2+ dp pulses, no cyanosis, 1+ LE edema. neuro: a&ox3, cn ii-xii intact; 3/5 strength b/l LE, sensory, coordination, and language grossly non-focal. Pertinent Results: [**2134-4-1**] 05:58PM BLOOD WBC-90.4*# RBC-2.56* Hgb-8.2* Hct-22.0*# MCV-86# MCH-31.9 MCHC-37.2* RDW-18.8* Plt Ct-19*# [**2134-4-1**] 05:58PM BLOOD Neuts-5* Bands-3 Lymphs-3* Monos-0 Eos-1 Baso-0 Atyps-0 Metas-1* Myelos-1* Promyel-1* Other-85* [**2134-4-3**] 03:55AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-1+ Macrocy-NORMAL Microcy-2+ Polychr-NORMAL Spheroc-3+ Ovalocy-1+ [**2134-4-1**] 05:58PM BLOOD PT-18.9* PTT-26.6 INR(PT)-1.8* [**2134-4-1**] 05:58PM BLOOD Plt Smr-RARE Plt Ct-19*# [**2134-4-1**] 05:58PM BLOOD Fibrino-931*# D-Dimer-4114* [**2134-4-2**] 06:07AM BLOOD FDP-80-160* [**2134-4-1**] 05:58PM BLOOD Glucose-131* UreaN-34* Creat-1.5* Na-134 K-3.6 Cl-93* HCO3-21* AnGap-24 [**2134-4-1**] 05:58PM BLOOD ALT-38 AST-134* LD(LDH)-[**Numeric Identifier 55199**]* AlkPhos-187* TotBili-3.3* DirBili-1.4* IndBili-1.9 [**2134-4-1**] 05:58PM BLOOD Albumin-3.2* Calcium-10.7* Phos-3.3 Mg-2.0 UricAcd-8.7* [**2134-4-1**] 05:58PM BLOOD Hapto-346* . CXR: Lung volumes remain low and the infrahilar opacity at the medial aspects of both lung bases could be atelectasis or pneumonia. The upper lungs are clear. There is no pleural effusion or indication of new central adenopathy. Widening of the right paratracheal stripe has been present and without appreciable change since at least [**2133-10-31**]. Tip of the right subclavian line projects over the superior cavoatrial junction. The heart is normal size. There is a suggestion of splenomegaly. . ECG: Sinus tachycardia. Since the previous tracing of [**2134-3-8**] the rate is more rapid. Minor non-specific ST-T wave abnormalities are now noted and may be due in part to the rapid rate. . CT chest [**3-30**]: 1. No pulmonary embolism. 2. Bilateral small pleural effusions. 3. Markedly improved axillary lymphadenopathy. . CT abd/pelvis [**3-30**]: 1. No evidence of abscess. 2. Stable enlarged spleen. 3. Marked interval reduction in previously identified areas of adenopathy with minimal residual soft tissue demonstrated along the right psoas muscle. There are small residual retroperitoneal lymph nodes also noted, though also markedly reduced in size compared to the prior study. 4. Non-specific residual enlarged periportal lymph nodes. . LENI [**3-26**]: No evidence of DVT in the bilateral lower extremities. . TTE [**11-4**]: LV EF 60% No LVH. e:a 1.0, nl RV size/fxn, could not determine PASP, no AS/AR, tr MR, [**2-1**]+TR. Brief Hospital Course: 35yo M w/ high-grade large cell lymphoma who was initially admitted to the [**Hospital Unit Name 153**] for fever, hypotension and pancytopenia. He was given empiric antibiotics - ceftaz, levo, vanc and had been afebrile but continued to have elevated WBC. On further evaluation, it was thought that he may have progressive lymphoma w/ failure on CODOX-MTX (s/p 2 cycles) alternating with IVAC (s/p 2 cycles). Preliminary [**Location (un) 1131**] of peripheral smear suggested high percentage of blasts. Pt decided to be DNR/DNI but consented to experimental chemotherapy (rituxan, cisplatin and daunorubicin) during this admission. lymphoma: Patient has progressive lymphoma with large tumor burden with concern for tumor lysis syndrome (WBC 90K, LDH 20K). He continued to receive allopurinol 900 mg po qd with IV decadron therapy. Pt had adverse rxn to rituxan - hypertensive, rigoring and desat down to 70s. Infusion was stopped, and pt was given benadryl and demerol. He completed cisplatin and daunorubicin treatment the following morning. Despite receiving multiple chemotherapy regimens, his WBC continued to rise, and his peripheral smear showed an increasing percentage of blasts. He was discharged with instructions to have his CBC checked and to follow up with Dr. [**Last Name (STitle) 2148**] within the week. HIV/AIDS: Planned to continue outpt HAART regimen. fevers: Source of infection was unclear; all cultures were negative. LE weakness: This was thought to be a sequellae of systemic fatigue/failure to thrive. Improved over the course of his hospitalization with physical therapy. tachycardia: Pt had persistent tachycardia, and EKG showed a sinus rhythm. Pt was dry on exam, and has preserved EF. Continued maintenance IVF, but his tachycardia did not resolve. renal: Baseline Cr ~1.0, and this increased over his hospital course. anemia/tcp: Transfused for goal Hct>25, plt>10. He had no signs of active bleeding. Ppx: neutropenic precautions, bowel regimen; no heparin as pt had low platelet count. Comm: with pt and partner/HCP [**Name (NI) **] [**Name (NI) 79**]. Code: DNR/DNI. Dispo: to home Medications on Admission: 1. Trimethoprim-Sulfamethoxazole 160-800 mg PO QMOWEFR 2. Allopurinol 300 mg PO DAILY 3. Abacavir 300 mg PO BID 4. Lamivudine 150 mg PO BID 5. Atazanavir 300 mg PO DAILY 6. Ritonavir 100 mg PO DAILY 7. Metoclopramide 10 mg PO QIDACHS 8. Hydromorphone 2 mg PO Q4-6H PRN pain 9. Docusate Sodium 100 mg PO BID Discharge Medications: 1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 2. Abacavir 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Lamivudine 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Atazanavir 100 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 5. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:*30 Tablet(s)* Refills:*2* 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*2* 9. Ibuprofen 400 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed. Tablet(s) 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 11. 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* 12. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 13. Oxycodone 10 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:*2* 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 15. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 16. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). Disp:*600 ML(s)* Refills:*2* 17. Ativan 1 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed. Disp:*30 Tablet(s)* Refills:*0* 18. Promethazine 12.5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours. Disp:*30 Tablet(s)* Refills:*2* 19. Neutra-Phos [**Telephone/Fax (3) 4228**] mg Packet Sig: Two (2) packets PO once a day. Disp:*60 * Refills:*2* 20. Outpatient Lab Work Please check CBC w/ differential and fax results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2148**] at [**Telephone/Fax (1) 1419**]. Discharge Disposition: Home Discharge Diagnosis: Primary: large cell lymphoma s/p chemotherapy w/ daunorubicin and cisplatin febrile neutropenia pancytopenia HIV/AIDS Discharge Condition: stable, breathing comfortably on RA and afebrile Discharge Instructions: Please call Dr. [**Last Name (STitle) 2148**] or go to the ED if you have any fever, chills, weakness, seizures, nausea, vomiting, diarrhea, shortness of breath, chest pain or any other symptoms that are concerning to you. . Make sure to have your blood drawn this week and have the results faxed to Dr.[**Name (NI) 7750**] at [**Telephone/Fax (1) 1419**]. . Please follow up with Dr. [**Last Name (STitle) 2148**] next week at the time listed below. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9561**], M.D. Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2134-4-21**] 1:30 Completed by:[**2134-7-17**]

[ "286.9", "112.0", "200.28", "208.00", "784.7", "284.8", "786.09", "780.6", "593.9", "E933.1", "362.81", "042" ]

icd9cm

[ [ [] ] ]

[ "99.04", "99.05", "99.25" ]

icd9pcs

[ [ [] ] ]

9601, 9607

4849, 6985

373, 380

9769, 9820

2436, 4826

10319, 10503

1836, 1924

7342, 9578

9628, 9748

7011, 7319

9844, 10296

1939, 2417

275, 335

408, 1049

1071, 1578

1594, 1820

13,696

162,258

17721+17722+17723+56881

Discharge summary

report+report+report+addendum

Admission Date: [**2197-5-2**] Discharge Date: [**2197-5-16**] Date of Birth: [**2148-10-22**] Sex: F Service: HISTORY OF PRESENT ILLNESS: This is a 48-year-old female without significant past medical history who was involved in a motor vehicle collision, initially seen at an outside hospital where she was found to be hypotensive. The patient, because of ongoing hemodynamic instability, was transferred emergently to the [**Hospital6 256**] for further evaluation and treatment. The patient was noted to have loss of consciousness at the time of the accident. Her initial GCS was difficult to assess secondary to a language barrier. The patient, on arrival to the [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **], was not intubated. She was found to have an initial blood pressure of 60/40, for which she received crystalloid boluses and 4 units of packed cells. The patient, because of her ongoing hemodynamic instability, was intubated by the anesthesia service. A left subclavian Cordis central line was placed for large bore IV access, and a left femoral A-line was placed. The patient was noted to be insensate and was not moving her lower extremities at that time. Because of this, a spinal cord injury was suspected, and Solu-Medrol bolus was given per protocol, as well as a Solu-Medrol IV drip which was initiated. The patient received, as I said, 4 units of packed cells. Diagnostic peritoneal lavage was performed in the trauma [**Last Name (Titles) **] with return of blood-tinged fluid. Because of this and her ongoing hypotension, the patient was brought to the operating room emergently for exploration. Her initial trauma films included a chest x-ray and a pelvis x-ray which were negative for acute fracture, pneumothorax, or hemothorax. PATIENT'S INITIAL EXAM: Included that the patient was not responsive, and was intubated. The patient's chest was clear to auscultation bilaterally with equal breath sounds. The trachea was noted to be midline. She had a C-collar in place. Cardiac exam was regular rate and rhythm. Her abdomen was soft, but noted to be progressively more distended throughout her initial evaluation. Her pelvis was stable. Neuro exam was notable for no motor or sensation function in the lower extremities. She was moving her upper extremities. Rectal exam was guaiac positive, and was noted to have no rectal tone. INITIAL LABS: Included a white count of 11.6, hematocrit 21.5. The patient's PT was 17, PTT 59, INR 1.9. Platelet count 134. The patient had a UA which was notable for large blood; however, on the micro exam there was only 0-2 RBCs and was otherwise unremarkable. The patient's DPL fluid showed a white count of 267, red blood cell count 78,000 with 73 polys, 12 bands, and 11 lymphs. Her initial chemistries were a sodium of 139, potassium 3.5, chloride 115, bicarb 18, BUN 13, creatinine 0.5, glucose 117. Her initial amylase was 36. Tox screen was noted to be negative. The patient, after being intubated, had an ABG drawn which showed a pH of 7.25, PCO2 39, PO2 268, with a bicarb of 18, and a base excess of -9. Her initial lactate was 1.2. HOSPITAL COURSE: The patient, as mentioned, was brought emergently to the operating room. As this was happening, a neurosurgery consult was obtained. The patient had an exploratory laparotomy which showed a large splenic laceration which required splenectomy to gain control of bleeding. The patient also had a mesenteric injury with some bleeding vessels which were sutured or suture ligated to gain hemostasis. The patient was packed open at that time and was transferred to the ICU with an open abdomen for further resuscitation. Neurosurgery had planned to place [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] during this operation, but due to the patient's coagulopathy that was not done at this time. On arrival to the ICU, further evaluation showed a right wrist deformity, for which orthopedic surgery was consulted. Plain films of the right wrist and entire upper extremity were negative for fractures. Plastic surgery was ultimately consulted and evaluated the patient for possible ligamentous injury for which he was placed in a 30?????? wrist splint, and they recommended follow-up in their clinic when the patient was more stable. Follow-up imaging of the C-spine was ordered by neurosurgery, and the patient had a CT of her entire spine. Findings included bilateral facet fractures at the C5-6 level, left pedicle fracture at C6, C5 spinous process fracture, a grade 2 anterolisthesis of C5 on C6 with significant narrowing of the C5-C6 spinal canal. The L-spine showed right transverse process fractures of L1 through L4. The T-spine without any evidence of fractures. The patient also underwent a CT scan of the head which was negative for intracranial nerve, or fracture. The patient remained in a C-collar on logroll precautions, and again remained on a Solu-Medrol drip for suspected spinal cord injury. The patient was taken back to the operating room on [**2197-5-3**] for a re-exploration, washout of the abdomen, and ultimately closure of the abdomen. The patient again returned to the Intensive Care Unit for further resuscitation and treatment. She remained intubated throughout this time. The patient underwent an MRI of the C-spine to further evaluate her injury, and neurosurgery planned on taking her to the operating room. She did return to the OR on [**2197-5-5**] where she underwent a posterior fusion of C5 through C7 by neurosurgery. She had a significant amount of blood loss during the case of 1.5 liters, and received again multiple transfusions of blood products to resuscitate her. She returned to the ICU with her neck now stabilized and remained essentially hemodynamically stable over the next several days. She completed a course of steroids per protocol. The patient was slowly weaned off of her ventilator support. She received physical therapy and occupational therapy for her spinal cord injury. She was essentially found to be quadriplegic with minimal use of her upper extremities, and no use or sensation of her lower extremities. The patient, postoperatively, was placed on vancomycin for perioperative antibiotic coverage. Towards the end of her hospital stay, she had several days in which she manifested fevers, the etiology of which was unknown. She was started on vancomycin and Levofloxacin prophylactically, and had multiple cultures sent, none of which grew any significant pathogens. She had a couple of sputum samples which had sparse growth of yeast. However, her white count which had been as high as 24 began to trend down, and her fever curve also decreased. She defervesced and has remained afebrile for multiple days. Her antibiotics will be discontinued on discharge. The patient was weaned to minimal support on the ventilator, but was unable to completely wean off. For this reason, she underwent tracheostomy on [**2197-5-12**]. The patient also, during her postoperative course, had a feeding tube and was receiving tube feeds at goal which she continued to tolerate well. The patient's clinical course was fairly unremarkable for the last week or so of her hospital stay. Once the tracheostomy was in place, it was felt that the patient was ready for transfer to an acute neuro rehab facility for her ongoing rehabilitation needs. The patient was also started on Lovenox postoperatively for long-term DVT prophylaxis. Upon discharge, the patient was receiving Lovenox 40 mg subcu qd. She was on a regular insulin sliding scale for which she was not requiring significant doses of insulin. She was on tube feeds and backed with fiber at goal rate of 60 through a Dobbhoff tube which she was tolerating well. The patient was currently on Levaquin and vancomycin which can be discontinued at discharge. She was receiving colace, and she was also receiving topical miconazole and nystatin swish-and-swallow. DISCHARGE DIAGNOSES: 1) Status post motor vehicle collision. 2) She is status post exploratory laparotomy and splenectomy with repair of a mesenteric injury. 3) She is also status post re-exploration and closure of the abdominal wall. 4) C5-6 fracture dislocation, status post C5 through C7 posterior fusion. 5) The patient was also noted to have L1 through L4 transverse process fractures. 6) Respiratory failure, status post tracheostomy. The patient is being discharged to [**Hospital3 **] in stable condition for ongoing physical therapy and rehabilitation. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**] Dictated By:[**Last Name (NamePattern1) 33441**] MEDQUIST36 D: [**2197-5-16**] 10:47 T: [**2197-5-16**] 09:52 JOB#: [**Job Number 49288**] Admission Date: [**2197-5-2**] Discharge Date: [**2197-5-16**] Date of Birth: [**2148-10-22**] Sex: F Service: HISTORY OF PRESENT ILLNESS: This is a 48-year-old female transferred from an outside hospital status post rollover motor vehicle collision at high speed, who was hypotensive at the outside hospital. Transferred to the [**Hospital1 **] for further assessment and management. The patient was noted to have reportedly loss of consciousness at the accident. It is difficult to assess the [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) 2611**] coma score secondary to language barrier. Patient was not intubated on transfer. Her blood pressure was noted to be 60/40 on initial arrival to the Trauma [**Last Name (NamePattern4) **] at the [**Hospital3 **]. The patient was intubated in the Trauma [**Hospital3 **] for airway control. A large-bore IV access was obtained via left subclavian cordis as well as a left femoral A-line. Patient was noted at that time be insensate and not moving the lower extremities, so Solu-Medrol bolus was given per protocol, and a drip was started as well. Patient received 4 units of pack cells in the Trauma [**Hospital3 **]. A diagnostic peritoneal lavage was performed with return of blood-tinged fluid. The patient's initial trauma series of chest x-ray and pelvis x-ray were negative for acute fractures, pneumothorax, but secondary to the patient's hypotension and positive diagnostic peritoneal lavage, the patient was taken straight to the operating room for urgent exploration. PAST MEDICAL AND SURGICAL HISTORIES AND MEDICATIONS: Patient did not have any significant past medical or surgical history, and was not on any known medications at presentation to [**Hospital3 **]. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION: Patient's examination on arrival after initial workup, the patient was unresponsive and intubated. Chest exam was clear to auscultation bilaterally. Her cardiac exam was regular, rate, and rhythm. Her abdomen showed progressive distention during her initial evaluation. Her pelvis exam was stable. Neurologic examination: There is no motor sensation in the lower extremities. She was moving her upper extremities at that time. Rectal exam was shown to be guaiac positive with no rectal tone appreciated. Patient was taken, as previously mentioned, emergently to the operating room for exploration, and was found to have splenic laceration which required splenectomy. She also was found to have a mesenteric injury with some bleeding vessels in the mesentery which were suture-ligated. Patient's bleeding was controlled in this fashion, and the patient was packed with an open abdomen and returned to the Intensive Care Unit for ongoing resuscitation. It was planned to place [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] ventricular drain at the time of operation, however, the patient was found to be coagulopathic, and the drain was not placed at that time. Patient's laboratories on admission included a white count of 11.6, hematocrit of 21.5 with a platelet count of 134. Her coags included a PT of 17, PTT of 59, INR of 1.9. Urinalysis showed large blood, but only 0-2 red blood cells, otherwise was unremarkable. DPL fluid showed 267 white cells, 78,000 red cells with 73 segs, 12 bands, and 11 lymphocytes. Her initial chemistries were a sodium of 139, potassium of 3.5, chloride of 115, bicarb of 18, BUN of 13, with a creatinine of 0.5, and a glucose of 117. Her amylase was 36. Her tox screen was negative. As previously mentioned, the patient had been brought to the operating room, underwent a splenectomy, and repair of a mesenteric injury. Was brought back to the Intensive Care Unit for resuscitation. The patient required multiple transfusions of blood products including packed blood cells, fresh-frozen plasma, cryoprecipitate, and platelets during her resuscitation. Neurosurgery was immediately consulted for her apparent paraplegia on initial exam. Additional films were obtained including a CT scan of the C spine which showed bilateral facet fractures at the C5-C6 level, a left pedicle fracture of C6. A C5 spinous process fracture as well as a grade 2 anterolisthesis of C5 on C6. There is significant narrowing of the neural canal at the C5-C6 level. The patient's L spine showed right transverse process fractures of L1 through L4. The thoracic spine was without any fractures. The patient also underwent a CT scan of the head which was negative for intracranial bleed or skull fracture. The patient was placed on cervical traction by the Neurosurgery team and operative repair of her C5-6 fracture dislocation was planned. After initial resuscitation in the Intensive Care Unit, the patient was taken back to the operating room on [**2197-5-3**] for washout of the abdomen, re-exploration, and ultimately closure of the abdomen. The patient tolerated this well. She remained on a steroid drip per spinal cord injury protocol. The patient remained fairly stable hemodynamically until [**2197-5-5**] when she was taken back to the operating room by the Neurosurgical team for posterior fusion of C5 through C7 to repair her fracture dislocation. She had 1.5 liter blood loss during this operation and again required multiple transfusions of blood products to resuscitate her. She came back again to the Intensive Care Unit, remained intubated throughout this first part of her hospital stay. Over the next several days the patient was weaned down on her ventilatory support. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**] Dictated By:[**Last Name (NamePattern1) 33441**] MEDQUIST36 D: [**2197-5-16**] 10:29 T: [**2197-5-16**] 10:34 JOB#: [**Job Number 49289**] Admission Date: [**2197-5-2**] Discharge Date: [**2197-5-31**] Date of Birth: [**2148-10-22**] Sex: F Service: This is to dictate notable events since the last discharge summary. Patient remained in house for an additional two weeks while rehabilitation placement was arranged. Of note, the patient was given a Psychiatry Consult for question of suicidal ideation. Ultimately, the psychiatrist felt that the patient was not exhibiting any suicidal ideation and did not recommend any additional treatment at this time. The patient was noted to have slowly increasing white blood cell count and routing cultures were sent including sputum. Her sputum grew out Staph aureus, as well as enterobacteria, which is pansensitive. Patient was placed on vancomycin empirically, as well as Levaquin. The patient also had a chest x-ray which showed a left-sided retrocardiac opacity concerning for a pneumonia. The patient was planned to continue course of these antibiotics for seven days to treat this pneumonia. Respiratory status did not deteriorate and she remained saturating well on >.......< collar. An additional event with the patient, she received Roxicet for pain control. She was noted to have several bradycardic episodes into the 40s associated with her doses of Roxicet. Patient remained hemodynamically stable throughout these episodes and the medication was discontinued and Cardiology was called in consultation. The electrophysiologist and cardiologist saw the patient and felt that it may have been medication related or possibly a vagal episode. They did not recommend any additional treatment or did not feel that an electrophysiology evaluation was necessary at this time. Patient essentially remained stable. Despite her slightly white blood cell count, she did not have any fevers. She continued with Physical Therapy and Occupational Therapy as she tolerated and remained on goal tube feeds. The patient underwent a swallow evaluation. She was noted to have episodes of penetration of the vocal cords without overt aspiration and it was recommended that she take only thin liquids at this time, however, the patient had difficulty taking even thin liquids. So, essentially at the time of discharge to rehabilitation, she remains solely on tube feeds, >.......<. DATE OF DISCHARGE: [**2197-5-31**]. MEDICATIONS ON DISCHARGE: Remain the same with the addition of a seven day course of vancomycin, as well as a seven day course of levofloxacin. DISCHARGE CONDITION: Stable. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**] Dictated By:[**Last Name (NamePattern1) 33441**] MEDQUIST36 D: [**2197-5-30**] 03:37 T: [**2197-5-30**] 16:25 JOB#: [**Job Number 49290**] Name: [**Known lastname **], [**Known firstname 9127**] Unit No: [**Numeric Identifier 9128**] Admission Date: [**2197-5-2**] Discharge Date: [**2197-5-16**] Date of Birth: [**2148-10-22**] Sex: F Service: The patient, on the day of discharge, received her vaccines for postsplenectomy prophylaxis of meningococcus, pneumococcus, and H. flu. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 845**], M.D. [**MD Number(1) 846**] Dictated By:[**Last Name (NamePattern1) 7206**] MEDQUIST36 D: [**2197-5-16**] 10:48 T: [**2197-5-16**] 10:52 JOB#: [**Job Number 9129**]

[ "865.03", "482.41", "806.09", "805.4", "286.9", "850.5", "868.03", "518.81", "285.1" ]

icd9cm

[ [ [] ] ]

[ "33.21", "96.04", "41.5", "46.73", "54.62", "96.72", "31.1", "38.91", "96.6", "03.53", "43.11", "81.03", "54.25", "38.93" ]

icd9pcs

[ [ [] ] ]

17264, 18214

8035, 8991

17123, 17242

3195, 8013

10711, 11012

9020, 10688

11037, 17096

53,861

100,783

58358

Discharge summary

addendum

Name: [**Known lastname 441**],[**Known firstname 121**] Unit No: [**Numeric Identifier 14003**] Admission Date: [**2181-12-13**] Discharge Date: [**2181-12-27**] Date of Birth: [**2159-2-18**] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 14004**] Addendum: Please review additions to discharge summary. Chief Complaint: 22 y/o male, right hand dominant, s/p motor vehicle accident at 1pm on [**2181-12-13**] in [**State 4488**], with severe left volar forearm injury. Surgeon in [**State 4488**] repaired radial and ulnar artery with cephalic vein graft. the patient was then transferred to [**Hospital1 **] for definitive management of his left arm injury. Major Surgical or Invasive Procedure: PROCEDURE [**2181-12-15**]: 1. Irrigation and debridement left hand and forearm wound. 2. Open reduction and internal fixation left proximal radius fracture. 3. Over reduction internal fixation left distal ulna fracture. 4. Adjustment external fixator. 5. VAC dressing change. . PROCEDURE [**2181-12-19**]: 1. Extensive debridement, associated with an open fracture of left forearm and hand. 2. Reconstruction left ulnar nerve gap with multi cable sural nerve graft, approximately 9 cm. 3. Partial coverage of left forearm and hand wound with anterolateral thigh flap from the right side with microvascular anastomosis. 4. Split-thickness skin grafting of remaining left forearm wound, greater than 100 cm2. 5. Split-thickness skin grafting less than 100 cm2 of right thigh donor site. History of Present Illness: 22-year-old male who was transported from an outside hospital in [**State 4488**] after a motor vehicle crash. This unfortunate male had a traumatic injury to his left arm after his car hit a telephone pole. He had a degloving injury of part of his left forearm. He was taken directly to an operating room in [**State 4488**] for grafting of his forearm artery secondary to arterial injury. He was transferred here for the remainder of traumatic workup and further care of his arm injury. Past Medical History: Denies . PSH: ORIF R ankle fracture three years ago Social History: 1ppd x 5 yrs, 1 drink EtOH/wk, denies IVDU, + marijuana, admits to using methadone (not prescribed by a clinic). Works driving heavy equipment for a logging company. Family History: N/C Physical Exam: PE [**2181-12-13**]: HR 154 BP 160/100 98%RA left hand with visible deformity at proximal forearm and wrist open surgical wound with ?alloderm on radial/volar aspect of left wrist 2+ nonpitting edema and echymosis throughout left hand. left hand cool to touch sensation intact to pinprick left thumb, insensate other four digits dopplerable radial pulse, ulnar pulse not dopplerable pulse ox wave forms absent in all five digits. Pertinent Results: ADMISSION LABS: [**2181-12-12**] 11:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 [**2181-12-12**] 11:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2181-12-12**] 11:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 418**]-1.014 [**2181-12-12**] 11:00PM FIBRINOGE-225 [**2181-12-12**] 11:00PM PT-13.5* PTT-24.0 INR(PT)-1.5* [**2181-12-12**] 11:00PM PLT COUNT-249 [**2181-12-12**] 11:00PM WBC-18.0* RBC-3.32* HGB-10.7* HCT-29.4* MCV-89 MCH-32.3* MCHC-36.5* RDW-13.2 [**2181-12-12**] 11:00PM URINE bnzodzpn-POS barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-POS [**2181-12-12**] 11:00PM URINE HOURS-RANDOM [**2181-12-12**] 11:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2181-12-12**] 11:00PM LIPASE-15 [**2181-12-12**] 11:00PM UREA N-14 CREAT-1.0 [**2181-12-12**] 11:17PM freeCa-1.06* [**2181-12-12**] 11:17PM GLUCOSE-114* LACTATE-2.1* NA+-140 K+-4.4 CL--109 TCO2-23 [**2181-12-12**] 11:17PM PH-7.35 COMMENTS-GREEN TOP [**2181-12-13**] 03:50AM FIBRINOGE-209 [**2181-12-13**] 03:50AM PT-14.7* PTT-29.1 INR(PT)-1.3* [**2181-12-13**] 03:50AM PLT COUNT-201 [**2181-12-13**] 03:55AM freeCa-1.03* [**2181-12-13**] 03:55AM HGB-7.9* calcHCT-24 O2 SAT-99 [**2181-12-13**] 03:55AM HGB-7.9* calcHCT-24 O2 SAT-99 [**2181-12-13**] 03:55AM GLUCOSE-108* LACTATE-1.8 NA+-137 K+-3.7 CL--112 [**2181-12-13**] 03:55AM TYPE-ART PO2-147* PCO2-32* PH-7.43 TOTAL CO2-22 BASE XS--1 [**2181-12-13**] 05:03AM freeCa-1.25 [**2181-12-13**] 05:03AM HGB-10.1* calcHCT-30 [**2181-12-13**] 05:03AM GLUCOSE-121* LACTATE-2.0 NA+-143 K+-4.3 CL--113* [**2181-12-13**] 05:03AM TYPE-ART PO2-170* PCO2-34* PH-7.44 TOTAL CO2-24 BASE XS-0 INTUBATED-INTUBATED [**2181-12-13**] 06:06AM freeCa-1.16 [**2181-12-13**] 06:06AM HGB-10.1* calcHCT-30 [**2181-12-13**] 06:06AM GLUCOSE-125* LACTATE-2.9* NA+-140 K+-4.3 CL--112 [**2181-12-13**] 06:06AM TYPE-ART PO2-198* PCO2-35 PH-7.42 TOTAL CO2-23 BASE XS-0 INTUBATED-INTUBATED [**2181-12-13**] 10:10AM PTT-26.4 [**2181-12-13**] 10:10AM PLT COUNT-247 [**2181-12-13**] 10:10AM WBC-15.9* RBC-3.28* HGB-10.2* HCT-29.4* MCV-90 MCH-31.2 MCHC-34.8 RDW-13.7 [**2181-12-13**] 10:10AM CALCIUM-8.3* PHOSPHATE-2.8 MAGNESIUM-1.7 [**2181-12-13**] 10:10AM GLUCOSE-159* UREA N-12 CREAT-1.0 SODIUM-144 POTASSIUM-4.2 CHLORIDE-113* TOTAL CO2-21* ANION GAP-14 [**2181-12-13**] 04:08PM PTT-35.7* [**2181-12-13**] 10:00PM PTT-32.9 . RADIOLOGY: Radiology Report TRAUMA #3 (PORT CHEST ONLY) Study Date of [**2181-12-12**] 11:05P IMPRESSION: No lung contusion. No pneumothorax. No displaced rib fracture. . Radiology Report CT C-SPINE W/O CONTRAST Study Date of [**2181-12-12**] 11:26 PM IMPRESSION: No fracture. . Radiology Report CT HEAD W/O CONTRAST Study Date of [**2181-12-12**] 11:26 PM IMPRESSION: No acute intracranial process. . Radiology Report CT TORSO W/CONTRAST Study Date of [**2181-12-12**] 11:27 PM IMPRESSION: No evidence of trauma to the torso on CT. . Radiology Report HAND (AP, LAT & OBLIQUE) LEFT Study Date of [**2181-12-12**] 11:39 PM IMPRESSION: Proximal radial shaft, distal radius and distal ulnar fractures in addition to fractures at the second and third metacarpal bases. . Radiology Report CT UP EXT W/O C Study Date of [**2181-12-16**] 8:24 AM IMPRESSION: 1. Proximal radial and distal ulnar shaft fractures transfixed with plate and screws. 2. Severe comminuted intraarticular fracture of distal radius with impaction. 3. Volar subluxation of the ulna at distal radioulnar joint. 4. Nondisplaced comminuted triquetral fracture. 5. Interarticular fracture through the base of the second metacarpal and possible fracture along the lateral aspect of the base of the third metacarpal bone. 6. Trapezium fracture. 7. Edema and degloving injury over the volar aapect of the forearm. . MICROBIOLOGY: [**2181-12-17**] 2:29 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2181-12-20**]** MRSA SCREEN (Final [**2181-12-20**]): No MRSA isolated. Brief Hospital Course: This patient was admitted to the Plastic Surgery service after sustaining a traumatic left arm injury when involved in a motor vehicle accident in [**State 4488**] on [**2181-12-12**]. . Hospital day #1~[**2181-12-12**] Patient was admitted to the Emergency Department and underwent emergent body imaging upon arrival. . Hospital day #2~[**2181-12-13**] Patient to the operating room with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 81**] for irrigation and debridement of degloving wound left forearm, wound exploration of left forearm, revision and repair laceration, left radial artery, revision and repair laceration left ulnar artery with interposition vein graft left foot, open repair of flexor digitorum superficialis left ring finger, open repair of flexor digitorum superficiality left small finger, open carpal tunnel release, wound VAC dressing placement and external fixation left ulna and radial fractures. Pt was admitted to ICU for close monitoring and to check left hand pulses by pulse oximetry. A heparin drip was started and patient was started on aspirin to maintain patency of blood flow to left upper extremity. Patient was started on gentamicin and unasyn for broad empiric coverage. He was started on dilaudid PCA for pain control but this provided insufficient pain control for the patient so the Acute Pain Service (APS) was consulted and a left axillary block was provided. . Hospital day #3~[**2181-12-14**] Patient received 2units of PRBCs today for a hematocrit drop to 17.9 (29.4 on admission). Pain control continued to be an issue so the axillary block and the PCA doses were increased by APS. Neurontin was also added to pain regimen and ativan was given PRN for periods of anxiety. Patient had symptoms of oral thrush and was given Nystatin swish and swallow. . Hospital day #4~[**2181-12-15**] Patient had a planned procedure in the Operating room with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 81**] for left forearm wound excision & debridement, Open reduction and internal fixation left proximal radius fracture, Over reduction internal fixation left distal ulna fracture, Adjustment of external fixator, and wound VAC dressing change. Patient continued on the dilaudid PCA, left axillary block and neurontin for pain control. He continued with heparin drip and daily aspirin to maintain patency of blood supply to left upper extremity. Patient continued on unasyn. . Hospital day #5 [**2181-12-16**]: Patient having increased difficulty with pain today so APS service added a Ketamine infusion, discontinued the axillary block and started a lumbar plexus infusion with Ropivacaine instead. Patient's pain came under good control. . Hospital day #6 [**2181-12-17**] Wound VAC therapy to left forearm continued. Patient was Transferred from ICU to floor today. . Hospital day #7 [**2181-12-18**] Pain management regimen continued guided by APS. Patient reported diminished relief of pain with dilaudid PCA so he was changed to Morphine PCA and his Ketamine dose was increased. Patient was prepped for operating room in the morning for closure of his left arm wounds. . Hospital day #8 [**2181-12-19**] Patient to operating room today with Dr. [**Last Name (STitle) 81**] for open reduction and internal fixation of comminuted multi-fragment fracture left distal radius, open reduction internal fixation of left proximal ulnar shaft fracture, closed reduction and percutaneous pin fixation of left distal radial ulnar joint, removal of external fixator left forearm and irrigation and debridement of wound left forearm. After this procedure, Dr. [**First Name (STitle) **] [**Name (STitle) 11867**] began the final procedure, this admission, for reconstruction of the left forearm; Extensive debridement, reconstruction left ulnar nerve gap with multi cable sural nerve graft (approximately 9 cm), partial coverage of left forearm and hand wound with anterolateral thigh flap from the right side with microvascular anastomosis, split-thickness skin grafting of remaining left forearm wound (greater than 100 cm2), and split-thickness skin grafting less than 100 cm2 of right thigh donor site. Patient tolerated the procedure well and was transferred to Post Anesthesia Care Unit for recovery. A wound VAC was applied to skin graft sites and flap checks were done, per protocol, to left forearm flap site. Patient was continued on Morphine PCA, ketamine drip, and neurontin post-procedure with good pain control noted. Patient was continued on aspirin therapy. Patient was transferred to the floor when recovery criteria were met. . Hospital day #9 [**2181-12-20**] Patient had PICC placement to right arm today for ongoing IV medications. APS recommended the discontinuation of morphine PCA and restarted dilaudid PCA. Ketamine drip was continued and patient was started on PO methadone. Neurontin was continued. Unasyn was continued. Patient was started on clear liquids. . Hospital day #10 [**2181-12-21**] Patient had his foley catheter discontinued and his diet was advanced to regular today. Flap checks continued. . Hospital day #11 [**2181-12-22**] Patient's IV fluids and dilaudid PCA were discontinued today. Patient was started on PO dilaudid 4-8 mg PO Q3h prn and methadone 40mg PO TID continued. Flap checks continued. Patient continued on Unasyn. . Hospital day #12 [**2181-12-23**] Flap checks were switched to q4. . Hospital day #13 [**2181-12-24**] Patient's skin graft dressings and VAC were taken down today and 100% take of skin grafts was noted. Graft sites were dressed with xeroform, fluffs, with kerlix wrap. Patient had a dorsal orthoplast splint fashioned by Occupational Therapy today that he will wear continuously. Patient had a Psych consult for substance abuse counseling today. . Hospital day #14 [**2181-12-25**] All dressings changed once a day and graft sites and flap remain healthy and patent. Occupational Therapy working with patient on range of motion and strengthening exercises for left upper extremity. Patient was also working with OT on ambulation. . Hospital day #15 [**2181-12-26**] Patient increasing ambulation about the unit, doing well. Father of patient assisting patient with ambulation around the unit multiple times today and learning dressing changes for home. Pain medication management discussed with Psych liaison RN who can assist with future pain medication weaning ([**Location (un) 7749**], [**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] ([**Telephone/Fax (1) 14005**]). She is happy to help with advising about weaning pain meds/methadone when it is time. . Hospital day #16 [**2181-12-27**] Patient prepared for discharge home today. The patient and his father were provided discharge instructions and prescriptions. They provided detailed follow up instructions. Patient's right thigh flap donor site with skin graft reconstruction to remaining defect appeared pink and healthy. Patient's left thigh donor site continued to dry out and was open to air with old drying xeroform intact. Left lower extremity ankle/foot incisions clean/dry/intact with steri-strips in place and no signs of infection. Left arm flap pink and healthy with strong doppler signal. Left forearm skin graft sites remained pink and healthy. PICC line was discontinued. Medications on Admission: Methadone (not clinic prescribed) Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day) for 30 days. Disp:*180 Capsule(s)* Refills:*1* 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours): Max 12/day. Do not exceed 4gms/4000mgs of Tylenol per day. 4. hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for 14 days. Disp:*224 Tablet(s)* Refills:*0* 5. methadone 10 mg Tablet Sig: Four (4) Tablet PO Q8H (every 8 hours) for 14 days. Disp:*168 Tablet(s)* Refills:*0* 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 8. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 9. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 7 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home with Service Discharge Diagnosis: 1. Crush injury with degloving injury left forearm, with associated radius and ulna fractures. 2. Left proximal radius fracture. 3. Left ulnar fracture. 4. Left forearm and hand wound. 5. Left forearm injury with open wound as well as an ulnar nerve gap, status post revascularization and partial reconstruction. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -Please change your skin graft sites (left arm and right thigh) dressings once a day. Dressing changes are as follows: 1) place fresh xeroforms over skin graft sites. 2) place 'fluffed up' gauze over the xeroform 3) Wrap sites with kerlix gauze wrap -Leave left thigh donor site open to air and do not cover with dressing. Let area continue to dry out. -Leave left foot/ankle incisions open to air and leave steri strips in place until they fall off. -Elevate you left arm as much as possible and maintain in your splint. -Practice your left arm range of motion and strenghtening exercises as taught to you by Occupational Therapy. -You MUST walk around at least 4 times or more a day. . Medications: * Resume your regular medications unless instructed otherwise. * You may take your prescribed pain medication for moderate to severe pain. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. Please note that Percocet and Vicodin have Tylenol as an active ingredient so do not take these meds with additional Tylenol. * Take prescription pain medications for pain not relieved by tylenol. * Take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication to prevent constipation. You may use a different over-the-counter stool softerner if you wish. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * You will need to be weaned off of your pain medications and Plastic Surgery and/or your PCP may not be comfortable managing this alone. The Psych Nurse Liaison that you met with in hospital, [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 14006**], RN, would be happy to help assist with this process and can be reached at : ([**Telephone/Fax (1) 14005**]. She has kindly volunteered to help with advising about weaning of your pain meds/methadone when it is time. . Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. Physical Therapy: Per discharge plan. Treatments Frequency: Per discharge plan. Followup Instructions: Please follow up in our HAND CLINIC in two weeks time. Hand Clinic: ([**Telephone/Fax (1) 14007**] [**Hospital Ward Name 600**], [**Hospital Ward Name **] Building, [**Location (un) 457**] Please follow up in the Hand Clinic on Tuesday, [**2182-1-8**]. You must call ([**Telephone/Fax (1) 14007**] to make an appointment. The clinic is open from 8-12pm most Tuesdays. The clinic is located on the [**Hospital Ward Name **], [**Hospital Ward Name **] Building, [**Location (un) 457**]. Please make sure that you obtain a referral from your insurance company prior to your clinic appointment. . Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14008**] office during the week of [**2-11**] (6 weeks from now). [**Telephone/Fax (1) 14009**] office -[**Hospital1 6925**]. Please ask them how you should arrange for follow up xrays for the appointment since you are coming from [**State 4488**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 14010**] MD [**Last Name (un) 14011**] Completed by:[**2181-12-27**]

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icd9cm

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icd9pcs

[ [ [] ] ]

15579, 15598

7047, 14425

839, 1659

15959, 15959

2927, 2927

18652, 19752

2456, 2461

14509, 15556

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16110, 18548

2476, 2908

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2271, 2440

53,850

172,476

4317

Discharge summary

report

Admission Date: [**2166-3-10**] Discharge Date: [**2166-3-15**] Date of Birth: [**2093-8-21**] Sex: M Service: CARDIOTHORACIC Allergies: Zocor / Ciprofloxacin / Quinolones / Statins-Hmg-Coa Reductase Inhibitors / Niacin Attending:[**First Name3 (LF) 165**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2166-3-10**] - 1. Redo sternotomy. 2. Redo coronary artery bypass grafting x3: Left internal mammary artery to left anterior descending artery, saphenous vein grafts to obtuse marginal and posterior descending arteries. 3. Endoscopic harvesting of the long saphenous vein. History of Present Illness: 72 year old male status post CABG and multiple PCIs. His most recent cardiac cath on [**2165-12-24**] showed native three vessel disease with stenosis in the LAD and LCx. During PTCA of the OM1 there was concern for dissection vs perforation and the cath was terminated early. No stents were placed. Echo did not show evidence of pericardial effusion. He was discharged and followed up with Dr [**Last Name (STitle) **] for medical management. Since that time he states he had been feeling well with no change in his symptom of chest heaviness that radiates to his neck and throat after walking 100 ft. which is relieved with rest. One week ago the chest heaviness was worse than usual and he went to the ED at [**Hospital3 **] on [**2166-2-27**]. He was discharged from the ED with plans for repeat cardiac catheterization. Upon cardiac cathererization he was found to have 80% LAD instent restenosis, ostial LMCA 40%, 80% ostial LCx and 80% OMB and is now being referred to cardiac surgery for redo bypass surgery. Past Medical History: Coronary artery disease s/p Coronary artery bypass graft x 2: [**2149**] (RIMA- RCA, SVG- OM) Memory loss after CABG multiple stents placed Peripheral arterial disease Prostate cancer s/p radiation 2 years ago History of pancytopenia Dyslipidemia - unable to tolerate statins, not on any medicine at present GI bleed [**3-6**] r/t Plavix Kidney stones Social History: Lives at home with wife. Denies ETOH or illicit drug use. Former smoker, smoked 1 ppd x 25 years. Disabled since back surgery. Used to work as a carpenter. Family History: Father passed away from CAD at age 49, uncle with CAD age 50. Mother with CVA in her 80's. No other cardiac history. No arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: Pulse:54 Resp:16 O2 sat:97/RA B/P Right:125/61 Left:125/64 Height:5'[**65**].5" Weight:195 lbs General: Skin: Dry [x] intact [x] Well healed mid sternal incision scar HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema trace LE edema Bilateral knee scars - heal healed Varicosities: None [x] Well healed left medial thigh scar Neuro: Grossly intact [x] Pulses: Femoral Right:cath site Left:2+ DP Right:1+ Left:1+ PT [**Name (NI) 167**]:1+ Left:1+ Radial Right:2+ Left:2+ Carotid Bruit Right: none Left: none Discharge Exam: VS: T: 98.2 HR 60-70 SR BP: 117-120/60's RR 2 Sats: 96% RA WT: 89.4 kg General: 72 year-old male in no apparent distress HEENT: normocephalic, muscus membranes moist Card: RRR normal S1,S2 no murmur Resp: clear breath sounds throughout GI: benign Extr: warm Left hand 1+ edema, LLE 2+ edema, Right trace edema Incision: sternal clean dry intact, no erythema or sternal click Neuro: non-focal Pertinent Results: [**2166-3-10**] ECHO: The left atrium is normal in size. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic root. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Post Bypass: The patient is now s/p CABGX2, on a Neosynephrine drip. LV function is preserved with EF> 55 % with no RWMA. Aorta is intact postdecannulation. CXR: [**2166-3-14**]: 1. Right internal jugular central line continues to have its tip in the mid to distal superior vena cava. The patient is status post median sternotomy for CABG with stable post-operative cardiac and mediastinal contours. There are small layering bilateral effusions with patchy opacity at the left base likely reflecting compressive atelectasis. Overall improvement in lung volumes with no evidence of pulmonary edema. No pneumothorax. Degenerative changes in the thoracic spine. [**2166-3-14**] WBC-3.4* RBC-2.96* Hgb-10.2* Hct-29.0* MCV-98 MCH-34.3* MCHC-35.0 RDW-14.5 Plt Ct-88* [**2166-3-10**] WBC-4.4 RBC-2.28*# Hgb-7.6*# Hct-22.8*# MCV-100* MCH-33.6* MCHC-33.5 RDW-14.1 Plt Ct-63* [**2166-3-15**] UreaN-27* Creat-1.0 Na-140 K-3.9 Cl-106 [**2166-3-14**] Glucose-128* UreaN-26* Creat-0.8 Na-141 K-3.9 Cl-106 HCO3-27 [**2166-3-10**] UreaN-11 Creat-0.6 Na-142 K-3.6 Cl-113* HCO3-25 [**2166-3-15**] Mg-2.0 Micro: [**2166-3-10**] MRSA SCREEN MRSA SCREEN (Final [**2166-3-12**]): No MRSA isolated. Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2166-3-10**] for surgical management of his caoronary artery disease. He was taken directly to the operating room where he underwent a redo sternotomy with coronary artery bypass grafting to two vessels. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. Over thenext several hours, he awoke neurologically intact and was extubated. On postoperative day two, he was transferred to the step down unit for monitoring. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. Chest tubes and pacing wires removed per protocol. Continued to make good progress and was discharged to home with [**Hospital1 1474**] VNA [**Telephone/Fax (1) 18681**] on POD 5. All f/u appts were advised. Medications on Admission: ALLOPURINOL 100 mg Daily AMLODIPINE (Not Taking as Prescribed: Was increased from 5 mg by Dr [**Last Name (STitle) 18682**] [**2166-3-4**]. Pt [**Known lastname **] taking one tablet.) - 5 mg Tablet two Tablets Daily GABAPENTIN 300 mg [**Hospital1 **] ISOSORBIDE MONONITRATE (Not Taking as Prescribed: Was increased from 60 mg by Dr [**Last Name (STitle) 18682**] [**2166-3-9**]. Pt [**Known lastname **] taking one tablet.) -60 mg Tablet Extended Release 24 hr - 1.5 Tablets DAily LUBIPROSTONE [AMITIZA] 24 mcg Daily METFORMIN 500 mg Daily METOPROLOL TARTRATE 25 mg Daily NITROGLYCERIN 0.4 mg Tablet, Sublingual - 1 Tablet(s) sublingually q 5 minutes as needed for as needed for chest pain RANOLAZINE [RANEXA] (Not Taking as Prescribed: Took for only two days. Currently taking one tablet at bedtime only.) - 500 mg Tablet Extended Release 12 hr - one Tablet [**Hospital1 **] SOLIFENACIN [VESICARE] 5 mg Daily ASPIRIN 81 mg Daily Discharge Medications: 1. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day. Disp:*10 Tablet Extended Release(s)* Refills:*0* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 8. metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. solifenacin 5 mg Tablet Sig: One (1) Tablet PO once a day. 10. lubiprostone 24 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 11. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 13. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Coronary artery disease s/p Redo-Sternotomy, coronary artery bypass graft x 3 Past history: Coronary artery bypass graft x 2: [**2149**] (RIMA- RCA, SVG- OM) Memory loss after CABG multiple stents placed Peripheral arterial disease Prostate cancer s/p radiation 2 years ago History of pancytopenia Dyslipidemia - unable to tolerate statins, not on any medicine at present GI bleed [**3-6**] r/t Plavix Kidney stones Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Wound check, [**Hospital Unit Name **] [**Last Name (NamePattern1) **] [**Hospital Unit Name **] [**2166-3-27**] at 10:00am Surgeon: Dr. [**First Name (STitle) **] [**2166-4-8**] at 2:15pm in the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **] [**Hospital Unit Name **] Cardiologist/PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2166-4-4**] at 4:30p **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2166-3-15**]

[ "V45.82", "427.41", "790.29", "V45.81", "284.19", "401.9", "458.29", "V43.65", "272.4", "780.93", "E935.2", "285.1", "443.9", "V15.3", "414.01", "V10.46", "780.79" ]

icd9cm

[ [ [] ] ]

[ "39.61", "36.12", "99.62", "36.15" ]

icd9pcs

[ [ [] ] ]

8520, 8575

5365, 6281

359, 637

9034, 9261

3647, 5342

10074, 10843

2248, 2424

7264, 8497

8596, 9013

6307, 7241

9285, 10051

2439, 3217

3233, 3628

309, 321

665, 1684

1706, 2059

2075, 2232

73,833

179,818

41644

Discharge summary

report

Admission Date: [**2138-7-3**] Discharge Date: [**2138-7-13**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 99**] Chief Complaint: Respiratory failure Major Surgical or Invasive Procedure: Intubated, arterial line History of Present Illness: Ms. [**Known lastname 10687**] was a [**Age over 90 **] year-old woman with no known PMH who had not seen a physician [**Name Initial (PRE) **] 35 years and presented with SOB x 1 month. She was having a monthly inspection at home when she told the inspector she had general body pain for 1 month with shortness of breath and productive cough in addition to sore throat. She was BIBA after c/o productive cough and general malaise. Denies fevers, chills, nausea, vomiting. Does endorse CP with precordial palpation. On arrival to the ED, the patient appeared comfortable and had O2 sats in the mid-90's. She was placed on a NRB and vitals were 98.4 92 131/46 24 100% 10L nrb. A CXR showed a mass in the apical portion of the left lung, concern for CA. Around 2pm, the patient began to have worsening respiratory distress with sats into the 80s. She was tachypneic and had a systolic BP >200. Concern was for flash pulmonary edema and she was started on a nitro drip and BIPAP with improvemnet. At 4:45, she was sent for a CTA which revealed complete collapse of the LUL with a central hypodensity concerning for mass vs. necrosis. On return for the CTA, the patient had respiratory decompensation requiring intubation. Following intubation, the patient's BPs fell and a CVL was placed for norepinephrine. Transferred to the MICU. On transfer, VS were 155/77, 88, 22, 99% vent. Review of systems: unable to obtain Past Medical History: None known Social History: Smoked for decades according to her brother. Lived alone but brother visited her regularly. Otherwise unknown. Family History: None known. Physical Exam: Admission Exam: Vitals: 97 110/68 80 22 100% intubated, CVP 4 General: Intubated and sedated HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP not elevated Lungs: Rhoncorous breath sounds throughout, breath sounds on left may be transmitted sounds. CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic murmur Abdomen: soft, non-distended, bowel sounds present GU: + foley Ext: 2+ pulses, cool, no cyanosis or edema Discharge: Expired. Pertinent Results: [**2138-7-3**] 11:00AM WBC-8.7 RBC-3.46* HGB-8.2* HCT-26.1* MCV-75* MCH-23.7* MCHC-31.4 RDW-14.7 [**2138-7-3**] 11:00AM NEUTS-83.0* LYMPHS-11.1* MONOS-4.6 EOS-0.3 BASOS-1.0 [**2138-7-3**] 11:00AM PLT COUNT-709* [**2138-7-3**] 11:00AM GLUCOSE-122* UREA N-30* CREAT-1.2* SODIUM-145 POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-25 ANION GAP-17 [**2138-7-3**] 11:00AM cTropnT-<0.01 [**2138-7-3**] 11:00AM D-DIMER->[**Numeric Identifier 3652**] [**2138-7-3**] 11:16AM LACTATE-1.2 Cytology Report BRONCHIAL BRUSHINGS Procedure Date of [**2138-7-4**] Bronchial brushings, endobronchial lung mass: POSITIVE FOR MALIGNANT CELLS, Consistent with carcinoid tumor. CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2138-7-3**] 3:35 PM IMPRESSION: 1. No acute pulmonary embolus. 2. Marked heterogeneity with focal areas of hypodensity in a collapsed left upper lung likely due to a neoplasm with areas of necrosis. Extensive mediastinal and hilar adenopathy causing attenuation of the right and left main pulmonary arteries and left upper lobe and lingular arterial branches. Soft tissue density within the left upper lobe bronchus may represent mucus plugging or tumor infiltrate. 3. Large pericardial effusion without definite radiographic evidence of tamponade physiology. Echocardiography should be considered as clinically indicated. 4. Moderate bilateral pleural effusions with simple fluid attenuation and bibasilar consolidative opacities could represent atelectasis or infection. 5. Patchy opacities in the right lung could represent aspiration or infection. 6. Probable vascular congestion and mild edema. 7. Thickening of the left adrenal gland without discrete nodule. 8. Incompletely evaluated hyperdense lesion arising from the left kidney, possibly a hyperdense cyst. CHEST (PORTABLE AP) Study Date of [**2138-7-11**] 10:38 AM IMPRESSION: Near resolved edema. Unchanged left lower lobe atelectasis and large left upper lobe mass. Right upper lobe resolving pneumonia. Portable TTE (Complete) Done [**2138-7-4**] at 10:23:49 AM Impression: moderate pericardial effusion; no chamber collapse but this may be absent despite the presence of high intrapericardial pressures when severe pulmonary hypertension is also present; apical hypokinesis of the left ventricle, with apical ballooning of the right ventricle (consider Takotsubo cardiomyopathy with right ventricular as well as left ventricular manifestation) Cardiology Report ECG Study Date of [**2138-7-3**] 10:32:14 AM Sinus rhythm. Possikble inferior wall myocardial infarction, age indeterminate. Non-specific lateral ST-T wave changes. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 94 142 86 338/397 56 -21 92 Brief Hospital Course: Ms. [**Known lastname 10687**] was a [**Age over 90 **] year old woman with no known previous medical history who presented with progressive shortness of breath, cough, and general malaise for a month, intubated for respiratory distress, found to have LUL lung mass (carcinoid vs small cell) and likely post-obstructive pneumonia on imaging. Ms. [**Known lastname 10687**] was extubated on [**7-11**] after family discussion and decision for no further aggressive treatment and passed away on [**2138-7-13**] on comfort measures. # Lung Mass Patient was found to have LUL mass. She underwent bronchoscopy on [**7-4**] at which time she was noted to have significant external compression of LUL bronchus, after which bronchus opened up again to friable tissue. Cytologic brushings returned positive for neuroendocrine tumor cells, most consistent with carcinoid tumor, though could not definitively rule out small cell, particularly based on bronchoscopy visualization. She was also noted to have pericardial effusion without signs of tamponade, presumed to be malignant pericardial effusion. Because of patient's poor prognosis, decision was made by family and medical team not to pursue treatment. Patient was extubated [**2138-7-11**]; decision for comfort measures only was made on [**2138-7-12**], and she passed away [**2138-7-13**]. # Respiratory Failure Multifactorial, secondary to LUL mass and post-obstructive pneumonia. Patient was treated with a 9 day course of vancomycin and zosyn for pneumonia in the setting of potential sepsis. Antibiotics were discontinued when patient was placed on comfort measures. Her blood pressures were intermittently low and requiring norepinephrine for support intermittently, though hypotension presumably partially secondary to sedation. TTE showed EF of 40-45% with apical hypokinesis, and she was noted to have some pulmonary edema and pleural effusions and was diuresed as tolerated by blood pressures. She was intermittently diuresed as blood pressure tolerated to optimize respiratory status prior to extubation. She was extubated in [**2138-7-11**] after family discussion. She was made comfort measures only on [**2138-7-12**] and passed away on [**2138-7-13**]. # Hypotension Initially hypotension attributed to sepsis. Patient required norepinephrine to maintain blood pressures on presentation and was weaned off within two days. She did require intermittent norepinephrine over the next several days as well, though this was temporally associated with midazolam dosing. # Demand Ischemia Patient was noted to have troponin leak to 0.5 on admission, trended downwards over the next day, thought to be secondary to demand ischemia. TTE showed EF 40-45% and apical hypokinesis with apical ballooning, potentially Takasubos cardiomyopathy. Patient was made DNR/DNI by family mid-way through the hospitalization and made comfort measures only on [**2138-7-12**] after extubation. She passed away comfortably on morphine drip on [**2138-7-13**]. Medications on Admission: None known Discharge Medications: None. Expired. Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired

[ "285.9", "416.8", "428.0", "783.21", "V15.82", "209.21", "423.8", "518.81", "V85.0", "785.59", "486", "V49.86", "E915", "934.1", "429.83", "599.0", "511.81", "518.0", "428.41", "995.94", "584.9", "585.9" ]

icd9cm

[ [ [] ] ]

[ "96.05", "96.6", "33.24", "96.72" ]

icd9pcs

[ [ [] ] ]

8339, 8348

5219, 8238

268, 295

8400, 8410

2438, 5196

8466, 8477

1929, 1942

8299, 8316

8369, 8379

8264, 8276

8434, 8443

1957, 2419

1732, 1750

209, 230

323, 1712

1772, 1784

1800, 1913

5,319

162,749

28808

Discharge summary

report

Admission Date: [**2174-9-21**] Discharge Date: [**2174-11-8**] Date of Birth: [**2110-12-17**] Sex: M Service: MEDICINE Allergies: Dolasetron Mesylate Attending:[**Known firstname 7591**] Chief Complaint: Admitted for chemotherapy for AML Major Surgical or Invasive Procedure: Placement of right IJ line; removal of right IJ bronchoscopy History of Present Illness: Mr. [**Known lastname 69581**] is a 63 year old man with history of Crohn's Disease that was recently admitted to an OSH for abdominal pain presumed to be a Crohn's flair, and during which he was found to be leukopenic. . Approximately ten days prior to admission at [**Hospital1 18**], Mr. [**Known lastname 69581**] experienced intense abdominal pain that was similar in quality to his normal Crohn's flair; the only difference was that he did not vomit as he normally does with his flairs. At the time, he attributed the pain to dietary indiscretion. The pain recurred over the next several days, even causing him to skip work. Finally, one week prior to admission at [**Hospital1 18**], he was admitted to an OSH for management of presumed Crohn's flair. . At the outside hospital, he was found to have a white blood cell count of 1.6. He was seen by heme/onc, and a bone marrow biopsy was performed. The patient was discharged before the bone marrow biopsy results were back. The bone marrow showed AML with 31% myeloblasts. He was called and told to come to [**Hospital1 18**] for direct admission under Dr. [**Last Name (STitle) **]. . He denies weight loss (lost 8 lbs with flair, but gained back; this is normal for flair), no fevers, some night sweats (in hospital). His energy level has decreased over the past few weeks, and he has felt extremely tired and fatigued. Noticed non-painful "lump" in neck approximately 2 years ago, saw surgeon, was told to wait 6 weeks, at which point "lump" was gone. The patient does complain of increased leg swelling R>L, but a venous Doppler was negative (per patient's wife). Past Medical History: Crohn's Disease, diagnosed in the 60's, s/p partial small bowel resection (20 cm), 20 years ago. Denies arthritis and rashes. Last flair approximately 8 months ago. Hx of Herpes zoster, was on Neurontin until recently MVP Hx of infectious mononucleosis No cardiac history (last stress test < 1 year ago) Social History: Quit smoking in [**2133**]. 1-2 beers with dinner. No IVDU. Has three children (ages 41, 38, and 35), 4 grandchildren. Works in home inspection. Family History: Mother died of cancer (age 67), father died of cerebral aneurysm. No other family history of cancer. Has one brother, in good health. Children are well. Physical Exam: Vitals: T 98.3, BP 131/75, P 77, RR 20, Sat 99%RA Gen: Well-appearing, no acute distress, appears somewhat distraught over new diagnosis Heent: EOMI, PERRL, OP clear Nodes: No cervical, supraclavicular, infraclavicular, or axillary nodes appreciated Heart: RRR, normal S1/S2, no m/r/g Lungs: CTAP Abd: Soft, non-tender, non-distended. Midline abdominal scar. No HSM. Back: No spinal tenderness, no CVAT. Ext: No clubbing, cyanosis. 2+ DP pulses bilaterally. 1+ pitting edema bilaterally Pertinent Results: BONE MARROW: [**9-21**]: 22% Blasts, 4% Promyelocytes, 4% Myelocytes, 3% Metamyelocytes, 2% Bands/Neutrophils, 2% Plasma cells, 15% Lymphocytes, 48% Erythroid . [**10-6**]: 1. Markedly hypocellular bone marrow consistent with post-therapy myelo-ablation (see note) 2. No morphologic evidence of acute myelogenous leukemia seen. . . IRON STUDIES:[**2174-10-25**] Iron-274* calTIBC-291 Ferritn-874* TRF-224 . . IMAGING: Echo [**2174-9-22**]: 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 normal (LVEF>55%). Tissue velocity imaging demonstrates an E/e' <8 suggesting a normal left ventricular filling pressure (<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated. The ascending aorta is mildly dilated. The aortic valve leaflets are mildly thickened. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . CT Abd/Pelv [**2174-9-28**]: 1. Inflammation and thickening of the wall of the distal small bowel up to the level of the anastomosis with the colon with resultant narrowing of the lumen. Findings are most consistent with a Crohn's disease with acute inflammation. There is dilation of the more proximal small bowel, though contrast is seen to flow into the colon, suggestive of partial obstruction. There is no focal abscess or fluid collection identified. Findings may be slightly worsened, though not significantly changed from the prior outside examination. 2. Heterogeneous appearance of the prostate gland with an area of slightly lower attenuation centrally. In the correct setting, the findings could be due to prostatitis or a small focal abscess. Correlation with symptoms, prostate exam, and urinalysis is recommended. . CT Chest/Abd/Pelv [**2174-10-10**]: 1. Multiple opacities in the right upper lobe are likely infectious. Three- month followup to confirm resolution is recommended. 2. A 11-mm nonobstructing left renal collecting system stone. 3. Persistent and slightly improved neoterminal ileitis consistent with Crohns flare. . Skin Biopsy [**2174-10-10**]: Epidermal acanthosis with parakeratotic scale, dyskeratotic keratinocytes and mild focal superficial perivascular lymphocytic inflammation. No fungi. . Brief Hospital Course: #) AML: Patient was diagnosed with AML and bone marrow biopsy on [**9-21**] revealed 22% Blasts. Central venous access obtained on [**9-22**], and [**Doctor First Name **]/Ara-C started on [**9-22**]. He initally tolerated induction well until he spiked fever on [**9-27**], pan cultured, cefepime added. In addition, he developed abdominal pain on [**9-28**] c/w his usual Crohn's flare and meropenem added. Stat abdominal CT showed no change from previous (2 weeks ago, OSH). His course was compplicated by a rash. It was seen by dermatology, biopsied. No leukocytoclastic vasculitis or leukemia cutis seen; no inflammation and no evidence of a deep fungal infection. It resolved with sarna lotion and triamcinolone cream. 14-day bone marrow biopsy on [**10-6**], showed empty core, 3% blasts on aspirate. 22-day bone marrow on [**10-14**], revealed 5% blasts, peripheral smear w/o blasts. The decision was made to start high dose cytarabine on [**10-19**] because he had already been on tube feeds (for Crohn's) and would not want to take out the line and replace. He tolerated HIDAC very well, and was started on GCSF to stimulate counts. He developed bone pain to neupogen which was well controlled with oxycodone. By [**11-5**] counts returned. At discharge, the decision was made that he should readdress surgical options for Crohn's prior to receiving further chemotherapy. He will follow-up with Dr. [**Known firstname 449**] [**Last Name (NamePattern1) 410**] as an outpatient and will have a repeat BM biopsy once his counts settle from the neupogen. . #) Fevers/hypotension: Over the hospital course, he developed fevers and hypotension. The work-up was negative with no evidence of bowel infection, but some infiltrates on chest CT. Bronchoscopy on [**10-12**] was negative, cultures negative. He was placed on broad spectrum Abx and improved. By discharge, cultures had been negative and azithro, vanco, flagyl, [**Last Name (un) 2830**], caspo were stopped on [**10-17**]. After [**10-17**], he had no further issues with fever or hypotension. . #) Transaminitis/Elevated INR: He was noted to have persistently elevated INR as well as periods of elevated LFT's. He was started on Vitamin K in his TPN with no improvement. He also has periods of mild transaminitis with negative work-up (normal RUQ U/S and no clincial symptoms). Iron studies were sent and he was ultimately found to have hemochromatosis. This was explained to him and his children were encouraged to also have iron tests. . #) Crohn's Disease. He was discharged from OSH on 20mg prednisone [**Hospital1 **] and upon admission to [**Hospital1 **], started a prednisone taper prior to chemotherapy. GI was consulted [**9-22**], and recommended strict dietary control (No fiber, no lactose). On [**9-30**], he developed worsening abdominal pain and was started on high dose steroids with a rapid taper. Howeevr, while on high dose steroids, he developed bradycardia to 30-40's. He was hemodynamically stable, walking around, etc. EP consulted, believed to be secondary to increased vagal tone vs. rare effect of methylprednisolone. The bradycardia resolved following steroid taper. He was then started on TPN and steroids ultimately at 10 mg QD. For the remainder of the hospital course, he was pain free. At discharge, it was felt that he should take this window of time before next course of chemo to have the 4 cm inflammed segment of his small bowel surgically resected. Both GI and the surgeon were in full agreement on this issue. . #) Elevated PSA. Elevated at 9.8, never been elevated before. It was felt that this could be prostatitis (given heterogenous appearance of prostate on CT) vs. prostate cancer, and he was started empirically on ciprofloxacin for prostatitis. . #) Hypertension. Blood pressure well controlled. Discontinued lisinopril on [**10-7**] and not restarted at discharge as BP had been doing well without it. . #) F/E/N: Repleted electrolytes per sliding scale; By discharge, he was tolerating full PO diet and no TPN. Medications on Admission: Elavil 25mg PO QD Lisinopril 2.5mg PO QD Prednisone 20mg PO BID Discharge Medications: 1. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*30 Tablet(s)* Refills:*2* 3. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*2* 4. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: AML Crohn's disease Secondary: Hemachromatosis Discharge Condition: stable Discharge Instructions: You have AML and received idarubinc/ara-C induction chemotherapy followed by high dose cytarabine therapy. In addition, your body iron levels are high and blood tests were suggestive of a disease called hemachromatosis. Please call 911 or your primary physician if you have any worsening abdominal pain, shortness of breath, fevers, chills, nausea/vomiting, or any other concerning symptoms. Please continue your home medications with the following exceptions: 1.) You should stay on Prednisone 10 mg daily until otherwise directed by your oncologist or gastroenterologist 2.) Your should stay on the ciprofloxacin for your prostatitis. Please ask your oncologist or primary care physician to further evaluate your prostate. 3.) You need to stay on fluconazole for fungal infection prevention Followup Instructions: You have an appointment to follow-up with Dr. [**Known firstname **] [**Last Name (NamePattern1) 5026**], MD Phone:[**Telephone/Fax (1) 3237**] Date/Time:[**2174-11-10**] at 10:30 AM. Also, you should contact your GI surgeon regarding resection for your Crohn's disease as we discussed.

[ "424.0", "427.89", "601.9", "238.71", "560.89", "787.01", "458.29", "518.3", "780.6", "528.01", "275.0", "555.0", "401.9", "205.00", "693.0", "E932.0", "E933.1" ]

icd9cm

[ [ [] ] ]

[ "33.24", "99.04", "99.25", "41.31", "38.93", "86.11", "99.05", "99.15" ]

icd9pcs

[ [ [] ] ]

10483, 10489

5750, 9782

314, 376

10589, 10598

3212, 5727

11442, 11733

2536, 2690

9896, 10460

10510, 10568

9808, 9873

10622, 11419

2705, 3193

241, 276

404, 2031

2053, 2358

2374, 2520

41,639

140,351

37143

Discharge summary

report

Admission Date: [**2123-4-13**] Discharge Date: [**2123-4-26**] Date of Birth: [**2054-2-18**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [**2123-4-15**] - Cardiac Catheterization [**2123-4-16**] - placement of IABP [**2123-4-16**] - 1. Urgent coronary artery bypass graft x4 - left internal mammary artery to left anterior descending artery and saphenous vein grafts to posterior descending artery and obtuse marginal 1 and 2. History of Present Illness: 69 year old female with h/o hypertension, hyperlipidemia, and recent traumatic brain injury who presents with worsening 'burning' chest pain. She states that she has had intermittent chest pain over the last 1-2 years. Over the last few weeks, it has occurred once daily for about 15 minutes and is relieved when she takes an aspirin and places a hot pack on her chest. Monday night a similar pain woke her from sleep and wouldn't go away with ASA and hot packs and lasted 2 hours. She saw her PCP yesterday who sent her to the ED. She reports that the pain occurs both at rest and with exertion, although doesn't clearly endorse that it worsens with exertion. She will admit that she can walk about 2 blocks before the pain begins, and that it improves when she rests. Denies any SOB, nausea, vomiting, diaphoresis or radiation of the pain. IN the ED she initially was chest pain free, but had recurrence of her symptoms and was noted to have atrial tachycardia with rate of [**Street Address(2) 83688**] depressions in V4-V6. At that time the chest pain radiated to her neck. Her symptoms improved after being given IV lopressor She given a dose of Lovenox as well due to concern for PE in the setting of tachycardia. Her initial troponin <was 0.01 and her repeat was 0.1. She was also given full dose aspirin and admitted. Notably, she had a traumatic brain injury after a fall in [**2121**] and is a difficult historian. She has had multiple difficulties with medication adherence in the past 6 months and has not taken multiple medications prescribed by her PCP. Past Medical History: Hypertension, hyperlipidemia(LDL 151, TG 198, HDL 45), hyperthyroidism(newly diagnosed this admission), Thyroid nodule, s/p TBI [**9-28**] with SAH and IPH, s/p Left ankle surgery with pin Social History: Originally from [**Country 5881**], lives at home with her husband and 3 sons. [**Name (NI) **] 4 children total. Denies current or previous tobacco use, alcohol use, or other drug use. Family History: Mother died of old age, father died in combat. Brother died in his 40's of some type of cancer. Physical Exam: On Admission: Vitals: T: 98.2 BP 128/70 92 20 100%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP 8cm, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, left ankle slightly larger than right (patient relates this to prior injury) Pertinent Results: [**2123-4-26**] 09:50AM BLOOD WBC-7.6 RBC-4.18* Hgb-12.1 Hct-36.5 MCV-87 MCH-29.0 MCHC-33.3 RDW-14.3 Plt Ct-324# [**2123-4-13**] 03:55PM BLOOD WBC-5.0 RBC-3.28* Hgb-10.2* Hct-28.7* MCV-88 MCH-31.1 MCHC-35.5* RDW-12.4 Plt Ct-249 [**2123-4-26**] 09:50AM BLOOD PT-26.3* PTT-33.1 INR(PT)-2.6* [**2123-4-14**] 11:10AM BLOOD PT-13.5* PTT-33.8 INR(PT)-1.2* [**2123-4-26**] 09:50AM BLOOD Glucose-171* UreaN-49* Creat-1.6* Na-134 K-5.2* Cl-98 HCO3-27 AnGap-14 [**2123-4-13**] 03:55PM BLOOD Glucose-98 UreaN-44* Creat-1.2* Na-139 K-4.9 Cl-106 HCO3-23 AnGap-15 [**2123-4-19**] 03:23AM BLOOD ALT-19 AST-14 LD(LDH)-195 AlkPhos-79 TotBili-1.1 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 83689**]Portable TTE (Focused views) Done [**2123-4-18**] at 6:20:26 PM 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: [**2054-2-18**] Age (years): 69 F Hgt (in): 63 BP (mm Hg): 106/47 Wgt (lb): 145 HR (bpm): 69 BSA (m2): 1.69 m2 Indication: s/p CABG with inferior ST elevations in ECG. Evaluate or inferior wall motion abnormality. ICD-9 Codes: 410.91, 424.1, 424.0, 424.2 Test Information Date/Time: [**2123-4-18**] at 18:20 Interpret MD: [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**], MD Test Type: Portable TTE (Focused views) Son[**Name (NI) 930**]: Doppler: Limited Doppler and color Doppler Test Location: West SICU/CTIC/VICU Contrast: None Tech Quality: Suboptimal Tape #: 2010W014-0:10 Machine: Vivid [**5-25**] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 2.9 cm <= 4.0 cm Left Atrium - Four Chamber Length: 4.4 cm <= 5.2 cm Right Atrium - Four Chamber Length: 4.2 cm <= 5.0 cm Left Ventricle - Ejection Fraction: >= 60% >= 55% Left Ventricle - Stroke Volume: 75 ml/beat Left Ventricle - Cardiac Output: 5.20 L/min Left Ventricle - Cardiac Index: 3.08 >= 2.0 L/min/M2 Aortic Valve - Peak Velocity: 2.0 m/sec <= 2.0 m/sec Aortic Valve - LVOT VTI: 24 Aortic Valve - LVOT diam: 2.0 cm TR Gradient (+ RA = PASP): *35 mm Hg <= 25 mm Hg Findings This study was compared to the prior study of [**2123-4-14**]. LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Overall normal LVEF (>55%). Estimated cardiac index is normal (>=2.5L/min/m2). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. AORTIC VALVE: Mildly thickened aortic valve leaflets. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate ([**11-21**]+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [[**11-21**]+] TR. Mild PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor parasternal views. Suboptimal image quality - bandages, defibrillator pads or electrodes. Emergency study performed by the cardiology fellow on call. Conclusions The left atrium is normal in size. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**11-21**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal global left ventricular systolic function. Cannot exclude focal wall motion abnormality due to suboptimal image quality. Compared with the prior study (images reviewed) of [**2123-4-14**], mitral and tricuspid regurgitation have increased. Otherwise, the findings are similar. Electronically signed by [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2123-4-20**] 10:37 ?????? [**2115**] CareGroup IS. All rights reserved. Brief Hospital Course: Mrs. [**Known lastname 83687**] was admitted to the [**Hospital1 18**] on [**2123-4-13**] for further management of her chest discomfort. She was treated for her atrial tachycardia with beta blockade and heparin was started for anticoagulation. The endocrinology service was consulted for assistance with her hyperthyroidism. She was noted to be hyperthyroid due to autoimmune thyroid disease. Tapazole was started. She underwent a cardiac catheterization on [**2123-4-15**] which revealed severe left main disease. Given the severity of her disease, the cardiac surgical service was consulted for surgical revascularization. She was worked-up in the usual preoperative manner. The neurology service was consulted given her history of a subarachnoid bleed to clear her for large dose heparinization. A CT scan was obtained which was stable and she was thus cleared for surgery. A carotid duplex ultrasound was performed which showed less then 40% stenosis bilaterally. Preoperatively on [**2123-4-16**], she was taken to the catheterization lab where an intra-aortic balloon pump was placed. Later on [**2123-4-16**], Mrs. [**Known lastname 83687**] was taken to the operating room where she underwent coronary artery bypass grafting to four vessels. Please see operative note for details. In summary she had: Urgent coronary artery bypass graft x4 - left internal mammary artery to left anterior descending artery and saphenous vein grafts to posterior descending artery and obtuse marginal 1 and 2.Her bypass time was 66 minutes with a crossclamp time of 44 minutes. She tolerated the operation well and postoperatively she was taken to the intensive care unit for monitoring. She required several blood transfusions for postoperative bleeding. Her balloon pump was removed on [**2123-4-17**] without issue. Later on [**2123-4-17**] she was extubated without complication. She developed rapid atrial fibrillation on [**2123-4-18**] for which amiodarone was started with good effect. Additionally anticoagulation was started at this time. She remained hemodynamically stable during this period. All tubes lines and drains were removed per cardiac surgery protocols. The Endocrinology service adjusted her methimazole based on her thyroid function. Left sided weakness was noted and a CT scan was obtained which was initially negative. Repeat CT scan showed no evidence of acute intracranial abnormality. The remainder of her hospital course was uneventful. She continued to make slow progress and on POD6 was transferred from the cardiac surgery ICU to the stepdown floor, she was screened for rehab as a part of this transfer. On POD#10 she had a brief burst of atrial fibrillation with sinus bradycardia in the 30's with conversion. Her Lopressor was decreased to 75 mg po TID and Amiodarone was decreased to 200 mg daily with sinus rhythm in the 70's at discharge. On POD #10 she was deemed ready clinically and was transferred to rehabilitation at [**Hospital 3137**] Care Center in [**Location (un) 1468**]. All follow up visits were advised. Medications on Admission: Amitryptiline 10mg qhs Lisinopril 10mg daily Discharge Medications: 1. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Warfarin 1 mg Tablet Sig: as directed to keep INR 2-2.5 Tablets PO DAILY (Daily): for atrial fibrillation, target INR 2-2.5. 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**2-23**] hours as needed for pain/fever. 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day for 1 months. 9. Methimazole 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO three times a day. 12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) tx Inhalation Q6H (every 6 hours) as needed for wheezing. 13. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. 15. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once for 1 days - goal INR 2.0-2.5 Discharge Disposition: Extended Care Facility: [**Hospital 3137**] Care Center - [**Location (un) 1468**] Discharge Diagnosis: Primary Diagnosis: Unstable Angina/3 vessel coronary artery disease s/p coronary artery bypass graft x4. Pre-operative placement of intra aortic ballon pump Secondary Diagnosis: Hypertension Hyperlipidemia H/o traumatic brain injury [**9-28**] with SAH and IPH hyperthyroidism(newly diagnosed this admission) Thyroid nodule s/p Left ankle surgery with ORIF/pin Discharge Condition: Mental Status: A&Ox3, nonfocal Level of Consciousness: Alert and interactive somewhat lethargic. Activity Status: Ambulatory -with assistance. Incisional pain managed with: Elavil and tylenol Incisions: Sternum healing well, incision without erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema 1+ bilat 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) 7772**] on [**5-31**] @1:15PM Please call to schedule appointments with your Primary Care Dr [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 250**] in [**11-21**] weeks Cardiologist please ask for referral from PCP and schedule appointment in [**12-23**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2123-4-26**]

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icd9cm

[ [ [] ] ]

[ "37.22", "39.61", "36.13", "88.56", "36.15", "37.61" ]

icd9pcs

[ [ [] ] ]

12521, 12606

8038, 11089

331, 623

13012, 13012

3374, 8015

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42820

Discharge summary

report

Admission Date: [**2164-2-27**] Discharge Date: [**2164-2-29**] Date of Birth: [**2101-8-14**] Sex: M Service: MEDICINE Allergies: naproxen / Plavix / Rofecoxib / fluoxetine Attending:[**Doctor First Name 3298**] Chief Complaint: Somnolence, fluctuating mental status Major Surgical or Invasive Procedure: None History of Present Illness: The patient presented to [**Hospital 8125**] Hospital at 915AM on [**2-27**] due to SOB and audible wheezes. The patient has a h/o COPD and is on 2 L NC at home. During this episode of dyspnea, the patient was 96% on his baseline 2L. The patient also c/o slurred speech, which he attributed to a swollen tongue. According to the notes, the patient recently started a new medication, which he said was Chantix three days prior. The patient was also recently diagnosed with Parkinsonism and is on Sinemet at home. The patient was also complaining of increased visual hallucinations at home prior to presentation. At [**Hospital1 **], the patient had an ABG that was 7.36/47/142/26 on 4L NC. He was given 125mg Solumedrol, Duoneb, Levaquin 750mg. His saturations remained in the high 90s on 2L NC. During the ED stay at [**Doctor First Name 8125**], the patient took off all of his EKG leads and wanted to leave, but was easily redirected. By 1430, it was reported that the patient's tongue swelling had improved. The patient was transfered to [**Hospital1 18**] due to altered mental status and neurology consult. During transport, the patient continued to have visual hallucinations and was repsonding to internal stimuli, which the patient says was baseline for him. He was not distressed by these. . At [**Hospital1 18**], initial VS were 98.8, 112/71, 79, 20, 96% RA. He triggered for 2 episodes of unresponsiveness even to sternal rub. On exam, at first incredibly somnolent, slurred speech, tongue fasciculations, otherwise CN II-XII intact; strength 5/5 throughout w/e/o L leg foot drop; lungs exp wheezing bilat. ? myoclonic jerks. Awoke spontaneously after minutes. Lactate normal, ABG 7.37/46/62/28. Normal head CT. Utox negative. Given narcan with no change in mental status. . On arrival to the MICU, the patient was initially difficult to arouse. Once awoken, the patient was appropriate, following commands, and logical. The patient says that he doesn't remember much of what happened today, but notes that it started this AM with some SOB and then increasing visual hallucinations. He says that he has had these hallucinations for 2-3 weeks, which he describes as seeing people whom he knows and he has conversations with. These are nonthreatening hallucinations. The patient also notes some orthostasis, especially dizziness when he arises from bed in the AM. He complains of tremor, both at rest and with movement, which he says has gotten better since starting Sinimet. He denies rigidity or gait disturbance. No urinary symptoms. He notes dry mouth, but little tongue swelling now. . Review of systems: (+) Per HPI, otherwise unable to be elicited by patient Past Medical History: Past Medical History: left foot drop s/p surgery in [**2154**] chronic back pain anxiety depression COPD on 2L NC at home HTN degenerative disk disease Past Surgical History: CABG with aneurysm repair [**2154**] Appendectomy Subclavian stenting BL knee surgeries [**2154**], [**2157**] Social History: - Home: Lives in an apartment by himself. Independent in most ADLs; drives; has an appointed clerk who receives his benefits check and manages his finances. Has family support from his 4 siblings. He us also close with his ex-wife. His HCP is his sister. - Tobacco: 1ppd smoker since childhood;; after recent hiospitalization he has been trying to use nicotine patch and chantix - Alcohol: prior h/o heavy EtOH abuse, but none for ~20 years - Illicits: occasional MJ only Family History: Mother: [**Name (NI) 2481**] disease with Parkinsonism/[**Last Name (un) 309**] Body features Father: killed by a drunk driver, but previously was healthy w/ thyroid disease Sister: thyroid disease Physical Exam: ADMISSION EXAM: Vitals: T: 97.9 BP: 113/61 P: 75 R: 18 O2: 99% RA General: Once arousable, AOx2, no hallucinations now, able to carry on logical conversation HEENT: Sclera anicteric, dry MM, dry tongue, non-swollen, no dysarthria, PERRLA Neck: obese, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: distant breath sounds, end-expiratory wheezes Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: warm, well perfused, has brace on left foot due to foot drop Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 1+ biceps reflex, unable to elicit other reflexes, gait deferred, finger-to-nose intact, some resting arm and chin tremor, but normal cerebellar function DISCHARGE EXAM: On discharge he is awake and alert, oriented x3, denies hallucinations. Neuro exam intact. Pertinent Results: ADMISSION LABS: [**2164-2-27**] 04:27PM BLOOD WBC-7.2 RBC-4.41* Hgb-13.3* Hct-39.2* MCV-89 MCH-30.2 MCHC-34.0 RDW-12.3 Plt Ct-175 [**2164-2-27**] 04:27PM BLOOD Neuts-90.9* Lymphs-8.3* Monos-0.3* Eos-0.3 Baso-0.2 [**2164-2-27**] 04:27PM BLOOD PT-10.5 PTT-32.7 INR(PT)-1.0 [**2164-2-27**] 04:27PM BLOOD Glucose-182* UreaN-24* Creat-1.4* Na-139 K-3.6 Cl-101 HCO3-24 AnGap-18 [**2164-2-27**] 04:27PM BLOOD ALT-12 AST-12 AlkPhos-114 TotBili-0.2 [**2164-2-27**] 04:27PM BLOOD Lipase-24 [**2164-2-27**] 04:27PM BLOOD Calcium-9.4 Phos-1.9* Mg-2.0 [**2164-2-27**] 04:27PM BLOOD VitB12-417 [**2164-2-27**] 04:27PM BLOOD TSH-0.82 [**2164-2-27**] 04:27PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2164-2-27**] 05:49PM BLOOD Type-ART pO2-62* pCO2-46* pH-7.37 calTCO2-28 Base XS-0 Intubat-NOT INTUBA [**2164-2-27**] 04:25PM BLOOD Lactate-2.9* [**2164-2-27**] 05:57PM BLOOD Lactate-3.0* [**2164-2-28**] 04:23AM BLOOD Lactate-1.8 DISCHARGE LABS: [**2164-2-29**] 08:05AM BLOOD WBC-13.2* RBC-4.35* Hgb-13.1* Hct-38.1* MCV-88 MCH-30.2 MCHC-34.4 RDW-12.8 Plt Ct-210 [**2164-2-29**] 08:05AM BLOOD Glucose-88 UreaN-23* Creat-1.2 Na-144 K-4.0 Cl-107 HCO3-29 AnGap-12 [**2164-2-29**] 08:05AM BLOOD Calcium-9.4 Phos-2.9 Mg-2.0 MICRO DATA: [**2164-2-27**] RAPID PLASMA REAGIN TEST: Negative [**2164-2-27**] BLOOD CULTURE: No growth IMAGING: [**2164-2-27**] CT HEAD W/O CONTRAST No acute intracranial process. [**2164-2-27**] CHEST (SINGLE VIEW) Mild bibasilar atelectasis. Low lung volumes. Blunting of the left costophrenic angle may be due to overlying soft tissue although a small left pleural effusion cannot be excluded. No definite focal consolidation. Brief Hospital Course: PRIMARY REASON FOR HOSPITALIZATION: Mr. [**Known lastname 69651**] is a 62y/o gentleman with COPD, CAD s/p distant CABG, depression, anxiety, smoking, and recent dx of Parkinsonism who presented from [**Hospital3 **] for neurological evaluation given increasing somnolence and visual hallucinations. ACTIVE ISSUES: #. AMS with hallucinations: The etiology of his AMS and hallucinations is not clear. His fluctuating consciousness on admission with non-threatening hallucinations could be c/w a neurologic process such as [**Last Name (un) 309**] Body dementia although he did not have the characteristic motor findings. The neurology service was consulted and felt his hallucinations were most likely [**3-8**] polypharmacy vs hypoxia from his underlying lung disease. His sinemet was discontinued as neurology felt he had no s/sx Parkinson's disease. His alprazolam, loratidine, oxycodone, amitriptyline, and gabapentin were held. His hallucinations resolved and mental status cleared. On discharge, it was recommended that he continue to hold these medications and follow up with his PCP and an outpatient neurologist for further evaluation. CHRONIC ISSUES: # COPD: The patient has a long hx of COPD and is a chronic smoker. He remained at his baseline O2 requirement of 2L throughout hospitalization, and ABG was wnl. he was continued on his home inhalers. # CAD s/p CABG: He was continued on his home ASA and statin. # HTN: He was continued on his home lisinopril and nifedipine. TRANSITIONAL ISSUES - The following medications were discontinued: Sinimet, chantix, ropinirole, alprazolam, loratidine, oxycodone, amitriptyline, and gabapentin. - He was scheduled to follow up with his PCP after discharge. It was recommended that he ask his PCP about referral to a neurologist in his area. Medications on Admission: Aspirin 81mg Qday Bisoprolol and HCTZ 5/6.25mg Qday Lisinopril 20mg Qday Nifedipine ER 30mg Qday Zocor 20mg QHS Sinemet 25/250 1 tab QID Gabapentin 100mg TID Celexa 10mg Qday Amitriptyline 25mg QHS Alprazolam 0.5mg [**Hospital1 **] Oxycodone 5mg TID Duoneb QID Albuterol 2 puffs Q4hr PRN Symbicort 2 puffs [**Hospital1 **] Singulair 10mg QHS Loratidine 10mg Qday Fluticasone nasal spray 2 sprays Qday Ropinirole 0.5mg TID Pyridoxine 100mg [**Hospital1 **] Vitamin B12 500mcg [**Hospital1 **] Prilosec 20mg Qday Nicotine patch Chantix --> started 3 days ago Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 2. montelukast 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 5. Flonase 50 mcg/Actuation Spray, Suspension Sig: Two (2) sprays Nasal once a day: 2 sprays each nostril once daily. 6. Vitamin B-6 100 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Vitamin B-12 500 mcg Lozenge Sig: One (1) lozenge PO twice a day. 8. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) neb Inhalation once a day. 9. Zocor 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 10. bisoprolol-hydrochlorothiazide 5-6.25 mg Tablet Sig: One (1) Tablet PO once a day. 11. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 12. Nifedical XL 30 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 13. Symbicort Inhalation 14. Neurontin 100 mg Capsule Sig: One (1) Capsule PO three times a day. 15. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 16. Nicoderm CQ 21 mg/24 hr Patch 24 hr Sig: One (1) patch Transdermal once a day. Discharge Disposition: Home With Service Facility: [**Location (un) 6138**] Home Care Services Discharge Diagnosis: Altered mental status due to medication side effect Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 69651**], You were admitted to [**Hospital1 18**] because you were confused and having hallucinations. We believe this happened as a side effect of multiple medications you were taking, including Sinimet, Chantix, Citalopram, ropinirole, and percocet. We stopped these medications while you were in the hospital, and your confusion improved. You were also evaluated by our neurologists while you were in the hospital. The neurologists do not feel that you have Parkinson's disease and recommend that you stop taking Sinimet as it could be contributing to your hallucinations. We recommend that you follow up with a neurologist as an outpatient. Please talk to your primary care provider about setting up an appointment with a neurologist near you. We recommend that you stop the following medications: -STOP Sinimet -STOP Chantix - we recommend you continue using your nicotine patch for smoking cessation -STOP Ropinirole -STOP Citalopram -STOP alprazolam -STOP percocet -STOP amitriptyline We made no other changes to your medications while you were in the hospital. Please continue taking the rest of your medications as prescribed by your outpatient providers. We have scheduled an appointment for you to follow up with your primary care provider. [**Name10 (NameIs) 357**] see below for your appointment time. It has been a pleasure taking care of you at [**Hospital1 18**] and we wish you a speedy recovery. Followup Instructions: Name: NP [**First Name8 (NamePattern2) **] [**Last Name (un) 10664**] Location: COMMUNITY HEALTH CENTER OF [**Hospital3 **] Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 18235**] Phone: [**Telephone/Fax (1) 14916**] Appointment: Friday [**2164-3-2**] 10:15am *It is recommended you follow up with a Neurologist within 2 weeks of discharge. Please discuss with your primary care provider at this appointment about getting setup with an appointment.

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

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342, 349

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5007, 5007

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3380, 3859

29,886

110,209

31991

Discharge summary

report

Admission Date: [**2175-10-3**] Discharge Date: [**2175-10-5**] Date of Birth: [**2101-11-10**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1**] Chief Complaint: Scheduled total thyroidectomy due to multinodular goiter Major Surgical or Invasive Procedure: 1. S/P total thyroidectomy 2. reexplored thyroid for bleeding & edema 3. obstructed airway requiring reintubation History of Present Illness: Mrs. [**Known lastname **] is 73 year old female with a h/o hypertension and Left breast cancer who was found to have a multinodular goiter on exam. She was referred to Dr. [**Last Name (STitle) **] for resection of the entire thyroid gland, and surgery was arranged. Past Medical History: Hypertension History of L breast cancer Social History: Patient denies use of tobacco, alcohol or recreational drugs. Lives with son. Family History: No familial history of thyroid abnormalities Physical Exam: Per Dr. [**Last Name (STitle) **] on [**2175-10-3**] Physical Exam: V: 96.1F HR 98 BP 109/59 98 % on AC 400 x 10/40%/5peep Gen: intubated, sedated HEENT: eyes closed, but pupils reactive, anicteric sclera, MMM, intubated Neck: wound dressing intact, some bruising around wound dressing CV: RRR, S1, S2, no murmurs appreciated Pulm: CTA-ant Abd: Normoactive BS, soft, ND/NT, no HSM appreciated Ext: WWP, no edema, with pneumoboots Pertinent Results: [**2175-10-4**] 03:04AM BLOOD WBC-11.7* RBC-3.19* Hgb-10.8* Hct-30.4* MCV-95 MCH-33.8* MCHC-35.4* RDW-12.6 Plt Ct-226 [**2175-10-5**] 06:40AM BLOOD Calcium-8.3* [**2175-10-4**] 03:04AM BLOOD Albumin-3.4 Calcium-8.1* Phos-3.5 Mg-1.8 . [**2175-10-3**] Pathology Tissue: Total Thyroid-pending Brief Hospital Course: This is a 73 year old female admitted for total thyroidectomy complicated by hematoma post-operatively resulting in airway obstruction necessitating intubation and reexploration. Arterial bleed found and clipped. Patient placed in ICU overnight. Extubated morning of [**2175-10-4**] and transferred to floor. Calcium and HCT levels stable. Problems 1. Hematoma/Hemorrhage - Arterial bleed clipped. Hematocrit stabilized 2. Hypertension - Will resume medication regime at home. 3. Electrolytes - Last calcium 8.3* Medications on Admission: Lisinopril 20 mg daily Levothyroxine 25 mcg daily MVI daily Fish oil 1 daily Albuterol Inhaler prn wheeze Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for Pain or fever. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 4. 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* 5. Synthroid 25 mcg Tablet Sig: One (1) Tablet PO once a day. 6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) Discharge Disposition: Home Discharge Diagnosis: Primary: multinodular goiter Post-op bleed . Secondary: Hypertension Breast cancer Discharge Condition: stable Tolerating a regular diet Adequate pain control with oral medication Discharge Instructions: Instructions after thyroid surgery: *Avoid driving while taking pain medication. *Continue taking stool softeners with pain medication to prevent constipation. *You may feel tingling around your lips, arms & legs. Take TUMS (2 tabs four times for a few days until tingling goes away). emergency room if unable to reach MD. *You may return to work once you feel comfortable. *Avoid physical/strenuous activity until you feel comfortable. *You may shower. Avoid swimming or bath for 5-7 days. Followup Instructions: 1.Please call Dr.[**Name (NI) 10946**] office for appointment next Tuesday [**2175-11-10**] for staple removal ([**Telephone/Fax (1) 9011**] 2.Follow-up with primary care provider regarding need for pneumococcal vaccine. Completed by:[**2175-10-5**]

[ "493.90", "518.5", "998.11", "786.1", "285.1", "401.9", "241.1", "V10.3" ]

icd9cm

[ [ [] ] ]

[ "06.02", "96.04", "06.4" ]

icd9pcs

[ [ [] ] ]

3057, 3063

1785, 2304

369, 485

3190, 3268

1471, 1762

3807, 4059

956, 1002

2460, 3034

3084, 3169

2330, 2437

3292, 3784

1087, 1452

273, 331

513, 782

804, 845

861, 940

3,917

161,862

5972

Discharge summary

report

Admission Date: [**2102-9-29**] Discharge Date: [**2102-10-3**] Date of Birth: [**2055-7-29**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1973**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: none History of Present Illness: Briefly, this is a 47yo man with long h/o alcohol abuse with alcohol related dilated cardiomyopathy and DTs, as well as h/o Hepatitis B and C, who presents with severe chest pain, radiating to L arm, lasting for approx 7hr. Of note, pt has had multiple admissions to [**Hospital1 18**] for ETOH related issues, last admission on [**2102-9-12**]. He has also had the same type of chest pain off and on for the last 6-7 months per his report, and has been worked up with stress test, echo, cardiac enzymes, and chest CT without clear cause of pain. Pt reports last drink afternoon of [**2102-9-28**]. He has been drinking about 1L of liquor daily. He currently reports feeling "shaky inside," though no seizure activity noted. . In the ED, the pt was afebrile, hypertensive (220's/110's), and tachycardic (HR up to 140's). He was given a total of 14mg of ativan for withdrawal, along with some morphine. He was started on a nitro gtt to help control his BP. However, his BP was still difficult to control despite nitro gtt. Pt denied HA/vision changes. No weakness/numbness. for placed on a CIWA scale. His tox screen was positive for alcohol with a level of 68 and benzos. His first set of cardiac enzymes were negative. . Pt was admitted to the MICU for close monitoring of his blood pressure with a nitro gtt and placed on CIWA scale. The CIWA scale was tightened given pt had high use of Valium thought to be for secondary gain by the patient. Pt titrated off nitro gtt before call-out and Lisinopril titrated up. Past Medical History: - EtOH abuse with multiple admissions for w/d - h/o withdrawl seizures - Alcoholic Dilated Cardiomyopathy (last [**Hospital1 18**] records indicated an EF of 40-45% with mild global HK) [**5-8**] - cocaine abuse - hypothyroidism: TSH 10 on [**2102-8-22**] -does not take prescribed levothyroxine - h/o head and neck cancer s/p resection and radiation in [**2093**] - bilateral cavitary lung lesions; bx demonstrated Aspergillous fumigatus and [**Female First Name (un) 564**] albicans [**2-/2102**]. Multiple r/o for TB negative. Pt did not comply with course of anti-fungals, had 3 AFB smears here which were nagative - h/o C. diff colitis - h/o IVDA per OSH records (pt notes only cocaine iv) - HBV (core Ab, surface Ab positive [**2102-6-23**]) - HCV ([**2102-6-23**]) - HIV negative [**2102-6-23**] Social History: Social History: Tobacco, unable to say how long, [**1-3**] PPD currently. Prior to that he smoked 1 ppd. Heavy EtOH use, currently 1L vodka daily. Sober x10 years, started drinking again 2 years ago. Also reports cocaine and marijuana. Sexually active with his girlfriend Family History: Mother - CAD. Sister - h/o CVA. Reports his father was the "[**Location (un) 86**] [**Location (un) 23530**]," and that he and his mother changed their names after his arrest, etc. Physical Exam: VITALS: T 98 P 110 BP 170/115 RR 20 O2sat 98%RA GENERAL: Resting in bed, alert, NAD; very talkative, wants to share stories about how he got "hooked" on ETOH as a kid growing up in Europe [**Location (un) 4459**]: Sclera anicteric, PERRL, EOMI, MMM NECK: Flat JVP CV: RRR, no MRG LUNGS: CTAB except for few crackles b/l bases ABDOMEN: NABS, soft, NTND, no HSM EXTREMITIES: No CCE SKIN: No jaundice, no spider angioma NEURO: CN II-XII intact, A&Ox3, biceps reflex [**2-5**], no tremulousness or asterixis Pertinent Results: [**2102-9-29**] 08:45PM GLUCOSE-99 UREA N-3* CREAT-0.9 SODIUM-140 POTASSIUM-3.4 CHLORIDE-105 TOTAL CO2-27 ANION GAP-11 [**2102-9-29**] 08:45PM ALT(SGPT)-27 AST(SGOT)-41* CK(CPK)-91 ALK PHOS-62 TOT BILI-0.3 [**2102-9-29**] 08:45PM cTropnT-<0.01 [**2102-9-29**] 08:45PM CK-MB-NotDone [**2102-9-29**] 08:45PM CALCIUM-8.9 PHOSPHATE-2.9 MAGNESIUM-2.2 [**2102-9-29**] 02:10PM GLUCOSE-114* UREA N-3* CREAT-0.9 SODIUM-141 POTASSIUM-3.1* CHLORIDE-107 TOTAL CO2-25 ANION GAP-12 [**2102-9-29**] 02:10PM CK(CPK)-100 [**2102-9-29**] 02:10PM CK-MB-3 cTropnT-<0.01 [**2102-9-29**] 02:10PM CALCIUM-8.4 PHOSPHATE-3.0 MAGNESIUM-1.4* [**2102-9-29**] 06:36AM URINE HOURS-RANDOM [**2102-9-29**] 06:36AM URINE HOURS-RANDOM [**2102-9-29**] 06:36AM URINE GR HOLD-HOLD [**2102-9-29**] 06:36AM URINE bnzodzpn-POS barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG [**2102-9-29**] 03:37AM GLUCOSE-97 UREA N-4* CREAT-0.9 SODIUM-146* POTASSIUM-3.5 CHLORIDE-108 TOTAL CO2-26 ANION GAP-16 [**2102-9-29**] 03:37AM estGFR-Using this [**2102-9-29**] 03:37AM ALT(SGPT)-29 AST(SGOT)-44* CK(CPK)-110 ALK PHOS-63 AMYLASE-20 TOT BILI-0.3 [**2102-9-29**] 03:37AM LIPASE-36 [**2102-9-29**] 03:37AM cTropnT-<0.01 [**2102-9-29**] 03:37AM CK-MB-3 ECG: Sinus tachycardia. Diffuse non-diagnostic repolarization abnormalities. Compared to previous tracing of [**2102-9-20**] the heart rate is increased. Otherwise, no major change. CHEST (PORTABLE AP) Reason: Evaluate for infiltrate/edema [**Hospital 93**] MEDICAL CONDITION: 47 year old man with hx of cocaine abuse, EtOH abuse, alcoholic cardiomyopathy presents chest pain REASON FOR THIS EXAMINATION: Evaluate for infiltrate/edema INDICATION: 47-year-old man with history of cocaine and alcohol abuse, with alcoholic cardiomyopathy who presents with chest pain. COMPARISON: [**2102-9-18**]. AP UPRIGHT CHEST: The cardiac, mediastinal, and hilar contours appear unremarkable and unchanged given differences in technique. The biapical pleural thickening with the left-sided cavitary lesion unchanged compared to the prior study. Vertically oriented linear opacities in the upper lobes are also stable consistent with scarring. The remainder of the lungs are clear. No pleural effusions are seen. The osseous structures demonstrate no gross abnormalities. IMPRESSION: No change since [**2102-9-18**]. Brief Hospital Course: A/P [**9-30**]: 47M h/o HTN, polysubstance abuse, admitted for alcohol withdrawal management, ruled out for MI. . # Alcohol Dependence/withdrawal/Anxiety: Pt was started on CIWA protocal with Diazepam 30mg PO q3 hours for CIWA >10 and then tapered off. He was given MVI, thiamine, folate PO during admission. He was completely off Diazepam by hospital day #3. He was seen and evaluated by psychiatry who felt diazepam should only be used in this patient was tachycardic or hypertensive given his history of large doses of benzos and hypotensive episodes. Pt was started on Zyprexa TID for anxiety in place of benzos with good result. . # Malignant Hypertension: he presented to the ED with malignant HTN with SBP 220/110 with chest pain. He was started on a nitroglycerine IV drip and transferred to the ICU. Pt was weaned off nitroglycerine and oral medications were titrated as needed. Pt was sent home on Lisinopril 20mg daily. . #Suicidal [**Name (NI) 23535**] Pt admitted to girlfriend during [**Name2 (NI) **] stay that he was suicidal and wanted to use scissors to injure himself. During remainder of his stay he was without SI and he contracted for safety. He was seen and evaluated by psychiatry during the stay who felt he was able to contract for safety and did not require a 1:1 sitter or further intervention. He had follow up with psychiatry as outpatient upon discharge. . Medications on Admission: MEDICATIONS: Patient states he does not take any medications at home due to concern of the medication interacting with ETOH. Medications on last discharge are below Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Buspirone 10 mg Tablet Sig: One (1) Tablet PO BID Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Medications: 1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Buspirone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Facility: Father [**Name (NI) **] Discharge Diagnosis: ETOH Withdrawal HTN Urgency Discharge Condition: improved. Discharge Instructions: You came into the hospital with chest pain and found to be have a very high blood pressure. You were also treated for Etoh withdrawal. Your dose of Lisinopril was increased from 5mg daily to 20mg daily to help control your blood pressure. Followup Instructions: You will need to follow up with the case manager at Father [**Name (NI) **] [**Name (NI) 23536**] who will help you apply to the [**Hospital **] rehabilitation program.

[ "303.91", "070.54", "425.5", "401.0", "291.81", "V62.84", "070.32", "428.0", "244.9", "276.0", "428.22" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8640, 8681

6115, 7510

326, 332

8753, 8765

3733, 5225

9054, 9226

3011, 3193

8011, 8617

5262, 5361

8702, 8732

7536, 7988

8789, 9031

3208, 3714

276, 288

5390, 6092

360, 1878

1900, 2705

2737, 2995

11,671

100,488

5249

Discharge summary

report

Admission Date: [**2147-4-25**] Discharge Date: [**2147-5-6**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor Last Name 10493**] Chief Complaint: guaiac positive stool Major Surgical or Invasive Procedure: colonoscopy EGD with cauterization of AVM capsule endoscopy History of Present Illness: 88M with CAD, atrial fibrillation on coumadin, CHF with EF of 35% (end-stage per prior notes), s/p placement of VVI pacer who presents after PCP found him to be guaiac positive on DRE. Patient has not noted bleeding himself, although he has previously noted some small red spots on the toilet paper. He has not seen streaks of blood in his stool of blood in the toilet. He also denies melanotic stool. He denies previous issues with GI bleeding (although previous discharge summaries document this history). His last full colonoscopy was in [**2141**] where he was found to have a rectal polyp (adenoma) which was removed. He denies recent history of worsening fatigue (patient reports chronic fatigue), lightheadedness, tachycardia. Of note he was recently discharged from [**Hospital1 18**] after a fall. 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. ([**5-17**] 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 15. VVI Pacemaker Placed [**8-17**] Social History: Single. He lives with his sister who is in her 90's. He and his sister have services at home and receive help from other relatives. [**Name (NI) 1094**] HCP is his [**First Name9 (NamePattern2) 21457**] [**Name (NI) **]. [**Name2 (NI) **] uses a walker to get around. He does not drive. He denies any tobacco history. Rare glass of wine. Family History: Positive for coronary artery disease and breast cancer. Physical Exam: 98.6 102/62 68 22 99%RA Gen: well-appearing elderly male, NAD HEENT: mucous membranes moist Chest: bibasilar crackles CV: RRR nl s1 and s2 no murmurs Abd: BS+ nontender nondistended Extrem: 1+ pedal edema to mid-shin. left shin with healing ulcer anteriorly Neuro: A+Ox3 Pertinent Results: [**2147-4-25**] 03:10PM BLOOD WBC-7.3 RBC-3.97* Hgb-11.2* Hct-34.1* MCV-86 MCH-28.3 MCHC-32.9 RDW-17.6* Plt Ct-184 [**2147-4-25**] 03:10PM BLOOD Neuts-67.9 Lymphs-22.7 Monos-5.9 Eos-3.0 Baso-0.5 [**2147-4-25**] 03:10PM BLOOD PT-29.4* PTT-34.7 INR(PT)-3.0* [**2147-4-25**] 03:10PM BLOOD Glucose-113* UreaN-40* Creat-1.3* Na-136 K-4.9 Cl-99 HCO3-25 AnGap-17 [**2147-4-25**] 03:19PM BLOOD Hgb-11.8* calcHCT-35 Brief Hospital Course: Hospital Course: 88 yo M with CAD, AF on coumadin, CHF, presenting with guaiac-positive stool, treated for GI bleed, with 2 MICU admission for hypotension, now stable. . # GI bleed: After reversal of her INR with vitamin K the patient underwent EGD, colonoscopy and capsule study. EGD showed an AVM which was cauterized. The colonoscopy showed polyps which were not removed. Capsule study showed nonbleeding red spots. The decision was made for the patient not to restart anticoagulation. He should have repeat colonoscopy and enteroscopy as an out-patient. The patient's PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1007**] will help arrange for this. . #AFib: The patient was continued on digoxin. Metoprolol was held during episodes of hypotesion but was restarted and tolerated well. Anti-coagulation was defered to the out-patient setting. . #chronic systolic CHF: Initially the patient was slightly volume overloaded (with crackles and pedal edema on exam). While NPO the patient was diuresed and exam was euvolemic. As his creatinine was then elevated, diuretics then stopped prior to colonoscopy. After colonoscopy patient became septic so patient was given fluids and became further volume overloaded. On transfer to ICU, bumetanide, spironolactone, metoprolol, lisinopril held. Digoxin was continued. On discharge the patient was breathing comfotably and satting well on room air. . #Septic Shock: After colonoscopy/EGD/capsule study the patient was febrile and hypotensive. This prompted an ICU transfer. Blood cultures grew MRSA in [**4-14**] bottles in 12hrs. The source felt to possibly be left lower extremity ulcer and/or right wrist abscess. A TTE did not show valvular lesions to suggest endocarditis. The patient was discharged to the floor without the need for pressors in the ICU. The patient again had an episode of low-grade hypotension prompting an ICU transfer. However, the patient remained stable off pressors and was transfered back to the floor. The patient was restarted on his metoprolol and continued on his ACE-inhibitor without further episodes of hypotension. The patient is to be continued on a 14 day course of vancomycin (day 1=[**4-29**]) for the bacteremia. . #CAD: The patient was continued on his statin. His aspirin was held given the GI bleed. Re-addition of aspirin was deferred to the out-patient setting. The patient's beta-blocker and ACE were added back as his pressure tolerated, as above. . # Aspiration pneumonia: On the patient's second transfer to the ICU as above an chest X-ray demonstrated a possible right sided infiltrate. There was some question of aspiration at the time. The patient was started on a ten day course of levofloxacin/flagyl (day 1=[**5-4**]). . # rash: The patient was seen by derm and diagnosed with likely miliaria rubra. He was started on a one week course of triamcinolone. He was also found to have several actinic keratoses on skin exam and was recommended to follow-up with dermatology as an out-patient. . # BPH: The patient's flomax was held in the setting of hypotension. Re-starting of the medication will be deferred to the out-patient setting. . #Depression: The patient was continued on his home celexa. . #Hypothyroidism: The patient was continued on levothyroxine. . #Code: Full code, discussed with patient and family Medications on Admission: per recent d/c summary: atorvastatin 40mg daily flomax 0.4mg citalopram combivent inhaler 1-2 puffs q6:prn asa 81mg allopurinol 50mg daily bumetanide 2mg [**Hospital1 **] lisinopril 2.5mg daily digoxin 0.125mg daily aldactone 25mg daily levothyroxine 25mcg daily warfarin 5mg daily metoprolol SR 25mg daily Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Allopurinol 100 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 8. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) treatment Inhalation Q6H (every 6 hours) as needed. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 12. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 13. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) for 1 weeks: Start date [**2147-5-4**]. End date [**2147-5-10**]. 14. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 16. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous once a day for 2 weeks: Start date: [**2147-4-29**] End date: [**2147-5-12**]. 17. Levofloxacin in D5W 750 mg/150 mL Piggyback Sig: One (1) Intravenous Q48H (every 48 hours) for 10 days: Start date: [**2147-5-4**] End date: [**2147-5-13**]. 18. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours) for 10 days: Start date: [**2147-5-4**] End date: [**2147-5-13**]. 19. Insulin Regular Human 100 unit/mL Solution Sig: PER SLIDING SCALE units Injection ASDIR (AS DIRECTED): PER SLIDING SCALE. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: MRSA bacteremia suspected pneumonia gastrointestinal bleed acute renal failure Congestive Heart Failure--Systolic and Diastolic dysfunction Discharge Condition: Stable. The patient is asymptomatic and his vitals are stable. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Take all medications as prescribed. Follow-up with your appointments as below. Call your doctor or return to the emergency room if you experience: --chest pain --shortness of breath --fever or chills --nausea or vomiting --abdominal pain --any other symptom that concerns you Followup Instructions: You should follow-up with the appointments below: . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**], MD Phone:[**Telephone/Fax (1) 142**] Date/Time:[**2147-5-9**] 9:30 . Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2147-5-29**] 3:00 . Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2147-6-6**] 8:30 . You were noted to have several actinic keratoses and a lesion concerning for NMSC along the right wrist. These lesions will need to be followed up as an outpatient. You should follow up with Dr. [**Last Name (STitle) **] in dermatology. His phone number is [**Telephone/Fax (1) 3965**]. Your caregivers at [**Hospital 100**] Rehab can help you set up an appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]

[ "507.0", "428.43", "682.3", "V58.61", "244.9", "427.31", "785.52", "428.0", "211.3", "537.83", "V10.83", "V45.81", "038.11", "274.9", "V45.01", "995.92", "584.9" ]

icd9cm

[ [ [] ] ]

[ "45.19", "44.43", "45.23", "86.04" ]

icd9pcs

[ [ [] ] ]

8651, 8717

2986, 2986

284, 346

8902, 8967

2555, 2963

9395, 10358

2191, 2248

6680, 8628

8738, 8881

6348, 6657

3003, 6322

8991, 9372

2263, 2536

223, 246

376, 1192

1214, 1818

1834, 2175

48,951

186,204

39534+58300

Discharge summary

report+addendum

Admission Date: [**2145-8-6**] Discharge Date: [**2145-8-10**] Date of Birth: [**2060-8-12**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2901**] Chief Complaint: Chest pain and shortness of breath Major Surgical or Invasive Procedure: Cardiac catheterization with placement of DES x2 in LAD History of Present Illness: 84 yo h/o HTN, Stage III CKD, c/o 3 weeks of worsening chest pain. Three weeks prior, the patient was walking in [**Location (un) 21601**] from 57th Street to 42nd street to attend a play ([**First Name8 (NamePattern2) 12239**] [**Last Name (NamePattern1) 5279**]). Approximately [**3-4**] blocks into his walk, he developed sharp chest pain along the anterior chest in a band like pattern associated with SOB. Denies diaphoresis, palpitations, N/V, lightheadedness. He did not stop and rest, but continued to walk. The pain persisted until he sat down to watch the play. In the days following, he continued to have pain upon exertion, occuring shorter distances (approximately 100 feet). Today, the patient first complained of chest pain driving to [**Location (un) 86**] that was releived with 1 SL NTG. Patient was staying in his vacation home in [**Location (un) 57605**], MA over the course of three weeks and eventually saw an internist Monday, 5 days prior to admission. An ekg was performed, and patient was told he had an MI. He was given a prescription for SL NTG and told to double his aspirin to 162 daily. He was sent for a nuclear stress test two days prior to admission. This showed large areas of infarct and smaller areas of peri-infarct ischemia involving the LAD and RCA. LCx appears relatively spared. Severely depressed LV systolic function (EF: 35%). Given these findings, the patient made an appointment with Dr. [**Last Name (STitle) **] today. He was noted to be volume overloaded. He was then directly admitted for further management of ACS and volume overload. Upon arrival to the CCU, he was chest pain free and had no complaints. Past Medical History: ?Hyperthyroidism x 6 years Hypertension Chronic Kidney Disease [**2-2**] Hypertensive nephrosclerosis (Baseline Cr per patient 2.1) H/O resected colon cancer in [**2135**] found on routine colonoscopy. Colonoscopy one year ago was reportedly normal. Cervical Degenerative Disc disease Alergic Rhinitis s/p right shoulder replacement s/p hip left replacement Social History: Married. Spends half year in [**State 108**] and the other half in MA. Retired CFO of [**Hospital3 **] -Tobacco history: 60 pack hear history, quit 30 years ago -ETOH: Drinks [**1-2**] shots of [**First Name4 (NamePattern1) 4884**] [**First Name4 (NamePattern1) 4886**] [**Last Name (NamePattern1) 4887**] Lable x 60+years -Illicit drugs: Denies Family History: Father died of Prostate Cancer at 85. Mother died of stomach cancer at 90, Sister died of breast cancer at 60. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: T: 36.6 HR: 61 BP: 119/66 RR: 18 O2Sa: 97% RA GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. Shaving. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. 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. Resp were unlabored, no accessory muscle use. Occasional bibasilar crackles. no wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. No back tenderness EXTREMITIES: No c/c. Trace edema at the ankles. No groin hematoma or swelling, mild tenderness. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Pertinent Results: [**2145-8-10**] 06:02AM BLOOD PT-13.2 PTT-24.7 INR(PT)-1.1 [**2145-8-8**] 11:50PM BLOOD PT-13.8* PTT-69.5* INR(PT)-1.2* [**2145-8-8**] 06:02AM BLOOD PT-13.3 PTT-71.4* INR(PT)-1.1 [**2145-8-7**] 05:20AM BLOOD Glucose-97 UreaN-30* Creat-1.5* Na-137 K-4.0 Cl-104 HCO3-23 AnGap-14 [**2145-8-7**] 07:55PM BLOOD Creat-1.5* Na-136 K-4.1 Cl-101 [**2145-8-9**] 06:16PM BLOOD UreaN-26* Creat-1.5* Na-135 K-4.4 Cl-99 [**2145-8-10**] 06:02AM BLOOD Glucose-98 UreaN-23* Creat-1.6* Na-137 K-4.4 Cl-101 HCO3-27 AnGap-13 [**2145-8-6**] 10:36PM BLOOD CK-MB-3 cTropnT-0.21* [**2145-8-7**] 05:20AM BLOOD CK-MB-3 cTropnT-0.22* [**2145-8-8**] 11:50PM BLOOD CK-MB-2 cTropnT-0.13* [**2145-8-10**] 06:02AM BLOOD CK-MB-5 [**2145-8-6**] 03:54PM BLOOD %HbA1c-5.8 eAG-120 [**2145-8-6**] 03:54PM BLOOD Triglyc-88 HDL-74 CHOL/HD-2.4 LDLcalc-83 [**2145-8-6**] 03:54PM BLOOD TSH-4.7* [**2145-8-7**] 05:20AM BLOOD T4-6.2 T3-77* Free T4-1.1 Echocardiogram Report: Date/Time: [**2145-8-7**] at 11:13 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], 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: West CCU Contrast: None Tech Quality: Adequate Tape #: 2010W051-0:26 Machine: Vivid [**7-8**] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 3.5 cm <= 4.0 cm Left Atrium - Four Chamber Length: 5.1 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.6 m/s Left Atrium - Peak Pulm Vein D: 0.4 m/s Left Atrium - Peak Pulm Vein A: 0.3 m/s < 0.4 m/s Right Atrium - Four Chamber Length: 4.4 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 0.8 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.3 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 2.6 cm Left Ventricle - Fractional Shortening: 0.40 >= 0.29 Left Ventricle - Ejection Fraction: 35% to 40% >= 55% Left Ventricle - Lateral Peak E': *0.07 m/s > 0.08 m/s Left Ventricle - Septal Peak E': *0.06 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 11 < 15 Aorta - Sinus Level: *4.1 cm <= 3.6 cm Aorta - Ascending: *4.3 cm <= 3.4 cm Aorta - Arch: *3.3 cm <= 3.0 cm Aortic Valve - Peak Velocity: 1.1 m/sec <= 2.0 m/sec Aortic Valve - Pressure Half Time: 459 ms Mitral Valve - E Wave: 0.7 m/sec Mitral Valve - A Wave: 0.5 m/sec Mitral Valve - E/A ratio: 1.40 Mitral Valve - E Wave deceleration time: 178 ms 140-250 ms TR Gradient (+ RA = PASP): 19 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Moderate regional LV systolic dysfunction. No LV mass/thrombus. False LV tendon (normal variant). No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Moderately dilated aortic sinus. Moderately dilated ascending aorta. Mildly dilated aortic arch. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No MS. Trivial MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Mild [1+] TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: No PS. PERICARDIUM: No pericardial effusion. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with distal LV an apical akinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The ascending aorta is moderately 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. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. [**2145-8-9**] Cardiac Catheterization Report: Left Heart Catheterization: was performed by percutaneous entry of the right femoral artery, using a 5 French angled pigtail catheter, advanced to the left ventricle through a 6 French introducing sheath. Coronary Angiography: was performed in multiple projections using a 5 French JL4 and a 5 French JR4 catheter, with manual contrast injections. Percutaneous coronary revascularization was performed using placement of drug-eluting stent(s). Conscious Sedation: was provided with appropriate monitoring performed by a member of the nursing staff. HEMODYNAMICS RESULTS BODY SURFACE AREA: m2 HEMOGLOBIN: gms % FICK **PRESSURES AORTA {s/d/m} 150/71/102 OTHER HEMODYNAMIC DATA: The oxygen consumption was assumed. **ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM **RIGHT CORONARY 1) PROXIMAL RCA DISCRETE 30 2) MID RCA NORMAL 2A) ACUTE MARGINAL NORMAL 3) DISTAL RCA DISCRETE 50 4) R-PDA NORMAL 4A) R-POST-LAT NORMAL 4B) R-LV NORMAL **ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM **LEFT CORONARY 5) LEFT MAIN NORMAL 6) PROXIMAL LAD NORMAL 6A) SEPTAL-1 NORMAL 7) MID-LAD DISCRETE 100 8) DISTAL LAD NORMAL 9) DIAGONAL-1 NORMAL 10) DIAGONAL-2 NORMAL 11) INTERMEDIUS NORMAL 12) PROXIMAL CX DISCRETE 30 13) MID CX NORMAL 13A) DISTAL CX NORMAL 14) OBTUSE MARGINAL-1 DISCRETE 40 15) OBTUSE MARGINAL-2 NORMAL 16) OBTUSE MARGINAL-3 NORMAL 17) LEFT PDA NORMAL 17A) POSTERIOR LV NORMAL **PTCA RESULTS LAD PTCA COMMENTS: Initial angiography revealed a mid LAD 100% total occlusion after the first diagonal branch. We planned to treat this total occlusion with PTCA/stenting and heparin was started prophylactically. A 6Fr long sheath was exchanged in for right femoral access and a [**Doctor Last Name **] 3 guide provided good support for the procedure. A Prowater wire was used to cross the mid LAD total occlusion with minimal difficulty. We pre-dilated the mid LAD lesion with an Apex OTW 2.75x15mm balloon at 12atm for 10sec. The Promus OTW 2.75x23mm drug-eluting stent (DES), however, would not cross the mid LAD lesion. We then introduced a Choice PT [**Name (NI) 9165**] Intermediate as a buddy wire and were then able to advance the stent into position. The Promus OTW 2.75x23mm DES was then deployed in the mid LAD at 16atm for 10sec. After further angiographic inspection, we then deployed a Promus OTW 2.5x12mm DES to overlap the distal portion of the previous stent. We then post-dilated the distal overlapping stent with an NC Quantum Maverick OTW 2.75x15mm balloon (max 21atm, 10sec) and the proximal overlapping stent with an NC Quantum Maverick 3.0x15mm balloon (max 22atm, 10sec). Final angiography revealed 0% residual stenosis, no angiographically apparent dissection and TIMI 3 flow established in LAD. R 6Fr femoral artery long sheath removed and angioseal closure devive deployed with no complications. The patient left the cath lab angina-free and in hemodynamically stable condition. TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 1 hour 55 minutes. Arterial time = 1 hour 49 minutes. Fluoro time = 36.6 minutes. IRP dose = 5076 mGy. Contrast injected: Non-ionic low osmolar (isovue, optiray...), vol 405 ml Premedications: Midazolam 0.5 mg IV Fentanyl 25 mcg IV Anesthesia: 1% Lidocaine subq. Anticoagulation: Heparin 4500 units IV Other medication: Plavix 600mg po Nitroglycerin 600mcg ic Cardiac Cath Supplies Used: - [**Company **], CHOICE PT EXTRA SUPPORT 300CM - [**Company **], CHOICE PT [**Name (NI) **] INTERMEDIATE 300CM 2.0MM [**Company **], MAVERICK 15MM 2.75MM [**Company **], MAVERICK 15MM 2.75MM [**Company **], QUANTUM MAVERICK 15MM 3.0MM [**Company **], QUANTUM MAVERICK 15MM 6FR CORDIS, XBLAD 4.5 6FR CORDIS, XB 4.5 6FR [**First Name8 (NamePattern2) **] [**Male First Name (un) **], ANGIOSEAL VIP - ALLEGIANCE, CUSTOM STERILE PACK - MERIT, LEFT HEART KIT - [**Doctor Last Name **], PRIORITY PACK 20/30 2.75MM [**Company **], PROMUS OTW 23MM 2.5MM [**Company **], PROMUS OTW 12MM COMMENTS: 1. Coronary angiography of this right dominant system revealed 3 vessel coronary artery disease. The LMCA had no angiographically significant coronary artery disease. The LAD had 100% occlusion in the mid-section after the 1st diagonal. The LCx had 30% proximal stenosis and 40% in the OM. The RCA had 30% proximal stenosis and 50% distal. 2. Partial resting hemodynamics revealed mildly elevated systemic arterial systolic with a SBP of 150mmHg and a normal systemic arterial diastolic pressure with a DBP of 71mmHg. 3. Successful PTCA/stenting of the mid LAD total occlusion with an overlapping Promus OTW 2.75x23mm drug-eluting stent (DES) post-dilated to 3.0mm with a Promus OTW 2.5x12mm [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]-dilated to 2.75mm distally. Final angiography revealed 0% residual stenosis, no angiographically apparent dissection and TIMI 3 flow established (see PTCA comments). 4. R 6Fr femoral artery sheath removed and closed with Angioseal closure device with no complications post procedure. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease 2. Mild systemic arterial systolic hypertension. 3. Successful PTCA/stenting of the mid LAD total occlusion with an overlapping Promus OTW 2.75x23mm drug-eluting stent (DES) post-dilated to 3.0mm with a Promus OTW 2.5x12mm [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 22595**] post-dilated to 2.75mm. 4. ASA indefinitely; clopidogrel 150mg daily x seven days followed by 75mg daily for at least 12 months. 5. Monitor renal function with large contrast load during procedure. [**Hospital1 18**] ATTENDING OF RECORD: [**Last Name (LF) **],[**First Name3 (LF) **] E. REFERRING PHYSICIAN: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) 251**] [**Doctor Last Name 640**] FELLOW: [**Last Name (un) **],FAIZUL [**Last Name (LF) **],[**First Name3 (LF) **] INVASIVE ATTENDING STAFF: [**Last Name (LF) **],[**First Name3 (LF) **] E. Brief Hospital Course: 84 yo M h/o HTN, CKD stage III, p/w ongoing chest pain concerning for UA/NSTEMI as well as concern for CHF exacerbation. # Unstable Angina/ACS - Patient appeared to have anterior infarct of unknown age, evidenced by both EKG, echocardiogram, and nuclear stress test. The patient was kept on a heparin gtt over the weekend to therapeutic PTT level. Patient had echocardiogram that showed EF of 35-40% with akinesis of the distal LV and apex with hypokinesis of the anterior wall. Coumadin was started for risk of thrombus formation due to his LV akinesis. He was stable throughout the weekend with one episode of chest pain, located in his axilla, that was relieved with 3 doses of nitro and Tylenol, we attribute this episode of cp to unstable angina. He had a cardiac catheterization on [**8-9**] that showed three vessel disease with 100% occlusion of his mid LAD. Two [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 10157**] were placed with good result. Patient also had 30% occlusion of RCA and circumflex. Patient was discharged on Toprol XL 50mg, and simvastatin 80mg daily. Patient also started on Plavix 150mg for 7 days followed by Plavix 75mg once a day thereafter. Aspirin was increased to 325mg a day. Patient will initially be followed by [**Hospital 197**] clinic in [**Location (un) **], MA associated with Dr.[**Name (NI) 87306**] office. Patient was chest pain free and had no difficulty ambulating at discharge. Patient will follow up with Dr. [**Last Name (STitle) **] on [**2145-9-24**] at [**Hospital1 **] and a cardiac MRI will be scheduled prior to that appointment. . # CHF - On arrival, the patient had bilateral crackles as well as bilateral pitting edema, and evidence of pulmonary congestion on CXR. He was given IV lasix with good urine output and improvement of his edema and crackles. Patient received total of 60mg of IV Lasix and was negative 5 liters for LOS. Patient was discharged with instructions to follow a low salt diet with fluid restriction. . #Chronic Kidney Disease: Patient reported baseline creatinine of 2.1, with creatinine of 1.7 in admission. After treatment with lasix, creatinine improved to 1.5. Patient was pre-treated with acetylcysteine in preparation for contrast that would be received during catheterization. Patient received 400cc of contrast during his catheterization and was then given 600cc of D5NS with total of 90meq of HCO3. Patient's creatinine increased mildly to 1.6 the following day. Patient will have BMP for evaluation of electrolytes and kidney function on Friday [**2145-8-13**] at Dr.[**Name (NI) 87306**] clinic in [**Location (un) **], MA. . #Hypertension: Patient was taking amlodipine and lisinopril at time of admission. He was started on metoprolol initially, with good control of blood pressure. His lisinopril was held [**2-2**] elevated serum cr; also held at discharge in preparation for insult that may result to the kidneys after receiving contrast during catheterization. Patient can be restarted on low dose ACEi after evaluation of his kidney function as an outpatient. Patient discharged on Toprol XL 50mg daily. . #Hyperthyroidism: Patient has history of hyperthyroidism, taking methimazole daily. Thyroid function tests suggested subclinical hypothyroidism with mildly elevated TSH and normal free T4, low T3. Patient will be reevaluated as outpatient in [**2-3**] months. . #Dispo: Patient was discharged with new medications including Plavix, Metoprolol, Coumadin, simvastatin, and increased dose of aspirin. Patient's lisinopril was held until further evaluation of kidney function occurs. Patient will follow up in [**Hospital 197**] clinic associated with Dr.[**Name (NI) 87306**] office in [**Location (un) **], MA on [**2145-8-13**] and [**2145-8-16**], with appointment to see Dr. [**Last Name (STitle) **] on [**2145-8-18**]. Patient will follow up with Dr. [**Last Name (STitle) **] on [**2145-9-24**]. Medications on Admission: Amlodipine 5 mg daily Loratadine 10 mg daily Flonase ASA 81 daily (has taken 162 daily x 5 days) Lisinopril 2.5 mg daily Methimazole 2.5 mg daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0* 3. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. Flonase 50 mcg/Actuation Spray, Suspension Sig: One (1) two puffs to each nostril Nasal once a day. 5. Methimazole 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 7. Clopidogrel 75 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 7 days: Take two tablets once a day for 1 week, than take 1 tablet once a day. Disp:*37 Tablet(s)* Refills:*0* 8. Outpatient Lab Work Please check a PT, PTT, INR, and Chem7 on Friday [**2145-8-13**] and [**2145-8-16**], and fax results to Dr. [**First Name4 (NamePattern1) 6382**] [**Last Name (NamePattern1) **]. If you do not hear back from Dr. [**Last Name (STitle) **] by the end of the day regarding your coumadin dose, please call him at [**Telephone/Fax (1) 54377**] 9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*90 Tablet(s)* Refills:*2* 10. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2* 11. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*90 Tablet(s)* Refills:*2* 12. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*90 Tablet(s)* Refills:*2* 13. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* **2 Rx for metoprolol, asa, simvastatin, and plavix bc pt fills temp rx at CVS and awaits monthly rx via express scrips (mail) Discharge Disposition: Home Discharge Diagnosis: Myocardial infarction with occlusion of LAD Discharge Condition: Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Discharge Instructions: You were admitted to [**Hospital1 69**] for chest pain that you experienced 3 weeks ago. You were admitted to the CCU where we diuresed you, and you had a cardiac catheterization performed on [**2145-8-9**]. Two drug eluting stents were placed in one of the arteries that feed your heart, the LAD. You will need to be started on some new medications as listed below. Please be sure to continue to take plavix, as this medication is very important. Your medications have changed. Please make note of the following changes: - Please START taking PLAVIX - take 2 tablets once a day for 1 week, then 1 tablet a day following that - Please INCREASE your aspirin dose to 325 mg a day - Please START taking metoprolol XL 50 mg once a day - Please START taking simvastatin 80 mg once a day - Please START taking coumadin (warfarin) 3 mg once a day - you will need to follow up with the coumadin clinic in order to figure out the best maintenance dose. You will want your INR to be between [**2-3**]. - Please STOP taking amlodipine - Please STOP taking lisinopril It will be very important for you to follow up in the coumadin clinic to further manage your coumadin dosing. The rest of your medications have not changed. Please continue to take them as originally prescribed. Followup Instructions: Please go to Dr.[**Name (NI) 87306**] clinic ([**Location (un) 87307**], [**Location (un) **], [**Numeric Identifier 54380**]) for blood work on Friday [**2145-8-13**] at 10:30, and Monday [**2145-8-16**] at 10:45. You will see Dr. [**Last Name (STitle) **] for follow up on Wednesday [**2145-8-18**] at 10:45 You will need to follow up with Dr. [**Last Name (STitle) **] on [**9-24**] at 3:20pm. Prior to this visit you will need to get a Cardiac MRI done. [**Doctor First Name **], from Dr.[**Name (NI) 7914**] office will call you regarding the time and date. If you have not heard from her within 2-3 days please call [**Telephone/Fax (1) 10464**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**] Name: [**Known lastname 12728**],[**Known firstname **] Unit No: [**Numeric Identifier 13837**] Admission Date: [**2145-8-6**] Discharge Date: [**2145-8-10**] Date of Birth: [**2060-8-12**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 949**] Addendum: Pt admitted for volume overload [**2-2**] acute on chronic systolic congestive heart failure (EF on ECHO 35%). Discharge Disposition: Home [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 950**] MD, [**MD Number(3) 951**] Completed by:[**2145-9-24**]

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Discharge summary

report

Admission Date: [**2171-12-4**] Discharge Date: [**2171-12-14**] Date of Birth: [**2117-5-3**] Sex: M Service: MEDICINE Allergies: Percocet Attending:[**Last Name (NamePattern1) 4377**] Chief Complaint: shortness of breath, lower extremity edema Major Surgical or Invasive Procedure: Pericardiocentesis, tunneled catheter exchange History of Present Illness: Mr. [**Known lastname 63305**] is a 54-year-old man with a history of AML 11 months s/p matched related allo SCT with busulfan/cyclophosphamide conditioning with complications of CMV viremia, GVHD and hemorrhagic cystitis, and longstanding disseminated TB s/p treatment, who presented on [**2171-12-4**] to [**Hospital 478**] clinic with 2-day h/o cough, SOB. No fever, chills, URI symptoms, hemoptysis, chest pain, palpitations, N/V/D, weight change, urinary symptoms, or change in BMs. He also noted discomfort in his left eye which had been bothering him for 1 month. Denied eye pain. . Past Medical History: ONC HISTORY (per OMR): 1. Diagnosed in early [**8-/2169**] with nightly fevers. BM bx revealed AML. Flow cytometry showed aberrant expression of CD2, CD7, HLA-DR, CD 34, dim CD33, CD 117, and CD 71. CT scan revealednecrotic lymph nodes in the superior mediastinum and periportalregion, and multiple low attenuation lesions in the liver and spleen concerning for microabscesses from a disseminated infection. 2. [**2169-8-17**]: Induction chemotherapy with cytarabine and idarubicin complicated by persistent fevers and extensive workup ultimately revealing disseminated tuberculosis infection. His course was also complicated by rapid atrial fibrillation and hypotension and the development of a severe cardiomyopathy. 3. S/P one dose of high-dose ARA-C at 1.5 mg per meter squared, lowered dose due to his disseminated tuberculosis, and then he received a second course of HiDAC at 3 gram per meter squared dose and developed acute onset of gait instability. No further chemotherapy given. 4. Relapsed in 7/[**2170**]. [**Year (4 digits) **] re-induction with ME on [**2170-8-13**]. Noted for pulmonary nodules which were suspicious for aspergillus and empirically treated with Voriconazole with improvement noted on CT. 5. Admitted on [**2170-10-25**] for maintenance therapy while awaiting BMT. However, upon admit he was again found to have blasts. He proceeded with Idarubicin and Cytarabine(7+2) butdid not achieve a remission. 6. S/P High dose Ara-c with remission. 7. [**Year (4 digits) **] sibling related allo transplant on [**2171-1-8**]. Allo course c/b increased LFTs of unclear etiology, possibly from chemotherapy, renal failure attributed to CSA, and received only 1 dose of MTX due to mucositis. 8. Post transplant course complicated by asymptomatic CMV viremia and viral/URI syndromes. 9. In [**2171-5-12**] developed diarrhea with e/o GVH on endoscopy. He also had hematuria, but no evidence of BK virus. He started photopheresis. Diarrhea abated but LFTs rose. Therapy attempted for GVH of liver using pulse of prednisone and increase in CellCept with stabilization but no significant improvement. 10. Received 1mg of Pentostatin on [**2171-6-14**]. 11. Liver Biopsy c/w GVHD. Started Rituxan for 4 weeks in 5/[**2171**]. Non-onc PMH - Disseminated TB - s/p treatment with INH, levofloxacin and rifabutin - Hypertension and a heart murmur - Diabetes mellitus type 2 - Chemo related heart failure and cardiomyopathy, EF 35-40% [**12-16**] - h/o atrial fibrillation, recent EKGs in NSR - CMV viremia ([**2-17**]) Social History: He is married and lives at home with his wife & children. He is a machine operator, but is currently not working. He immigrated from [**Country 5976**] in early [**2144**]. He smoked approximately 3 cigarettes per day for 20 years and stopped 1 year ago. He does not drink alcohol. Family History: Notable for mother who passed away of myocardial infarction. His father passed away of liver disease. He has four living brothers and two living sisters, all in good health. Physical Exam: PHYSICAL EXAMINATION ON TRANSFER TO BMT SERVICE: VS: T 98.7, BP 128/84, HR 86, RR 16, 96%RA GENERAL: Pleasant middle-aged man lying in bed in NAD HEENT: PERRL with anicteric sclerae. Left eye non-injected. No diplopia, extraocular muscle movement intact. OP moist, no lesion. LUNGS: Clear to auscultation bilaterally. HEART: Reg rate, nl S1/S2, no m/r/g. [**Year (4 digits) **] site without erythema or tenderness. ABDOMEN: Soft, NT, ND, BS present, no HSM EXTREMITIES: 2+ pitting LE edema to knees bilaterally SKIN: Warm and dry with marked hyperpigmentation changes noted on his torso and lower extremity. Pertinent Results: LABS ON ADMISSION: [**2171-12-4**] 10:40AM WBC-2.2*# RBC-2.75* HGB-9.7* HCT-31.2* MCV-114* MCH-35.5* MCHC-31.2 RDW-22.4* [**2171-12-4**] 10:40AM NEUTS-32* BANDS-0 LYMPHS-29 MONOS-35* EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 PROMYELO-3* NUC RBCS-14* [**2171-12-4**] 10:40AM PLT SMR-VERY LOW PLT COUNT-27*# LPLT-2+ [**2171-12-4**] 10:40AM GRAN CT-1150* [**2171-12-4**] 10:40AM GLUCOSE-115* UREA N-41* CREAT-1.2 SODIUM-141 POTASSIUM-4.0 CHLORIDE-109* TOTAL CO2-23 ANION GAP-13 [**2171-12-4**] 10:40AM ALT(SGPT)-231* AST(SGOT)-177* LD(LDH)-398* ALK PHOS-916* TOT BILI-1.3 DIR BILI-0.8* INDIR BIL-0.5 [**2171-12-4**] 10:40AM ALBUMIN-3.3* CALCIUM-8.8 PHOSPHATE-2.1* MAGNESIUM-2.2 URIC ACID-6.0 . STUDIES: * EKG [**12-5**]: Sinus tachycardia. Compared to the previous tracing tachycardia has appeared. Voltage has increased in the precordial leads. T wave inversions persist. * Echo [**12-9**]: LV systolic function appears depressed. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. * Echo [**12-6**]: There is mild symmetric left ventricular hypertrophy with normal cavity size. There is a trivial/physiologic pericardial effusion. * Echo [**12-5**]: Very limited views. There is only trivial pericardial effusion. * Echo [**12-4**]: Overall left ventricular systolic function is moderately depressed (LVEF= 30-40 %). The right ventricular cavity is unusually small but is not frankly collapsing in diastole. The estimated pulmonary artery systolic pressure is normal. There is a large pericardial effusion. The effusion appears circumferential. There is sustained right atrial collapse, consistent with low filling pressures or early tamponade. * CXR [**12-4**]: Marked short interval enlargement of the cardiac silhouette could represent pericardial effusion or myocarditis. There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. Brief Hospital Course: Mr. [**Known lastname 63305**] is a 54-yo M h/o AML, 11 months s/p allo SCT, h/o disseminated TB, who presented with pericardial effusion, which was drained. . # Pericardial effusion: In clinic he was found to have new cardiomegaly on CXR, and an echocardiogram revealed a large pericardial effusion. Mr. [**Known lastname 63305**] [**Last Name (Titles) 1834**] a pericardiocentesis in the cath lab, which removed 1300 ml of serosanguinous fluid, creating a fall in RA pressure from 25 to 13 mm Hg. The patient recovered well in the CCU, with no dyspnea. Subsequent echocardiograms revealed no reaccumulation of the pericardial fluid. The patient continued to recover well after his transfer to the BMT service. He experienced no dyspnea, no chest pain by discharge. The pericardial fluid studies were unrevealing. The possible etiologies included post-viral pericardial effusion, GVHD, or TB reactivation. He was sent home with an appointment for a repeat chest CT on [**2171-12-20**]. . # AML: On [**2171-11-29**], prior to this admission, the patient [**Date Range 1834**] a bone marrow for persistent pancytopenia. The marrow showed no sign of active leukemia. He was continued on prophylatic regimen of acyclovir, atovaquone, and posaconazole. He was discharged with instructions to follow up with Dr. [**First Name (STitle) **] on [**2171-12-20**]. . # History of TB: Mr. [**Known lastname 63306**] recent disseminated TB infection prompted TB precautions and isolation. Induced sputum was AFB negative. He refused bronchoscopy. The patient had no coughs by discharge. He was to follow up in the [**Hospital **] clinic on [**2171-12-20**]. . # Urinary tract infection: The patient was found to have Morganella and enterococcus in his urine. Given his complicated history of hemorrhagic cystitis, he was started and sent home with cefpodoxime and daptomycin to finish a 14-day course. . # GVHD: chronic extensive GVHD as evidenced by his increased liver enzymes, skin and mouth changes. He was continued on prednisone, and mycophenolate 250 mg [**Hospital1 **] was restarted. . # pancytopenia: The patient required platelet transfusions. His WBC was 2.2 on admission. By discharge, however, his WBC was 5.5 with Hct 32 and platelets 63. . # Left eye discomfort: not injected, not painful. Ophthalmology was consulted and recommended aggressive eye hydration and Lumigan drops. He was sent home with instructions to follow up in the ophthalmology clinic. . # DMII: The patient was continued on an insulin regimen. . # HTN: He was continued on metoprolol. . #. Access: His double-lumen [**Hospital1 **] catheter was exchanged, by Interventional Radiology, for a triple-lumen tunneled [**Hospital1 **] catheter. Medications on Admission: ACYCLOVIR 400 mg--1 tablet(s) by mouth twice a day ATOVAQUONE 750 mg/5 mL--10 ml suspension(s) by mouth once a day BACITRACIN ZINC 500 unit/gram--Apply topically four times a day as needed for penile pain BD Insulin Syringe 25 gauge X [**6-18**]"--as directed CELLCEPT [**Pager number **] mg--1 capsule(s) by mouth three times a day DEXAMETHASONE 0.5 mg/5 mL--5 ml by mouth twice a day swish and spit. do not swallow. DOCUSATE SODIUM 100 mg--1 capsule(s) by mouth twice a day Ergocalciferol (Vitamin D2) 50,000 unit--1 capsule(s) by mouth q friday FOLIC ACID 1 mg--2 (two) tablet(s) by mouth once a day HUMALOG 100 unit/mL--per sliding scale Hydromorphone 2 mg--[**2-12**] tablet(s) by mouth every four (4) hours as needed for pain Insulin Glargine 100 unit/mL--16 units sq daily METOPROLOL SUCCINATE 100 mg--1 tablet(s) by mouth daily NYSTATIN 100,000 unit/mL--5 ml by mouth four times a day swish and spit OMEPRAZOLE 20 mg--1 capsule(s) by mouth once a day OXYCONTIN 10 mg--3 (three) tablet(s) by mouth twice a day One Touch Test --as directed qac and qhs PREDNISOLONE ACETATE 1 %--1 drop ophthalmic twice a day PREDNISONE 20 mg--1 tablet(s) by mouth once a day PYRIDIUM 200 mg--0.5 (one half) tablet(s) by mouth once a day Posaconazole 200 mg/5 mL--1 suspension(s) by mouth three times a day Pyridoxine 50 mg--2 tablet(s) by mouth once a day Saliva Substitution Combo No.2 --30 ml to mucous membrane q2 hours as needed for dryness TACROLIMUS 0.1 %--Apply to skin affected with gvhd. three times a day VITAMIN E 400 unit--1 capsule(s) by mouth daily Insulin Glargine 100 unit/mL--14 units sq daily PYRIDIUM 200 mg--1 (one) tablet(s) by mouth once a day Discharge Medications: 1. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Three (3) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). Disp:*180 Tablet Sustained Release 12 hr(s)* Refills:*2* 2. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). Disp:*120 Capsule(s)* Refills:*2* 3. Dexamethasone 0.5 mg/5 mL Solution Sig: 0.5 ML PO BID (2 times a day). Disp:*30 ML(s)* Refills:*2* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. Folic Acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. Disp:*1000 ML(s)* Refills:*2* 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 8. Atovaquone 750 mg/5 mL Suspension Sig: Ten (10) ml PO DAILY (Daily). Disp:*300 ml* Refills:*2* 9. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). Disp:*1 bottle* Refills:*2* 10. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Pyridoxine 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 12. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 13. Artificial Saliva 0.15-0.15 % Solution Sig: Thirty (30) ML Mucous membrane Q2H (every 2 hours) as needed. Disp:*3 L* Refills:*2* 14. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day) as needed. Disp:*30 grams* Refills:*2* 15. Posaconazole 200 mg/5 mL Suspension Sig: Two Hundred (200) mg PO TID (3 times a day). Disp:*[**Numeric Identifier 7206**] mg* Refills:*2* 16. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-12**] Drops Ophthalmic q4hours and prn. Disp:*1 bottle* Refills:*2* 17. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic QHS (once a day (at bedtime)). Disp:*1 bottle* Refills:*2* 18. Lumigan 0.03 % Drops Sig: One (1) drop Ophthalmic at bedtime: both eyes. Disp:*1 bottle* Refills:*2* 19. Daptomycin 500 mg Recon Soln Sig: Three Hundred (300) mg Intravenous Q24H (every 24 hours) for 8 days. Disp:*3000 mg* Refills:*0* 20. Insulin Regular Human 100 unit/mL Solution Sig: resume your home insulin regimen Injection four times a day. 21. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 22. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 23. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. Disp:*1000 ML(s)* Refills:*0* 24. Phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 25. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO QFRI (every Friday). Disp:*30 Capsule(s)* Refills:*2* 26. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 8 days. Disp:*40 Tablet(s)* Refills:*0* 27. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 28. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 29. [**Month/Day (2) **] catheter Sig: One (1) as needed: Please perform [**Month/Day (2) **] catheter care per protocol. When not in use, [**Month/Day (2) **] catheter is to be flused with 1000 unit/cc heparin equal to the volume of the catheter. Caps on the [**Month/Day (2) **] catheter are changed every 7 days. Disp:*1 1* Refills:*2* 30. Heparin Flush 100 unit/mL Kit Sig: as needed 1000 units/cc Intravenous per protocol: 1000 units/cc heparin flush. Disp:*qs * Refills:*2* 31. Saline Flush 0.9 % Syringe Sig: as needed Injection as needed. Disp:*qs * Refills:*2* Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Primary diagnoses: Pericardial tamponade, urinary tract infections Secondary diagnoses: acute myelogenous leukemia, tuberculosis infection, diabetes mellitus type 2, hypertension Discharge Condition: Stable. No respiratory difficulty. No chest pain. No pulsus. Lower extremity edema 2+ bilaterally. Discharge Instructions: You presented to [**Hospital1 18**] with shortness of breath on [**2171-12-4**]. You were found to have fluid in the sac surrounding your heart, a condition called pericardial effusion. The fluid was removed. It was unclear what caused the fluid accumulation. You were given medications to help remove extra fluid in body to help you breath better and reduce your leg swelling. You were also found to have a urinary tract infection. Please take your antibiotics as [**Date Range 8757**]. Please follow up with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 8757**] below. Please take all medications as [**Last Name (Titles) 8757**]. If you develop shortness of breath, chest pain, any difficulty breathing, worsening leg swelling, fevers, chills, or any other symptom that concerns you, please call your doctor or go to the nearest Emergency Room. Followup Instructions: * Radiology for chest CT: 9 am [**2171-12-20**], [**Hospital Ward Name 23**] Building, [**Location (un) **], [**Hospital1 69**] * Oncologist: Dr. [**First Name (STitle) **], [**2171-12-20**], at 2:30 p.m. * Infectious Disease: Dr. [**Last Name (STitle) 63307**], [**2171-12-20**], at 11:30 a.m. * Ophthomologist: please call [**Telephone/Fax (1) 253**] to make an appointment within 2 weeks for follow-up care of your eyes * Primary care: please call Dr.[**Name (NI) 63308**] office at [**Telephone/Fax (1) 63309**] to make an appointment within 2 weeks

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7582

Discharge summary

report

Admission Date: [**2123-3-9**] Discharge Date: [**2123-3-20**] Date of Birth: [**2061-3-31**] Sex: F Service: MEDICINE Allergies: Sulfur / Morphine / Imipramine / Oxybutynin / Oxycontin / Ace Inhibitors Attending:[**First Name3 (LF) 1145**] Chief Complaint: Transfer from [**Hospital3 **] for respiratory distress, elevated troponins and pneumonia. Major Surgical or Invasive Procedure: Cardiac cath s/p 2 bare metal stents to SVG-OM History of Present Illness: Ms. [**Known lastname 27671**] is a 60 year-old patient of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**] with a long history of CAD s/p 2-vessel CABG in [**2100**] (SVG to LAD and SVG to OM), s/p PTCA to RCA and multiple PTCAs and brachytherapy of the SVG to OM (last in [**2121-1-29**]), who was admitted to [**Location (un) **] with cough and wheezing, as well as anginal symptoms on [**2123-3-8**]. She describes a sore throat with "gland swelling" for 2-3 days PTA, anorexia, as well as a productive cough and wheezing on the day prior to presentation. She also had several anginal episodes in the day prior to admission, some at rest, relieved with NTG SL. She presented to the OSH on [**2123-3-8**], and was found to have a temperature of 101.4 in the ED, WBC 13.1, 18% bands, and CXR revealed a LLL infiltrate on CXR. Given her history of chest pain, cardiac enzymes were also sent. She was started on Ceftriaxone and Azithromycin for LLL pneumonia. While in hospital, her cardiac enzymes rose with peak CK-MB 41.6, Troponin I 13.02, and EKG revealed ST depressions in anterolateral leads. On [**2123-3-9**], she also developed what seems to be acute respiratory distress in the setting of elevated blood pressure with SBP 150-200, and desaturation to 60s on 2L via NC. ABG 7.25/69/103. She was placed on BiPAP 13/6-->15/6, and was given Lasix 80 mg IV X 2 with 1 liter diuresis. She was also started on Heparin gtt, Aggrestat gtt (D/C'd because of nose bleeding) and NTG gtt, and received Labetalol 5 mg IV X 4. She was transferred to the [**Hospital1 18**] for consideration for further management. Of note, by the patient account, she recently had an echo and had her Nitro patch increased to 0/8 mg/24 hours over 24 hours because of accelerating anginal symptoms. Past Medical History: 1. Coronary artery disease, s/p CABG in [**2100**] with SVG to the LAD and an SVG to the OM. S/p RCA stenting in [**2114**], s/p stenting of SVG to OM in [**2117**], s/p PTCA of focal instent restenosis at the ostium of SVG to the OM, s/p PTCA and gammatherapy of SVG to OM in 01/[**2121**]. Last cath in [**7-/2122**]: SVG to the LAD had mild diffuse disease up to 30%, patent SVG to OM with 40-50% stenosis in the mid distal graft section not hemodynamically significant to the obtuse marginal and the previously placed stent was widely patent. Concern over possible ostial RCA lesion, but could not be engaged. 2. Peripheral vascular disease 3. CHF, EF unknown. Had echo in past month at OSH. 4. Status post bilateral carotid stenting [**10/2117**] 5. COPD/Asthma, no prior intubation, no home O2. 6. Depression 7. GERD 8. Irritable bowel syndrome 9. Osteoarthritis 10. Kidney stones 11. Obesity NOTE: She has had a 70 point difference in blood pressure in both arms in the past. Past surgical history: 1. Status post cholecystectomy 2. Status post hysterectomy 3. Status post tonsillectomy 4. Status post umbilical hernia repair 5. Basal cell carcinoma removed from face Social History: She lives alone. She has a housekeeper who comes in once a week to help with her laundry. Ex-smoker, she quit 23 years ago. She denies EtOH use. Family History: Non-contributory Physical Exam: Physical examination on admission to CCU: VITALS: T 99.0, HR 81, BP right arm (164/67, left arm 117/67) previously documented, RR 16, Sat 100% on NRB GEN: Morbidly obese caucasian woman. Mildly tachypneic. HEENT: Anicteric. MMM. NECK: Bilateral carotid bruits. Bilateral clavicular bruits (? subclavian). JVP difficult to assess secondary to body habitus. RESP: Distant breath sounds. Distant inspiratory crackles, wheezing anteriorly. CVS: Distant heart sounds. Normal S1, S2. No S3, S4. SEM at LLSB, difficult to characterize. GI: Obese abdomen. Soft, non-tender. EXT: Good right femoral pulse, unable to palpate left femoral pulse. Difficult to assess for bruit secondary to body habitus. Palpable right DP pulse, unable to palpate other pulses. 1+ bilateral edema, slightly more on the right. NEURO: Alert and oriented X 3. Pertinent Results: Laboratory data from the OSH on admission: CBC: WBC 13.1 with 18% bands, 66% neutrophils. Hct 40.6, Plt 137. Chemistry: Na 144, K 4.6, Cl 102, HCO3 27, BUN 21.6, Creat 1.3 (was 1.1 in [**3-/2122**]), Glucose 1.3. Normal LFTs. Cardiac enzymes: CK 404-->576 CKMB 29.9-->41.6 MB index 7.4-->7.2 Trop 0.06-->13.02-->7.42 Microbiology data: [**2123-3-8**] Blood cultures pending CXR: LLL infiltrate EKG [**2123-3-9**]: NSR, rate 110, normal intervals, normal axis. ST elevation in aVR (and V1, V2 on different EKGs), 1-[**Street Address(2) 1766**] depressions in I, II, aVF, V3-6. No T wave inversion. Qs in III. EKG on arrival to CCU [**Hospital1 18**]: NSR, rate 77 bpm. Less than 1mm ST elevation in V1,V2. ST depression I, II, aVL, V5. Cath: 1. Selective graft angiography revealed a SVG->OM with a 60% lesion in the distal segment followed by a 70% lesion in the distal anastomosis into the native OM. 2. Hemodynamic evaluation revealed normal right and left heart filling pressures. There was no evidence of significant pulmonary HTN. 3. Successful PTCA/stenting of the SVG->OM graft with a 3.0x18mm Driver stent in the anastomosis postdilated to 3.5 in the proximal segment and with a 3.5x18mm Driver stent in the distal segment overlapping the previously placed Cypher DES as well as the new Driver stent in the anastomosis. Final angiography revealed 10% residual stenosis in the distal SVG, no dissection and TIMI-3 flow (see PTCA comments). FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Normal right and left heart filling pressures. 3. PCI of the SVG->OM. Echo: The left atrium is moderately dilated. There is left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function iis probably preserved but views are technically suboptimal for assessment of global and regional wall motion. Right ventricular chamber size is normal. Right ventricular systolic function is probably normal. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. Pertinent Labs: [**2123-3-20**] 02:56PM BLOOD Hct-34.3* [**2123-3-20**] 06:25AM BLOOD Glucose-121* UreaN-50* Creat-1.7* Na-142 K-4.0 Cl-100 HCO3-35* AnGap-11 [**2123-3-19**] 05:55AM BLOOD calTIBC-239* VitB12-1621* Folate->20 Ferritn-174* TRF-184*, IRON-53 [**2123-3-9**] 09:47PM BLOOD %HbA1c-6.1* [**2123-3-19**] 05:55AM BLOOD TSH-5.0* [**2123-3-19**] 05:55AM BLOOD Ret Aut-3.8* Brief Hospital Course: Mrs. [**Known lastname 27671**] is a 61 year-old female with long-standing history of CAD status post 2-vessel CABG in [**2100**], s/p multiple stents and interventions to SVG to OM graft, admitted with LLL pneumonia, CHF and NSTEMI. 1) NSTEMI: Ruled in at OSH with elevated CK-MB, troponin I. Cath was attempted after pt diuresed, however cath was aborted d/t pt discomfort and desaturation on table. She likely became anxious, which caused tachycardia, demand-mediated ischemia, and then flash pulmonary edema. She quickly recovered. Cath showed 30-40% SVG-LAD-D, and 80% OM distal to SVG. She was subsequently re-cathed and two bare metal stents were placed to her SVG-OM. Pt now on ASA, plavix, BB, lipitor, Imdur, hydralazine, CCB. Of note, pt gets ARF on ACE inhibitors. 2) Refractory HTN: Pt's outpt hydralazine was doubled with better control of her blood pressure, around 130-150 systolically. The suspicion of renal artery stenosis was raised. 3) CHF: She had flash pulmonary edema at the OSH, likely due to ischemia as described above. ECHO was limited, but showed probably normal EF, with 3-4+ MR. Pt was aggresively diuresed to a dry weight of 133.8kg, which is the lowest she has weighed per pt. Pt will continue spironolactone and Demadex, which was increased in dose. 4) LLL pneumonia: Treated with CTX and Azithromycin. 5) COPD: Pt not on standing inhalers at home. Started on Advair 100/50 1 inhalation [**Hospital1 **]. She received Atrovent and Albuterol nebs for bronchodilator therapy during her hospitalization, and was d/c'd on MDI's. There was no need for steroids. 6) ARF: Due to Lisinopril, with resolution of the medication. Would not give pt ACE inhibitors in the future given her propensity to go into ARF on them. 6) Hyperglycemia: Patient denies history of DM type 2. However, she has risk factors for it, and prior records document DM type 2. Her HBA1C = 6.1%, consistent with borderline diabetes. 7) Anemia, maybe d/t hypothyroidism: Pt was guiaic negative with normal iron, vitamin B12, and folate. Her TSH was elevated, and her [**Hospital1 27672**] dose was increased. She was transfused a total of 2 units of PRBC during her hospitalization with her hematocrit on discharge = 34. She will follow up with her outpt PCP. 8) Hypothryoidism: Inadequately treated on [**Last Name (LF) 27672**], [**First Name3 (LF) **] her dose was increased. 9) Left forearm thrombophlebitis: Due to an IV, with no evidence of infection. FULL CODE Medications on Admission: Nitro-Patch 0.8 mg/hour 24 hours a day Adalat CC 90 mg PO QD Aldactone 50 mg PO QD Albuterol 2 inh q4 hours prn (not using it) Serevent (not using it) Hydralazine 25 mg PO TID Atenolol 150 mg PO QD Calcium 600 mg PO BID with vitamin D 400 IU daily Celexa 20 mg PO QD Demadex 40 mg PO BID Depakote 250 mg PO BID Detrol LA 4 mg PO QD ECASA 325 mg PO QD Folic acid ? dose Imdur 120 mg PO BID Klor-Con 20 mEq PO QD [**First Name3 (LF) 27672**] 50 mcg PO QD Lipitor 80 mg PO QD MVI 1 tablet PO QD NTG SL prn Plavix 75 mg PO QD Protonix 40 mg PO BID Colace 100 mg PO BID Welchol 625 mg PO QD Zyprexa 2.5 mg PO QHS Discharge Medications: 1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*60 Disk with Device(s)* Refills:*0* 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 6. Calcium 600mg by mouth twice a day 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Divalproex Sodium 250 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 10. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 12. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Atenolol 50 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 14. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. Torsemide 20 mg Tablet Sig: Three (3) Tablet PO 3 pills (60mg) every morning and 2 pills (40mg) every evening. Disp:*150 Tablet(s)* Refills:*0* 16. Hydralazine HCl 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:*90 Tablet(s)* Refills:*0* 17. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 18. Nitroglycerin 0.4 mg/hr Patch 24HR Sig: One (1) Patch 24HR Transdermal Q24H (every 24 hours): On for 12 hours, off for 12 hours. 19. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO BID (2 times a day). 20. Detrol LA 4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO once a day. 21. Adalat CC 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. 22. Atrovent 0.03 % Aerosol, Spray Sig: One (1) Nasal twice a day. 23. WelChol 625 mg Tablet Sig: One (1) Tablet PO once a day. 24. Klor-Con 20 mEq Packet Sig: One (1) PO once a day. Discharge Disposition: Home With Service Facility: [**Location (un) **] Nursing Services Discharge Diagnosis: 1. NSTEMI s/p cardiac cath with 2 bare metal stents to SVG-OM 2. Decompensated CHF 3. LLL Pneumonia 4. Anemia NOS 5. Left forearm thrombophlebitis 6. Hyperglycemia 7. Hypothyroidism Discharge Condition: Pt had stable vital signs, a blood pressure around 140 systolically, with a Hct of 34, able to ambulate with walker, saturating > 91% on room air, weighing 133.8 kgs, which is her dry weight. Discharge Instructions: Please weight yourself each morning. If you gain more than 3 pounds call your doctor. Adhere to a 2mg Sodium per day diet. Please continue taking all your medications as prescribed. Call your doctor or return to the hospital if you experience chest pain, shortness of breath, weakness, pallor, inability to urinate, fever. Followup Instructions: Call Dr. [**Last Name (STitle) **] for a follow up appointment this week. He will check your fluid status, blood counts, and kidney function.

[ "451.89", "410.71", "428.0", "486", "244.9", "584.9", "999.2", "E878.4", "285.9", "414.04" ]

icd9cm

[ [ [] ] ]

[ "36.01", "37.22", "88.53", "36.06", "88.56" ]

icd9pcs

[ [ [] ] ]

12715, 12783

7330, 9820

423, 471

13008, 13201

4568, 4597

13576, 13721

3685, 3703

10478, 12692

12804, 12987

9846, 10455

6041, 6927

13225, 13553

3337, 3507

3718, 4549

4813, 6024

293, 385

499, 2307

4611, 4796

6943, 7307

2329, 3314

3523, 3669

43,589

194,064

49493+49535

Discharge summary

report+report

Admission Date: [**2195-11-25**] Discharge Date: [**2195-11-29**] Date of Birth: [**2132-9-21**] Sex: F Service: PLASTIC Allergies: Percodan / simvastatin Attending:[**First Name3 (LF) 5883**] Chief Complaint: right breast cancer Major Surgical or Invasive Procedure: 1. Right immediate reconstruction of acquired absence of breast with deep inferior epigastric perforator flap reconstruction. 2. Harvest of right internal mammary artery and vein pedicle. 3. Right partial rib harvest. 4. Closure of the abdominal donor site History of Present Illness: The patient is a 63-year-old woman with a history of right breast cancer who is interested in bilateral mastectomy and reconstruction. She is referred to me by Dr. [**Last Name (STitle) **] [**Name (STitle) 3459**]. Her primary care physician is [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Name (STitle) 8682**]. She is planning in genetic testing. She has an umbilical hernia that she is scheduled to have repaired in two weeks from now. She is a retired teacher. She presents today with a friend. Past Medical History: PMH: Arthritis, heart murmur. Also includes mitral valve prolapse. SH: She does not smoke or drink. FH: Breast cancer in mother and a maternal aunt, stroke, depression, and heart disease. PSH: Includes an ovarian cyst resection and appendectomy. MEDS: Effexor and pravastatin. ALL: She is allergic to Percodan. Social History: SH: She does not smoke or drink. Family History: FH: Breast cancer in mother and a maternal aunt, stroke, depression, and heart disease. Physical Exam: PHYSICAL EXAMINATION: VITAL SIGNS: She is 5 feet tall, she is 126 pounds. GENERAL: She is a well-developed, well-nourished 63-year-old woman in no apparent distress: Alert and oriented x3 with normal mood and affect. HEENT: Extraocular motor function is normal. Vision is normal. Nose midline. Nasal septum is midline. Inspection and palpation of skin reveals no evidence of any rashes, ulcer or lesions. No palpable lymph nodes in neck and axilla. Her neck has full range of motion, supple, no evidence of thyromegaly. Trachea is midline. BREASTS: Her breast size is A cup. She has grade 2 ptosis. She has pseudoptosis. Her sternal notch to nipple distance on the right side is 21.5, on the left side is 22.5. Inframammary fold to nipple distance on the right side is 5 cm, on the left side is 5.5 cm. She has two palpable masses in the superior aspect of the breast. There is no evidence of any tenderness, asymmetry. ABDOMEN: Soft, nontender. She has no evidence of any masses. She has a small umbilical hernia. There is no evidence of any hepatosplenomegaly, rash, intertrigo. She has an infraumbilical volume to create two A-cup size breasts. She has a well-healed lower midline incision from a previous ovarian cyst and appendectomy. Her Latissimus muscle is intact. She has enough gluteal volume to create a B cup size reconstruction. There is no evidence of any extremity varicosities. Respiratory effort is normal with no intercostal retractions. There is no evidence of any peripheral edema, digital cyanosis, or lymphadenopathy. Pertinent Results: [**2195-11-26**] 03:15AM BLOOD WBC-8.5# RBC-2.83*# Hgb-8.3*# Hct-25.1*# MCV-89 MCH-29.1 MCHC-32.8 RDW-13.7 Plt Ct-162 [**2195-11-26**] 03:15AM BLOOD Glucose-173* UreaN-12 Creat-0.6 Na-142 K-4.1 Cl-107 HCO3-30 AnGap-9 [**2195-11-26**] 03:15AM BLOOD Calcium-8.3* Phos-2.9 Mg-1.8 Brief Hospital Course: The patient was admitted to the plastic surgery service on [**2195-11-25**] and had a Right Breast Reconstruction with [**Last Name (un) 5884**] Flap. The patient tolerated the procedure well. Neuro: Post-operatively, the patient received Dilaudid IV/PCA with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. Her diet was advanced when appropriate, which was tolerated well. She was also started on a bowel regimen to encourage bowel movement. Foley was removed on POD#1. Intake and output were closely monitored. ID: Post-operatively, the patient was started on IV cefazolin, then switched to PO cephalexin on discharge. The patient's temperature was closely watched for signs of infection. Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. At the time of discharge on POD#, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Medications on Admission: Effexor and pravastatin Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO DAILY (Daily). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 2 weeks: continue while taking narcotic pain medication. 3. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Three (3) Capsule, Ext Release 24 hr PO DAILY (Daily). 4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 2 weeks: do not drive or drink alcohol while taking this medication. Disp:*84 Tablet(s)* Refills:*0* 6. Keflex 500 mg Capsule Sig: One (1) Capsule PO twice a day for 2 weeks. Disp:*28 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Right breast cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: DISCHARGE INSTRUCTIONS: Personal Care: 1. Remove dressings and discard. Dressings may be replaced as needed. Use tape sparingly. 2. Clean around the drain site(s), where the tubing exits the skin, with soap and water. 3. Strip drain tubing, empty bulb(s), and record output(s) [**1-8**] times per day. 4. A written record of the daily output from each drain should be brought to every follow-up appointment. your drains will be removed as soon as possible when the daily output tapers off to an acceptable amount. 5. DO NOT wear a bra for 3 weeks. You may wear a camisole for comfort as desired. 6. You may shower daily with assistance as needed. 7. The Dermabond skin glue will begin to flake off in about [**6-14**] days. 8. No pressure on your chest or abdomen 9. Okay to shower, but no baths until after directed by your surgeon . Activity: 1. You may resume your regular diet. Avoid caffeine and chocolate. 2. DO NOT drive for 3 weeks. 3. Keep hips flexed at all times for 1 week, and then gradually stand upright as tolerated. 4. DO NOT lift anything heavier than 5 pounds or engage in strenuous activity for 6 weeks following surgery. 5. Please perform the occupational therapy exercises as instructed. . Medications: 1. Resume your regular medications unless instructed otherwise and take any new meds as ordered . 2. Take Aspirin, 120 mg by mouth once daily, for 30 days after surgery. 3. You may take your prescribed pain medication for moderate to severe pain. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. Please note that Percocet and Vicodin have Tylenol as an active ingredient so do not take these meds with additional Tylenol. 4. Take prescription pain medications for pain not relieved by tylenol. 5. Take your antibiotic as prescribed. 6. Take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication. You may use a different over-the-counter stool softerner if you wish. 7. Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. . Call the office IMMEDIATELY if you have any of the following: 1. Signs of infection: fever with chills, increased redness, welling, warmth or tenderness at the surgical site, or unusual drainage from the incision(s). 2. A large amount of bleeding from the incision(s) or drain(s). 3. Fever greater than 101.5 oF 4. Severe pain NOT relieved by your medication. . Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness,swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. . DRAIN DISCHARGE INSTRUCTIONS You are being discharged with drains in place. Drain care is a clean procedure. Wash your hands thoroughly with soap and warm water before performing drain care. Perform drainage care twice a day. Try to empty the drain at the same time each day. Pull the stopper out of the drainage bottle and empty the drainage fluid into the measuring cup. Record the amount of drainage fluid on the record sheet. Reestablish drain suction. Followup Instructions: Please call Dr.[**Last Name (STitle) 17650**] office at [**Telephone/Fax (1) 6331**] to schedule your follow-up appointment upon discharge. Completed by:[**2195-11-29**] Admission Date: [**2195-11-25**] Discharge Date: [**2195-11-29**] Date of Birth: [**2132-9-21**] Sex: F Service: PSU ADDENDUM: Please note that there is an additional diagnosis which is a micrometastatic carcinoma involving 1 lymph node. Please document this as part of her discharge diagnosis. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 39103**] Dictated By:[**Last Name (NamePattern4) 51569**] MEDQUIST36 D: [**2195-12-28**] 13:42:49 T: [**2195-12-28**] 14:04:12 Job#: [**Job Number 103611**]

[ "174.8", "722.6", "424.0", "553.1", "458.9", "272.0", "196.3" ]

icd9cm

[ [ [] ] ]

[ "53.49", "85.34", "40.23", "85.74" ]

icd9pcs

[ [ [] ] ]

5742, 5800

3532, 4924

304, 575

5864, 5864

3231, 3509

9540, 10306

1537, 1628

5000, 5719

5821, 5843

4952, 4977

6039, 9517

1643, 1643

1665, 3212

245, 266

603, 1127

5879, 5991

1149, 1469

1485, 1521

8,980

101,170

24391

Discharge summary

report

Admission Date: [**2106-2-5**] Discharge Date: [**2106-2-26**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: ischemic right foot Major Surgical or Invasive Procedure: [**2-5**] Abdominal aortogram with right lower extremity runoff. [**2-9**] Right above-knee amputation. [**2-9**] Percutaneous endoscopic gastrostomy tube placement. [**2-10**] Exploratory laparotomy, Colectomy including right colon, transverse and descending colon, with Ileostomy. [**2-17**] Exploratory laparotomy, Resection of small intestine, Ileostomy. History of Present Illness: This is an 81-year-old woman who presented with extensive gangrene of the right lower extremity. The patient had noticed [**9-2**] pain and discolouration worsening over the previous 2 weeks. She had been started on cipro/garamycin as an outpatient. Past Medical History: PMHx: depression, anxiety, hypothyroidism, anemia, MRSA ulcers, neuropathy, f/l foot ulcerations PSH: appy '[**93**], b/L foot debridement [**6-28**] Arteriogram ([**2105-7-7**]): LLE 80% stenosis distal PTA, RLE patent Social History: Resident at [**Hospital **] Health Care Centre since [**2105-8-31**] neg tobacco, neg alcohol Family History: non contributory Physical Exam: Temp: not recorded, 120/77, RR 16, 96% CVS: RRR, S1S2 normal, +SEM Ext: LLE: discoloured, bluish discolouration over entire foot (several necrotic lesions), RLE: cold bluish discolouration of the distal portion of the dorsum of the foot, with two large necrotic ulcers over dorsum associated with loss of sensation of the toes Pertinent Results: LABS: [**2106-2-5**] 02:15PM WBC-8.2# RBC-3.93* HGB-12.7 HCT-34.9* MCV-89 MCH-32.2* MCHC-36.3* RDW-15.4 PLT COUNT-121* NEUTS-76.7* LYMPHS-18.7 MONOS-3.4 [**2106-2-5**] 02:15PM PT-14.0* PTT-25.3 INR(PT)-1.3 [**2106-2-5**] 02:15PM GLUCOSE-142* UREA N-34* CREAT-0.7 SODIUM-138 POTASSIUM-3.3 CHLORIDE-105 TOTAL CO2-26 ANION GAP-10 [**2106-2-5**] 02:20PM LACTATE-1.0 . [**2106-2-10**] 05:30AM BLOOD WBC-15.5*# RBC-3.80* Hgb-12.2 Hct-34.3* MCV-90 MCH-32.0 MCHC-35.6* RDW-16.2* Plt Ct-197# [**2106-2-10**] 05:30AM BLOOD PT-14.0* PTT-30.5 INR(PT)-1.3 [**2106-2-10**] 04:50PM BLOOD Glucose-111* UreaN-17 Creat-0.9 Na-138 K-3.8 Cl-111* HCO3-16* AnGap-15 . [**2106-2-17**] 04:18AM BLOOD WBC-33.8* RBC-3.15* Hgb-10.1* Hct-28.1* MCV-89 MCH-32.0 MCHC-35.8* RDW-15.5 Plt Ct-215 [**2106-2-17**] 09:21PM BLOOD PT-20.7* PTT-39.9* INR(PT)-2.0* [**2106-2-17**] 04:18AM BLOOD Glucose-171* UreaN-18 Creat-0.8 Na-140 K-3.0* Cl-109* HCO3-20* AnGap-14 . [**2106-2-21**] 08:00AM BLOOD WBC-29.5* RBC-3.62* Hgb-11.8* Hct-33.1* MCV-92 MCH-32.8* MCHC-35.8* RDW-15.4 Plt Ct-185 [**2106-2-21**] 04:50AM BLOOD Glucose-272* UreaN-26* Creat-1.0 Na-147* K-6.4* Cl-115* HCO3-17* AnGap-21* . [**2106-2-26**] 03:08AM BLOOD WBC-9.6 RBC-3.41* Hgb-10.6* Hct-31.3* MCV-92 MCH-31.1 MCHC-33.8 RDW-15.4 Plt Ct-101* [**2106-2-26**] 03:08AM BLOOD Plt Ct-101* [**2106-2-26**] 03:08AM BLOOD Glucose-145* UreaN-30* Creat-0.9 Na-143 K-4.4 Cl-113* HCO3-24 AnGap-10 . STUDIES: [**2106-2-5**] Abdominal aortogram with right lower extremity runoff. ANGIOGRAPHIC FINDINGS: The abdominal aorta is extremely angulated but smooth. There were patent bilateral common, internal and external iliac arteries. The renal arteries and single and patent bilaterally. The right lower extremity shows a patent common femoral artery, profunda femoral artery and superficial femoral artery, popliteal, anterior tibialis and peroneal arteries. The PT is occluded and both the AT and the peroneal arteries occlude at the ankle. There were vessels seen in the foot. SUMMARY: Either thrombosis or embolism of the right foot arteries. Nonviable foot. Will likely need a right below knee amputation. . [**2-10**] CT abd/pelvis: There is free fluid in the pelvis. There is dilatation of bowel loops with a maximum of 7 cm in diameter. . [**2-13**] CTA abd/pelvis: 1.A slight interval increase in size in the bilateral pleural effusions and adjacent consolidation/atelectasis. 2.The aorta is normal in caliber, all its main branches are widely patent. 3. Hypodense areas in both lobe of the thyroid gland. 4. Mild cardiomegaly. 5. Cholelithiasis. 6. Splenic and cortical renal infarcts. 7. Ascites. . Pathology: Ileocolectomy: Acute hemorrhagic infarction involving the mucosa of the cecum and colon. The infarction extends in the mucosa to the proximal ileal margin. . Brief Hospital Course: Ms [**Known lastname 61764**] was admitted to vascular surgery service with gangrene of the right foot that was likely secondary to thrombosis or embolism of the right foot arteries, as confirmed by angiography. As she was not a candidate for revascularization, she was prepped for right below knee amputation. She was started on broad spectrum antibiotics. Given the patient's poor nutritional status, MIS surgery was consulted regarding PEG placement at the time of amputation. The patient underwent above knee amputation of the right extremity by vascular surgery and PEG placement by MIS surgery on [**2106-2-9**]. Please see operative report for full details. . On post-operative day #1, the patient complained of abdominal pain. Initially, this was not associated with peritoneal signs and the patient underwent CT scan evaluation. This revealed some free air and ascites. Subsequent exam of the patient did reveal abdominal distention and peritoneal signs that were associated with elevation in WBC and decreased urine output. As a result, the patient was taken to the OR for exploratory laparotomy on [**2106-2-10**]. Please see operative report for full details. . In the OR, the patient was found to have ischemic colon without frank perforation extending from the cecum to the end of the descending colon. SHe underwent extended R colectomy and end ileostomy. She was transferred to the SICU for care. . In the SICU, the patient received IV antibiotics. In the week following admission, the patient remained intubated but appeared to be improving slowly. THe patient was extubated on [**2106-2-14**] with a functioning ostomy. The following day, however, the patient developed blood per rectum. This was associated with a fall in her hematocrit. On [**2106-2-17**], the patient was taken back to the OR for exploratory laparotomy. In the OR, 46 cm of necrotic and ischemic bowel was found. The patient underwent resection of small intesting as well as ileostomy. Please see operative report for full details. . Post-operatively, the patient underwent extensive hypercoagulable work-up and was found to be HIT positive. She was started on Agastroband. On [**2106-2-21**], a code was called on the patient for pulseless electrical activity secondary to respiratory distress. She was re-intubated and resuscitated successfully. A family meeting was held on [**2106-2-23**] at which time her code status was changed from full code to DNR/DNI (if successfully extubated). After several days, as the patient was not tolerating extubation, the patient's code status was discussed again with the family. On [**2106-2-26**], the patient was made comfort measures only and she expired at 13:47 on that same day. . Medications on Admission: Levothyroxine Calcium MVI Colace Senna Morphine Remeron Cipro (until [**2106-2-11**]) Vicodin Garamcyin (until [**2106-2-15**]) Discharge Disposition: Expired Discharge Diagnosis: Peripheral Vascular disease Ischemic colitis Respiratory Arrest Cardiac arrest Discharge Condition: expired Completed by:[**2106-3-12**]

[ "287.4", "E879.8", "276.0", "998.32", "412", "567.9", "E934.2", "507.0", "557.0", "440.24", "518.5", "578.9", "294.9", "300.4", "997.3", "414.01", "782.4", "789.5", "285.1", "276.2", "401.9", "244.9", "V66.7", "783.7", "799.1", "707.14" ]

icd9cm

[ [ [] ] ]

[ "96.6", "45.73", "46.41", "46.20", "43.11", "99.04", "96.72", "96.04", "88.47", "99.19", "45.62", "84.17", "99.15" ]

icd9pcs

[ [ [] ] ]

7394, 7403

4499, 7216

280, 641

7525, 7563

1671, 4476

1291, 1309

7424, 7504

7242, 7371

1324, 1652

221, 242

669, 920

942, 1163

1179, 1275

13,253

183,072

16143

Discharge summary

report

Admission Date: [**2124-9-3**] Discharge Date: [**2124-9-8**] Date of Birth: [**2045-8-27**] Sex: M Service: SURGERY Allergies: Penicillins / simvastatin Attending:[**First Name3 (LF) 46126**] Chief Complaint: RUQ pain, fever Major Surgical or Invasive Procedure: ERCP History of Present Illness: Patient is Cantonese only speaking, so history obtained with the aid of patient's son. History of Present Illness: Mr. [**Known lastname **] is a 79 year old Cantonese only speaking man with HTN, HL, and CAD s/p CABG ([**2118**]) with a recent admission to the [**Hospital1 18**] in [**2124-6-4**] for cholecystitis/duodenitis and sepsis treated with percutaneous cholecystostomy tube. The tube had been draining approximately 100cc/day sine that time until 2 weeks ago when the output increased to 200cc/day. He reported no symptoms at that time. Friday prior to admission ([**9-1**]), he noted decreased output of only 85cc, and the subsequent two days he noted zero output from his perc cholecystostomy tube. He has had severe RUQ pain that began on Saturday and has also noted yellow/greenish drainage from around the drain site. He noted some shaking chills, but denied fever, nausea or vomiting. No urinary symptoms, no black or tarry stool. His inspirations are limited due to RUQ pain. He called ems this AM becuase of the lack of drainage from the tube and pain and they sent him to [**Hospital1 3278**] where his labs at 14:36 today were consistent with a cholestatic picture with ALT 169, AST 244, alk phos 359, T bili 1.3, CRP 15.79, WBC of 6.5. Since all of his previous care was provided here his family elected for transfer to the [**Hospital1 18**]. In the ED, initial VS were: 101, 113/76, hr 100, rr16, sat99 2ln/c. He he continued to complain of RUQ pain and dyspnea from splinting due to pain. He was noted to have a R percutaneous cholecystostomy tube on R lat side with green drainage coming through around the tube and an empty bag, and RUQ tenderness. He spiked to 101.8 at 6:30pm and was tachycardic to the low 100s. Labs were notable for worsening LFTs with ALT: 353, AST: 707, AP: 537, Tbili: 1.6. A left IJ was placed and he was given 2 L NS and started on Vanco, cefepime, and Flagyl. Surgery was consulted and performed a fluro study of the tube and felt the perc chole tube was patent and the cystic duct was patent and emptied into the duodenum. There was noted to be a filling defect in the distal CBD likely from a stone. He was admitted to the [**Hospital Unit Name 153**] for ERCP. Surgery is also following to discuss the possibility of cholecystectomy. On arrival to the MICU, patient's vital signs were T 100.9, HR 101, BP 142/91, RR 24, O2 sat 91%RA (O2 sat increased to 96-99% on 2L NC). He reported the history above with his son who aided in interpretation. He continued to complain of RUQ pain and mild shortness of breath due to splinting with deep breaths. Patient did note baseline mild shortness of breath with increasing activity, and had seen a pulmonologist recently who prescribed [**Name (NI) **] (unclear if patient is actually using this). He appears to have a very good baseline functional status. He does [**Doctor First Name **] [**Doctor First Name **] every morning and walks several blocks without dyspnea. Review of systems: (+) Per HPI (-) Denies headache, changes in vision, chest pain or pressure, palpitations, orthopnea, cough, wheezing. Denies constipation, diarrhea, dark, bloody or light colored stools. Denies dysuria, frequency, urgency, or change in urine color. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - Coronary artery disease s/p CABG [**3-/2119**] (LIMA to the LAD and -separate SVGs to the PDA and an OM) - HLD - HTN - BPH - Emphysema per ct scan - TB many years ago, treated for 2 years Social History: Prior 20 pack year smoker, quit 20 years ago. Retired CEO of auto parts business in [**Country 651**]. Lives with his wife and is independent with ADLs. Rare alcohol, denies illicits. Family History: Mother had hypertension and history of cancer. Physical Exam: Admission Physical Exam: Vitals: T 102 HR 98 BP 121/57 RR 20 O2 96% 2L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP less than 7, no LAD, left IJ in place, no tenderness at site CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Bibasilar rales, no wheezes or rhonchi, appears to be splinting due to pain with deep inspiration Abdomen: RUQ tenderness to palpation, soft, non-distended, bowel sounds present, no organomegaly, no rebound or guarding 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. Admission Physical Exam: Vitals: AFVSS General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: clear to auscultation bilaterally Abdomen: abdomen minimally and appropriately tender to palpation near incision sites, no organomegaly, no rebound or guarding GU: Foley in place 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. Pertinent Results: Admission labs: [**2124-9-3**] 04:13PM BLOOD WBC-7.5 RBC-4.47* Hgb-13.5* Hct-41.4 MCV-93 MCH-30.3 MCHC-32.7 RDW-14.4 Plt Ct-300 [**2124-9-3**] 04:13PM BLOOD Neuts-78.9* Lymphs-14.7* Monos-4.6 Eos-1.3 Baso-0.5 [**2124-9-3**] 04:13PM BLOOD PT-11.9 PTT-31.4 INR(PT)-1.1 [**2124-9-3**] 04:13PM BLOOD Glucose-124* UreaN-14 Creat-0.8 Na-139 K-3.7 Cl-103 HCO3-26 AnGap-14 [**2124-9-3**] 04:13PM BLOOD Albumin-4.4 Calcium-9.4 Phos-3.1 Mg-2.0 [**2124-9-3**] 04:13PM BLOOD ALT-353* AST-707* AlkPhos-537* TotBili-1.6* [**2124-9-3**] 04:13PM BLOOD Lipase-26 [**2124-9-3**] 08:45PM BLOOD ALT-467* AST-864* AlkPhos-547* TotBili-1.8* [**2124-9-3**] 08:45PM BLOOD Lipase-21 [**2124-9-3**] 08:45PM BLOOD Albumin-3.7 [**2124-9-3**] 04:20PM BLOOD Lactate-1.7 [**2124-9-3**] 08:57PM BLOOD Lactate-0.7 Discharge labs: Studies: [**2124-9-3**] RUQ u/s: The liver is heterogeneous in echogenicity with a possible area of focal fatty sparing in the left lobe spanning approximately 2.8 cm. This does not represent a definite lesion. The gallbladder is collapsed, but does not appear mildly edematous. There is no intra- or extra-hepatic biliary ductal dilatation and the common bile duct measures 8 mm. The spleen measures 11.0 cm and is unremarkable. There is a 1.4 x 0.8 x 0.7 cm simple cyst in the right lobe of liver, corresponding to prior CT. The main portal vein is patent and displays hepatopetal flow. IMPRESSION: 1. No intra- or extra-hepatic biliary ductal dilatation. 2. Collapsed gallbladder. 3. Heterogeneous liver compatible with history of acute hepatitis or areas of focal fatty deposition. [**2124-9-3**] T-TUBE CHOLANGIO: FINDINGS: 20 cc of Optiray iodinated contrast material was injected into the patient's percutaneous cholecystostomy tube under fluoroscopy. The gallbladder followed by the cystic duct, common bile duct, and common hepatic duct opacified without evidence of obstruction. No leak was identified. Contrast passed freely into the duodenum. Subsequently the cholecystostomy tube was flushed with approximately 10 cc of saline. IMPRESSION: Patent biliary system. No malposition of the cholecystostomy tube. [**2124-9-3**] CXR: pending Micro: Blood cultures [**2124-9-3**]: [**2124-9-3**] 4:30 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): GRAM NEGATIVE ROD(S). Aerobic Bottle Gram Stain (Final [**2124-9-4**]): GRAM NEGATIVE ROD(S). Reported to and read back by DR. [**Last Name (STitle) 15413**] @ 07:40AM ON [**2114-9-4**]. Brief Hospital Course: Brief Course: Mr. [**Known lastname **] is a 79 year old Cantonese only speaking man with HTN, HL, history of distant TB s/p treatment, and CAD s/p CABG ([**2118**]) with perc chole tube for cholecystitis/duodenitis and sepsis in [**2124-6-4**], now back with decreased tube output, fevers, chills, severe RUQ pain and tenderness with obstructing pattern on LFTs concerning for cholangitis, admitted to the ICU for concern for developing sepsis. Active issues: # Cholangitis: Patient with recent cholecystitis requiring perc chole tube in [**2124-6-4**]. Did not have a cholecystectomy at that time due to inflammation. Now presents with decreased tube output, fever, RUQ pain, and LFTs with a cholestatic pattern concerning for cholangitis. RUQ ultrasound revealed a collapsed gallbladder and no biliary ductal dilation. Fluoro study revealed patent tube and flow of contrast material up to the intrahepatic ducts and flow to CBD draining into the duodenum. There is a filling defect in the distal CBD that could represent a stone.He was started on Vanc/Cefepime/Flagyl and ERCP was consulted. He remained hemodynamically stable in the ICU. ERCP showed a 6mm single stone that was removed. Cannulation of the biliary duct was performed with a sphincterotomy. The common bile duct measured about 8mm with a single mobile filling defect. There was no significant dilatation of the intrahepatic biliary tree. LFTs trended down after the procedure and patient was restarted on a regular diet and tolerated it well. He also reported improvement of his abdominal pain. # Emphysema: Possible obstructive ventalitory defect on PFTs from [**2117**] and CT scan with evidence of emphysema. He has noted increasing dyspnea on exertion recently, though appears to have a robust baseline functional status with daily [**Doctor First Name **] [**Doctor First Name **] and walking for exercise without symptoms. He was recently seen by pulm and prescribed [**Doctor First Name **], though it is unclear if patient has been using this. It was noted that if he is intubated, bronchodilators should be used post-extubation. He was placed on nebs, and remained on nasal cannula while in the ICU satting in the 90s. # CAD s/p CABG: CAGB with LIMA to LAD and separate SVGs to PDA in [**2118**]. Given his CAD history, we will continue ASA and beta blocker. Denies symptoms currently and ECG revealed no ischemic changes. He was continued on ASA, and beta blocker. His ACEI was initially held in the ICU given low BP.... # Coagulopathy: On HD#1, his PTT and INR increased. Considered antibiotics, decreased synthetic function given transaminitis, and also possibly [**1-6**] heparin given acute increase after starting heparin SC. He was given IV Vitamin K and his heparin SC was decreased to [**Hospital1 **].... Inactive issues: # Hypertension: Initially hypotensive in the ICU, but fluid responsive. His beta blocker was restarted and ACEI initially held.... # Hyperlipidemia: Continued Atorvastatin 10 mg PO DAILY. # BPH: Held doxazosin 4 mg PO HS initially in the ICU. The patient had difficulty urinating in PACU after his cholecystectomy so a foley catheter was replaced. He was resumed on his home doxazosin and will be going home with the catheter in place. A Urology appointment has been scheduled for the patient. # GERD: Continued home omeprazole. # Restless leg: Stable. Continued home ropinirole. Mr. [**Known lastname **] [**Last Name (Titles) 1834**] a laparoscopic cholecystectomy on [**9-6**]. Please see the operative report for details of this procedure. He tolerated the procedure well and was extubated upon completion. He we subsequently taken to the PACU for recovery. As noted above, Mr. [**Known lastname **] was unable to urinate after his Foley catheter was discontinued. The catheter was replaced and his urine output was closely monitored. He was transferred to the surgical floor hemodynamically stable. His vital signs were routinely monitored and he remained afebrile and hemodynamically stable. The patient was initially given IV fluids postoperatively, which were discontinued when he was tolerating oral intake. His diet was advanced on the morning of [**9-7**] to regular, which he tolerated without abdominal pain, nausea, or vomiting. He was voiding adequate amounts of urine without difficulty. He was encouraged to mobilize out of bed and ambulate as tolerated, which he was able to do independently. His pain level was routinely assessed and well controlled at discharge with an oral regimen as needed. On the afternoon of [**9-8**], Mr. [**Known lastname **] was discharged home with scheduled follow up in the [**Hospital 2536**] clinic as well as Urology to address his urinary retention. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Family/Caregiver[**Name (NI) 581**]. 1. Doxazosin 4 mg PO HS 2. Lisinopril 2.5 mg PO DAILY 3. Tiotropium Bromide 1 CAP IH DAILY 4. Metoprolol Succinate XL 25 mg PO DAILY 5. Atorvastatin 10 mg PO DAILY 6. Ropinirole 1 mg PO TID 7. Omeprazole 40 mg PO DAILY 8. Aspirin 81 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 10 mg PO DAILY 3. Doxazosin 4 mg PO HS 4. Omeprazole 40 mg PO DAILY 5. Ropinirole 1 mg PO TID 6. Acetaminophen 650 mg PO Q6H:PRN pain 7. Docusate Sodium 100 mg PO BID 8. Ciprofloxacin HCl 500 mg PO Q12H last dose 10/11 RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*12 Tablet Refills:*0 9. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 0.5-1 tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills:*0 10. Senna 1 TAB PO BID:PRN Constipation 11. Tiotropium Bromide 1 CAP IH DAILY 12. Metoprolol Succinate XL 25 mg PO DAILY 13. Lisinopril 2.5 mg PO DAILY Discharge Disposition: Home With Service Facility: Multicultural VNA Discharge Diagnosis: Chronic cholecystitis BPH, urinary retention Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with acute cholecystitis. You were taken to the operating room and had your gallbladder removed laparoscopically. You tolerated the procedure well and are now being discharged home to continue your recovery with the below instructions. Please note that you are now going home with a urinary catheter ("Foley" catheter) in place because you had difficulty urinating after your surgery. You will go home with a leg bag. A follow-up appointment with Urology has been scheduled for you. You will also follow up in the Acute Care Surgery clinic at the appointment listed below. ACTIVITY: o Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. o You may climb stairs. o You may go outside, but avoid traveling long distances until you see your [**Name (NI) 5059**] at your next visit. o Don't lift more than [**9-18**] lbs for 4 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. o You may start some light exercise when you feel comfortable. o You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. HOW YOU [**Month (only) **] FEEL: o You may feel weak or "washed out" for a couple of weeks. You might want to nap often. Simple tasks may exhaust you. o You may have a sore throat because of a tube that was in your throat during surgery. o You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. o You could have a poor appetite for a while. Food may seem unappealing. o All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your [**Month (only) 5059**]. YOUR INCISION: o Tomorrow you may shower and remove the gauzes over your incisions. Under these dressing you have small plastic bandages called steri-strips. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that that's okay). o Your incisions may be slightly red around the stitches. This is normal. o You may gently wash away dried material around your incision. o Avoid direct sun exposure to the incision area. o Do not use any ointments on the incision unless you were told otherwise. o You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your [**Month (only) 5059**]. o You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. YOUR BOWELS: o Constipation is a common side effect of narcotic pain medications. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. o If you go 48 hours without a bowel movement, or have pain moving the bowels, call your [**Month (only) 5059**]. PAIN MANAGEMENT: o It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". o Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your [**Name2 (NI) 5059**]. o You will receive a prescription for pain medicine to take by mouth. It is important to take this medicine as directed. o Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. o Your pain medicine will work better if you take it before your pain gets too severe. o Talk with your [**Name2 (NI) 5059**] about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your [**Name2 (NI) 5059**] has said its okay. o If you are experiencing no pain, it is okay to skip a dose of pain medicine. o Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the following, please contact your [**Name2 (NI) 5059**]: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. If you have any questions about what medicine to take or not to take, please call your [**Name2 (NI) 5059**]. Followup Instructions: Department: SURGICAL SPECIALTIES/ UROLOGY When: THURSDAY [**2124-9-14**] at 9:30 AM With: PELVIC FLOOR UNIT [**Telephone/Fax (1) 274**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] With: [**First Name4 (NamePattern1) 5877**] [**Last Name (NamePattern1) 16471**],MD When: WEDNESDAY [**2124-9-27**] at 3:00 PM With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

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Discharge summary

report

Admission Date: [**2182-4-24**] Discharge Date: [**2182-5-4**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7591**] Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: ERCP History of Present Illness: [**Known firstname **] [**Known lastname **] is an 87-year-old man with a previous history of a spindle cell myoepithelial tumor involving the right parotid gland. In addition, he has myelodysplastic disorder, which is transforming to leukemia. He was recently admitted to [**Hospital1 18**] from [**Date range (1) 62739**] for altered mental status and febrile neutropenia. No clear cause for his altered mental was found and he had a negative LP and MRI. It eventually spontaneously improved. He was initially treated with Vanc/CTX/Amp/Acyclovir but was changed to cefepime/vanc on when the LP was negative. D/C'd on 7 day course of Levofloxacin for febrile neutropenia with no clear source. . He now returns with severe epigastric pain since this morning with associated profuse vomitting and diarrhea. He could no characterize the vomit. Denies any aggravating or alleviating symptoms. States he may have had a somewhat similar pain "a while ago". Denies HA, visual changes, CP, SOB, palpitations, F/C, dysuria, focal weakness, numbness or tingling. . Review of systems is otherwise negative. . In the emergency department, initial VS were: 97.3, 66, 136/66, 16, 100% RA. An initial CT scan showed signs concerning for pancreatitis. He remained afebrile but given his persistent neutropenia and a lactate of 4.6, he was given cefepime, vanco, and clindamycin. He remained HD but received a total of 3L NS. He was also treated for a K+ of 5.4 with Calcium gluconate, 10 units of insulin, and 1 amp D50. The patient also had some brief ([**6-2**] sec) of asymptomatic bradycardia to the 30s to 40s. BP remained stable and no intervention given. He is admitted to the [**Hospital Unit Name 153**] for further care and monitoring Past Medical History: PAST ONCOLOGIC HISTORY (as per previous notes): Mr. [**Known lastname **] was first evaluated by Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**4-5**], [**2181**]. He first noticed a soft-tissue mass in front of his right ear in [**2180-12-23**]. The painless mass grew in size so a CT head was done on [**2181-1-19**], which was notable for a 2 cm enhancing mass in the superficial lobe of the right parotid gland. He underwent a superficial parotidectomy on [**2181-2-5**]. Pathology was consistent with a 3.2 cm spindle cell myoepithelial carcinoma focally extending into the surrounding fibroadipose tissue. It was less than 1 mm from the inked margin. It was in the background of a residual pleomorphic adenoma. He then started radiation, but unfortunately the mass continued to increase in size during radiation. It was re-biopsied on [**2181-3-26**], and found to be consistent with mild pleomorphic spindle cells. He restarted radiation therapy on [**2181-4-2**]. The decision at that time was to start concurrent Erbitux for radiosensitization. This was started on [**2181-4-6**]. He continued Erbitux through [**2181-5-4**], and completed radiation on [**2181-5-18**]. On [**2181-5-25**], he went back to the OR and underwent right anterolateral thigh flap to the right facial and temporal region and multiple facial nerve grafts after undergoing total parotidectomy, with sacrifice of the facial nerve and subtotal right auriculectomy and a right modified radical neck dissection. Pathology was notable for a tumor which measured 2.4 cm in greatest dimension in the cartilage of the external ear canal. LVI was not seen. Pathology seemed consistent with but not completely compatible with his previous myoepithelial carcinoma, although the thought was this difference was secondary to radiation. No malignancy was identified in 10 lymph nodes. He was seen in follow up with Dr. [**Last Name (STitle) **] on [**2181-8-17**]. At that time, he remained persistently pancytopenic and a concern for myelodysplastic syndrome was raised. Mr. [**Known lastname **] and his family wanted to defer a bone marrow biopsy at that time. He had a blood transfusion on [**2181-10-3**], at [**Location (un) 620**]. On [**2181-10-17**], he underwent a revision flap with right myocutaneous facial flap, right lower lid repair. Surgery was uncomplicated. On [**12-14**], [**2181**], he underwent further revision with a split-thickness skin graft external auditory canal. After creation of the external auditory canal with adjacent tissue of the thigh flap, he developed redness and drainage at the site of thigh flap on [**2181-12-31**]. This was felt to be adequately treated with topical antibiotics. He started Decitabine therapy on [**2182-2-26**] and has received 2 cycles. . PAST MEDICAL HISTORY: 1. Postoperative DVT. LLE DVT following original parotid mass resection in [**2181-1-23**]. Thrombus extended from the inferior portions of the superficial femoral vein to the entire popliteal vein and superior portions of the left saphenous vein with nonocclusive thrombus in the mid superficial femoral vein. Initially, patient was treated with Lovenox as a bridge to Coumadin. Lupus anticoagulant and cardiolipin antibodies were sent at that time per the discharge summary. It was later reported LA was positive. Coumadin discontinued [**2182-2-15**] due to ongoing thrombocytopenia. 2. CHF. He most recently had an EF of 35%. 3. Hypertension. 4. History of coronary artery disease-- no history of MI or CABG, . Has severe inferior hypokinesis, and less severe hypokinesis in the anterior/anterolateral/anteroseptal walls on echo ([**5-31**]). 5. BPH. 6. Facial cellulitis . PAST SURGICAL HISTORY: - Extensive surgery and reconstruction related to his parotid gland tumor (as above). He is also status post appendectomy and TURP. Social History: He has a history of tobacco use. He smoked 3 packs a day for 15 to 20 years approximately 45 years ago. He rarely drinks wine. He lives with his wife. Family History: He has no family history of cancers that he is aware of. No family history of blood disorders that he is aware of. Physical Exam: 94.2, 141/48, 66, 97% RA . . PHYSICAL EXAM GENERAL: Pleasant, well appearing male in NAD HEENT: s/p facial reconstruction on right with facial nerve palsy. Well healed reconstructive surgery. PERRL, OP clear (exam limited) without ulcers or thrush, MMM, poor dentition CARDIAC: Regular rhythm with occ. PVC, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. JVP 7-8cm LUNGS: CTAB, good air movement biaterally. ABDOMEN: Soft, diffusely tender in epigastrium, no rebound, voluntary guarding EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 7 palsy. Preserved sensation throughout. 5/5 strength throughout. [**1-25**]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant . Pertinent Results: [**4-24**] CTabd 1. Findings compatible with acute pancreatitis. 2. Cholelithiasis. Recommend clinical correlation for gallstone pancreatitis. Consider US to further assess for choledocholithiasis. 3. Diverticulosis without evidence of diverticulitis. 4. Abdominal aortic aneurysm measuring up to 3.9 cm in diameter. 5. Foley catheter in place with balloon at the level of the prostatic urethra. Recommendation for repositioning was made with Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 4223**] at approximately 7:25 p.m. on [**2182-4-24**]. [**2182-4-24**] CT head1. No evidence of acute hemorrhage. 2. Bilateral mastoid air cell opacification with an air-fluid level is in the left mastoid air cells, chronic [**2182-4-24**] RUQ u/s IMPRESSION: Equivocal findings for cholecystitis with gallstones, gallbladder wall thickening and pericholecystic fluid but no biliary ductal dilatation or son[**Name (NI) 493**] [**Name2 (NI) 515**] sign. While GB wall thickening and free fluid may be reactive secondary to underlying pancreatitis, acute cholecystitis cannot be entirely excluded. Consider HIDA or MRCP to further assess. [**2182-4-25**] ERCP Successful removal of sludge from the common bile duct with interval placement of common bile duct stent. Otherwise, unremarkable biliary system. Please refer to ERCP note in OMR from [**2182-4-24**], for further findings, full details, and further recommendations [**5-1**] CXR: FINDINGS: Worsening volume status of the patient with increasing perihilar haziness and interstitial edema. Persistent left basilar opacity with adjacent small-to-moderate left pleural effusion. Brief Hospital Course: 87 year old male MDS s/p gallstone pancreatitis and febrile neutropenia, hospital course complicated by tachy-brady syndrome, altered mental status in the setting of peri-operative opiods, hypernatremia, and pancreatitis. Patient recovered mental status with correction of hypernatremia and treatment of pancreatitis long enough to express his wishes for hospice. Made DNR/DNI/CMO and expired in the hospital while awaiting transfer to hospice. #Delerium: Multiple etiologies including peri-operative opiods, hypernatremia worsened by poor PO intake and diarrhea, hypoxia in the setting of pulmonary edema, and gallstone pancreatitis. Noticed to be delerious the night after ERCP, so pain meds were held. Patient was frequently re-oriented. Pancreatitis and hypernatremia were treated (see below), and all bowel regimen was held. Patient recovered from delerium long enough to express wishes for hospice. Once DNR/DNI/CMO, all unessential medications were removed, comfort medications including morphine, and gentle fluids with D5 were continued for comfort since patient remained NPO, and PICC line was placed at the wishes of the family to minimize pain/blood draws. The day of death, patient was noted to be having more secretions, and sounding more rhonchorous on exam. Fluids were stopped, scopolamine patch was placed. Patient noted to become oliguric/anuric with discontinuation of IV fluids, and passed away peacefully on [**2182-5-4**]. #. Gallstone Pancreatitis: Pt. was initially admitted with elevated LFTs, bilirubin and amylase/lipase consistent with gallstone pancreatitis. He went to ERCP and sludge was extracted from the bile ducts and a plastic stent was placed without sphincterotomy. He initially required frequent fluid boluses to maintain his blood pressure but then began to autodiurese. Enzymes were trending downwards on transfer to BMT floor. Patient never recovered mental status enough to tolerate a regular diet and was made NPO to prevent aspiration per speech and swallow consult. Was initially treated with cefepime/flagyl and vancomycin, all of which were d/c-ed once patient was made CMO. # Hypernatremia: Noted to be hypernatremic in the setting of poor PO intake and diarrhea secondary to lactulose (given in ICU presumably to treat encephalopathy). Corrected with D5W and D5 1/2 NS to low 140s, and patient recovered mental status enough to agree to hospice. Once made DNR/DNI/CMO, gentle D5 1/2 NS at 50 ccs/hr was administered for comfort as patient was NPO, and d/c-ed once patient began having more secretions. #Atrial fibrillation, with RVR: Improving after autodiuresis. Treated with PO metoprolol and IV metoprolol when patient unable to take POs. Stopped upon CMO status. #Tachy-Brady Syndrome: Patient noted to be tachycardic and bradycardic intermittently, without hemodynamic instability. Per HCP, patient was not to be coded (shocked, have chest compressions, or IV medications) if hemodynamically unstable in the event of any persistent tachycardic or bradycardic events. Cardiology was consulted, who recommended IV metoprolol 5 mg q6H around the clock. Pacer not recommend (unofficially) by EP due to patients poor cancer prognosis. Metoprolol stopped and telemetry discontinued once patient was made CMO. #.ARF: Undulating baseline, was prerenal on admission but then improved with IVFs. Once made CMO and all IV fluids were stopped, patient rapidly became oliguric and passed away. #. MDS/AML: Patient has MDS transforming to leukemia, with poor prognosis (< 1 year). Neutrapenia improving spontaneously. Received one transfusion of packed red blood cells while in the ICU. Counts appeared improved after recent 2 cycles of dacogen therapy. No further chemotherapy plans were made once patient was made CMO. #. CHF: EF of 35%. Held ramipril and careful hemodynamic monitoring. Stopped all CHF meds once patient made CMO. ACCESS:PICC line placed to minimize blood sticks per family request. CODE STATUS: DNR/DNI/CMO EMERGENCY CONTACT: HCP is [**Name (NI) **] [**Last Name (NamePattern1) 62740**], [**Telephone/Fax (1) 62741**] DISPOSITION: Expired Medications on Admission: 1. Ramipril 2.5mg PO DAILY 2. Allopurinol 15 mg PO DAILY 3. Multivitamin PO DAILY 4. Acetaminophen 650mg q6 PRN 5. Neomycin-Polymyxin-HC 3.5-10,000-1 mg-unit/mL-% Drops, Four (4) Drop Otic TID 6. Levofloxacin 500 mg PO Q24H until [**2182-4-29**] Discharge Medications: None, expired Discharge Disposition: Expired Discharge Diagnosis: You were admitted with abdominal pain due to gallstone pancreatitis. You underwent an ERCP and gallstones were improved. You were also noted to have high sodium levels that were treated with IV fluids. Your mental status never improved despite correction of all medical causes of confusion. It was decided to make you comfort measures only and to seek hospice. In the process of doing so, patient passed away peacefully in the hospital. Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None Completed by:[**2182-5-13**]

[ "V12.51", "584.9", "574.31", "205.00", "577.0", "414.01", "427.81", "428.22", "428.0", "276.0", "293.0", "V10.02", "427.31", "441.4", "600.00", "401.9" ]

icd9cm

[ [ [] ] ]

[ "51.87", "38.93" ]

icd9pcs

[ [ [] ] ]

13283, 13292

8832, 12948

276, 282

13772, 13781

7154, 8809

13834, 13869

6127, 6244

13245, 13260

13313, 13751

12974, 13222

13805, 13811

5809, 5942

6259, 7135

222, 238

310, 2042

4905, 5786

5958, 6111

31,470

168,141

32933

Discharge summary

report

Admission Date: [**2149-2-15**] Discharge Date: [**2149-2-28**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1042**] Chief Complaint: chills and SOB Major Surgical or Invasive Procedure: None History of Present Illness: 89YOM with CAD s/p CABG [**2149-1-31**], CHF, HTN, and polymyalgia [**Year (2 digits) 23389**] who presents from [**Hospital 745**] Healthcare Center with chills and SOB early this AM. SOB occured during episode of chills during which pt "could not catch my breath." Per notes from NHC, at that time he was febrile 102.5 and sat 88% 3L NC and lethargic. He reports a dry cough x3 weeks, never productive of sputum. He denies HA, vision changes, LOC, myalgias, N/V, abdominal pain, dysuria, and urinary retention. +loose stools since d/c from hospital, usually once a day, has been on senna and colace; he is unable to comment of the presence of blood in stool. He denies melena and hematochezia. . Of note, today he finished a course of Keflex 500mg [**Hospital1 **] x7d which was started at NHC for "left knee incision site". The patient denies knowledge of infection at that site. . ED course: In the ER, he was given flagyl for possible c. diff. CXR demonstrated LLL pneumonia and he was also started empirically on vanc/levo. . Past Medical History: - CAD s/p CABG (Off-pump coronary artery bypass graft x4, saphenous vein grafts to left anterior descending artery, diagonal, obtuse marginal and posterior descending arteries) - CHF ([**2-1**] EF 35-40%, mild symmetric LV hypertrophy, mild to moderate regional left ventricular systolic dysfunction with anteroseptal inferior hypokinesis with Apical akinesis, mild AS, mild MR, normal RV function) - hypertension - polymyalgia [**Month/Year (2) 23389**], duration of prednisone tx unkown - h/o kidney stones - [**Month/Year (2) **] 7 years ago - s/p hernia repair for bilateral inguinal hernia - s/p lap cholecystectomy for cholelithiasis - Scarlet fever, [**5-17**] yrs old. . Social History: Patient used to work part time as a constable, but has not been working since his MI/CABG. He lives with his wife in [**Name (NI) 1110**], but has been in rehab in [**Location (un) **] since his CABG. He has a supportive family in the area. He has a 13-pack-year smoking history, quit about 56yrs ago. He quit drinking alcohol 29 yrs ago. Family History: 2 brothers died of heart attacks: one in ~77yo and other in his 80s. 1 sister also died of heart attack in her 80s. 1 sister has "half of a lung" not know why?. His father died of lymphoma at age 80, and his mother died at age 40 from a hospital pneumonia, and possibly a cancer-had stomach surgery before death. Physical Exam: V/S on admission on floor: T: 98.9 BP:122/72 P:82 RR:18 O2 sats:95, on 2L O2 Gen: NAD, relaxed appearing male, of stated age, pleasant HEENT:NCAT, PERRL, EOMI Skin: Ecchymoses on medial aspect of left thigh, and on suprapubic area. Neck: no masses, no ausc carotid bruits. CV: RRR, nl S1, S2, II/VI systolic murmur Resp: bilateral basilar crackles, otherwise clear Abd: BS+, soft, NTND, no guarding/rigidity/rebound, Back: no CVA tenderness Rectal: def Ext: no CCE, 2+symmetric pedal pulses, L popliteal incision site C/D/I, no erythema, exudates, or drainage, healing by secondary intention Neuro: O&Ax4, non-focal, sensation intact, strength 5/5 bilaterally Pertinent Results: Labs upon admission: [**2149-2-15**] 08:00AM PT-17.5* PTT-33.7 INR(PT)-1.6* [**2149-2-15**] 08:00AM PLT COUNT-217# [**2149-2-15**] 08:00AM NEUTS-87.3* LYMPHS-7.9* MONOS-4.1 EOS-0.5 BASOS-0.1 [**2149-2-15**] 08:00AM WBC-14.7* RBC-3.61* HGB-10.8* HCT-33.3* MCV-92 MCH-29.8 MCHC-32.3 RDW-14.7 [**2149-2-15**] 08:00AM CK-MB-NotDone cTropnT-0.76* [**2149-2-15**] 08:00AM CK(CPK)-77 [**2149-2-15**] 08:00AM estGFR-Using this [**2149-2-15**] 08:00AM GLUCOSE-113* UREA N-27* CREAT-1.2 SODIUM-137 POTASSIUM-4.9 CHLORIDE-106 TOTAL CO2-20* ANION GAP-16 [**2149-2-15**] 08:14AM LACTATE-1.8 [**2149-2-15**] 09:09PM CK-MB-NotDone cTropnT-0.61* [**2149-2-15**] 09:09PM CK(CPK)-96 . CHEST (PA & LAT) [**2149-2-15**]: 1. Left lower lobe pneumonia. 2. Slight increase in small bilateral pleural effusions. 3. Stable cardiomegaly. . ABDOMEN U.S. (COMPLETE STUDY) [**2149-2-18**]: FINDINGS: The liver shows no focal or textural abnormality. There is no biliary dilatation and the common duct measures 0.4 cm. Note is made of a linear echogenic structure within the gallbladder fossa which most likely represents a surgical clip. The gallbladder is noted to have been surgically removed. The portal vein is patent with hepatopetal flow. The visualized portion of the pancreas is unremarkable however the pancreas is mostly obscured by overlying bowel gas. The spleen is unremarkable and measures 9.3 cm. Both right and left kidneys show no hydronephrosis and no solid masses. The right kidney measures 10.4 cm and the left kidney measures 10.0 cm. The renal cortex is noted to be thinned bilaterally. The aorta is not well visualized on this exam. IMPRESSION: Unremarkable abdominal ultrasound. . [**2149-2-15**] 8:00 am BLOOD CULTURE: (pending) . [**2149-2-16**] 6:07 am URINE Source: Catheter URINE CULTURE (Final [**2149-2-17**]): NO GROWTH Brief Hospital Course: Mr. [**Known lastname **] was admitted for treatment of his left lower lobe pneumonia. # fever/pneumonia Mr. [**Known lastname **] was started on levoquin. His chills and shortness of breath resolved. His WBC count improved as well as his lung exam. His dry cough improved during his hospital course, it was not productive of sputum and no sputum cultures were sent. His urine culture was negative and blood cultures demonstrate no growth to date at the time of discharge. He was afebrile for >48 hours at the time of discharge. He was discharge to finish a 7 day course of levoquin. . # loose stools: Upon admission to the hospital, Mr. [**Known lastname **] did not have another episode of loose stools. . #CAD s/p CABG with h/o of MI in [**2149-1-11**]. on telemetry He had elevated troponin however has had no change in his EKG and was asymptomatic for MI. He was placed on telemetry and had no cardiac complaints during his hospital course. He was continued on aspirin, plavix, metoprolol; he was also started on atorvostatin for his h/o CAD, with LDL goal <70. He was seen by cardiothoracic surgery who evaluated his scars/wounds; he had no acute surgical issues. His left popliteal graft harvest site has been healing well with secondary intention with no evidence of erythema, purulent drainage, or induration. It was cleaned with normal saline daily, dressed with bacitracin and daily dry gauze dressing changes. As his creatinine normalized, he was started on lisinopril given his history of coronary artery disease. . # CHF, chronic systolic. He appeared to be overall volume overloaded given his BLE edema, however was depleted intravascularly. He was gently rehydrated with IVF and had no evidence of worsening heart failure during his hospital course. His BLE edema improved with elevation, despite discontinuation of lasix because of increased creatinine. He can be restarted on lasix if needed as his creatinine tolerates. . # HTN Blood pressure was slightly elevated on admission in the 150s/80s-90s so metoprolol was increased from 150mg to 200mg daily. After this increased in metoprolol, his blood pressure remained in an excellent range, <120/80. . # Urinary retention Mr. [**Known lastname **] developed urinary retention on hospital day 2; he was unable to urinate despite having the urge to do so. He has a h/o an enlarged prostate but denied h/o recent urinary complaints (no dysuria, no dribbling, no difficulty in starting stream, no frequency). He mentioned a h/o a procedure 30 years ago where physicians "took scrapings of the prostate" but he has not had problems since then; he denies ever being told he has cancer. He is followed by his primary care provider for the enlarged prostate. He was discharged with a foley in place. He has an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**], Urologist, at [**Hospital1 18**] on [**2149-2-27**] at 4pm. The foley should be in place until his appointment. . # elevated CR Likely due to intravascular volume depletion as FeNa<1% (0.5%). He was gently rehydrated and creatinine returned to baseline. His urinanalysis was unremarkable and he had a negative urine culture. . # elevated INR Differential diagnosis included vitamin K deficiency, however he received vitamin K 5mg daily for 3 days did not decrease his INR. Right upper quadrant ultrasound was unremarkable. He will need work-up of this as an outpatient. . # Bilateral foot pain This has been ongoing since his discharge after his CABG. It was greatly improved with TID application of Hydrocerin cream and thought to be secondary to dry skin. . # Anemia, normocytic: He has had anemia since his CABG, but hematocrit has been steadily increasing since that time. . # Polymyalgia [**Year (4 digits) 23389**] Mr. [**Known lastname **] was continued on his prednisone. He had no acute issues regarding his PMR during his hopital course.. . # FEN: regular diet, colace, electrolytes repleted as needed. . # PPX: Clopidogrel was continued. . # Dispo: Skilled nursing facility with physical therapy. . # Code Status: full Medications on Admission: 1. Aspirin 81 mg daily 2. Docusate Sodium 100 mg [**Hospital1 **] 3. Prilosec 20mg daily 4. PredniSONE 9 mg daily 5. Senna 8.6 mg Tablet Sig: 1-2 Tablets [**Hospital1 **] 6. Clopidogrel 75 mg daily 7. Metoprolol Tartrate 50 mg TID 8. Lasix 20mg [**Hospital1 **] 9. KCL 20mEQ [**Hospital1 **] while on lasix 8. Keflex 500mg [**Hospital1 **] x 7d (finished [**2148-2-16**]) Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(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. PredniSONE 1 mg Tablet Sig: Nine (9) Tablet PO DAILY (Daily). Disp:*270 Tablet(s)* Refills:*0* 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:*0* 5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. Disp:*2 Tablet(s)* Refills:*0* 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*0* 8. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl Topical TID (3 times a day) as needed for to both feet. Disp:*qs * Refills:*0* 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 10. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. Disp:*qs ML(s)* Refills:*0* 11. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day). Disp:*qs * Refills:*2* 12. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital 54752**] Rehab & Skilled Nursing Center - [**Location (un) 1110**] Discharge Diagnosis: Pneumonia Discharge Condition: Good Discharge Instructions: You were diagnosed with pneumonia during your hospital stay. You were treated with antibiotics; please finish your antibiotics as prescribed. . You also developed urinary retention during your hospital stay. You will go to rehabilitation with a foley catether and follow-up with a urologist (Dr. [**Last Name (STitle) 770**] as detailed below. . Please also go to your follow-up appointment with your cardiothoracic surgeon (Dr. [**Last Name (STitle) **] as detailed below. . Please come to the emergency room if you develop fevers/chills, worsening cough, chest pain, shortness of breath, nausea/vomiting, diarrhea, or any other concerns. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2149-2-27**] 4:00 . Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2149-3-5**] 1:00 . Please follow-up with your primary care provider [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 70216**], [**Telephone/Fax (1) 72189**], as needed or within 2-4 weeks to update him on your hospitalization.

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icd9cm

[ [ [] ] ]

[ "38.91", "99.10", "00.14" ]

icd9pcs

[ [ [] ] ]

11284, 11389

5316, 9410

277, 284

11443, 11449

3437, 3444

12137, 12684

2424, 2739

9833, 11261

11410, 11422

9436, 9810

11473, 12114

2754, 3418

223, 239

312, 1346

3458, 5293

1368, 2048

2064, 2408

2,324

129,210

22233

Discharge summary

report

Admission Date: [**2135-11-27**] Discharge Date: [**2135-12-4**] Date of Birth: [**2066-12-22**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 613**] Chief Complaint: right knee swelling and tenderness Major Surgical or Invasive Procedure: I and D-right knee abscess History of Present Illness: This is a 68 y.o woman with a history of alcohol abuse, OA s/p bilateral TKR, recurrent right lower extremity cellulitis, Type 2 diabetes mellitus, and chronic renal failure presenting with right knee swelling and tenderness. The patient was in her usoh until [**Month (only) 205**] of this year when she was admitted with cellulitis of the right knee, at which point an incision and drainage was performed and she was treated with a course of levofloxacin. She then presented in [**Month (only) 359**] with similar symptoms and again underwent an I and D of an abscess and was treated with a 7 day course of levofloxacin. She was discharged to home and was doing well until 1-2 days prior to admission when she noted increased right knee swelling to 2x the size of the other knee. She also noted increased redness of her right knee and difficulty ambulating secondary to pain. She has not noted any associated fever or chills. She denies recent trauma to her knee or recent falls. In the ED, the patient was febrile to 101 F. Surgery did an incision and drainage of a fluctuant area in the lateral aspect of the right knee and drained ~4 oz brown, thick fluid (per daughter's report). She was also started on levo/vanco/flagyl. Of note, the patients daughters also report that the patient has become increasingly confused over the past few days and that she is not eating or drinking very much. The patient reports that she is not hungry. She also reports being more short of breath than usual and decreased exercise tolerance (now cannot walk with her walker to the bathroom without being short of breath -normally can walk throughout house). She denies nausea/vomiting/weakness. She denies chest pain/palpitations. She denies change in bowel movements -baseline [**4-18**] loose stools per day. She denies hematochezia/melena/BRBPR. She denies decreased urinary frequency/hematuria/dysuria. ROS: otherwise unremarkable; no changes in vision/ numbness/tingling/lightheadedness Past Medical History: 1. Anemia-c/w anemia of chronic disease vs liver disease 2. Gastro-esophageal reflux disease 3. Asthma 4. Hypothyroidism-levothyroxine increased from 50-75 on [**2135-11-18**] 5. Type II diabetes mellitus-diet controlled 6. s/p ventral hernias x2 7. Upper GI bleed 8. Portal hypertension [**2135-11-3**] RUQ US Coarse and echogenic liver consistent with fatty infiltration. Enlarged splenic vein and splenomegaly. Patent hepatic vasculature. 9. OA s/p bilateral total knee replacement 10. Right lower extremity cellulitis 11. Intestinal bypass in 70s, now with short gut syndrome 12. Renal insufficiency - baseline 7/04-1.7, 11/1/04-3.1 [**2135-11-1**]-Renal US: Unremarkable renal ultrasound. No hydronephrosis, hypoechogenicity, mass Social History: Lives at home, history of alcohol abuse -drinks range from 2 drinks - 6 pack per day, stopped 1-2 weeks before admission in [**2135-7-14**], no tobacco use/IV drug use Family History: mother died of renal disease at 49, brother with MI at 60, son with coronary artery disease Physical Exam: Vitals: T 96.6 HR 82 BP 112/56 RR 24 O2 Sat 100% 2L FS 153 Gen: awake, alert, speaking in complete sentences, (+) nasal cannula in place; no increased work of breathing/accessory muscle use HEENT: PERRL, EOMI, MMM, (+) few palatal petechiae, neck supple with no LAD, trachea midline, no JVD, no thyromegaly/nodules Lungs: CTA bilaterally, no wheezes/rhonchi/rales Heart: RRR, nml S1/S2, no murmurs/rubs/gallops, no carotid bruit, 1+ DP pulses bilaterally Abdomen: obese, soft, NT/ND, +NABS, lower abdominal mass (per patient is a hernia, s/p multiple surgeries) Extr: Right knee, 1 inch incision lateral to patella, no drainage, no erythema/warmth Neuro: A&O x3, CNII-XII grossly intact, 5/5 strength bilaterally UE/LE, full sensation throughout, FTN slow, slight tremor with left hand, no asterixis Serial 7s -unable to do. Pertinent Results: [**2135-11-27**] 12:50PM WBC-7.9# RBC-3.08* HGB-10.3* HCT-32.1* MCV-104* MCH-33.3* MCHC-31.9 RDW-20.2*NEUTS-91.6* BANDS-0 LYMPHS-4.8* MONOS-2.9 EOS-0.3 BASOS-0.3 PLT SMR-VERY LOW PLT COUNT-79* [**2135-11-27**] 12:50PM UREA N-20 CREAT-3.4* SODIUM-138 POTASSIUM-3.0* CHLORIDE-116* TOTAL CO2-7* ANION GAP-18 [**2135-11-27**] 12:50PM CALCIUM-7.6* PHOSPHATE-3.2 MAGNESIUM-1.0* [**2135-11-27**] 12:50PM AST(SGOT)-26 ALK PHOS-111 AMYLASE-43 TOT BILI-1.3 [**2135-11-27**] 12:50PM LIPASE-22 [**2135-11-27**] 01:13PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.012 [**2135-11-27**] 01:13PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2135-11-27**] 01:13PM URINE RBC-0-2 WBC->50 BACTERIA-MANY YEAST-NONE EPI-0-2 [**2135-11-27**] 05:48PM TYPE-ART PO2-145* PCO2-16* PH-7.25* TOTAL CO2-7* BASE XS--17 [**2135-11-27**] 05:48PM LACTATE-1.4 [**2135-12-4**] 04:53PM BLOOD WBC-21.2* RBC-2.55* Hgb-7.4* Hct-21.4* MCV-84 MCH-29.0 MCHC-34.5 RDW-16.3* Plt Ct-45* [**2135-12-4**] 02:47PM BLOOD WBC-21.1* RBC-2.12* Hgb-6.2* Hct-17.6* MCV-83 MCH-29.3 MCHC-35.4* RDW-16.8* Plt Ct-59* [**2135-12-4**] 12:59PM BLOOD WBC-17.2* RBC-2.04*# Hgb-6.0*# Hct-17.9*# MCV-88 MCH-29.4 MCHC-33.6 RDW-17.1* Plt Ct-41* [**2135-12-4**] 11:20AM BLOOD WBC-19.3* RBC-1.34*# Hgb-4.0*# Hct-12.4*# MCV-92 MCH-29.9 MCHC-32.5 RDW-20.0* Plt Ct-46* [**2135-12-4**] 10:25AM BLOOD WBC-21.4* RBC-1.98*# Hgb-5.9*# Hct-18.1* MCV-91 MCH-29.8 MCHC-32.6 RDW-19.3* Plt Ct-48* [**2135-12-4**] 07:56AM BLOOD Hct-17.2*# Plt Ct-47* [**2135-12-4**] 05:57AM BLOOD WBC-37.2* RBC-3.07*# Hgb-9.8*# Hct-28.4* MCV-93 MCH-32.0 MCHC-34.6 RDW-17.9* Plt Ct-82* [**2135-12-4**] 04:01AM BLOOD Hct-26.9*# [**2135-12-4**] 02:00AM BLOOD WBC-32.2* RBC-1.80* Hgb-5.9* Hct-17.5* MCV-97 MCH-32.7* MCHC-33.7 RDW-22.7* Plt Ct-135* [**2135-12-4**] 12:00AM BLOOD WBC-28.2*# RBC-2.00* Hgb-6.6* Hct-19.6* MCV-98 MCH-32.8* MCHC-33.6 RDW-22.1* Plt Ct-144*# [**2135-12-4**] 04:53PM BLOOD Plt Ct-45* [**2135-12-4**] 02:47PM BLOOD Plt Ct-59* [**2135-12-4**] 02:47PM BLOOD PT-11.1* PTT-62.2* INR(PT)-0.8 [**2135-12-4**] 12:59PM BLOOD Plt Ct-41* [**2135-12-4**] 12:59PM BLOOD PT-20.1* PTT-104.6* INR(PT)-2.5 [**2135-12-4**] 11:20AM BLOOD Plt Ct-46* [**2135-12-4**] 11:20AM BLOOD PT-22.9* PTT-149.7* INR(PT)-3.3 [**2135-12-4**] 10:25AM BLOOD Plt Ct-48* [**2135-12-4**] 10:25AM BLOOD PT-34.8* PTT-150* INR(PT)-7.6 [**2135-12-4**] 09:57AM BLOOD PT-38.0* PTT-150* INR(PT)-9.1 [**2135-12-4**] 07:56AM BLOOD Plt Ct-47* [**2135-12-4**] 05:57AM BLOOD Plt Ct-82* [**2135-12-4**] 05:57AM BLOOD PT-22.0* PTT-119.9* INR(PT)-3.1 [**2135-12-4**] 02:00AM BLOOD Plt Ct-135* [**2135-12-4**] 02:00AM BLOOD PT-22.1* PTT-105.6* INR(PT)-3.1 [**2135-12-4**] 12:00AM BLOOD Plt Ct-144*# [**2135-12-4**] 12:59PM BLOOD Fibrino-133*# [**2135-12-4**] 11:27AM BLOOD FDP-40-80 [**2135-12-4**] 11:20AM BLOOD Fibrino-76* D-Dimer->[**Numeric Identifier 961**]* [**2135-12-4**] 02:00AM BLOOD Fibrino-69*# D-Dimer->[**Numeric Identifier 961**]* Brief Hospital Course: A: 68 -year old woman with PMH Type 2 DM, EtOH abuse, OA s/p bilateral knee replacements and recurrent right LE cellulitis, presenting with right knee abscess, shortness of breath and confusion. * ANEMIA/TRANSFUSION REACTION: Large number of anti-red cell antibodies identified during this hospitalization [**2-14**] past history of transfusions. Of note, patient's baseline hematocrit had been previously identified at ~22-24. During initial hospitalization, patient was transfused one unit of PRBCs and developed acute stridor within one hour of initiation of transfusion. 0.3mg epinephrine, diphenhydramine, and steroids were administered, and stridor was relieved. This prompted overnight transfer to MICU for closer observation, but patient had no further respiratory distress and did well following. Transfusion reaction investigation revealed new anti red cell antibodies, but no IgE suggestive of an etiology for reaction. As such, it was felt by transfusion medicine consultants that patient may have had allergic reaction to penicillin contaminant in donor blood. However, it was felt that if patient required red cell or blood product transfusion, that extensive washing of all cell products was required given extensive number of patient's anti-red cell antibodies. * RIGHT KNEE INFECTED HARDWARE - MSSA, with bacteremic spread as 3/4 bottles (+) for gram positive cocci in clusters. Patient was treated with q48hours, trough ~15, levo, flagyl. In discussion with orthopedic consultants, it was felt that patient required emergent removal of hardware given continued bacteremia. Given comorbidities (see below), extensive pre, intra, and post-op planning with anesthesia, orthopedics, hematology, renal, and allergy consultants was made. Indeed, as noted below patient was a poor candidate for post-op anticoagulation given multiple red cell antibodies, anaphylactoid reaction, and history of massive GI bleed. Given issues with red cell antibodies, it was felt that patient would require fully staffed blood bank during surgery, and trip to OR was coordinated with blood bank staff as this would likely occur on a Saturday morning. However, given OR schedule and multiple traumas the night before patient's scheduled surgery, patient did not go to OR until Saturday evening, and staffing of blood bank was unclear at this point. On [**2135-12-4**] she was taken to the or and underwent a radical arthroplasy rt infected total knee peplacement with removal of all hardware and complete synovectomy dedbridement excision of sinus fistulous tract and insertion of abx spacer. Patient was transfered to the pacu in stable condition was extubated in pacu where she was seen by the medical night float floor team. At this point, patient had been started on phenylephrine for hypotension by anesthesia intraop. Given hemodynamic instability, MICU team converted pressor to levophed and transfused red cells, platelets, and IVFs as patient's hematocrit began to drop acutely. Indeed, it was felt that patient was most likely losing large amounts of blood through surgical site and orthopedics was called to evaluate the knee for post op bleeding. The dressing was not overly saturated and the hemovac did not have great deal of drainage, but because the INR was 3.1, it was felt by orthopedics PA that because of the extensive surgery there would be some bleeding and that this amt was not excessive. At this point the ortho resident and dr [**Last Name (STitle) **] the ortho attending were called and came to see the patient. The leg was redressed and a cryo cuff placed over the knee. Further complicating volume replacement was the fact that the cell washer in the blood bank on the [**Hospital Ward Name 517**] had malfunctioned, with minimal blood bank staff in the early AM. Therefore, all products had to be transported to [**Hospital Ward Name 5074**] for washing prior to administration. The patient was then transfered to the sicu on the sicu service where a tourniquet was applied in an attempt to stem the persistent bleeding. Patient was given blood products as needed but developed DIC [**2-14**] extensive bleeding. Patient was seen by the transfusion service, but patient had begun to develop acidemia secondary to poor perfusion. The family was made aware of the poor prognosis and agreed that the patient be made a DNR and CMO at 9:25 on [**2135-12-4**]. The patient expired shortly thereafter, and the family was notified Medications on Admission: ADVAIR DISKUS 100-50MCG--One puff twice a day ARANESP 60MCG/.3ML--One injection sc per week, ordered by renal CALCIUM CARBONATE 500MG--One tablet by mouth twice a day FOLACIN-K 1MG--Ordered by another md K CL-40 40MEQ/15ML--40meq a day, ordered by other md LASIX 80MG--Ordered by another md LEVOXYL 50MCG--One tablet by mouth every day PROTONIX 40MG--One tablet by mouth every day VITAMIN D 400 UNIT--One tablet by mouth every day CALCITRIOL 0.25 mcg--1 capsule(s) by mouth 3x/week (mon, wed, fri) Sodium Citrate-Citric Acid 500-334 mg/5 mL--30ml solution(s) by mouth three times a day Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Lumbar Stenosis Anemia secondary to anti-red cell antibodies Anaphylaxis Renal Failure Metabolic Acidosis Sepsis Disseminated Intravascular Coagulation Septic knee hardware/arthritis s/p rt knee arthroplasy removal of all hardware insertion of abx spacer Discharge Condition: expired Discharge Instructions: n/a Followup Instructions: n/a [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

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icd9cm

[ [ [] ] ]

[ "99.60", "86.22", "38.93", "80.06", "96.04", "96.71", "99.04", "81.91" ]

icd9pcs

[ [ [] ] ]

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308, 336

12756, 12765

4269, 7283

12817, 12944

3310, 3403

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234, 270

364, 2349

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3125, 3294

11,544

156,336

43779

Discharge summary

report

Admission Date: [**2107-9-25**] Discharge Date: [**2107-9-30**] Date of Birth: [**2027-2-6**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 99**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: On pressor support Central line placement PICC line placement Post-pyloric feeding tube placement Transfusion of packed RBC History of Present Illness: 80 yo male with hx of schizophrenia, dementia was admitted to MICU from [**Hospital1 18**] ED after being found to be septic. Patient was being transported to [**Hospital1 336**]/[**Hospital1 **] for evaluation of vomiting x few days (2 or 4 days, depending on whose report you read). He was only responsive to verbal stimuli per EMS notes. and per evaluation from the ambulance, his BP was 70/30, RR 30s and HR 60s. Of note, patient has been having poor appetite x 4 days. KUB was apparently negative for obstruction. . From his RN home, he was noted to have: - Cr of 2.9 BUN of 65 on [**2107-9-24**] and digoxin level of 1.5 - INR of 1.07 on [**2107-9-24**] and Pt of 11.6 . In the ED: He was alert and following commands. Initially BP responded to fluids and was in the 110s, then dropped to 67/59 - started on dopamine. He was also initially bradycardic to the 40s-50s (but then 110s for unclear reasons). Dopamine was titrated to 10mcg/kg/min and then was placed on levophed at 0.5mcg/kg/min and then titrated up to 3mcg/kg/min. On arrival to the floor, he was on only Levophed at 3mcg/kg/min. - increased pulmonary congestion and BiPAP was applied. - received 7L NS in ED - got Levo/Flagyl/Vanco . Access: A L groin was attempted. Then a R IJ was attempted - which led to guidewire getting stuck in the IVC filter. This was removed by Vascular Surgery. Finally, a R femoral line was placed. Past Medical History: CAD CHF PVD Dementia Schizophrenia CRI Cardiac Dysrhythmias Social History: Lives at long-term care facility. Sister, [**Name (NI) **] [**Name (NI) 976**], is his [**Name (NI) 5993**]. Family History: Non-contributory Physical Exam: T:99.4 BP:109/62 P:112 RR:28 O2 sats:95% BiPAP Gen: Elderly man with nonsensical speech HEENT: CV: +s1+s2 Quiet heart sounds. No murmurs appreciated. Resp: Mild crackles and decreased sounds at lung bases. Abd: Soft NT ND Skin: Warm. Perfused. Ext: RLE with cellulitis from area below knee to above the ankle with area of increased erythema around R medial malleolus. - + DP and PT pulses B/L - need doppler to identify. Neuro: Patient moving extremities x 4 . EKG: Tachycardia w/ RBBB Pertinent Results: Labs on admission: [**2107-9-25**] 08:59PM BLOOD WBC-17.0* RBC-3.77* Hgb-11.8* Hct-35.4* MCV-94 MCH-31.3 MCHC-33.3 RDW-15.9* Plt Ct-180 [**2107-9-25**] 08:59PM BLOOD Neuts-76* Bands-4 Lymphs-6* Monos-5 Eos-6* Baso-3* Atyps-0 Metas-0 Myelos-0 [**2107-9-25**] 08:59PM BLOOD PT-16.8* PTT-27.4 INR(PT)-1.6* [**2107-9-26**] 02:05AM BLOOD Fibrino-477* [**2107-9-26**] 02:05AM BLOOD D-Dimer-2929* [**2107-9-25**] 08:59PM BLOOD Glucose-117* UreaN-81* Creat-5.6* Na-151* K-4.3 Cl-108 HCO3-25 AnGap-22* [**2107-9-25**] 08:59PM BLOOD CK(CPK)-124 [**2107-9-25**] 08:59PM BLOOD CK-MB-3 [**2107-9-25**] 08:59PM BLOOD cTropnT-0.67* [**2107-9-25**] 08:59PM BLOOD Calcium-9.1 Phos-4.0 Mg-3.6* [**2107-9-26**] 03:47AM BLOOD Cortsol-27.4* [**2107-9-25**] 11:25PM BLOOD Digoxin-1.3 [**2107-9-25**] 11:40PM BLOOD Type-[**Last Name (un) **] pO2-140* pCO2-45 pH-7.28* calTCO2-22 Base XS--5 [**2107-9-25**] 09:00PM BLOOD Lactate-4.3* . Pertinent labs during hospital course: [**2107-9-26**] 08:14AM BLOOD CK(CPK)-372* [**2107-9-26**] 04:00PM BLOOD CK(CPK)-357* [**2107-9-27**] 06:00AM BLOOD CK(CPK)-242* [**2107-9-26**] 08:14AM BLOOD CK-MB-14* MB Indx-3.8 cTropnT-1.22* [**2107-9-26**] 04:00PM BLOOD CK-MB-11* MB Indx-3.1 cTropnT-0.90* [**2107-9-27**] 06:00AM BLOOD CK-MB-6 cTropnT-0.57* [**2107-9-28**] 08:40AM BLOOD calTIBC-156* VitB12-1080* Folate-13.8 Ferritn-543* TRF-120* [**2107-9-26**] 01:15PM BLOOD Triglyc-125 HDL-28 CHOL/HD-3.9 LDLcalc-55 [**2107-9-25**] 11:40PM BLOOD Glucose-113* Lactate-2.9* Na-149* K-4.0 Cl-118* [**2107-9-26**] 08:24AM BLOOD Lactate-1.3 . Labs on discharge: [**2107-9-30**] 02:57AM BLOOD WBC-8.5 RBC-3.54* Hgb-10.6* Hct-32.3* MCV-91 MCH-30.0 MCHC-32.9 RDW-15.8* Plt Ct-203 [**2107-9-30**] 02:57AM BLOOD Neuts-71.6* Lymphs-16.1* Monos-3.7 Eos-8.0* Baso-0.6 [**2107-9-30**] 02:57AM BLOOD PT-13.9* PTT-29.8 INR(PT)-1.2* [**2107-9-30**] 02:57AM BLOOD Glucose-125* UreaN-14 Creat-1.1 Na-138 K-3.7 Cl-109* HCO3-19* AnGap-14 [**2107-9-28**] 04:12AM BLOOD ALT-13 AST-27 AlkPhos-82 TotBili-0.4 [**2107-9-30**] 02:57AM BLOOD Calcium-8.3* Phos-2.1* Mg-1.7 . Microbiology: [**2107-9-25**] Blood cx: 2/2 bottles coag neg staph [**2107-9-25**] Urine cx: mixed flora, contaminant [**2107-9-26**] Blood cx: NGTD [**2107-9-26**] Urine legionella: negative [**2107-9-27**] Blood cx: NGTD [**2107-9-27**] Sputum cx: oropharyngeal flora [**2107-9-27**] Catheter tip cx: Multimicrobial bacteria [**2107-9-28**] Blood cx: NGTD [**2107-9-28**] Urine cx: Negative [**2107-9-29**] Urine cx: Negative . Imaging: [**2107-9-25**] CXR: CHEST, SINGLE VIEW: No prior for comparison. Lung volumes are low. The cardiac shadow is slightly enlarged. Aorta is ectatic. Considerable right lung volume loss with collapse of right lower lobe and partial atelectasis right middle lobe with questionable cut-off of bronchus intermedius. Although possibly due to secretions, an obstructing neoplastic mass should be considered. Initial further evaluation with PA and lateral CXR is recommended. If persistent, contrast-enhanced CT would be recommended. . [**2107-9-26**] ECHOCARDIOGRAM: Conclusions: The left atrium is moderately dilated. Normal left ventricular wall thicknesses and cavity size. There is moderate regional left ventricular systolic dysfunction with akinesis of the distal half of the inferior, septal, and anterior walls. The remaining segments are mildly hypokinetic. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is moderate to severe aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-13**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size with extensive regional dysfunction c/w multivessel coronary disease. Moderate to severe aortic valve stenosis. Mild aortic regurgitation. Pulmonary artery systolic hypertension. Based on [**2097**] AHA endocarditis prophylaxis recommendations, the echo findings indicate a moderate risk (prophylaxis recommended). Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. . [**2107-9-26**] Bilateral lower extremity ultrasound: IMPRESSION: 1. Right deep venous thrombosis of indeterminate age (old clot per radiology) 2. No evidence of deep venous thrombosis involving the left lowerextremity. . [**2107-9-27**] CXR: CONCLUSION: Short-interval improvement in the aeration of the right lower lung field, with some residual opacities present in the right infrahilar region. . [**2107-9-30**] PICC line placement. . [**2107-9-30**] nasogastric tube placement. Brief Hospital Course: Patient is an 80 year old male with history of CAD, CHF, dementia, schizophrenia, chronic renal insufficiency, cardiac dysrythmia who was admitted for sepsis. . 1. Septic shock/infectious disease issues: Patient presented from his nursing home with hypotension, leukocytosis, acute on chronic renal failure, indicating sepsis. Initial studies demonstrated CXR with right lower lobe pneumonia, and u/a that was positive. Patient also with some cellulitis in left lower extremity. Therefore, intially thought source of sepsis was pneumonia vs UTI vs cellulitis. Cortisol stimulation test was negative, ruling out adrenal insufficiency on admission. The patient was fluid rescusitated and initially started on levaphed for pressor support. He was maintained on vancomycin and zosyn for broad spectrum antibiotics coverage. Shortly after admission, patient had improved blood pressure and levaphed pressor was weaned off. Blood cultures from admission grew coag negative staph, 2/2 bottles, likely source of this infection being his left lower extremity cellulitis. Therefore he was maintained on vancomycin to complete a 14 day course. Wound care nursing was also consulted and dressing changes were applied per their recommendations. For his pneumonia, sputum culture did not grow any bacteria. Urine legionella antigen was negative. Therefore patient was empirically treated with vancomycin to complete a 14 day course, as above, and zosyn, which was converted to levofloxacin on discharge, for gram negative coverage to complete a 7 day course. For his presumed UTI, the patient had 2 positive U/A's during the hospital course, with negative urine cultures. The 3rd u/a prior to discharge was negative, with a corresponding negative culture. Therefore, upon discharge, patient had a very stable blood pressure, stable oxygenation off of oxygen, and was discharged on vancomycin to complete a 14 day course and levofloxacin to complete a 7 day course (started with zosyn). He had a PICC line placed prior to discharge. . 2. Cardiac: A. Ischemia: Patient has a history of coronary artery disease. On presentation, EKG demonstrated right bundle branch block (last EKG in our system is from [**2092**] that demonstrates no RBBB - however, obtained outside hospital records that does show RBBB, so not new). On admission, cardiac enzymes were elevated. Cardiology was therefore consulted. Patient was thought to be having a demand ischemic event, and therefore was started on heparin drip to complete 48 hours per cardiology recommendations. His outpatient aspirin dose was increased from 81mg to 325mg daily. He initially could not be on beta blocker therapy given his hypotensive sepsis. Upon resolution of his hypotension, his outpatient lopressor was re-started and titrated up to his outpatient dose of 50mg [**Hospital1 **]. His CK peaked at 372, and cardiac enzymes trended down throughout remainder of hospital course. No plans for cardiac catheterization given the nature of his MI in setting of sepsis, and his co-morbid conditions. B. Rhythm: Patient had a known history of some cardiac dysrhythmia, but unknown type. During hospital course, patient was noted to have strange rhythm on telemetry and EKG. The electrophysiologist cardiologists were curbsided, and believed the patient's rhythm to be due to wenkebach rhythm. They recommended no further intervention and believed that the patient's outpatient digoxin could be discontinued. Otherwise patient was maintained on lipitor, as above. C. Pump: Patient has a history of CHF, and was on lisinopril and lasix and digoxin as and outpatient. All of these medications were held on admission due to the patient's renal failure and sepsis. ECHO on admission demonstrated diffuse disease, EF 20-25%, mod-severe aortic stenosis, mild aortic regurgitation, mild-mod mitral regurgiation. Upon resolution of the patient's sepsis/hypotension, his lisinopril was restarted. Digoxin and lasix were not restarted. Spironolactone was initiated given the patient's heart failure and low EF. He remained euvolemic during remainder of hospital course. . 3. Acute on chronic renal failure: Patient with a history of chronic renal insufficiency with baseline creatnine thought to be 2.0. On day of admission, Cr was elevated at 2.9 and quickly rose to peak of 5.6. Patient was fluid rescusitated and Cr dropped throughout admission and was down to 1.1 at time of discharge. During hospital course, the patient's lisinopril, lasix, and digoxin were held due to the patient's renal failure. Only his lisinopril was restarted, as above. His antibiotics were renally dosed and adjusted throughout hospital course. . 4. Anemia: Patient had a hematocrit of low 30's on admission, trended down to low of 26 during hospital course. Iron studies were consistent with anemia of chronic disease. Patient was transfused 1 unit of pRBC for Hct of 26, given his history of CAD, and Hct bumped appropriately to 29, and remained stable during remainder of . ? baseline. Hct increased to 29 w/ 1 unit pRBC. Plan to: - will f/u iron studies - guaiac all stools - tfs to keep hct > 28 - moniter . 5. Facial eccymoses and erythema: Patient had noted left sided peri-orbital facial erythema and eccymoses on exam on [**9-27**]. Radiology and opthalmology were contact[**Name (NI) **] as this was thought possibley secondary to peri-orbital cellulitis. MRI scan was initially considered for futher evaluation. However, opthalmology evaluated the patient and thought it was unlikely to be peri-orbital cellulitis, and therefore no imaging was necessary. This exam finding was thought likely secondary to the heparin drip that the patient was on for his cardiac issues, and continued to improve throughout remainder of hospital course once heparin was discontinued. . 6. Guidewire caught on IVC filter: Patient had a right IJ guidewire get caught in his IVC filter during his ED course. This was removed by vascular surgery. Patient was given 1U PRBC in ED for fear of bleed. Hematocrit remained stable. Nothing further was done. . 7. Mental status: Patient was somnolent on admission, likely secondary to his infectious status. He returned quickly to his baseline mental status that included being awake, alert, pleasant, responsive, oriented only x 1 to person. He was written for zyprexa 5mg PRN for agitation, but did not receive any during hospital course. . 8. Peripheral vascular disease: Patient had dopplerable pulses on this admission. . 9. Coagulopathy: Patient on coumadin as outpatient for dysrhythmias and lower extremity DVT. Coumadin was initially held given the patient's poor clinical condition. It was restarted during hospital course, and he was discharged on his outpatient dose of 1mg qhs, with a subtherapeutic INR. It should be addressed with his outpatient primary care physician whether or not to continue his coumadin, given his fall risk and his risk vs benefit ratio. . 10. Hypernatremia: Patient was quite hypernatremic during hospital course, with sodium of 151 on admission. This was thought likely a hypovolemic hypernatremia. His hypernatremia improved slightly with initial fluid rescusitation. The patient then proceded to get free water boluses per his NG tube, which continued to control his hypernatremia. . 11. Nutrition: Patient underwent speech and swallow evaluation early in hospital course which he failed. Therefore he had an NG tube placed and received tube feeds and medications per his NG tube. Upon improved alertness, patient underwent a repeat bedside speech and swallow evaluation, which he also failed. Following this, patient lost his NG tube. He therefore had an IR placed post-pyloric feeding tube to continue his tube feeds and medications. He was discharged with this tube in place with plans for a repeat speech and swallow upon improvement at rehab. If he fails this, the issue of PEG tube placement should be brought up with his [**Name (NI) 5993**], his sister [**Name (NI) **] [**Name (NI) 976**]. . 12. Prophylaxis: Patient was initially maintained on heparin drip for his non ST elevation MI for DVT prophylaxis, which was changed to subcutaneous heparin after 48 hours. He was also re-started on his coumadin as above. He was also maintained on a PPI. . 13. Access: PICC line was placed prior to discharge. . 14. Code: DNR/DNI - per nursing home records and confirmed by [**Name (NI) 5993**], his sister. . 15. Contacts: [**Name (NI) **] [**Name (NI) 976**] (sister and [**Name2 (NI) 5993**]) ([**Telephone/Fax (1) 94072**], Nursing home [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 69555**], PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] ([**Telephone/Fax (1) 68737**]. Medications on Admission: Meds: - coumadin : 1mg PO QD - lopressor: 50mg PO BID - zyprexa: 5mg QHS - vicodin: 5/500: 1 tab PO QD 1 hour prior to dressing change - lanoxin-digoxin : 1 tab PO QD - omeprazole: 1 tab PO BID - MVI - Lasix : 40mg QD - Lisinopril: 5mg PO QD - ASA : 81mg QD - Vitamin C - MOM: PRN - Dulcolax: PRN - Fleet Enema : PRN - Maalox: PRN - Tylenol: PRN -Robitussin : PRN - duonebs PRN - cepacol lozenges Discharge Medications: 1. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)) as needed. 2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Erythromycin 5 mg/g Ointment Sig: One (1) aplication Ophthalmic QID (4 times a day) for 4 days. 7. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 8. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please adjust dose to achieve INR of 2. 9. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Please hold for SBP < 100, HR < 60. 10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please hold for SBP < 100. 11. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO DAILY (Daily): Per nasogastric tube. 15. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. 17. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous Q 24H (Every 24 Hours) for 9 days. 18. PICC line care PICC line care per protocol 19. PICC line care Please flush PICC line per protocol Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Sepsis Urinary tract infection Pneumonia Coag negative staph bacteremia Wenkebach cardiac dysrrhythmia Non ST elevation myocardial infarction acute renal failure Discharge Condition: Stable. Discharge Instructions: Please contact physician if develop worsening cough, chest pain/pressure, shortness of breath, fever, low blood pressure, any other questions/concerns. . Please take medications as directed. . Please follow up with physician as directed. Followup Instructions: Please follow up with primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in the next 1-2 weeks. Can contact him at ([**Telephone/Fax (1) 68737**].

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icd9cm

[ [ [] ] ]

[ "99.04", "00.17", "96.6", "38.93" ]

icd9pcs

[ [ [] ] ]

18354, 18425

7408, 13509

325, 451

18631, 18641

2650, 2655

18927, 19110

2105, 2123

16649, 18331

18446, 18610

16227, 16626

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273, 287

4217, 7385

479, 1878

2669, 3584

13525, 16201

1900, 1962

1978, 2089

75,369

178,100

40072

Discharge summary

report

Admission Date: [**2130-12-5**] Discharge Date: [**2130-12-25**] Date of Birth: [**2081-9-29**] Sex: F Service: NEUROSURGERY Allergies: Amoxicillin Attending:[**First Name3 (LF) 78**] Chief Complaint: Headache Major Surgical or Invasive Procedure: Cerbral angiogram w/coiling of the R MCA aneurysm [**2130-12-5**] Cerebral angiogram [**2130-12-8**] Cerebral angiogram [**2130-12-12**] Cerebral angiogram [**2130-12-18**] Cerebral angiogram [**2130-12-25**] History of Present Illness: HPI: 49 yo F with no significant PMHx c/o the worst HA of her life at 2 am on [**2130-12-4**]. The headache subsided somewhat but then became worse and she was eventually brought to an outside hospital where she was found to have a SAH and R sylvian SAH. She complains of headache, notes she is tired. No nausea/vomiting, no weakness/numbness. Past Medical History: PMHx: h/o pilonidal cyst removal Social History: Social Hx: +1 ppd smoker Family History: Family Hx: mother - "stroke" Physical Exam: On admission: PHYSICAL EXAM: O: T: 98.1 BP: 103/50 HR: 63 R 20 O2Sats 97% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 2mm min react bilat EOMs intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Asleep, awakens to voice, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**4-12**] 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, 2mm reactive bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**6-14**] 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 Pertinent Results: CTA Head [**2130-12-5**]: IMPRESSION: 1. Unchanged extensive subarachnoid hemorrhage centered within the right sylvian fissure and extending into the basal cisterns. 2. An 8 x 14 x 6 mm multilobulated aneurysm at the bifurcation of the right middle cerebral artery. CT Head [**2130-12-6**]: IMPRESSION: Status post recent right MCA bifurcation aneurysm with unchanged subarachnoid hemorrhage, but no evidence of large vascular territorial infarction. Brief Hospital Course: Pt was admitted through the emergency department after OSH imaging revealed SAH and possible aneurysm. She was admitted to the ICU for close observation. She was started on Dilantin and Nimodipine. On the morning of admission she was taken to the angio suite and while under general anesthesia had coiling of the right MCA aneurysm. She tolerated the procedure well and was extubated immediately after. A cat scan was performed the following am to assess for hydrocephalus and / or infarct. This showed unchaged SAH with no evidence of infarct. On [**12-8**], patient remained intact. On [**12-8**] she returned for a cerebral angiogram which showed patency of On [**12-12**] patient underwent a follow up angiogram which showed moderate vasospasm in the right MCA. Patient will continue to be watched in the hospital and be monitored for stroke symptoms in the setting of vasospasm. On [**12-14**],The patient had a hand surgery consult for a superficial pustule on the dorsum of the left hand. A procedure ws performed to decompress pustule.1cc 1% lidocaine injected subcuteously. Overlying skin resected off sharply. No expressible pus. Cx swabs taken from wound bed. Irrigated w/ normal saline. Dry dressing applied.It was determined that dry sterile dressing changes daily until completely dry. No antibiotics were required as no cellulitic component was noted and the pustule was thoroughly debrided. On [**12-15**] the patient was transferred to the floor from the step down unit. On [**12-16**] and [**12-17**] the patient was seen. The patient experienced a headache behind her right eye with stabbing sensation in the back of the head. On [**12-18**], The patient underwent cerebral angiogram which showed severe spasm of the supraclinoid area. She was returned back to the step down for close neurochecks and started back on IV fluids. On [**12-19**] she complained of some right eye wavy vision. Opthamology saw the patient and felt it might related to BP drops with Nimodipine adminstration. Her Nimodipine was changed from 60mg Q4 to 30mg Q2 which she tolerated well. She remained stable and remained in the Step Down Unit until [**12-25**] when she was transferred to the floor. She had a repeat Cerebral Angiogram on [**12-25**] which was stable, she was monitored for a couple of hours and then discharged home on [**12-25**]. Medications on Admission: none Discharge Medications: 1. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**2-11**] Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Brain Aneurysm: R MCA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Angiogram with Coiling Medications: ?????? Take Aspirin 325mg (enteric coated) once daily. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs. ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal). ?????? After 1 week, you may resume sexual activity. ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate. ?????? No driving until you are no longer taking pain medications What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or [**Known lastname **], yellow or green drainage from incisions ?????? Bleeding from groin puncture site *SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call our office. If bleeding does not stop, call 911 for transfer to closest Emergency Room! Followup Instructions: You will need to be seen by Dr. [**First Name (STitle) **] in the clinic on 4 weeks with a MRI/MRA of the brain. Takeisha ([**Telephone/Fax (1) 4296**]) will call you to make these appointments. Completed by:[**2130-12-25**]

[ "368.15", "788.20", "430", "686.8", "305.1", "435.9", "599.0" ]

icd9cm

[ [ [] ] ]

[ "86.3", "39.75", "88.41" ]

icd9pcs

[ [ [] ] ]

5875, 5881

2915, 5274

284, 495

5947, 5947

2438, 2892

8048, 8276

987, 1018

5329, 5852

5902, 5926

5300, 5306

6098, 7090

7116, 8025

1062, 1322

236, 246

523, 871

1624, 2419

1047, 1047

5962, 6074

893, 928

944, 971

28,588

141,664

13231

Discharge summary

report

Admission Date: [**2150-8-17**] Discharge Date: [**2150-8-28**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 106**] Chief Complaint: hypotension, bradycardia Major Surgical or Invasive Procedure: placement of pacemaker placement of right internal jugular catheter History of Present Illness: [**Age over 90 **]yo woman with h/o HTN, DM on insulin, remote CVA, anticoagulated for h/o PE and AFib presents as transfer from [**Location (un) 620**] with complete heart block. Pt was found to be lethargic at skilled nursing facility today; BP could not be obtained, pulse in 30s. Pt was brought to [**Location (un) 620**], where she was noted to have decreased responsiveness and SOB. Found to be in complete HB, intubated for labored breathing with declining mental status, and transferred to [**Hospital1 18**]. Per transfer notes, pt had GCS of 15, was alert and oriented x 3 and following commands. . Upon arrival to the [**Name (NI) **], pt had HR 22 and SBP 73. She was given atropine 1mg without effect then placed on dopamine and levophed gtt. Also received 1mg glucagon in ED. RIJ cordis with TV pacer placed. HR in 80s, SBP 100 upon admission to CCU. . Review of symptoms could not be completed secondary to intubation, impaired mental status. Per chart review, pt had denied chest pain. Past Medical History: Epilepsy HTN DM CAD AFib CVA-?right side stroke Hyperthyroidism Asthma PE COPD Depression with Anxiety Dementia Social History: Patient lives in [**Hospital3 5277**] ([**Telephone/Fax (1) 40327**]), long term care facility. Son is health care proxy. Family History: not available on admission Physical Exam: VS: T 97.6, BP 127/89, HR 93, RR 16, O2 100% on FiO2 100% AC PEEP 5 100% FiO2 500 16-18 Gen: Elderly woman, not currently receiving sedation, responsive only to tactile stimuli. Intubated. HEENT: Sclera anicteric. Pupils equally round, reactive to light. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple. CV: PMI located in 5th intercostal space, midclavicular line. RR, distant S1, S2. No S4, no S3. ? soft systolic murmur Chest: No chest wall deformities, scoliosis or kyphosis. On vent with good air entry b/l, coarse breath sounds throughout. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Neuro: Responding only to tactile stimuli with movement of limb. Pupils equal and reactive to light b/l. Increased muscle tone in R arm with ?contractures. +clonus in UE and LE b/l. Spontaneous movement of LE b/l. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 1+; 1+ DP Left: Carotid 2+ without bruit; Femoral 2+; 1+ DP Pertinent Results: [**2150-8-17**] 11:31PM GLUCOSE-246* UREA N-30* CREAT-1.7* SODIUM-141 POTASSIUM-5.8* CHLORIDE-105 TOTAL CO2-23 ANION GAP-19 [**2150-8-17**] 11:31PM estGFR-Using this [**2150-8-17**] 11:31PM ALT(SGPT)-18 AST(SGOT)-25 CK(CPK)-88 ALK PHOS-146* AMYLASE-63 TOT BILI-0.4 [**2150-8-17**] 11:31PM LIPASE-34 [**2150-8-17**] 11:31PM cTropnT-0.08* proBNP-354 [**2150-8-17**] 11:31PM ALBUMIN-4.0 CALCIUM-8.9 PHOSPHATE-5.2* MAGNESIUM-2.2 [**2150-8-17**] 11:31PM DIGOXIN-<0.2* [**2150-8-17**] 11:31PM WBC-11.6* RBC-4.76 HGB-11.1* HCT-33.9* MCV-71* MCH-23.2* MCHC-32.7 RDW-16.6* [**2150-8-17**] 11:31PM NEUTS-72.2* LYMPHS-23.0 MONOS-3.7 EOS-1.0 BASOS-0.1 [**2150-8-17**] 11:31PM PLT COUNT-403 [**2150-8-17**] 11:31PM PT-20.3* PTT-28.6 INR(PT)-1.9* . EKG [**8-18**] demonstrated normal sinus rhythm with no significant ST-T changes. EKG from [**8-17**] signficant for complete heart block. Prior EKG unavailable for examination. . TELEMETRY demonstrated: no legitimate alars . 2D-ECHOCARDIOGRAM performed on [**2149-12-26**] demonstrated: EF 65% Concentric LVH, preserved LV systolic function, calcification of mitral annulus with minimal MR, aortic sclerotic changes, and normal pulmonary artery pressures. Brief Hospital Course: 1. Cardiac a. Rhythm Bradycardia: The patient presented with complete heart blcok, with a rhythm that appeared to have been CHB with junctional escape given the narrow complex and the fact that the QRS is similar to when the pt is in SR. Unclear what the primary process was causing the bradycardia, hypoxemia vs sepsis vs primary cardiogenic. Medication effect of Toprol and verapamil likely playing a large role as well. After the day of admission, the patinet remained in sinus rhythm with 1:1 conduction throughout hospitalization. The patinet had a transvenous pacer wire placed upon admission. The patient remained without continued bradycardia, and temporary pacer was removed. Given unknown etiology of block, patient had a permanent pacemaker placed without complication set at VVI. The patient was restarted on low-dose metoprolol given history of atrial fibrilltion and hypertension while hospitalized and tolerated well. . b. CAD: Patient with unclear history of CAD, though known risk factors of CVA, dm2. The patient was continued on ASA and BB. . c. Pump: Patient was hypotenison upon admission, in the setting of bradycardia, and was supported on dopa/levophed. After initial event, patient was hypertensive during hospitalization, and placed on hydralazine, low dose metoprolol, and HCTZ with adequate control. 2. Respiratory failure: The patient presented with respiratory failure, and was intubated in the emergency room. Unclear etiology. PNA vs CHF vs PE. Mental status may have precipitated intubation as well, unclear from the records. PE is a possibility as well, though INR was 1.9 on admission. Patient had an elevated WBC to 21, and was started on vanc/zosyn for suspected aspiration pneumonia, was titrated to levo, and completed the course. CTA was performed which had an equivical read of possible PE, and patient was started on heparin. Upon discharge, patient still not therapeutic on coumadin, and will be sent on lovenox (PPx dose given recent PPM placement) and coumadin. The patient was extubated on third day of admissison without difficulty, and had remained comfortable. . # Neuro: Mental status changes at rehab likely [**1-23**] hypotension and metabolic disturbances. Also with head CT revealing hypodensity in the left parietooccipital region in which acute stroke, possibly watershed infarct cannot be ruled. Patient showed myoclonic movements at admission, and neuro was consulted to evaluate non-convulsive status vs. anoxic brain injury. EEG not c/w NCSE. Patient was extubated, and showed deficit compared to baseline. Neuro started keppra for seizure ppx, which should be titrated up 250mg each week until at goal of 1000mg [**Hospital1 **]. - serial neuro exams - consider neuro consult - consider MRI if more stable tomorrow . # ARF: Patient presented with Cr 1.7 from baseline of Cr 0.7. Improved with hydration, and beleived to be secondary to dehydration coupled with hypoperfusion w/ bradycardia/hypotension. . # DM2 - SSI, NPH Medications on Admission: ASA 81mg daily Toprol XL 50mg daily Verapamil 240mg [**Hospital1 **] Lasix 20mg daily Coumadin 11mg every other day Coumadin 10.5mg every other day--increased from 10mg on [**8-4**] Novolin 70/30 44units QAM NPH 12 units QPM Synthroid 25mcg daily Potassium Cl 10mEq daily Zoloft 100mg daily Singulair 10mg daily Trazadone 25mg QPM Colace 100mg [**Hospital1 **] Duonebs Q6H SSI Discharge Medications: 1. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day. 3. Levetiracetam 500 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day): increase dose to 1000mg [**Hospital1 **] on [**9-4**]. Disp:*60 Tablet(s)* Refills:*2* 4. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Singulair 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. Colace 100 mg Capsule Sig: [**12-23**] Capsules PO twice a day as needed for constipation. 8. Outpatient Lab Work Please have INR checked on Sunday [**8-30**] and have the results faxed to Dr. [**Last Name (STitle) **] 9. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily). 10. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q6H (every 6 hours). 11. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 13. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 14. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once a day: please d/c when therapeutic on coumadin. 15. NPH 18U qam, 6U qpm + ISS Discharge Disposition: Extended Care Facility: [**Hospital3 5277**] - [**Location (un) 745**] Discharge Diagnosis: Primary Diagnosis: Complete Heart Block Secondary Diagnoses: Pneumonia, Pulmonary Embolism Discharge Condition: Patient had no further episodes of bradycardia. She was maintaining good blood pressures and had improved mental status to baseline. She was able to eat and drink, and her vital signs were stable, without fevers. Discharge Instructions: You were admitted to the hospital with a dangerously slow heart rate. A pacemaker was placed, and this should protect you from further episodes in the future. You developed a pneumonia, which was treated with antibiotics. You were also found to have a small clot to the lung, for this, and for your history of atrial fibrillation, you will continue taking a blood thinner called coumadin. 1. Please take all your medications as prescribed. 2. Please attend all follow-up appointments. 3. Call your doctor or come to the hospital for shortness of breath, palpitations, chest pain, fevers, or any other concerning symptom. Followup Instructions: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2150-9-1**] 11:00

[ "788.20", "496", "300.00", "997.5", "345.90", "244.9", "426.0", "311", "276.8", "294.8", "427.31", "584.9", "250.00", "V58.61", "401.9", "486", "415.19", "414.01" ]

icd9cm

[ [ [] ] ]

[ "38.93", "37.82", "96.04", "37.71", "96.71" ]

icd9pcs

[ [ [] ] ]

8769, 8842

4064, 7066

286, 355

8979, 9196

2821, 4041

9869, 9980

1686, 1714

7493, 8746

8863, 8863

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1729, 2802

8926, 8958

222, 248

383, 1395

8883, 8904

1417, 1530

1546, 1670

46,853

169,436

38680

Discharge summary

report

Admission Date: [**2151-4-13**] Discharge Date: [**2151-4-19**] Date of Birth: [**2087-10-14**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: Right Brain Mass Major Surgical or Invasive Procedure: [**2151-4-14**] Right Craniotomy for mass History of Present Illness: Patient is a 63M transferred from OSH for definitive NSURG care in the setting of newly identified brain mass. He reports having a history of headache and difficulty swallowing as of recently. On [**4-10**], he had an episode of sudden weakness, falling in the bathtub. He was then admitted to said OSH, where workup was revealing for the aformentioned mass. Past Medical History: CAD s/p PCTA, MIx4, seizure dx, dyslipidemia,DM,asthma,DVT,HTN, BPH,ASCVD,PVD,DJD, s/p Neck surgery, s/p lbsurgery, s/p CCY Social History: Divorced for 20 years, has one daughter. +Tobacco 1ppdx50yrs Family History: Non contributory Physical Exam: On Discharge: Oriented x 3. PERRL. EOMS intact. Face symmetric, tongue midline. No drift. Full strength throughout. Sensation intact throughout. Incision - clean, dry, intact. Sutures in place. Pertinent Results: Labs on Admission: [**2151-4-13**] 09:30PM BLOOD WBC-17.0* RBC-5.36 Hgb-16.0 Hct-48.4 MCV-90 MCH-29.8 MCHC-33.0 RDW-14.9 Plt Ct-245 [**2151-4-13**] 09:30PM BLOOD Neuts-87.9* Lymphs-7.4* Monos-4.2 Eos-0.2 Baso-0.3 [**2151-4-13**] 09:30PM BLOOD PT-12.8 PTT-22.7 INR(PT)-1.1 [**2151-4-13**] 09:30PM BLOOD Glucose-152* UreaN-15 Creat-0.6 Na-142 K-3.9 Cl-106 HCO3-25 AnGap-15 [**2151-4-13**] 09:30PM BLOOD Calcium-9.4 Phos-3.6 Mg-2.1 [**2151-4-14**] 04:55AM BLOOD Phenyto-7.1* Labs on Discharge: [**2151-4-19**] 06:40AM BLOOD WBC-11.0 RBC-3.52* Hgb-11.0* Hct-31.6* MCV-90 MCH-31.1 MCHC-34.7 RDW-14.0 Plt Ct-317 [**2151-4-19**] 06:40AM BLOOD Plt Ct-317 [**2151-4-19**] 06:40AM BLOOD PT-12.4 PTT-24.2 INR(PT)-1.0 [**2151-4-19**] 06:40AM BLOOD Glucose-134* UreaN-18 Creat-0.6 Na-143 K-3.6 Cl-103 HCO3-32 AnGap-12 [**2151-4-19**] 06:40AM BLOOD Phenyto-11.8 IMAGING: -------------------- MRI HEAD [**4-14**]: IMPRESSION: 1. Heterogeneously enhancing multiloculated dural-based extra-axial right frontotemporal mass with mass effect on the right lateral ventricle, slight right uncal herniation, marked surrounding vasogenic edema, and leftward shift of the normally midline structures. Differential diagnosis includes an atypical meningioma, or hemangiopericytoma. 2. No acute infarction or hemorrhage. No additional enhancing lesions are identified. CTA HEAD [**4-14**]: IMPRESSION: 1. Large right frontotemporal heterogeneously enhancing extra-axial dural-based mass with mass effect, surrounding vasogenic edema, and approximately 1.5 cm shift of the normally midline structures. The differential diagnosis includes an atypical meningioma, or hemangiopericytoma. 2. No acute territorial infarction or hemorrhage.Vascular displacement by mass. CT HEAD [**4-15**]: IMPRESSION: 1. Interval mild increase in effacement of cerebral sulci bilaterally and decreased differentiation of [**Doctor Last Name 352**]-white matter, likely representing a component of cerebral edema. Clinical correlation is recommended. 2. Stable amount of blood and mass effect at the surgical site. 3. Severely increased subcutaneous edema in the left frontal scalp extending to the periorbital area. IMPRESSION: Status post right frontotemporal craniotomy and removal of large right extraaxial mass with a postoperative small amount of extraaxial and intraparenchymal bleed and 1.6 cm of midline shift towards the left. MRI Head [**4-16**]: 1. Infarction of the right frontal lobe adjacent to the surgical cavity. 2. Possible residual tumor enhancement, most pronounced at the right temporal lobe. 3. Post-surgical changes after craniotomy with a fluid-filled surgical cavity, as well as blood products surrounding the surgical cavity and small left subdural pneumocephalus. 4. Compared to the CT earlier from the day, unchanged, about 1.5 cm shift of normally midline structures to the left with subfalcine herniation. Brief Hospital Course: Patient admitted to the NSURG service after transfer from OSH for definitive care for newly identified brain mass. On admission, he was sent for MRI of the head, and CTA of the head for further evaluation and surgical planning. Due to the size of the lesion; it was decided to take him to the OR on [**4-14**] to resect the mass and obtain diagnosis to guide treatment. Pre-operatively, due to his extensive cardiac history, a cardiology consult was obtained. They recommended the addition of a beta blocker(which was done), and did not recommend continuing the plavix post-operatively as his stending procedure was completed greater than one year prior. They did however, recommend restarting aspirin as soon as it was safe for us to do so. Post-operativley, he was returned to the SICU for q1h neurochecks and diligent system monitoring. After an uneventful night of monitoring, he was OOB with Physical therapy. His Blood pressure was kept under strict control under 140mmHg. On post op day 3 he had an improving neurological exam, and was transferred out of the unit to the step down floor. The patient was evaluated by physical therapy and he was deemed an appropriate candidate for rehab. He was discharged to a rehab facility on [**2151-4-19**]. Medications on Admission: Plavix, Metformin, Nitro SL, Lisinopril, Lipitor, HCTZ, Percocet, Flomax, Avodart Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for Pain. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 8. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 14. Phenytoin 50 mg Tablet, Chewable Sig: Three (3) Tablet, Chewable PO BID (2 times a day). 15. Nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 16. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours): [**Month (only) 116**] discontinue once dexamethasone is completed. 18. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 19. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 2 doses. 20. Dexamethasone 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 3 doses: please start after 2 mg dose. Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Right Frontal parietal brain mass **Preliminary Pathology: Meningioma Discharge Condition: Neurologically Stable Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance Discharge Instructions: GENERAL INSTRUCTIONS WOUND CARE: ?????? You or a family member should inspect your wound every day and report any of the following problems to your physician. ?????? Keep your incision clean and dry. ?????? You may wash your hair with a mild shampoo 24 hours after your sutures are removed. ?????? Do NOT apply any lotions, ointments or other products to your incision. ?????? DO NOT DRIVE until you are seen at the first follow up appointment. ?????? Do not lift objects over 10 pounds until approved by your physician. DIET Usually no special diet is prescribed after a craniotomy. A normal well balanced diet is recommended for recovery, and you should resume any specially prescribed diet you were eating before your surgery. Be sure however, to remain well hydrated, and increase your consumption of fiber, as pain medications may cause constipation. MEDICATIONS: ?????? Take all of your medications as ordered. You do not have to take pain medication unless it is needed. It is important that you are able to cough, breathe deeply, and is comfortable enough to walk. ?????? Do not use alcohol while taking pain medication. ?????? Medications that may be prescribed include: -Narcotic pain medication such as Dilaudid (hydromorphone). -An over the counter stool softener for constipation (Colace or Docusate). If you become constipated, try products such as Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or Fleets enema if needed). Often times, pain medication and anesthesia can cause constipation. ?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. ?????? You were on Plavix (clopidogrel) prior to your surgery, you have been discontinued on this medication at the request of the inpatient cardiologist. As your stenting procedures were greater than 1yr ago, it is no longer needed. Please verify with your regular cardiologist. ?????? You may restart your aspirin in 1 month. ?????? You are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ACTIVITY: The first few weeks after you are discharged you may feel tired or fatigued. This is normal. You should become a little stronger every day. Activity is the most important measure you can take to prevent complications and to begin to feel like yourself again. In general: ?????? Follow the activity instructions given to you by your doctor and therapist. ?????? Increase your activity slowly; do not do too much because you are feeling good. ?????? You may resume sexual activity as your tolerance allows. ?????? If you feel light headed or fatigued after increasing activity, rest, decrease the amount of activity that you do, and begin building your tolerance to activity more slowly. ?????? DO NOT DRIVE until you speak with your physician. ?????? Do not lift objects over 10 pounds until approved by your physician. ?????? Avoid any activity that causes you to hold your breath and push, for example weight lifting, lifting or moving heavy objects, or straining at stool. ?????? Do your breathing exercises every two hours. ?????? Use your incentive spirometer 10 times every hour, that you are awake. WHEN TO CALL YOUR SURGEON: With any surgery there are risks of complications. Although your surgery is over, there is the possibility of some of these complications developing. These complications include: infection, blood clots, or neurological changes. Call your Physician Immediately if you Experience: ?????? Confusion, fainting, blacking out, extreme fatigue, memory loss, or difficulty speaking. ?????? Double, or blurred vision. Loss of vision, either partial or total. ?????? Hallucinations ?????? Numbness, tingling, or weakness in your extremities or face. ?????? Stiff neck, and/or a fever of 101.5F or more. ?????? Severe sensitivity to light. (Photophobia) ?????? Severe headache or change in headache. ?????? Seizure ?????? Problems controlling your bowels or bladder. ?????? Productive cough with yellow or green sputum. ?????? Swelling, redness, or tenderness in your calf or thigh. Call 911 or go to the Nearest Emergency Room if you Experience: ?????? Sudden difficulty in breathing. ?????? New onset of seizure or change in seizure, or seizure from which you wake up confused. ?????? A seizure that lasts more than 5 minutes. Important Instructions Regarding Emergencies and After-Hour Calls ?????? If you have what you feel is a true emergency at any time, please present immediately to your local emergency room, where a doctor there will evaluate you and contact us if needed. Due to the complexity of neurosurgical procedures and treatment of neurosurgical problems, effective advice regarding emergency situations cannot be given over the telephone. ?????? Should you have a situation which is not life-threatening, but you feel needs addressing before normal office hours or on the weekend, please present to the local emergency room, where the physician there will evaluate you and contact us if needed. Followup Instructions: ??????Please return to the office in [**7-10**] days (from your date of surgery) for removal of your sutures and a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. YOU [**Month (only) **] HAVE YOUR SUTURES REMOVED AT REHAB. THEY MUST BE REMOVED BY [**2151-4-24**]. ??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**5-10**] at 3pm. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your appointment, or require additional directions. **You may restart your aspirin in 1 month. Completed by:[**2151-4-19**]

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Discharge summary

report

Admission Date: [**2169-5-23**] Discharge Date: [**2169-6-2**] Service: Neurosurgery/cardiac medicine HISTORY OF PRESENTING ILLNESS: Mr. [**Known lastname 30097**] is a 79 year-old Russian male with history of renal cell carcinoma diagnosed in [**2166**], status post left nephrectomy in 2,000, status post IL2 therapy, with lung metastasis, hypertension, atrial fibrillation, and diabetes who presented one year ago with an metastatic renal cell carcinoma in [**Month (only) 547**] of this year. An MRI on [**2169-5-1**] showed a dural based mass involving the calvarium and superior sagittal sinus. He was admitted on [**5-23**] for tumor embolization and left frontal parietal craniectomy with resection of the tumor and cranioplasty on the 13th. The patient's surgery was uneventful. On the evening of [**5-24**], however, the patient developed right arm Enzymes were cycled at that time and the patient ruled in for non-Q wave myocardial infarction with troponin peaking at greater than 50 and CK of 1,014 with an MB of 82. Electrocardiogram showed a new left bundle branch with ST elevation and T wave inversions in V3 and V4. The patient was started on intravenous Lopressor and nitroglycerin. The patient was then taken for cardiac catheterization which revealed three vessel disease with left main disease and an intra-aortic balloon pump was placed prophylactically. At this time the patient came under care at the Cardiac Care Unit team. At the time of our evaluation the patient had no complaints. PAST MEDICAL HISTORY: 1) Metastatic renal cell carcinoma left, diagnosed in [**2167-11-11**] with lung metastasis at diagnosis. Patient underwent IL2 therapy beginning in [**Month (only) 956**] of 2,000 complicated by atrial fibrillation. Patient underwent left nephrectomy in [**2168-5-12**]. Brain metastasis a per History of Present Illness. 2) Non-insulin dependent diabetes mellitus. 3) Hypertension. 4) Anemia. 5) Paroxysmal atrial fibrillation secondary to IL2 treatment. 6) Status post appendectomy. MEDICATIONS (Outpatient): 1) Digoxin 0.25 mg q. day, 2) Atenolol 25 mg p.o. q. day, 3) Coumadin. 4) Colace. 5) Multivitamin. 6) Boost. TRANSFER MEDICATIONS: 1) Insulin sliding scale. 2) Lopressor 25 mg b.i.d. 3) Nitroglycerin drip. 4) aspirin 325 mg q. day. 5) Captopril 25 mg t.i.d. SOCIAL HISTORY: The patient moved to the U.S. in [**2126**] from [**Country 12930**]. He has worked as an engineer until retirement last month. He has a tobacco history but said he quit in the [**2117**]. PHYSICAL EXAMINATION: On transfer temperature of 99, blood pressure of 150/90, pulse was 75, O2 saturation was 95% on three liters. In general the patient was an elderly male who was lying flat in bed and appeared comfortable. He was in no acute distress. Head, eyes, ears, nose and throat examination revealed a bandaged scalp with an incision that went across the top of his head. Pupils are equal, round and reactive to light. There were no oral lesions. Mucous membranes were moist. Neck was supple without bruits. Heart was regular rate and rhythm with a grade II/VI holosystolic murmur at the apex radiating to the axilla. Lungs were clear to auscultation anteriorly. Abdomen was soft and nontender. Extremities were without edema. A balloon pump was placed in the right femoral vein. Patient had warm feet. On brief neurologic testing the patient showed no focal signs. Cranial nerves appeared to be intact and patient was alert and oriented with fluent language. LABORATORY STUDIES: White count was 8.2 with hematocrit of 28 and platelets of 194. Chem-7 was remarkable only for BUN of 36, creatinine of 1.7 which was the patient's baseline. Serum glucose was 285. CKs peaked at 1,014 with an MB of 82 and MB index of 8. Troponin was greater than 50. Chest x-ray showed mild congestive heart failure and no focal infiltrates. Electrocardiogram on [**5-17**] showed sinus bradycardia with left ventricular hypertrophy and left axis deviation. There was poor R wave progression and left anterior vesicular block. Electrocardiogram on [**5-24**] showed bigeminy with flattened T waves anteriorly and later in the evening with development of chest pain and new left bundle branch block. Electrocardiogram on [**5-25**] elevations in V3 and V4 with T wave inversion. Echocardiogram from [**2168-4-11**] showed left atrial enlargement with slight left ventricular hypertrophy. Ejection fraction was measured at 45 percent. Echocardiogram postoperatively on this admission showed left atrial enlargement as well as right atrial enlargement. There was left ventricular hypertrophy. Ejection fraction was estimated at 20 to 25 percent. Patient had pulmonary hypertension, moderate aortic stenosis, 1 to 2+ mitral regurgitation and wall motion abnormality. Cardiac catheterization on [**5-25**] showed left main disease with an ostial 38 or 40 percent, distal 90 percent, mid LAD lesion of 80 percent, diagonal of 100 percent, mid left circumflex of 90 percent with right to left collateral flow distally, RCA with 90 percent involving the PDA. HOSPITAL COURSE AFTER TO CARDIAC CARE UNIT BY SYSTEMS: 1) Cardiovascular. Given the patient's three vessel with left main disease the patient was evaluated by CT surgery. With the severity of his disease, decreased ejection fraction, and other co-morbid illnesses the patient was thought to be too high risk exceeding the possible benefit of bypass grafting. The patient was initially maintained on intravenous nitroglycerin and intravenous heparin was discontinued after removal of intra-aortic balloon pump and intravenous nitroglycerin was weaned. The patient was maintained on daily dose of aspirin and Lopressor was increased gradually to 100 mg t.i.d. and later switched to 150 mg b.i.d. Accupril was increased slowly to 100 mg t.i.d. Given the patient's elevated left ventricular and diastolic pressure of 26 the patient was diuresed and later started on a daily dose of Lasix orally. As for the patient's atrial fibrillation with the patient's increasing risk of falling anticoagulation was discussed wit the neurosurgery team who felt that it would be wise to hold off on restarting Coumadin postoperatively and to re-evaluate this in one month after the patient is back on his feet. 2) Hematology. The patient's hematocrit stayed persistently between 28 and 30 while the intra-aortic balloon pump was in. Hemolysis laboratories were sent ruling this out as the etiology. Patient was transfused several units of blood with inappropriate bumps after intra-aortic balloon pump was removed hematocrit climbed to the 33 and was stable for several days. During the time the balloon pump was in the platelets also fell from approximately 200 to low 100s. Heparin was discontinued and Zantac was changed to Prilosec. Platelet count began to rise after the balloon pump was removed. 3) Neurology. On postoperative day #6 the patient' activity the was changed from out of bed to chair. At this point it was noted that he was not able to bear weight on his right lower extremity. On muscle strength testing the patient showed an upper motor neuron distribution of weakness with proximal muscle strength muscle groups being 4 to 4+/5 on motor testing. A head CT obtained showed postoperative changes with edema and effacement of the sulci over the left parietal region. There was no hemorrhage or infarction in any major territory noted. MRI obtained showed mild compression of the lateral [**Doctor Last Name 534**] on the left . After discussion with neurosurgery these changes were considered normal for his postoperative course and the patient's strength was expected to improve. On subsequent days motor strength was improved. On the date of discharge right and left biceps were noted to 4+/5, triceps were 5-/5, right iliopsoas was -[**4-15**], quads and hamstrings were [**4-15**], tibialis anterior was [**4-15**] and plantar flexors were [**4-15**]. The remainder of the neurologic examination was unremarkable. The patient will have follow up radiation therapy in one week with radiation of the sagittal sinus portion of the tumor that was unresectable. 3) Diabetes mellitus. The patient was maintained on a regular insulin sliding scale with fingerstick blood glucose checks. The patient will likely benefit from daily doses of scheduled NPH and regular insulin. 4) Renal. Given the patient's chronic renal insufficiency creatinine was followed daily, especially when the intra-aortic balloon pump was in place. Patient' creatinine stayed stable at 1.7 to 1.9 with adequate urine output. 5) Infection disease. The patient was eventually started on ciprofloxacin renally dosed for his creatinine clearance of a sterile pyuria. 6) Oncology. The patient will have follow up with Dr. [**Last Name (STitle) 17466**] in the radiation therapy clinic. As per discussion with Dr. [**Last Name (STitle) 17466**] prognosis is good given tumor responsiveness to IL2 therapy. For prophylaxis the patient was prophylaxed with heparin subcutaneously a well as pneumoboots and Prilosec p.o. DIAGNOSIS ON DISCHARGE: 1. Metastatic renal cell carcinoma. 2. Status post tumor embolization and left frontoparietal craniotomy with resection of tumor and cranioplasty. 3. Postoperative non-Q wave myocardial infarction. 4. Congestive heart failure with decreased left ventricular systolic function. 5. Anemia. 6. Resolving right sided lower extremity hemiparesis secondary to postoperative surgical edema. 7. Diabetes mellitus. MEDICATIONS ON DISCHARGE: 1) Lopresor 150 mg p.o. b.i.d., 2) Captopril 100 mg t.i.d., 3) Lipitor 10 mg p.o. q. day, 4) Isordil 20 mg p.o. t.i.d., 5) Lasix 20 mg p.o. q. day. 6) enteric coated aspirin 325 mg p.o. q. day. 7) Colace 100 mg p.o. b.i.d. 8) Prilosec 20 mg q. day. 9) Heparin subcutaneously 5,000 units subcutaneously t.i.d. 10) Dulcolax 10 mg p.o./p.r. p.r.n. 11) sublingual nitroglycerin 0.4 mg sublingual q. 5 minutes times 3 p.r.n. 12) regular insulin sliding scale 0 to 70 give D50 or juice, 71 to 160 give nothing, 161 to 200 give 2 units, 201 to 250 give 4 units, 251 to 300 give 6 units, 301 to 350 give 8 units, 351 to 400 give 10 units, greater than 401 give 12 units. STATUS: To [**Hospital3 **]. CONDITION: Satisfactory. FOLLOW UP: The patient will follow up with the brain tumor clinic on [**6-12**] at 3 P.M. for radiation therapy. The patient will follow up with his primary care physician. [**Name10 (NameIs) **] note, the patient had a mildly elevated heart rate at discharge to rehabilitation in the 80s given his high dose of beta blocker. Hematocrit was found to be within normal limits. TSH was still pending at the time of discharge. Please follow up with these results. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**] Dictated By:[**Name8 (MD) 10039**] MEDQUIST36 D: [**2169-6-2**] 11:01 T: [**2169-6-2**] 12:14 JOB#: [**Job Number 9901**]

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icd9cm

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3354

Discharge summary

report

Admission Date: [**2130-12-8**] Discharge Date: [**2130-12-14**] Date of Birth: [**2052-6-6**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1990**] Chief Complaint: GIB Major Surgical or Invasive Procedure: [**2130-12-6**]: esophagogastro duodenoscopy History of Present Illness: 78 yo F with hypertension, diabetes mellitus type II, chronic kidney disease admitted for deep venous thrombosis and probable pulmonary embolism on [**11-9**]. During admission patient also noted to have malalignment of her previous left hip repair and underwent revision. Seen in ortho clinic [**11-27**], had oozing from hip wound, patched. . Today at rehab, pt reported dizziness on standing and diffuse abd pain, 1x episode of non bloody non bilious emesis. Also had semi urgent BM that was normal in consistency, no blood, no melena. At rehab labs were checekd, INR was 3.0, hgb 5, bun cr 67/1.7. Sent to ED for anemia. . On arrival to the ED VS were T 99.1 HR 97 BP 149/79 RR 16 SpO2 95%/RA. She was noted to have melena in her diaper. Had one episode of dark emesis in the ED, guaiac positive. Labs significant for Hct 16.8, INR 3.2 BUN/Cr 71/1.7, trop 0.04. EKG showed ST segment depression in anterolateral leads (V4/5/6, I, avl). Given 2L NS, 1 U FFP, 1 U PRBC, 2nd unit PRBC hung. 2 x 20g IVs placed. GI consulted, plan for am EGD. Protonix 80 + 8/hr. VS on transfer Temp: 98.1, Pulse: 87, RR: 18, BP: 117/86, O2Sat: 99, O2Flow: 2L, Pain: . On arrival to the MICU, . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Diabetes hypertension history of stroke shingles depression dementia renal insufficiency adnexal masses endometrial thickening glaucoma Social History: Smoked for 10 years, quit in [**2114**]. Husband died of lung cancer. Family History: Diabetes Mellitus (one brother died of diabetes, other brother currently has diabetes) No history of blood disorders, hypercoagulability, heart disease . Physical Exam: ADMISSION PHYSICAL EXAM: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact DISCHARGE FEX 99.0 150/63 58 18 98%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Sutures over left hip c/d/i wihtout erythema or drainage. Neuro: CNII-XII intact, grossly normal sensation, gait deferred, finger-to-nose intact Pertinent Results: LABS: See below. Notable for HCT 16.8([**12-8**])-->27.1([**12-9**])-->24.3([**12-9**])-->29.4 ([**12-10**])-->29.4 ([**12-11**])-->32.9-->35.9 . MICROBIOLOGY: [**2130-12-10**] SEROLOGY/BLOOD HELICOBACTER PYLORI ANTIBODY TEST-FINAL Negative [**2130-12-8**] URINE URINE CULTURE-FINAL No growth . STUDIES: EGD [**2130-12-8**]: 3 ulcers seen in stomach, duodenal bulb and D2. D2 lesion most likely culprit for significant bleed. No active bleed at the time of endoscopy. Recommend PPI gtt to continue, NPO. Please reverse INR. If re-bleeds IR, surgery and GI consultation. Potential embolization of GDA likely as great difficulty with endoscopic intervention given size, location. . LENI [**12-9**]: Persistent partially occlusive deep venous thrombosis in the left mid superficial femoral and popliteal veins. Left calf veins are not visualized. No DVT in the right lower extremity. . Hip Plain Films [**12-11**] In comparison with study of [**11-27**], there is little overall change in the appearance of the metallic fixation device about previously described fracture of the proximal femur. Lesser trochanteric fracture fragment remains ununited with the fracture mass. Continued moderate joint space narrowing in both hip joints with degenerative changes in the lower lumbar spine. . IVC Filter placement [**12-12**]: 1. Single patent IVC. 2. Two left renal veins. 3. Infrarenal IVC diameter measured about 7 mm. 4. Successful placement of G2 IVC filter in the infrarenal IVC. . CHEMISTRY [**2130-12-8**] 03:20PM BLOOD WBC-15.4* RBC-1.75*# Hgb-5.2*# Hct-16.8*# MCV-96# MCH-29.6# MCHC-30.8* RDW-23.9* Plt Ct-416 [**2130-12-8**] 10:12PM BLOOD WBC-11.0 RBC-2.47*# Hgb-7.5*# Hct-22.4*# MCV-91 MCH-30.3 MCHC-33.5 RDW-19.1* Plt Ct-251 [**2130-12-9**] 04:29AM BLOOD WBC-10.7 RBC-3.19*# Hgb-9.9*# Hct-27.1* MCV-85 MCH-31.1 MCHC-36.6* RDW-20.3* Plt Ct-226 [**2130-12-9**] 06:25PM BLOOD Hct-27.1* [**2130-12-10**] 01:29AM BLOOD WBC-9.3 RBC-3.42* Hgb-10.1* Hct-29.4* MCV-86 MCH-29.4 MCHC-34.2 RDW-21.0* Plt Ct-240 [**2130-12-11**] 03:48AM BLOOD WBC-7.3 RBC-3.34* Hgb-9.9* Hct-29.4* MCV-88 MCH-29.8 MCHC-33.9 RDW-21.2* Plt Ct-267 [**2130-12-12**] 06:40AM BLOOD WBC-7.5 RBC-3.73* Hgb-10.9* Hct-32.9* MCV-88 MCH-29.2 MCHC-33.2 RDW-20.7* Plt Ct-319 [**2130-12-13**] 07:35AM BLOOD WBC-8.2 RBC-3.95* Hgb-11.7* Hct-35.9* MCV-91 MCH-29.7 MCHC-32.6 RDW-20.1* Plt Ct-347 [**2130-12-8**] 03:20PM BLOOD Neuts-63.9 Lymphs-30.8 Monos-4.1 Eos-0.8 Baso-0.3 [**2130-12-8**] 03:20PM BLOOD PT-33.4* PTT-58.4* INR(PT)-3.2* [**2130-12-9**] 06:49AM BLOOD PT-19.5* PTT-29.7 INR(PT)-1.8* [**2130-12-10**] 01:29AM BLOOD PT-16.2* PTT-31.0 INR(PT)-1.5* [**2130-12-12**] 06:40AM BLOOD PT-14.9* PTT-29.8 INR(PT)-1.4* [**2130-12-13**] 07:35AM BLOOD PT-14.5* PTT-30.4 INR(PT)-1.4* [**2130-12-8**] 02:50PM BLOOD Glucose-184* UreaN-71* Creat-1.8* Na-134 K-4.8 Cl-104 HCO3-21* AnGap-14 [**2130-12-11**] 03:48AM BLOOD Glucose-106* UreaN-37* Creat-1.3* Na-142 K-3.5 Cl-109* HCO3-28 AnGap-9 [**2130-12-13**] 07:35AM BLOOD Glucose-76 UreaN-18 Creat-1.3* Na-137 K-4.1 Cl-106 HCO3-24 AnGap-11 [**2130-12-8**] 03:20PM BLOOD CK(CPK)-26* [**2130-12-8**] 10:12PM BLOOD CK(CPK)-32 [**2130-12-9**] 04:29AM BLOOD CK(CPK)-28* [**2130-12-8**] 03:20PM BLOOD cTropnT-0.04* [**2130-12-8**] 10:12PM BLOOD CK-MB-1 cTropnT-0.03* [**2130-12-9**] 04:29AM BLOOD CK-MB-1 cTropnT-0.03* [**2130-12-8**] 03:20PM BLOOD Lipase-50 [**2130-12-8**] 03:20PM BLOOD Calcium-9.9 Phos-4.4# Mg-2.0 [**2130-12-9**] 04:29AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.9 [**2130-12-10**] 01:29AM BLOOD Calcium-9.2 Phos-2.9 Mg-1.8 [**2130-12-11**] 03:48AM BLOOD Calcium-9.1 Phos-2.8 Mg-1.7 [**2130-12-12**] 06:40AM BLOOD Calcium-9.2 Phos-2.9 Mg-1.6 [**2130-12-13**] 07:35AM BLOOD Calcium-9.7 Phos-2.4* Mg-1.8 [**2130-12-8**] 03:40PM BLOOD Hgb-5.4* calcHCT-16 URINE [**2130-12-8**] 05:30PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.011 [**2130-12-8**] 05:30PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2130-12-8**] 05:30PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-0 [**2130-12-8**] 05:30PM URINE CastGr-9* CastHy-3* Brief Hospital Course: PRINCIPLE REASON FOR ADMISSION Ms. [**Known lastname **] is a 78 year old female with recent left hip surgery complicated by deep venous thomrbosis (DVT) of the left leg and suspected pulmonary embolus (PE) treated with warfarin who was found to have melena at her nursing home and anemia in the ED. . # Gastrointestinal Bleed (GIB): She presented with melena and so there was concern for upper GI source. She underwent an EGD which found 3 ulcers--1 pre-pyloric which was not bleeding, and 2 duodenal which both had evidence of fresh clots. The GI team injected epinephrine into each of these ulcers but were unable to perform other interventions due to the size and location of the ulcers. She tested negative for H. pylori. She was maintained on a pantoprazole drip for a few days and then later transitioned to twice daily oral pantoprazole. She required 5 units of packed RBCs and vitamin K with 2 units of FFP to reverse her INR. Also, her anticoagulation was stopped (see below). . # DVT/PE: No current leg swelling but still has persistent left deep vein thrombosis found on repeat doppler. Because the GI team felt that she was a very high risk of rebleeding in the ulcers, further anticoagulation was held. Instead, an IVC filter was placed while her ulcers had time to heal over. Interventional radiology was consulted and placed the filter on [**2130-12-12**] without incident. . # Chest pain/EKG changes: Her chest pain on admission was likely due to demand ischemia given her profound anemia (hematocrit of 16.8) on admission. Alternitively, it may have been due to irritation of suspected PE. Her troponins were mildly elevated and decreased. Her chest pain resolved with blood transfusion. Cardiology follow up as outpatient for further testing and/or possible revascularization could be considered. . # Hypertension: Originally, her anti-hypertensives were held due to concern for large volume GIB and hypotension. However, she was restarted sequentially on her home amlodipine, metoprolol, HCTZ, and lisinopril. . # Diabetes mellitus: Continued home lantus, half dose for NPO, covered with sliding scale humalog, qid fingersticks. Held metformin. Due to low blood glucose. Lantus dose was decreased to 24 units qpm. . # h/o hip arthroplasty: Patient had flawed hip arthroplasty in the [**Country 13622**] Republic, revised here in [**2130-10-24**]. Still has staples in right incision, orthopedics consulted to remove the staples. Plain film Xrays showed little change from [**11-27**] films, but did note persistent lesser trochanteric fragment nonunion. Films were reviewed by orthopedic staff to their satisfaction. . TRANSITIONAL ISSUES: - Please give education on avoiding NSAIDs, steroids, etc to prevent further ulcers - Will set up cardiology follow up to evaluate need for further testing/management due to demand ischemia noted on presentation. - Patient will need to follow up with GI in [**3-29**] weeks to arrange repeat EGD to assess healing of ulcers. At that time, reinitiation of coumadin and aggrenox should be considered. If she is to be anticoagulated, would consider removal of IVC filter. Medications on Admission: 1. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 2. Lantus 100 unit/mL Solution Sig: Thirty Five (35) units Subcutaneous every morning. 3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 5. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 6. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for anxiety. 10. dipyridamole-aspirin 200-25 mg Cap, ER Multiphase 12 hr Sig: One (1) Cap PO DAILY (Daily). 11. metformin 850 mg Tablet Sig: One (1) Tablet PO once a day. 12. multivitamin Tablet Sig: 1-2 Tablets PO DAILY (Daily). 13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 15. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 16. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for rash. 17. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 18. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 19. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 20. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 21. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for nausea. 22. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). 23. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). Discharge Medications: 1. Lantus 100 unit/mL Solution Sig: Twenty Four (24) units Subcutaneous qpm: or as otherwise directed. 2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. 3. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 4. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 5. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 7. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for anxiety. 9. metformin 850 mg Tablet Sig: One (1) Tablet PO once a day. 10. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO QAM (once a day (in the morning)). 13. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 15. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 16. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 17. senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day as needed for constipation. 18. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once a day as needed for constipation. 19. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**] Discharge Diagnosis: PRIMARY DIAGNOSIS Pyloric ulcers deep vein thrombosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [**Known lastname **], . You were admitted to the hospital because you were having dark colored stools which is a sign that you were bleeding in your stomach. You had an EGD where the GI doctors looked down your throat with a camera and found 3 ulcers in your stomach which were bleeding. They used medications to stop the bleeding and you received several units of blood. You should avoid taking pain medications such as Motrin and Advil because these can cause ulcers. . Also, you still have a clot in your leg where they did the surgery. Because you cannot take blood thinning medication right now due to ulcers, you had a filter placed in your veins to stop this clot from moving to your lungs. . The following changes were made to your medications: STOP warfarin, aggrenox, miconazole, oxycodone, prochlorperazine START omeprazole 40mg tablet twice daily DECREASE lantus to 24 units daily . No other changes were made to your medications. . It is very important that you keep all of the follow-up appointments listed below. . It was a pleasure taking care of you in the hospital! Followup Instructions: Department: DIV. OF GASTROENTEROLOGY When: TUESDAY [**2131-1-9**] at 1 PM With: [**Name6 (MD) 11170**] [**Last Name (NamePattern4) 11171**], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage Department: CARDIAC SERVICES When: WEDNESDAY [**2131-1-10**] at 9:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15553**], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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Discharge summary

report+report

Admission Date: [**2184-10-18**] Discharge Date: [**2184-11-5**] Date of Birth: [**2131-3-30**] Sex: M Service: MEDICINE Allergies: Benadryl Allergy / Ambisome / Flomax Attending:[**Last Name (NamePattern1) 4377**] Chief Complaint: Rigors Major Surgical or Invasive Procedure: [**11-3**] Wedge resection of right halux onchocrytptosis History of Present Illness: Mr. [**Known lastname 39623**] is a 53 yo M with AML Day+333 s/p cord SCT who presented to clinic with fever and back pain. He was discharged on [**10-13**] with course of cipro, clinda for cellulitis. This AM he awoke with fevers and rigors and came to clinic for evaluation. In clinic, VS: T 99.4 HR 125 BP 158/86 Sat 95%/RA. He then spiked a temp to 101.1. Two sets of blood cultures were drawn. He received 1 L NS, 5 mg oxycodone, and Tylenol and was transferred to BMT service. On arrival to the floor, systolic BP of 85. He was rigoring and satting 85% on 2L. He came up to 99% on 5L facemask. He was given Vancomycin and meropenem and transferred to the [**Hospital Unit Name 153**] for further management of presumed sepsis. On ROS, pt reports vomiting x 1 this AM. He denies abdominal pain, diarrhea, cough, SOB, rash. He reports arthralgias of several months duration and chronic back pain that seemed worse this AM. Past Medical History: Past Medical History Per OMR, updated and confirmed with patient: 1) AML, M5b diagnosed 07/[**2182**]. - Received induction chemotherapy with 7 + 3(ARA-C and idarubicin)-[**2182-7-23**] until [**2182-8-22**]. The patient achieved a CR after this therapy. - High-dose ARA-C x 2 cycles from [**2182-8-28**] until [**2182-9-27**]. - Pt found to have relapsing dz and reinduced with Mitoxantrone and Ara-C [**Date range (1) 39624**]. Pt was found to have relapsing dz on bone marrow bx [**2183-9-2**] with 16% blasts, then was admitted between [**Date range (1) 39625**] for Mitoxantrone, Etopiside and Cytarabine. - s/p myeloablative sequential unrelated double cord blood transplant. Day 100 bone marrow biopsy showed no diagnostic morphologic features of involvement by acute leukemia, with cytogenetics revealing karyotype 46XX, consistent with that of female donor. 2) hepatic insufficiency due to secondary hemochromatosis and steatosis 3) Aspergillosis of the sinus/nares on voriconazole. 4) Bacillary angiomatosis 5) Acute appendicitis deep into his nadir during transplant that was successfully treated with daptomycin, meropenem, levofloxain and metronidazole 6) Incidental HHV6 IgG-positive, without disease 7) Hx of post chemo cardiomyopathy; TTE [**6-19**] with preserved EF. 8) Sarcoid - diagnosed in [**2172**], received intermittent steroids 9) GERD 10) HTN 11) Hypercholesterolemia 12) s/p cholecystectomy in [**6-/2180**] complicated by sinus tract to the abdominal wall 13) Hepatic and splenic microabscesses ([**8-/2182**]) 14) BOOP requiring extended ICU/hospital course in 3/[**2184**]. 15) Peripheral Neuropathy Social History: Patient is married, lives in [**Location 620**] with his wife [**Name (NI) 2048**] and 16 year old son. [**Name (NI) **] 3 other grown children (2 sons and 1 daughter). Has not worked in 2 years due to illness and is on disability; worked as an auto parts supervisor and mechanic for many years. Has 2 grandchildren. The patient has a history of tobacco use and notes that he smoked one-half pack per day x30 years. He uses alcohol occasionally; however, is not drinking at this time. He denies use of illicit drugs. Family History: Father- CAD s/p CABG. Type II Diabetes, HTN Mother- Type [**Name (NI) **] Diabetes. Multiple paternal uncles with heart disease. 2 siblings in good health. Physical Exam: VS: BP 90/50 HR 108 O2 Sat 100% on Face mask GEN: Obese male ill-appearing HEENT: EOMI, PERRL, anicteric NECK: Supple, no JVD, no meningismus CHEST: CTABL, no w/r/r CV: Tachycardic, RR, S1S2, no m/r/g ABD: Soft/NT/ND, Obese, negative [**Doctor Last Name **] sx, +BS EXT: Warm, 3+ pitting edema bilaterally, 2+ DPs SKIN: no rashes, line intact without erythema Neuro: AAOx3, CN ii-xii intact, strength 4+/5 R HF, 5/5 L HF, [**5-17**] dorsiflexion bilaterally Lines: Hickman triple lumen Pertinent Results: pH 7.34 pCO2 41 pO2 79 HCO3 23 Lactate:2.7 140 105 37 AGap=15 --------------< 88 4.3 24 1.6 Ca: 8.4 Mg: 1.4 P: 1.9 . ALT: 38 AP: 128 Tbili: 0.6 Alb: 3.8 AST: 43 LDH: 290 CK: 15 UricA:8.7 TSH:1.8 Cholesterol:158 T4: 5.7 CRP: 13.9 . 10.5 5.5 >----< 55 30.9 N:92 Band:3 L:2 M:0 E:2 Bas:0 Myelos: 1 Nrbc: 1 Neuts: TOXIC GRANULATION PRESENT Anisocy: OCCASIONAL Macrocy: 2+ Microcy: OCCASIONAL Polychr: OCCASIONAL Tear-Dr: OCCASIONAL . PT: 13.2 PTT: 23.7 INR: 1.1 . Blood culture ([**10-19**]): STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA Blood culture ([**10-18**]): STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA | CEFTAZIDIME----------- 8 S TRIMETHOPRIM/SULFA---- <=1 S . Studies: CT L-spine ([**10-19**]): No obvious evidence for discitis/osteomyelitis or epidural collection, though evaluation is limited by CT technique. Consider MRI for further evaluation, if indicated. . CT Chest ([**10-19**]): 1. Interval improvement of previously seen ground glass and peribronchiolar opacities. No focal consolidation. No evidence of bacterial or fungal pneumonia on the current study. 2. Decreasing small bilateral pleural effusions. 3. Splenomegaly and mediastinal and hilar lymphadenopathy again identified. . CXR ([**10-23**]): Persistent asymmetrical pulmonary opacities, for which differential diagnosis includes asymmetrical pulmonary edema, infection such as PCP, [**Name10 (NameIs) **] hemorrhage, and drug toxicity. . CT Chest ([**10-28**]): 1. New clustered peribronchovascular and peribronchiolar nodules in the right upper lobe and less marked in the left upper lobe, suggesting endobronchial spread of infection. 2. Diffuse heterogeneous attenuation and widespread air trapping is more marked than on [**10-19**], probably related to acute infectious process and small airway disease. Rapid progression makes bronchiolitis obliterans very less likely. 3. No volume overload. No pleural effusion. 4. Splenomegaly and mediastinal and hilar lymphadenopathy. . Cardic Echo: ([**10-20**]) The left atrium is elongated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. There is mild to moderate global left ventricular hypokinesis (LVEF = 40 %). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. There is mild pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2184-10-11**], the left ventricular ejection fraction is somewhat reduced. . ([**11-3**])No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. However, the study is technically suboptimal. If the clinical suspicion of intracardiac shunt is high, right heart catheterization is recommended. Brief Hospital Course: 53 M d 338 s/p allo SCT presented on [**10-18**] with fever and diffuse pain, then hypoxic repiratory failure, found to have stentotrophomonas bacteremia. . ICU COURSE - He had two ICU stays on this admission. On [**10-18**], he was transferred to the [**Hospital Unit Name 153**] for respiratory distress. He is on 2L NC for BOOP at home and he was transferred to [**Hospital Unit Name 153**] with a O2 sat of 85% on 2L NC. He was given Vanc and Meropenem. Overnight in the [**Hospital Unit Name 153**] he did well and in the a.m. of [**10-19**] he was called out to the floor as he was sating well on 2L NC which was back to baseline. . The evening of [**10-19**], a code blue was called for acute respiratory distress 30 minutes after Hickman was flushed. At the time, he had wheezing, RR > 40, coughing, agitated, he was hypertensive and tachycardic. His sat had dropped to 69% with a good pleth on a non-rebreather. He had a depressed mental status and was not responding commands. A code was called and a plan was made to intubate- just prior to intubation while being bag-mask ventilated his O2 sat increased to 100% and then he was switched to a non rebreather and was feeling well. Patient felt acutely short of breath- this was preceeded by rigors. He felt that it was difficult to take a breath of air in, he also began coughing at that time but had not been coughing previously. He denied any orthopnea. no chest pain. No hemoptysis. Cough was minimally non productive. He began to feel better slowly when the non rebreather was applied. He states that he was beginning to get tired of breathing but then he started to improve and since has been steadily improving. + nausea, no vomiting. He did have chills / rigors that were witnessed during his "code blue." . In the ICU, he was found to have GNR bacteremia, likely [**2-14**] infected hickman. On [**10-20**], his hickman was removed and he was given a dose of Tobra. Based on the sensitivities of the GNR, abx were changed to ceftaz. An echo showed no vegitations but global hypokenesis. On [**10-21**] he was started on bactrim for possible stenotrophomonas and carvedilol. On [**10-22**] GNR found to be steno; Ceftaz was discontinued. . STENOTROPHOMONAS BACTEREMIA - Following admission to the floor, he remained afebrile, without leukocytosis, with no indwelling lines. He was continued on IV bactrim. Surveilence cultures remained negative. Bactrim was stopped on [**11-1**] for hyperkalemia with mild T-wave changes, at which point he had completed a 12 day course. . HYPOXEMIA- His oxygen requirement improved from 5L NC on transfer to the floor to his baseline of 1.5L at rest and 3L with activity. The original elevation was thought to be related to volume overload vs mild ARDS/[**Doctor Last Name **] from bacteremia. He has significant underlying lung disease. He was continued on gentle diuresis home dose lasix, goal 0-1 L per day, but this was stopped on [**10-28**] given elevated creatinine. A CT with contrast showed a new cluster of peribronchovascular and peribronchiolar nodules, concerning for infection. Pulmonary was consulted, who had seen him as an outpatient, and felt his respiratory issues to be chronic. Given concern for pulmonary hypertension, a bubble study was done, showing no evedence of cardiac shunt. Beta-glucan and galactomanan sent on presentation were negative. He was continued on prednisone. Outpatient pulmonary follow-up was scheduled. ** Will likely need outpatient right-heart catheterization ** Follow-up repeat beta-glucan/galactomanan . MENTAL STATUS CHANGES - Per nursing and patient, he has had some mild decine in short-term memory and occasionally will lose track of what people are saying. Mental status and neurological exams were normal. An MRI was ordered to assess for change in mental status. MRI/MRA showed only mild brain atrophy, but no evidence of infarct or signs of acute or chronic ischemia. . ACUTE RENAL FAILURE - Creatinine rose steadily on IV bactrim, lasix, lisinopril. Renal was consulted and felt that the creatinine rise was largely dut to the non-toxic effect of bactrim on creatinine absorbtion. Lasix and acyclovir were held. Renal consult team felt that the increased creatinine was due to the benign effect of bactrim on inhibiting tubular secretion of creatinine that would resolve following discontinuation of treatment. Urine lytes were unrevealing. Cr remained at 2.0-2.1 for 2 days following discontinuation of bactrim but then returned to 1.6 on discharge. Renal follow up was scheduled. He will return to clinic on monday for electrolytes. ** continue to monitor Creatinine. . ACUTE MYELOGENOUS LEUKEMIA, history of STEM CELL TRANSPLANT - Daily CBCs with differential showed his disease to be in remission. He was transfused to keep Hct > 25 and continued on immunosuppression with cellcept. ** Atovaquone was stopped, he needs to restart Bactrim at PCP prophylaxis levels. . INGROWN TOENAILS - Patient with chronic ingrown toenails, missed podietry appointment secondary to hospital stay. On [**11-3**] developed new toe redness and bloody pirulent discharge. Vancomycin was started and podietry evaluated. A wedge resection of right halux onchocrytptosis was done and cultures were sent. He was given two doses of vancomycin and started on a 5 day course of augmentin. Podietry follow-up appointment was scheduled. ** Follow wound culture and adjust abx as needed . HEART FAILURE - An echocardiogram in the ICU was notable for an EF of 40 % which is depressed compared to [**10-11**]. He did not require lasix to maintain volume status and this was held while his creatinine was elevated and there were no exam findings of volume overload. He was discharged on his home dose of lasix with sheduled follow up in heart failure clinic. ** Consider follow-up echo to look for resolution of depressed ejection fraction . ASPIRGILLOSIS - He was continued on voriconazole 300 po q12h. . HYPERTENSION - In the ICU, he was restarted on carvedilol and recently restarted on his ACE. SBP 117-152 in ICU. His ace was subsequently held for elevated creatinine ** consider restarting ACE if Cr stable.. . BLURRY VISION - Patient had blurry vision on this and previous admission that was associated with early sepsis. These vision changes resolved quickly both times with resussitation, but he notes his lens prescription is out of date. He was scheduled for opthomology follow-up. . NEUROPATHY - He was continued on neurontin. . FEN/GI - Regular diet . Full Code Medications on Admission: ACYCLOVIR - 400 mg PO bid ATOVAQUONE - 1500 PO DAILY CARVEDILOL - 12.5 mg [**Hospital1 **] COMBIVENT - 2 puffs QID PRN CYANOCOBALAMIN- 1,000 mcg/mL Solution IM once per month FUROSEMIDE 40 mg PO qdaily GABAPENTIN - 100 mg Capsule - 3 3x tid INSULIN ASPART INSULIN GLARGINE - 5 u at bedtime LANSOPRAZOLE - 30 mg Tablet,Rapid Dissolve PO daily LISINOPRIL - 5 mg PO daily MONTELUKAST - 10 mg PO DAILY MYCOPHENOLATE MOFETIL - 500mg PO bid q 12pm NITROGLYCERIN - 0.3 mg Tablet sublingually ASDIR PRN OXYCODONE - 5 mg PO q6hrs PRN pain PREDNISONE - 20mg PO mouth daily VORICONAZOLE - 300 mg PO q12 AMINO ACIDS-MAGNESIUM SULFATE [MG-PLUS-PROTEIN] - (OTC) - Tablet - 1 Tablet(s) by mouth once a day ASCORBIC ACID [VITAMIN C] - 500 mg Tablet PO q daily ASPIRIN - 81 mg Tablet PO QOD CALCIUM CARBONATE - 1000mg PO Q 12H CHOLECALCIFEROL (VITAMIN D3) - 400 unit PO daily HEXAVITAMIN - Tablet - 1 Tablet(s) by mouth once a day LORATADINE - 10 mg PO daily MICONAZOLE NITRATE - 2 % Powder - apply to affected areas twice a day MICONAZOLE NITRATE [CRITIC-AID CLEAR AF] - 2 % Ointment - apply to affected area twice a day as needed for rash THIAMINE HCL - 50 mg Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. Oxygen Supplemental oxygen continuous at 2 liters for portability pulse dose system 2. Lasix 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day: use as needed for fluid overload or weight gain. Disp:*30 Tablet(s)* Refills:*2* 3. Carvedilol 12.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Combivent 18-103 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) puffs Inhalation four times a day as needed for shortness of breath or wheezing. Disp:*4 inhailers* Refills:*0* 5. Cyanocobalamin 1,000 mcg/mL Solution [**Hospital1 **]: One (1) injection Injection once a month. 6. Gabapentin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO every twelve (12) hours. Disp:*60 Capsule(s)* Refills:*2* 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day. 8. Montelukast 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Mycophenolate Mofetil 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 10. Oxycodone 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 11. Voriconazole 200 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO Q12H (every 12 hours). Disp:*90 Tablet(s)* Refills:*2* 12. Calcium Carbonate 1,000 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable PO twice a day. Disp:*60 Tablet, Chewable(s)* Refills:*2* 13. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 14. Loratadine 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 15. Mycophenolate Mofetil 250 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 16. Prednisone 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 17. Amoxicillin-Pot Clavulanate 500-125 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q8H (every 8 hours) for 4 days. Disp:*12 Tablet(s)* Refills:*0* 18. Enteric Aspirin 81 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 19. Hexavitamin Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 20. Insulin Glargine 100 unit/mL Solution [**Last Name (STitle) **]: Five (5) units Subcutaneous at bedtime. Disp:*10 ml* Refills:*2* 21. Insulin Aspart 100 unit/mL Solution [**Last Name (STitle) **]: variable units Subcutaneous four times a day: as per sliding scale. Disp:*10 ml* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: STENOTROPHOMONAS BACTEREMIA HYPOXIC RESPIRATORY FAILURE MENTAL STATUS CHANGES ACUTE RENAL FAILURE ACUTE MYELOGENOUS LEUKEMIA, history of STEM CELL TRANSPLANT INGROWN TOENAIL SYSTOLIC HEART FAILURE ASPIRGILLOSIS HYPERTENSION BLURRY VISION NEUROPATHY Discharge Condition: Stable VS: T 97.9, HR 80, BP 138/78, RR 18, Sat 98%/1.5 L Cr: 1.6, K 4.9 Discharge Instructions: You were admitted with fevers and general body ached and found to have a rare bacteria called Stenotrophomonas. You were treated in the ICU and completed a course of IV antibiotics for this infection. It is likely that this antibiotic temporarily reduced your kidney function. You should follow up in clinic on Monday to have your kidney function checked. You should also follow up with your kidney doctor. You also had difficulties breathing that have returned to baseline. You should follow up in pulmonary clinic to discuss further studies and treatments. An ingrown toenail was removed. You should complete your course of oral antibiotics for this and follow up in [**Hospital 39629**] clinic. In the ICU, your heart function was somewhat decreased. You should follow up with cardiology to ensure this returns to normal. Followup Instructions: [**2184-12-7**] 10:00a [**Location (un) **],TCC SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] PULMONARY UNIT-CC7 (SB) [**2184-12-7**] 09:30a [**First Name9 (NamePattern2) 1570**] [**Hospital Ward Name **] 7 - RM 2 [**Hospital6 29**], [**Location (un) **] PULMONARY LAB [**2184-12-1**] 01:00p [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] HEMATOLOGY/ONCOLOGY-SC [**2184-11-25**] 09:00a [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] RENAL DIV-CC7 (SB) [**2184-11-16**] 03:20p PODIATRY,[**Doctor Last Name 15351**] BA [**Hospital Unit Name **] ([**Hospital Ward Name **] COMPLEX), [**Location (un) **] [**Hospital 1947**] CLINIC (SB) [**2184-11-16**] 02:00p [**Doctor Last Name 22344**] [**Last Name (LF) **],[**First Name3 (LF) **] SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] OPTOMETRY [**2184-11-11**] 03:50p PODIATRY,[**Doctor Last Name 15351**] BA [**Hospital Unit Name **] ([**Hospital Ward Name **] COMPLEX), [**Location (un) **] [**Hospital 1947**] CLINIC (SB) [**2184-11-10**] 02:30p [**Last Name (LF) 3524**],[**First Name3 (LF) 3523**] SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] NEUROLOGY UNIT CC8 (SB) [**2184-11-10**] 01:00p EMG,ALL SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] EMG LAB Phone:[**Telephone/Fax (1) 2846**] [**2184-11-9**] 03:30p NP-HF SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] CC7-HEART FAILURE (SB) [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] [**2184-11-8**] 01:00p BED 1-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F Completed by:[**2184-11-5**] Admission Date: [**2184-11-8**] Discharge Date: [**2184-11-12**] Date of Birth: [**2131-3-30**] Sex: M Service: MEDICINE Allergies: Benadryl Allergy / Ambisome / Flomax Attending:[**First Name3 (LF) 3913**] Chief Complaint: Joint pain, toe pain Major Surgical or Invasive Procedure: - Excisional debridement of left hallux - PICC line placement History of Present Illness: 53 year old male with AML day +354 s/p myeloablative sequential unrelated double cord blood transplant presenting to the outpatient 7F clinic with generalized body aches and painful toes. Mr. [**Known lastname 39623**] has had several admissions over the last several weeks. He was admitted from [**Date range (1) 39630**]/08 with a right lower extremity rash and was treated for cellulitis. He was treated with vancomycin and cefepime until [**10-12**] and then transitioned to clindamycin/ciprofloxacin to complete a course on [**2184-10-26**]. He was seen by Podiatry on that hospitalization, who did not feel that his toes were the source of infection. . He was hospitalized again from [**Date range (3) 39631**] for fevers and back pain and had a long/complicated course including, hypotension/sepsis, fevers, respiratory distress, Stenotrophomonas bacteremia, acute renal failure, hyperkalemia, diffuse joint pains, infected ingrown toenail and decreased EF on echocardiogram. He completed 11 days of a 14 day course of high dose bactrim, stopped due to renal failure, persistent hyperkalemia and joint pains. He was feeling well on the day of discharge without specific complaint. He was discharged to complete a 7 day course of Augmentin for the infection related to his ingrown toenail. . He presents to the 7F outpatient clinic today complaining of diffuse joint/generalized body aches and painful toes. Reports all joints are painful, and particularly shoulders, hips, elbows, and knees bilaterally. Joint pain is chronic, although this is worse than he has ever experienced. Improvement with oxycodone, worsened when climbing stairs. Toe pain present from last hospital stay. Large toes bilaterally and spreading laterally with erythema, pain, and bleeding. . Of note, his creatinine remains elevated from baseline, but improved from the last hospitalization. He also has leukocytosis, elevated potassium, and stable thrombocytopenia. . On review of systems, also complains of general fatigue worsening since discharge. Febrile to 100.3 two days prior to admission that resolved without intervention. Denies dyspnea. Home oxygen requirement unchanged - 1.5L NC when sleeping, 3L NC walking. Slight dysuria, now resolved. Denies chest pain, abdominal pain. Bowel movements daily. Past Medical History: Past Medical History (taken from previous notes) 1) AML, M5b diagnosed 07/[**2182**]. - Received induction chemotherapy with 7 + 3(ARA-C and idarubicin)-[**2182-7-23**] until [**2182-8-22**]. The patient achieved a CR after this therapy. - High-dose ARA-C x 2 cycles from [**2182-8-28**] until [**2182-9-27**]. - Pt found to have relapsing dz and reinduced with Mitoxantrone and Ara-C [**Date range (1) 39624**]. Pt was found to have relapsing dz on bone marrow bx [**2183-9-2**] with 16% blasts, then was admitted between [**Date range (1) 39625**] for Mitoxantrone, Etopiside and Cytarabine. - s/p myeloablative sequential unrelated double cord blood transplant, now D+334. Day 100 bone marrow biopsy showed no siagnostic morphologic features of involvement by acute leukemia, with cytogenetics revealing karyotype 46XX, consistent with that of female donor. 2) hepatic insufficiency due to secondary hemochromatosis and steatosis 3) Aspergillosis of the sinus/nares on voriconazole. 4) Bacillary angiomatosis 5) Acute appendicitis deep into his nadir during transplant that was successfully treated with daptomycin, meropenem, levofloxain and metronidazole 6) Incidental HHV6 IgG-positive, without disease 7) Hx of post chemo-induced cardiomyopathy; TTE [**6-19**] with preserved EF. 8) Sarcoid - diagnosed in [**2172**], received intermittent steroids 9) GERD 10) HTN 11) Hypercholesterolemia 12) s/p cholecystectomy in [**6-/2180**] complicated by sinus tract to the abdominal wall 13) Hepatic and splenic microabscesses/candidiasis ([**8-/2182**]) 14) BOOP requiring extended ICU/hospital course in [**3-/2184**] and home oxygen 15) Peripheral neuropathy Social History: Patient is married, lives in [**Location 620**] with his wife and 16 year old son. [**Name (NI) **] 3 other grown children (2 sons and 1 daughter). Has not worked in 2 years due to illness and is on disability; worked as an auto parts supervisor and mechanic for many years. Has 2 grandchildren. Family History: Father- CAD s/p CABG. Type II Diabetes Mother- Type [**Name (NI) **] Diabetes. Multiple paternal uncles with heart disease. 2 siblings in good health. Physical Exam: GEN: Well appearing, in NAD SKIN: Bilateral big toe erythematous, with erythema spreading to HEENT: NC/AT, Anicteric, conjuntiva non-injected, O/P clear CV: RRR, normal S1/S2, no murmurs or gallops PULM: Crackles at left base extending to left middle lung field ABD: Obese, soft, NT/ND. EXT: WWP, [**1-14**]+ edema to level of knees NEURO/PSYCH: A&Ox3. CN2-12 intact. Strength 4+ lower extremities; upper extremity exam limited by joint pain; grip strength 5+ Pertinent Results: [**2184-11-12**] 06:15AM BLOOD WBC-7.2 RBC-2.52* Hgb-8.6* Hct-25.8* MCV-103* MCH-34.1* MCHC-33.3 RDW-13.6 Plt Ct-71* [**2184-11-12**] 06:15AM BLOOD Neuts-78.7* Lymphs-11.9* Monos-8.6 Eos-0.5 Baso-0.4 [**2184-11-12**] 06:15AM BLOOD Glucose-123* UreaN-41* Creat-1.5* Na-143 K-4.2 Cl-106 HCO3-28 AnGap-13 [**2184-11-12**] 06:15AM BLOOD ALT-15 AST-9 LD(LDH)-233 AlkPhos-152* TotBili-0.2 [**2184-11-12**] Radiology PICC LINE PLACMENT SCH [**Last Name (LF) **],[**First Name3 (LF) **] E. Unread [**2184-11-11**] Radiology TOE(S), 2+ VIEW BILAT P [**Last Name (LF) **],[**First Name3 (LF) **] E. Unsigned [**2184-11-10**] Cardiology ECHO [**2184-11-10**] [**Last Name (LF) **],[**First Name3 (LF) **] E. [**2184-11-9**] Radiology US EXTREMITY NONVASCULA [**Last Name (LF) **],[**First Name3 (LF) **] E. Approved [**2184-11-9**] Radiology UNILAT UP EXT VEINS US [**Last Name (LF) **],[**First Name3 (LF) **] E. Approved [**2184-11-8**] Radiology BILAT HIPS (AP,LAT & AP Brief Hospital Course: 53 year old male day diffuse joint pain and painful toes; recently hospitalized with hypoxic repiratory failure and found to have stentotrophomonas bacteremia. . 1. Toe pain - Presented with history of chronic in-grown toe nails. s/p toe nail biopsy at previous hospitalization. Wound culture with coag positive Staph aureus. At previous hospitalization, was initially treated with vancomycin (2 doses), then given at discharge 5 day course of Augmentin. On admission for present hospitalization, vancomycin IV was started. Podiatry was also consulted; excisional debridement of left first toe was performed. Pain and erythema improved considerably on IV antibiotics. On discharge, patient was provided information to arrange follow-up with podiatry in one week. A PICC line was also placed to allow the patient to complete additional 7 day course of vancomycin IV. . 2. Stenotrophomonas bactermia - Patient did not complete antibiotic course for Stenotrophomonas bacteremia at last infection secondary to renal failure and hyperkalemia which was thought to be due to Bactrim. Received 12 of 14 day course. Stenotrophomonas sensitivities from previous hospitalization show sensitivity to Bactrim and ceftazidime. On admission, patient was restarted on ceftazidime based on the possibility that his diffuse arthralgias may be due to a systemic infection. Blood cultures were no growth to date. Ultrasound at former central line site was ultrasounded to assess for abscess - no abscess or clot was seen. Given patient's improvement on steroids (as explained below), ceftazidime was stopped prior to discharge. . 3. Diffuse arthralgias/myalgias - Has history of aspergillosis, which can in itself cause severe muscle aches. Has been on voriconazole. Differential diagnosis on presentation also included GVH, avascular necrosis given longterm steroid use, rhemautoid arthritis, osteoarthritis, gout, Still's, Lyme. No outdoor exposure. Voriconazole was continued at home regimen of 300mg PO Q12. Hip films were negative for avascular necrosis. Neurology was consulted given that patient's outpatient workup for these issues included an EMG - their recommendation was to hold off on the EMG as would likely not alter management. Two to three days after presentation, patient was tried on increased dose of prednisone. Within 12-24 hours, patient's pain completely resolved. On discharge, patient was on prednisone 20mg PO QAM and 15mg PO QPM. Further dose adjustment/tapering is to be done on an outpatient basis. Overall, the aches were thought to be secondary to GVH. . 4. Renal failure - Creatinine better than at discharge, although considerably higher [**First Name8 (NamePattern2) **] [**Month (only) **]/[**Month (only) 205**] of this year. Source unclear, although during previous admission creatinine rose steadily on IV bactrim, furosemide, lisinopril. Creatinine continued to improve during this hospitalization with IV fliuds, increased PO intake. . 5. Acute myelogyenous leukemia - s/p allo SCT. Continued Cellcept per home regimen. Monitored daily blood counts. Transfused for platelets <10. Transfused for hematocrit <25. . 6. Hyperkalemia - On presentation. Unclear reason. At last admission was thought to be related to renal failure, which was thought to be secondary to Bactrim. Hyperkalemia improved on admission with Kayexelate. Patient was given calcium and furosemide given EKG changes associated with hyperkalemia. Resolved without further intervention. Potassium levels were checked twice daily. . 7. History of aspergillosis - Continued voriconazole 300 PO Q12H per home regimen. . 8. Hypertension - During previous admission was restarted on carvedilol; ACE inhibitor was held secondary to elevated creatinine. Continued to hold ACE inhibitor as creatinine improved. . 9. Neuropathy - Continued neurontin per home regimen. . 10. Diabetes mellitus - Continued glargine 4U at bedtime. Sliding scale insulin with QID blood glucose checks. Of note, blood glucose ran high after [**Hospital1 **] steroids were started. **FULL CODE **Contact - Wife, ([**Telephone/Fax (1) 39632**] (h) or ([**Telephone/Fax (1) 39633**] (c) Medications on Admission: Lasix 40 mg Tablet on tablet daily Carvedilol 12.5 mg [**Hospital1 **] Combivent 2 puffs qid prn B12 1000 mcg/mL once monthly Gabapentin 300 mg q12 hours Lansoprazole 30 mg daily Singulair 10 mg daily MMF 500 mg [**Hospital1 **] Oxycodone 5 mg po q4h prn pain Voriconazole 300 mg po q12 hours Calcium, Vitamin D Loratadine 10 mg daily Prednisone 20 mg daily Augmnetin q8h Aspirin 81 mg daily MVI Lantus 5u qhs, Aspart prn SSIg Discharge Medications: 1. Furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 2. Carvedilol 12.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 3. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Hospital1 **]: [**1-14**] Puffs Inhalation Q6H (every 6 hours) as needed for Dyspnea. 4. Gabapentin 300 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO Q12H (every 12 hours). 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 6. Montelukast 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 7. Calcium Carbonate 500 mg Tablet, Chewable [**Last Name (STitle) **]: Two (2) Tablet, Chewable PO BID (2 times a day). 8. Voriconazole 200 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO Q12H (every 12 hours). 9. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 10. Loratadine 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Daily (). 11. Mycophenolate Mofetil 250 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY (Daily). 12. Insulin Glargine 100 unit/mL Cartridge [**Last Name (STitle) **]: Five (5) U Subcutaneous at bedtime. 13. Insulin Aspart 100 unit/mL Cartridge [**Last Name (STitle) **]: Per home sliding scale regimen Subcutaneous four times a day as needed for based on sliding scale regimen. 14. Mycophenolate Mofetil 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). Tablet(s) 15. Prednisone 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QAM (once a day (in the morning)). 16. Prednisone 5 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO QPM (once a day (in the evening)) for 3 days. Disp:*9 Tablet(s)* Refills:*0* 17. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Last Name (STitle) **]: One (1) gram Intravenous Q 12H (Every 12 Hours) for 10 days: Last Dose [**2184-11-22**]. Disp:*20 gram* Refills:*0* 18. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO MWF (Monday-Wednesday-Friday). Disp:*14 Tablet(s)* Refills:*2* 19. Saline Flush 0.9 % Syringe [**Month/Day/Year **]: 5-10 cc Injection three times a day: prn: line care, antibiotics. Disp:*60 syringes* Refills:*2* 20. Heparin Flush 10 unit/mL Kit [**Month/Day/Year **]: Three (3) cc Intravenous three times a day: prn: line care, antibiotics. Disp:*60 flushes* Refills:*2* 21. Oxycodone 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 22. Acyclovir 400 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO every twelve (12) hours. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary 1. Graft versus host disease 2. MRSA infection of left first digit 3. Herpes infection of oral mucosa Secondary 1. Acute myelogenous leukemia s/p cord blood transplant Discharge Condition: Ambulatory. Hemodynamically stable. Discharge Instructions: You were admitted on [**2184-11-8**] with joint pain and pain in your toes. While in the hospital your prednisone dose was increased and your joint pain resolved. You were also started on vancomycin, an antibiotic, and seen by podiatry and your toe pain improved. Your medication regimen has changed. Continue taking your home medications as you were prior to this hospitalization EXCEPT for the following changes. - Stop taking Augmentin. - Take vancomycin through your PICC line for an additional 10 days. - In addition to the 20mg prednisone which you take in the morning, take 15mg prednisone in the evenings for the next 3 nights (Friday-Sunday). - Take acyclovir daily. - Take Bactrim every Monday, Wednesday, and Friday. Please follow-up with your provider as below. Please return to the emergency department or call your provider for any increase in joint pain, fevers, toe pain or pus, or for any other concerns. Followup Instructions: Outpatient 7F clinic appointment: - Provider: [**Name10 (NameIs) 3310**],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/ONCOLOGY-7F Date/Time:[**2184-11-15**] 9:30 -Dr. [**First Name (STitle) **], [**2184-12-1**] 1 pm Optometry follow Up: - Provider: [**Name10 (NameIs) **] [**Doctor Last Name **] [**Doctor Last Name 22344**], OD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2184-11-16**] 2:00 Podiatry Follow Up: - Tuesday [**2184-11-16**] 3:20 pm, Dr. [**Last Name (STitle) **], [**Hospital Ward Name **] 3 Renal Follow Up: - [**2184-11-25**] 9 am. Dr. [**Last Name (STitle) **]. [**Hospital Ward Name 23**] [**Location (un) **] Completed by:[**2184-11-15**]

[ "516.8", "995.92", "054.9", "041.12", "584.9", "996.85", "703.0", "205.01", "428.20", "279.50", "518.81", "999.31", "250.00", "038.8", "428.0", "403.90", "117.3", "714.0", "585.9", "V42.82", "276.7", "287.5" ]

icd9cm

[ [ [] ] ]

[ "38.93", "86.23" ]

icd9pcs

[ [ [] ] ]

35164, 35222

27794, 31936

21731, 21795

35442, 35480

26777, 27771

36453, 36731

26128, 26280

32413, 35141

35243, 35421

31962, 32390

35504, 36430

26295, 26758

37034, 37171

21671, 21693

21823, 24115

24137, 25799

25815, 26112

32,212

135,900

25521

Discharge summary

report

Admission Date: [**2158-10-27**] Discharge Date: [**2158-11-1**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Melena Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] F c hx chronic back/hip/leg pain, HTN, multi-infarct related dementia, who presents with melena from nursing home. Pt. had episode of 200 cc of melena this afternoon. By report, no chest pain, dizziness, light headedness, abdominal pain at the time. No prior history of GIB. On ASA, Plavix for hx of CVA. Has been taking NSAIDS for chronic pain. . In the ED, hemodynamically stable with HCT 28 (last 31 [**6-29**]). Family had decided to pursue upper endoscopy at this time as per report. Admitted for further monitoring. . While on the floor, patient had coffee ground emesis and melena. Underwent NG lavage with return of "coffee grounds" and bilious fluid, which did not clear after 250 cc lavage. Patient noted to be increasing tachycardic with HR to 130s. BP 107/80 at time of transfer to MICU. Patient's family was present and consented to blood transfusions and EGD. . On arrival to the MICU, patient noted to have ST seg depressions on tele. EKG with new 3-[**Street Address(2) 5366**] seg depressions in V2-V6 concerning for acute MI. Cardiology was consulted via phone and agreed that the ST seg changes were probably [**2-24**] to demand in setting of dropping HCT and that she would not be a candidate for anti-coagulation in the setting of a significant GI bleed. Past Medical History: PMH: (from prior clinic notes/nightfloat admission) 1. Chronic back, hip, and leg pain- This initially began after a riding accident in the [**2081**]. The right hip pain has been worse since her fracture. 2. [**Name (NI) 12329**] Pt's caregiver reports that the pt has been on medication for her BP for approximately 10 years. 3. Anxiety- She has been taking Ativan for her anxiety for about one year. 4. Depression 5. Back surgery for a slipped disc- [**2136**] 6. S/P fracture of right humerus- [**2151**] 7. S/P right hip fracture with fixation- [**2153**] 8. S/P hysterectomy- [**2138**]; unclear uterine or cervical CA 9. S/P cataract removal 10. Hard of hearing 11. Dementia- Evidence in old notes of vascular dementia but also labelled by previous PCP as having Alzheimer's type dementia. 12. S/P CVA- [**2139**] Pt has slight residual slurring of her speech. 13. S/P MVA- [**2109**] This resulted in multiple leg and clavicle fractures. 14. S/P fall from horse resulting in back injury- [**2081**] . Social History: Lives at [**Hospital3 537**]. Widowed. Has 3 daughters. [**Name (NI) **] past or current tobacco use. No drug use. One etoh beverage before dinner for over 50 years but none since moving into the [**Hospital **]. (as per prior [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 3782**] note) Family History: [**Name (NI) 1094**] mother died at age [**Age over 90 **] from "old age". Her father died at age 52 from an unknown type of brain tumor. The pt had four siblings and is the only one still living. One had Alzheimer's disease and another a brain tumor. The other two died of "old age". Physical Exam: VS- t 96.1 oral, hr 120, bp 131/33, rr30, sat 100% 2 l nc GEN- Elderly woman lying in bed, appears intermittently uncomfortable HEENT- Pale conjunctivae, MMM LUNGS- CTA anteriorly HEART- RRR, S1, S2, no murmurs ABDOM- soft, NT, BS+; + melena EXTRE- no edema, DP pulse 2+ bilat . Pertinent Results: [**2158-10-27**] 03:25PM BLOOD WBC-11.8* RBC-2.93* Hgb-9.4* Hct-28.7* MCV-98 MCH-32.1* MCHC-32.7 RDW-12.9 Plt Ct-386 [**2158-10-28**] 12:05AM BLOOD Hct-22.9* [**2158-10-28**] 03:27AM BLOOD WBC-19.9*# RBC-3.87*# Hgb-12.1# Hct-35.5*# MCV-92 MCH-31.3 MCHC-34.1 RDW-15.6* Plt Ct-241 [**2158-10-29**] 04:07AM BLOOD WBC-21.0* RBC-3.38* Hgb-10.4* Hct-30.2* MCV-89 MCH-30.9 MCHC-34.5 RDW-16.5* Plt Ct-195 [**2158-10-31**] 02:35PM BLOOD Hct-31.6* [**2158-10-27**] 03:25PM BLOOD Glucose-163* UreaN-62* Creat-1.6* Na-135 K-5.0 Cl-103 HCO3-25 AnGap-12 [**2158-10-29**] 04:07AM BLOOD Glucose-96 UreaN-46* Creat-1.0 Na-142 K-4.3 Cl-114* HCO3-20* AnGap-12 [**2158-10-28**] 03:27AM BLOOD CK-MB-NotDone cTropnT-0.04* [**2158-10-28**] 10:52AM BLOOD CK-MB-37* MB Indx-12.7* cTropnT-0.38* [**2158-10-28**] 04:55PM BLOOD CK-MB-37* MB Indx-8.1* cTropnT-0.55* [**2158-10-29**] 04:07AM BLOOD CK-MB-34* MB Indx-3.9 cTropnT-0.49* CHEST (PORTABLE AP) [**2158-10-31**] 2:41 AM CHEST (PORTABLE AP) Reason: ? change [**Hospital 93**] MEDICAL CONDITION: [**Age over 90 **] year old woman with CAD now with UGIB and wheezing/SOB s/p blood products with slightly lessening O2 requirement REASON FOR THIS EXAMINATION: ? change AP CHEST, 3:07 A.M., [**10-31**]: HISTORY: Coronary artery disease, upper GI bleed, wheezing and shortness of breath after blood product administration. Coronary artery disease. IMPRESSION: AP chest compared to [**2157-1-12**] through [**2158-10-30**]. What looked more like mild pulmonary edema and small bilateral pleural effusions on [**10-28**] has improved in the left lung leaving areas of dense consolidation at the lung bases and more discrete mass-like lesions in the right upper lobe. Overall, the findings suggest widespread infection even infarction. Small bilateral pleural effusions remain. Heart size is normal. Thoracic aorta is generally large and tortuous. No pneumothorax. A severe thoracolumbar scoliosis is noted. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1887**] was paged to report these findings at the time of dictation. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**] Approved: TUE [**2158-10-31**] 2:42 PM Brief Hospital Course: # GIB - Suspect upper source given coffee ground emesis and melena. Now with dropping HCT and increased heart rate suggestive of hemodynamic instability. GI came to bedside and attempted EGD, however, patient desatted x 2 when they tried to pass the endoscope. Procedure was aborted and family meeting was held. Patient did not wish to be intubated for any reason, so the family decided not to intubate for an EGD and instead to manage her GI bleed in a non-invasive manner. A pantoprazole drip was begun and the patient received a total a 5 units of PRBCs. After transfusion, her HCT stabilized and she showed no further signs of bleeding/melena. Her pantoprazole was eventually changed to a PO formulation and she was advanced to purree diet with nectar thick liquids with no complications. # Myocardial ischemia - The patient presented with significant ST depressions in V2-V6 during her acute bleed which resolved after fluid and blood administration. Her cardiac enzymes did increase to a peak troponin of >0.5, likely demand ischemia. Cardiology felt she was not a candidate for anticoagulation in the setting of the acute bleed. She was tachycardic and hypertensive after blood administration which was initially controlled with an esmolol drip but was eventually transitioned to PO lopressor. # HTN - Transitioned to lopressor PO TID . . # Psych/depression- She was continued on her home seroquel, trazadone, and lexapro when she began taking POs. She was occasionally more delirious with some periods of mild aggitation for which she received Zydis 5mg. . # Hypothyroidism - Restarted on home dose of synthroid . # FEN - dysphagia purree with nectar thick liquids . #Dispo- In discussion with the patients family, a palliative care consult and the medical team, it was decided that there would be no further escalation in the care of Ms. [**Known lastname 63749**]. She would continue on her current PO meds, taking them as she could, as well as her current diet but that no further interventions including NG tubes, IV drugs, or other invasive procedures. She should not be hospitalized again. She will return home to [**Hospital3 537**] on essentially hospice. . # Communication - HCP is her daughter - [**Name (NI) **] [**Name (NI) **] cell - [**Telephone/Fax (1) 63750**], home - [**Telephone/Fax (1) 63751**] . # CODE- DNR/DNI Medications on Admission: Tylenol 1000 mg q8h standing Armour Thyroid 60 mg daily ASA 81 mg daily Calcium + Vitamin D [**Hospital1 **] Celebrex 100 mg daily Docusate 100 mg qod Enalapril 10 mg [**Hospital1 **] Fosamax 70 mg weekly HCTZ 12.5 mg daily Lexapro 15 mg daily Metoprolol 50 mg [**Hospital1 **] MVI Plavix 75 mg daily Seroquel 25 mg [**Hospital1 **] Trazodone 50 mg qhS Discharge Medications: 1. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical QID (4 times a day) as needed. Disp:*qs qs* Refills:*0* 2. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 3. Trazodone 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime). 4. Escitalopram 10 mg Tablet [**Hospital1 **]: 1.5 Tablets PO DAILY (Daily). 5. Thyroid 30 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: Three (3) Tablet PO Q 8H (Every 8 Hours). Disp:*4 Tablet(s)* Refills:*2* 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). Disp:*60 Tablet,Rapid Dissolve, DR(s)* Refills:*2* 8. Morphine Concentrate 20 mg/mL Solution [**Last Name (STitle) **]: 5-20 mg PO Q2H (every 2 hours) as needed for pain/discomfort. Disp:*qs mg* Refills:*0* 9. Olanzapine 5 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: 0.5 Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)). Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*2* 10. Olanzapine 5 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: 0.5 Tablet, Rapid Dissolve PO Q8 PRN (). Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*2* 11. Ativan 0.5 mg Tablet [**Last Name (STitle) **]: 0.5 mg please dispense solution PO three times a day as needed for pain, anxiety: please dispense liquid solution. Disp:*qs qs* Refills:*0* Discharge Disposition: Home With Service Facility: Hospice of the Good [**Doctor Last Name 9995**] Discharge Diagnosis: Primary diagnoses: GI bleed Myocardial infarction Discharge Condition: All vitals stable, comfortable Discharge Instructions: You were admitted with bleeding from your GI tract. During this event you also had evidence of myocardial ischemis (a "heart attack"). During your stay you were treated with medications to help stop the bleeding and given blood transfusions. After discussions with your family, the decision was made to transfer you home with comfort care. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2847**], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2159-1-8**] 10:00

[ "110.5", "041.86", "290.40", "244.9", "428.31", "428.0", "410.71", "403.90", "585.9", "578.9" ]

icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

10064, 10142

5821, 8167

270, 277

10237, 10270

3578, 4569

10658, 10812

2976, 3263

8570, 10041

4606, 4738

10163, 10215

8193, 8547

10294, 10635

3278, 3559

224, 232

4767, 5798

305, 1603

1625, 2639

2655, 2960

47,887

161,454

36546

Discharge summary

report

Admission Date: [**2143-9-30**] Discharge Date: [**2143-10-21**] Date of Birth: [**2074-11-4**] Sex: F Service: MEDICINE Allergies: Penicillins / Optiray 350 Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Left Heel Pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname **] is a 68yo F w/hx of DM type 2, diastolic HF, HTN, PVD, DVT [**9-1**] s/p IVC filter, hx of GI bleed who was admitted to the vascular surgery service [**2143-9-30**] for L heel pain X 3 and was found to have a L heel ulcer. Pt was found to have acute on chronic renal failure with creatinine 1.9 (baseline 1.3), anemia with HCT 24.9 and ?CHF on CXR. Medicine was consulted for assistance with medical management of comorbidities. At admission, the patient denied any chest pain, shortness of breath, abdominal pain, dysuria. She has chronic urinary incontinence. No new meds or recent changes. no nsaids, abx, hypotension, recent dye Past Medical History: PVD: s/p R fem-[**Doctor Last Name **] bypass (approx 10yrs ago), L aorto-iliac bypass (approx 8yrs ago), R common femoral endarterectomy ([**6-1**]) Obesity GI bleed (in [**7-/2143**] at [**Hospital6 **]) diastolic CHF HTN PVD Obstructive sleep apnea obesity renal artery stenosis s/p left renal stenting [**2-1**] history of UTI [**4-1**] treated levaquin history of left arm hematoma with left brachial pseudoaneurysm thrombin, left arm median nerve neuropathy coronary artery disease s/p MI12/08,s/p CABG"S x4 DM2 w neuropathy,insulin dependant Social History: Currently coming from rehab. Has family in the area whom she sees often but still is very depressed and just wantes to go home. Daughter is HCP, she lives in [**Name (NI) **] Former smoker with a 20+ pack/yr history. No alcohol use. Is a retired Social Worker Family History: Non-contributory. Physical Exam: At Admission VS: 96.9 BP 178/56 HR 70 RR18 98% RA Gen: Somnolent but arousable, alert and oriented X 3 HEENT: NCAT. Sclera anicteric. PERRL, EOMI. OP clear, no exudates or ulceration. Neck: Supple, JVP not appreciated due to neck size. CV: RRR, normal S1, S2. No m/r/g. Chest: Resp were unlabored, no accessory muscle use. Diffuse crackles throughout posterior left and right lung fields Abd: Obese, Soft, NTND. No HSM or tenderness. Ext: 2+ edema to thighs, legs wrapped in ACE bandages. Neuro: Alert and oriented x 3, 5/5 strength in upper and lower extremities bilaterally, CNs II-XII grossly intact At Transfer 1) 1 + Pitting edema B - LE 2) Bilateral dry gangrene of toes, R > L 3) Open ulcers on top of L toe and bottom of L heel Pertinent Results: STUDIES ECHO [**2143-10-2**] The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is mildly depressed (LVEF= 40-45 %) with hypokinesis of the septum, apex and basal inferior wall. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. RV with mild global free wall hypokinesis. 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. Mild to moderate ([**1-25**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [**2143-5-28**], the LVEF has decreased. CTA [**10-10**] 1. Patent right common iliac and external iliac artery stents with severe narrowing at the distal portion of the right external iliac artery stent. Stable severe narrowing of the right popliteal artery at the level of the knee with occlusion of the right anterior tibial artery. 2. Complete occlusion of the left iliac artery stent with patent aortofemoral bypass graft. Persistent complete occlusion of the left superficial femoral artery with patent profunda which reconstitutes at the popliteal. Complete occlusion of the left posterior tibial artery at the ankle, but there is reconstitution at the plantar arch. 3. Patent left renal artery stent. 4. Bilateral pleural effusions and septal thickening at the lung bases which may be related to CHF. Renal US [**10-7**] IMPRESSION: 1. No evidence of hydronephrosis. 2. Suboptimal study, as detailed, with reversal of diastolic flow noted in the interlobar arteries in the upper, mid, and lower poles of the left kidney. These findings can be seen in the setting of renal vein thrombosis. FOOT XR [**10-7**] There is significant diffuse osteoporosis, mostly affecting the right foot but also seen on the left. Within the limitations of this finding, no evidence of fracture is present. There is no evidence of cortical destruction to suggest osteomyelitis, but if clinically warranted further evaluation with MRI given its increased sensitivity compared to chest radiograph is recommended. CXR [**10-3**] There is interval placement of right-sided PICC whose tip is noted to be in the right atrium. The course of the line is unremarkable and there is no evidence of pneumothorax or other complications. The heart is large with a prominent left fat pad but no evidence of heart failure. The lung fields do not appear significantly changed from previous study. There is no pleural effusion. ADMISSION/TRANSFER LABS [**2143-9-30**] 08:45PM BLOOD WBC-6.1 RBC-2.78* Hgb-8.1* Hct-24.9* MCV-90 MCH-29.0 MCHC-32.4 RDW-14.6 Plt Ct-188 [**2143-9-30**] 08:45PM BLOOD PT-14.4* PTT-23.4 INR(PT)-1.2* [**2143-9-30**] 08:45PM BLOOD Glucose-206* UreaN-68* Creat-1.9* Na-138 K-4.5 Cl-100 HCO3-28 AnGap-15 [**2143-9-30**] 08:45PM BLOOD ALT-13 AST-11 CK(CPK)-78 AlkPhos-163* TotBili-0.2 [**2143-10-3**] 06:52AM BLOOD TSH-0.15* [**2143-10-3**] 06:52AM BLOOD T4-4.5* DISCHARGE/FOLLOW UP LABS [**2143-10-10**] 07:00AM BLOOD TSH-0.89 [**2143-10-10**] 07:00AM BLOOD Free T4-0.79* [**2143-10-11**] 06:07AM BLOOD Calcium-8.8 [**2143-10-10**] 07:00AM BLOOD Glucose-82 UreaN-32* Creat-1.5* Na-138 K-4.8 Cl-104 HCO3-26 AnGap-13 [**2143-10-11**] 06:07AM BLOOD Glucose-183* UreaN-31* Creat-1.5* Na-138 K-5.4* Cl-99 HCO3-27 AnGap-17 [**2143-10-6**] 04:46AM BLOOD PT-13.3 PTT-23.6 INR(PT)-1.1 [**2143-10-11**] 06:07AM BLOOD Plt Ct-264 [**2143-10-11**] 06:07AM BLOOD WBC-9.3 RBC-3.03* Hgb-8.8* Hct-27.4* MCV-91 MCH-29.0 MCHC-32.0 RDW-15.1 Plt Ct-264 [**2143-9-30**] 07:14PM URINE RBC-0 WBC->1000* Bacteri-MANY Yeast-NONE Epi-3 [**2143-10-2**] 01:45AM URINE RBC-0 WBC->1000* Bacteri-MOD Yeast-NONE Epi-0 [**2143-9-30**] 07:14PM URINE Blood-SM Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG [**2143-10-2**] 01:45AM URINE Blood-SM Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG [**2143-9-30**] 07:14PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.017 [**2143-10-2**] 01:45AM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.016 MICRO URINE CULTURE (Final [**2143-10-4**]): Culture workup discontinued. Further incubation showed contamination with mixed skin/genital flora. Clinical significance of isolate(s) uncertain. Interpret with caution. ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 16 I CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- 32 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 4 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: SUMMARY FROM PRE-MICU COURSE This is a 68 y.o. female with multiple medical problems including severe peripheral artery disease, coronary artery disease, diabetes, CKD, and chronic diastolic heart failure who presented to the vascular surgery service in early [**Month (only) **] with a painful, nonhealing left lower extremity ulcer. Plan had been to perform an angiogram but the patient was unable to tolerate so eventually underwent a CT angiogram that showed extensive vascular occlusion of the left lower extremity. The patient was transferred to medicine for management peri-scan. The procedure was complicated by some acute kidney injury on her CKD presumed due to contrast nephropathy. The patient was also diagnosed with a questionable pneumonia on [**2143-10-14**] and started on levofloxacin. MICU COURSE: On [**2143-10-17**] pt was found to acutely SOB with oxygen saturations in 70s after a witnessed aspiration of [**Location (un) 2452**] [**Last Name (un) 16320**]. Suctioning revealed [**Location (un) 2452**], thick, bloody secretions. When hypoxia failed to improve with increased oxygen provided by mask she was intubated by anesthesia and transferred to the MICU. Pt's antibiotics were broadened to vancomycin and meropenem to cover hospital acquired type bacteria including the ampicillin sensitive enterococcus that she grew from her urine earlier in admission. Pt's vent settings were able to be weaned over night and sedation weaned as well. Pt self-extubated the following morning and was found to be delerious and in pain. Pt's right foot was cold to the touch and vascular surgery was called who reported that the foot was ischemic and would need to be amputated. Pt was started on heparin and reintubated as for management and adequate pain control. Patient was unable to immediately go to surgery, and a plan to continue the heparin gtt and await demarcation of viability was agreed upon with the family. Over the next several days it became clear that the entire leg would need to be amputated. As patient has been hospitalized for most of the past year, there were continuing discussions with family about appropriate goals of care and it was ultimately felt that current care including amputation of right leg and many ongoing medical problems requiring invasive interventions would not be consistent with the patient's wishes. Pt was terminally extubated on [**2143-10-22**] and quickly passed away from hypoxic respiratory failure with cardiac arrest. Medications on Admission: Tegretol/Carbamezapine 100mg TID Ativan 1mg PO qHS Nitrostat 0.4mg SL PRN NPH 28 units QAM, 20 units qPHM Novolog SS Ultram 50mg PO q4H PRN Colace 100mg PO BID Miralax 17gm qday Torsemide 60mg PO qday Simvastatin 40mg PO qday Renagel 800mg TID w/meals Iron 325mg PO qday Sertraline 75mg PO BID Neurontin 600mg PO BID, 300 qHS Metoprolol 75mg PO BID Prilosec 40mg PO qday Zofran ODT PRN Discharge Medications: Patient Expired. Discharge Disposition: Expired Discharge Diagnosis: Patient Expired Discharge Condition: Patient Expired Discharge Instructions: Patient Expired Followup Instructions: Patient Expired [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "440.24", "486", "357.2", "707.03", "440.1", "707.15", "584.9", "507.0", "428.0", "041.4", "518.81", "V45.81", "250.62", "707.22", "428.42", "599.0", "V58.67", "414.8", "276.7", "278.00", "403.90", "733.00", "V12.51", "707.14", "327.23", "585.3" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

11098, 11107

8130, 10620

309, 315

11166, 11183

2667, 8107

11247, 11401

1874, 1893

11057, 11075

11128, 11145

10646, 11034

11207, 11224

1908, 2648

255, 271

343, 1005

1027, 1579

1595, 1858

14,738

106,243

18390

Discharge summary

report

Admission Date: [**2195-12-18**] Discharge Date: [**2195-12-23**] Date of Birth: [**2135-12-21**] Sex: M Service: UROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name8 (NamePattern2) 19908**] Chief Complaint: bladder cancer Major Surgical or Invasive Procedure: cystectomy with ileal conduit History of Present Illness: 59yM s/p radical cystectomy, ileal conduit IVF: 5.0L EBL:800cc PMH: CAD s/p MI x 3, CABG, CHF with EF 40%, DM diet, HTN, lipid Meds: ASA 81, Atenolol 12.5, Cristor 20, Lopid 600 [**Hospital1 **]; NKDA; +TOB Plan: MSO4 PCA; if UOP good later can give Toradol EKG, Lop 5q4 IS NPO/NGT/Pepcid; KUB for stents D5LR at 150; lytes RISS SCH3 Ancef/Flagyl x48hrs R IJ, L art line, NGT, stoma with labelled stents, JP PT consult Brief Hospital Course: Patient was admitted to the Urology service after undergoing radical cystectomy and ileal conduct. No concerning intraoperative events occurred; please see dictated operative note for details. Patient received perioperative antibiotic prophylaxis and deep vein thrombosis prophylaxis with subcutaneous heparin. With the passage of flatus, patient's diet was advanced. The patient was ambulating and pain was controlled on oral medications by this time. The ostomy nurse saw the patient for ostomy teaching. At the time of discharge the wound was healing well with no evidence of erythema, swelling, or purulent drainage. The ostomy was perfused and patent. Patient is scheduled to follow up in one weeks time with in clinic for wound check. Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 2. 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* 3. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Location (un) 932**] Area VNA Discharge Diagnosis: bladder cancer Discharge Condition: stable Discharge Instructions: -Please resume all home meds -Do not drive while taking oxycodone. Please take Tylenol in addition to oxycodone, and transition to Tylenol as pain improves. -You may shower, but do not immerse incision, no tub baths/swimming. -Small white steri-strips bandages will fall off in [**6-17**] days, you may remove at that time if irritating. -Call if incision becomes markedly more red, swollen, or begins to drain purulent fluid, or for fever more than 101.5. -Please refer to visiting nurses (VNA) for management of the ileal conduct. Followup Instructions: 1-2 weeks Completed by:[**2195-12-23**]

[ "305.1", "414.00", "V45.81", "188.8", "250.00" ]

icd9cm

[ [ [] ] ]

[ "38.93", "57.71", "56.51", "40.3" ]

icd9pcs

[ [ [] ] ]

1931, 1994

850, 1594

343, 375

2053, 2062

2649, 2691

1617, 1908

2015, 2032

2086, 2626

289, 305

403, 827

20,000

136,817

3900

Discharge summary

report

Admission Date: [**2192-2-1**] Discharge Date: [**2192-2-6**] Date of Birth: [**2136-2-3**] Sex: M Service: Cardiac Surgery HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 55-year-old male who presents with atypical chest pain for several weeks. Has a history of known carotid disease, left 80-90%, right 70-80%, and he is scheduled for a left CEA on [**2192-2-1**], and has been undergoing a preoperative evaluation. PAST MEDICAL HISTORY: 1. Peripheral vascular disease. 2. Bilateral carotid disease. 3. Hypertension. 4. Hyperlipidemia. 5. Left renal artery stenosis. PREOPERATIVE MEDICATIONS: 1. Norvasc 10 mg q day. 2. Lipitor 10 mg q day. 3. Folate 1 mg q day. 4. Toprol 25 mg q day. ALLERGIES: Mussels and shellfish. SOCIAL HISTORY: Positive smoker x40 years. PHYSICAL EXAMINATION: At the time of admission, vital signs are a heart rate 65 sinus rhythm, 130/67 blood pressure, respiratory rate 16, and 97% on room air sat. Alert and oriented times three. Extraocular movements are intact. Neck is supple. Lungs are clear to auscultation. Cardiovascular: Regular, rate, and rhythm, distant heart sounds. Abdomen positive bowel sounds, tender in the left upper quadrant. Extremities: No edema noted. LABORATORIES: On [**1-20**], BUN is 18, creatinine 1.0, white blood cells 8.0, hematocrit 41, platelets 244. PT 12.0, PTT 27.4, INR of 1.0. Urinalysis is negative. Total cholesterol 239, LDL 157, HDL 67, TGL 107. Homocysteine level 19.3. Vitamin B12 level 328. LFTs within normal limits. Enzymes were cycled and were flat. Troponin-I less than 0.3 and CPKs were 61. ELECTROCARDIOGRAM: Showed ectopic atrial rhythm in the 70s. On [**1-26**], an echocardiogram was done showed an ejection fraction of 44%, normal perfusion, and mild cavity enlargement. No anginal or ischemic electrocardiogram changes noted. On [**2-1**] cardiac catheterization was done: Left ventricular ejection fraction of 60%, and mitral regurgitation noted, LMCA 90% ostial to the left anterior descending artery, the left anterior descending artery mid vessel is 60% tubular, left circumflex 40-50% proximal, right coronary artery small vessel tortuous irregularities, 70% proximal disease. An AIBP was placed in the catheterization laboratory secondary to uncontrolled pain in order to assist the balloon pump insertion, a stent was placed in the right iliac artery. The patient was placed on Heparin and transferred to the CCU pain free. Cardiac Surgery was consulted. HOSPITAL COURSE: On [**2-1**], the patient was taken emergently to the operating room, where he had left CEA and a CABG x3, LIMA to the LAD, SVG to the distal RCA, SVG to the OM. IBP was discontinued in the operating room. No intraoperative complications. See the operative note for complete details. The patient was transferred to the Intensive Care Unit. Anesthesia was reversed and the patient was successfully weaned from the ventilator early on postoperative day #1. He remained in the Intensive Care Unit due to slow weaning from vasopressor, eventually discontinued on postoperative day #3. Chest tubes were also discontinued on postoperative day #3, and patient was transferred to the floor for continued cardiac rehabilitation and recovery. He received 1 unit of packed red blood cells on the floor for a low hematocrit. Physical Therapy was consulted, and assisted patient with rehabilitation and determined to be stable. Mr. [**Known lastname **] continues to do well, ambulating independently, tolerating po, full strength in all extremities. Neurologically intact and hematocrit stable. PHYSICAL EXAM AT TIME OF DISCHARGE: Alert and oriented times three. Pupils are equal, round, and reactive to light. Follows commands. Neck is supple. No bleeding, oozing noted at the incision site at the left neck. Lungs are decreased bilateral bases, but otherwise clear to auscultation. Cardiovascular: Regular, rate, and rhythm, S1, S2, no murmurs, rubs, or gallops. Abdomen is soft, nontender, and nondistended, and positive bowel sounds, [**1-1**] pulses bilateral radial and femorals, and +[**12-1**] dorsalis pedis and PT. Sternal incision is clean, dry, and intact. No drainage noted. The patient has full strength bilaterally. LABORATORIES AT TIME OF DISCHARGE: White count of 6.7, hematocrit 27.7, platelets 140. BUN 11, creatinine 0.9, calcium 7.5, phosphorus was 1.8. DISCHARGE MEDICATIONS: 1. Lasix 20 mg q day. 2. Potassium chloride 20 mEq q day. 3. Metoprolol 12.5 mg po bid. 4. Ranitidine 150 mg po bid. 5. Enteric coated aspirin 325 mg q day. 6. Plavix 75 mg q day. 7. Ibuprofen 400 mg q6 prn. 8. Percocet 1-2 tablets po q4-6 prn. 9. Tylenol 650 mg q4 prn. DISPOSITION: The patient is stable and discharged to home. FOLLOW-UP INSTRUCTIONS: Follow up with Dr. [**Last Name (STitle) 70**] in six weeks with a primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17399**] in [**12-1**] weeks and Vascular surgeon, Dr. [**Last Name (STitle) 1391**] in two weeks. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Last Name (NamePattern1) 17400**] MEDQUIST36 D: [**2192-2-6**] 10:18 T: [**2192-2-6**] 10:18 JOB#: [**Job Number 17401**]

[ "401.9", "411.1", "433.10", "414.01", "440.1", "443.9" ]

icd9cm

[ [ [] ] ]

[ "36.12", "39.90", "37.22", "36.15", "39.61", "38.12", "88.42", "88.55", "39.50", "88.53", "37.61" ]

icd9pcs

[ [ [] ] ]

4441, 4774

2531, 4418

631, 761

829, 2513

174, 453

4799, 5348

475, 605

778, 806

46,466

185,055

35909

Discharge summary

report

Admission Date: [**2125-4-6**] Discharge Date: [**2125-4-18**] Date of Birth: [**2046-5-25**] Sex: F Service: CARDIOTHORACIC Allergies: Atenolol / Penicillins / Ampicillin / Bactrim / Ibuprofen / Aspirin / Niaspan Attending:[**First Name3 (LF) 922**] Chief Complaint: DOE/angina/fatigue Major Surgical or Invasive Procedure: [**2125-4-6**] Bentall procedure ( 23 mm Medtornic Freestyle porcine aortic root/valve)/ Repl. hemiarch aorta ( 26 mm Gelweave sidearm graft) / CABG x2 (LIMA to LAD, SVG to RCA) History of Present Illness: 78 yo female with known dilated asc. aorta. Recent cath and echo revealed 2 vessel CAD and mild-moderate AI .Referred for surgical eval. Past Medical History: asc. aortic aneurysm aortic insufficiency coronary artery disease hypertension hypercholesterolemia CVA/TIA [**2090**] non-insulin dependent DM hypothyroidism hx of falls arthritis hiatal hernia gastroesophageal reflux basal cell CA Lyme dz. hepatic hemangioma rosacea UTI bilat. varicosities obesity PSH: right breast abscess skin CA rem. LLE and face bil. cataracts [**Doctor First Name **]. D&C's Social History: retired lives with husband never used tobacco rare ETOH Family History: sister died of aortic rupture Physical Exam: HR 52 148/74 right 4'[**26**]" 150# NAD obese skin unremarkable PERRLA,EOMI,anicteric sclera;OP unremarkable neck suppple with full ROM, no JVD CTA on R; basilar rales on L RRR with 4/6 SEM, faint diastolic murmur at LUSB soft,NT,ND, + BS; point tenderness LUQ; obese abd;no HSM/CVA tenderness warm,well-perfused, no edema, left greater than right varicosities MAE [**3-27**] strengths ; nonfocal neuro exam, grossly intact fem 2+ bil. DP Non palp. bil. PT 1+ bil. radials 2+ bil. murmur transmits to both carotids Pertinent Results: [**2125-4-17**] 02:26AM BLOOD WBC-14.2* RBC-2.83* Hgb-8.6* Hct-26.0* MCV-92 MCH-30.4 MCHC-33.2 RDW-15.6* Plt Ct-602* [**2125-4-17**] 02:26AM BLOOD Plt Ct-602* [**2125-4-17**] 02:26AM BLOOD Glucose-83 UreaN-17 Creat-0.7 Na-140 K-3.7 Cl-107 HCO3-24 AnGap-13 [**2125-4-15**] 03:07AM BLOOD ALT-78* AST-37 LD(LDH)-381* AlkPhos-105 Amylase-144* TotBili-1.7* [**2125-4-17**] 02:26AM BLOOD Albumin-2.4* Mg-2.3 [**2125-4-15**] 03:07AM BLOOD Lipase-207* [**2125-4-16**] 09:18AM BLOOD Type-ART Rates-/30 FiO2-50 pO2-60* pCO2-34* pH-7.50* calTCO2-27 Base XS-3 Intubat-INTUBATED Vent-SPONTANEOU IMPRESSION: 1. Extensive bilateral infarcts, involving cerebellum, occipitotemporal lobes, mid brain, corpus callosum, basal ganglia, cerebral peduncle, and centrum semiovale bilaterally, consistent with combination of embolic and watershed etiology of infarct. No evidence of hemorrhagic conversion. 2. Absent flow in the mid-distal left PCA which may be related to technique. Recommend evaluation with CTA in future. Anterior and middle cerebral arteries remain normal bilaterally. 3. Paranasal sinus disease as described above. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) **] [**Name (STitle) **] DR. [**First Name (STitle) **] [**Name (STitle) 12563**] Approved: SAT [**2125-4-14**] 10:51 AM PREBYPASS 1. No atrial septal defect or PFO is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses and cavity size are normal. 3. Overall left ventricular systolic function is normal (LVEF>55%). 4. Right ventricular chamber size and free wall motion are normal. 5. The ascending aorta is moderately dilated. There are simple atheroma in the aortic arch and descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Moderate to severe (3+) aortic regurgitation is seen. 6. There is moderate thickening of the mitral valve chordae. Trivial mitral regurgitation is seen. 7. There is a trivial/physiologic pericardial effusion. 8. Dr. [**Last Name (STitle) 914**] was notified in person of the results during the procedure on [**2125-4-6**] at 850. POSTBYPASS 1. A well seated well functioning tissue valve is seen in the aortic position. A mass or tissue is seen at the right and noncoronary cusp junction. There was no aortic regurgitation but this not a normal finding of a tissue valve. We returned to cardiopulmonary bypass and this was found to be a thrombosis. 2. Patient is on phenylephrine for 2nd attempt off bypass 3. A well seated, well functioning tissue valve is seen in the aortic position. The mass/tissue that was seen previously is now gone and all three aortic cusps are well visualized. No perivalvular leaks are noted. 4. Left ventricular function remains similar at 65% 5. The mitral regurgitation is somewhat worse at +1 6. Dr. [**Last Name (STitle) 914**] notified of findings I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2125-4-17**] 09:56 ?????? [**2118**] CareGroup IS. All rights reserved. Brief Hospital Course: Admitted [**2125-4-6**] and underwent surgery with Dr. [**Last Name (STitle) 914**]. Transferred to the CVICU in stable condition on titrated phenylephrine and propofol drips. She was noted to have focal motor seizures on POD #1 and neuro was consulted for eval. CT head showed bil. CVAs in the PCA territory, left greater than right, and likely embolic. All sedation turned off to allow for pt to attempt to wake and wean from vent.Dilantin given for seizure control.She was gently diuresed and EEGs were performed with diffuse slowing. Neurology advised the family on POD #6 that there was very little chance of meaningful recovery given the large areas of brain infarction. This was also confirmed by MRI of brain on [**4-13**]. Family mtg held and they also met with social worker.Made DNR on [**4-13**].Started on clindamycin for sinusitis by scan and was also treated for rapid A Fib. The pt did not make any significant neurologic recovery and was made CMO by family on the evening of [**4-17**]. She was started on a morphine infusion and extubated per their wishes. She expired a few hours later and was pronounced by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17470**] at 1:27 AM on [**4-18**]. Medications on Admission: celexa 20 mg daily flaxseed oil daily fenofibrate 200 mg daily lasix 20 mg daily levothyroxine 25 mcg daily cozaar 75 mg daily Vit.D 400 mg [**Hospital1 **] protonix 40 mg daily simvastatin 80 mg daily januvia 50 mg daily calcium 1200 mg daily fish oil 1200 mg daily Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: asc. aortic aneurysm s/p Bentall/hemiarch repl/CABG x2 postop CVA aortic insufficiency coronary artery disease hypertension hypercholesterolemia prior CVA/TIA [**2090**] non-insulin dependent DM hypothyroidism hx of falls arthritis hiatal hernia gastroesophageal reflux basal cell CA Lyme dz. hepatic hemangioma rosacea UTI bilat. varicosities obesity Discharge Condition: expired Discharge Instructions: none Followup Instructions: none Completed by:[**2126-6-13**]

[ "780.62", "401.9", "V12.54", "441.2", "434.91", "V10.83", "244.9", "V66.7", "780.39", "716.90", "530.81", "424.1", "997.02", "440.20", "414.01", "250.00", "272.4", "E878.2" ]

icd9cm

[ [ [] ] ]

[ "96.72", "39.61", "38.93", "34.91", "36.11", "36.15", "38.45", "35.21" ]

icd9pcs

[ [ [] ] ]

6648, 6657

5070, 6301

361, 541

7053, 7062

1805, 5047

7115, 7150

1221, 1252

6619, 6625

6678, 7032

6327, 6596

7086, 7092

1267, 1786

303, 323

569, 707

729, 1132

1148, 1205

81,309

199,051

40768

Discharge summary

report

Admission Date: [**2125-3-27**] Discharge Date: [**2125-4-3**] Date of Birth: [**2069-6-28**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5810**] Chief Complaint: Worsening liver failure Major Surgical or Invasive Procedure: None. History of Present Illness: 55 year old woman with a history of HTN, depression, polysubstance abuse presented was transferred from [**Hospital1 **] for worsening liver and renal failure. She was in her usual state of health up until [**2125-3-25**] when she noticed worsening headache when she took 7 percocet or vicodine. She also has been drinking alcohol. She cannot say what any other associated symptoms were going on but she noted vomitting and a curious rash on her face, legs, and arms. She did note she was recently treated for Zoster a few weeks ago with Valtrex. When she noted worsening vomitting she decided to come to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. . At the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] she was afebrile and hemodynamically stable. Her exam revealed multiple bullous erythematous lesions and facial swelling conerning for a fall. Her labs revealed AST/ALT in the 6-7,000s, CK 17,000, WBC 28, creatinine of 2.6. CT head, neck, face, CXR, renal U/S, was negative. She was afebrile throughout her hospital stay. Her urine output was minimal. Her creatinine rose to 4.0 within 24 hours despite IVF. She was given levoquin and cefazolin for this rash. She was transferred to [**Hospital1 18**] MICU for further management. . Past Medical History: 1) GERD 2) Right knee surgery 3) Depression 4) Hypertension 5) Polysubstance abuse including alcohol, cocaine, methadone, vicodin but no IVDU. Social History: Works as a bartender at a country club. Smokes [**1-4**] cig/day. Drinks occasionally, but adamantly denies heavy drinking. Admits to smoking crack, taking methadone illegally. Denies IVDU, denies history of STIs. Has been in monagamous relationship with a man. Family History: Sister with psoriasis, ?Lupus. No other autoimmune hx. Physical Exam: On admission GEN: Subtley altered, middle aged woman tan complexion (says she goes to tanning salon), somnolent but AO3, in NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, mild RUQ ttp, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: no jaundice/no splinters, bullous erythematous eruptions on left hand, right lateral thigh, right cheek (erupted) and erythematous warm rash patch over R knee and L elbow. NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. No pass-pointing on finger to nose. 2+DTR's-patellar and biceps. No pronator drift, no asterixis, no nuchal rigidity, negative Kernig and Bruzinski exam. Pertinent Results: On Admission [**2125-3-28**] 01:04AM BLOOD WBC-9.9 RBC-3.52* Hgb-11.7* Hct-33.6* MCV-95 MCH-33.4* MCHC-35.0 RDW-13.8 Plt Ct-197 [**2125-3-28**] 01:04AM BLOOD PT-14.0* PTT-23.7 INR(PT)-1.2* [**2125-3-28**] 01:04AM BLOOD Glucose-97 UreaN-59* Creat-5.1* Na-132* K-7.4* Cl-98 HCO3-22 AnGap-19 [**2125-3-28**] 03:41AM BLOOD Na-141 K-2.9* Cl-119* [**2125-3-28**] 01:04AM BLOOD ALT-4151* AST-3241* LD(LDH)-1879* CK(CPK)-[**Numeric Identifier 89112**]* AlkPhos-66 TotBili-0.4 [**2125-3-28**] 02:26AM BLOOD Lactate-1.4 [**3-28**] CXR: FINDINGS: No previous images. The heart is normal in size and the lungs are clear without vascular congestion or pleural effusion. Elevation of the right hemidiaphragmatic contour is seen and there is evidence of a prior cervical fusion device. IMPRESSION: No evidence of acute focal pneumonia. [**3-28**] Abdominal U/S with Doppler: Normal abdominal ultrasound. Specifically, the portal vein is patent. MICRO: [**3-28**] Blood cultures x2- pending [**3-28**] Urine culture- negative [**3-28**] HIV VL- Not detected; HIV Ab negative [**3-28**] HCV VL- Not detected; HCV Ab negative [**3-28**] HBV VL- Not detected; HBC Ab negative [**3-28**] EBV serologies- pending [**3-28**] CMV serologies- negative DISCHARGE LABS: [**2125-4-3**] 07:10AM BLOOD WBC-7.2 RBC-3.10* Hgb-10.4* Hct-29.5* MCV-95 MCH-33.6* MCHC-35.3* RDW-14.9 Plt Ct-198 [**2125-4-3**] 07:10AM BLOOD Plt Ct-198 [**2125-4-3**] 07:10AM BLOOD Glucose-102* UreaN-52* Creat-4.8* Na-141 K-3.5 Cl-106 HCO3-25 AnGap-14 [**2125-4-2**] 06:55AM BLOOD ALT-273* AST-73* AlkPhos-62 TotBili-0.5 [**2125-4-3**] 07:10AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.1 Brief Hospital Course: #. Acute Hepatitis: Patient with ALT/AST in 6000s on admission and no underlying liver disease. Her liver synthetic function was intact and although initially seemed to be mildly confused on arrival had no asterixis, no waxing and [**Doctor Last Name 688**] mental status and was not felt to be encephalopathic. A work up for viral hepatitis (Hep A, B, C, EBV, CMV, HIV), and ischemic hepatitis (Budd Chiari) was negative. Shock liver was felt to be likely given the rapid improvement in LFTs though no hypotension was noted while in the ICU. Tylenol level was low on arrival but NAC was given empirically as it was felt to cause little possible harm. Toxin mediated (either one of the medications she ingested or something mixed in with the cocaine) was also felt to be likely contributing given her concominant ATN and skin findings. She was managed supportively and her LFTs trended down but not to normalization prior to discharge. Her statin was held at discharge, with plan for PCP follow up to help check LFTs to decide when this should be restarted. . #. ATN: Creatinine rose from 4 to 5.1 on the day of admission. Urine lytes suggested a prerenal etiology and patient was treated with IVF. Renal was consulted and spun his urine which revealed muddy brown casts suggestive of ATN. Paient was aggressively hydrated with bolus fluids until her urine output was >30cc/hr. Her creatinine continued to rise to 7.7, but urine output improved tremendously without further boluses being required. Cr trended down to 4.8 prior to discharge. . #. Bullous erythematous lesions: Patient presented with several patches of well demarcated bullous lesions on an erythematous base (on her elbow, her hip, her knee and her right cheek). Patient had no lesions on her mucous membranes. DDX considered included cocaine-related lesion versus trauma. Patient was given one dose of Vancomycin and Keflex on arrival but this was discontinued as it was felt unlikely to be infectious. Dermatology was consulted and felt her lesions were most consistent with trauma. A skin biopsy from one of her fingers was done and was still pending prior to discharge. She has dermatology followup for these results early next week. . #. Depression: Patient with a history of depression and a toxic ingestion which was concerning for suicidal ideation. However the patient denied any SI on multiple occasions. She was continued on her home sertraline. . #. HTN: Patient low/normotensive on arrival and her antihypertensives were held. They were restarted and she was discharged on metoprolol 50 mg [**Hospital1 **]. She has PCP followup the day after discharge so that beta blocker can be adjusted as necessary. . #. GERD: She was continued on PPI. . # UTI: Patient had positive UA on [**3-28**], and was empirically started on Cipro. Urine culture was negative, but patient was discharged on Cipro to complete a 7 day course. Medications on Admission: 1) Vicodin as needed 2) Zoloft 50 mg daily 3) Valtrex a few weeks ago 4) Metoprolol 75mg PO BID 5) Diltiazem 120mg PO Daily 6) Pantoprazole 40mg PO Daily 7) Pravastatin 20mg PO Daily 8) Isosorbide Mononitrate 60mg PO Daily 9) Alprazolam 0.25mg PO HS 10)?Tylenol with codeine 11)?Toprol XL 50 daily Discharge Medications: 1. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. Disp:*2 Tablet(s)* Refills:*0* 7. mupirocin calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*1 bottle* Refills:*0* 8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Acute hepatits Acute tubular necrosis . Secondary: Polysubstance abuse Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [**Known lastname 8360**]: . You were transferred to the [**Hospital1 18**] from [**Hospital3 4107**] with liver and kidney failure. You were monitored and treated in the intensive care unit and seen by the team of kidney doctors. Your condition improved and you were transferred to the general medical wards. You were also treated for a urinary tract infection. You were also seen by dermatologists for the blisters on your skin- they felt these lesions were likely related to trauma when you passed out. . We recommend that you stop using cocaine, alcohol, opioids and other drugs to avoid risking your life and causing further damage to your liver and kidneys. It is eseential that you not use any of these substances. . We have made the following changes to your medications: - START taking ciprofloxacin for your urinary tract infection - START taking metoprolol for your blood pressure - START taking multivitamins, folate and thiamine - STOP taking cholesterol medicine pravastatin while your liver recovers Followup Instructions: Please keep all follow-up appointments: . PRIMARY CARE: Wednesday, [**4-4**] at 1:30 PM [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 18359**], MD [**Location (un) 89113**], [**Apartment Address(1) **] [**Location (un) 5110**], [**Numeric Identifier 89114**] Phone: ([**Telephone/Fax (1) 89115**] . KIDNEY DOCTOR: Department: WEST [**Hospital 2002**] CLINIC When: WEDNESDAY [**2125-4-18**] 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 SKIN DOCTOR: Department: DERMATOLOGY When: TUESDAY [**2125-4-10**] at 2:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8157**], M.D. [**Telephone/Fax (1) 1971**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2125-4-3**]

[ "304.00", "401.9", "910.2", "599.0", "305.60", "913.2", "570", "285.9", "914.2", "578.0", "518.0", "286.7", "276.2", "311", "276.7", "916.2", "728.88", "530.81", "584.5" ]

icd9cm

[ [ [] ] ]

[ "86.11" ]

icd9pcs

[ [ [] ] ]

8899, 8905

4744, 7649

327, 335

9029, 9029

3093, 4323

10224, 10240

2110, 2166

7997, 8876

8926, 9008

7675, 7974

9180, 9935

4339, 4721

2181, 3074

10264, 11295

9964, 10201

264, 289

363, 1649

9044, 9156

1671, 1815

1831, 2094

26,696

134,855

29834

Discharge summary

report

Admission Date: [**2108-1-16**] Discharge Date: [**2108-1-24**] Date of Birth: [**2037-9-13**] Sex: M Service: CARDIOTHORACIC Allergies: Antihistamines Attending:[**First Name3 (LF) 922**] Chief Complaint: angina with back pressure Major Surgical or Invasive Procedure: cardiac catheterization [**2108-1-17**] cabg x3 [**2108-1-19**] History of Present Illness: Pt is 70 yo m with h/o heavy EtOH abuse, anxiety, tobacco use, hypercholesterolemia, who awoke on [**1-13**] with 8/10 L sided chest pain and L mid scapular pain. He took Maalox, but the pain continued and was described as a dull ache. + diaphoresis, but no SOB. Had similar pain the past two night prior to admission to OSH. Pt was admitted to [**Hospital3 1280**], and had EKG which showed inferolateral STD. Pain improved with nitro. CK was normal, trop indeterminate. He was given ASA, lovenox, integrilin gtt, and nitro paste. Pt reportedly wanted to leave the hospital, and was then placed on CIWA scale. Echo at OSH showed EF 15% w/ inf akinesis, distal apex and distal anterior wall motion abnormalities. . Pt was then transferred to [**Hospital1 18**] for consideration of cardiac cath. . Pt currently has no complaints. He denies CP, back pain, SOB, N/V, F/C. Past Medical History: - hypercholesterolemia - EtOH abuse: sober for 17 yrs, restarted drinking [**2-25**] wks ago (but not heavily, 1-2 drinks every few days). - anxiety/depression Social History: Lives with wife and son. Smokes [**2-25**] cigs/day since age 17. H/o heavy ETOH abuse (has been to detox programs in past), now reports 1-2 drinks/day several days per week, sober for 17 years but restarted drinking [**2-25**] wks ago. Stopped working as delivery person 3 months ago. Family History: Father died at age 57 of heart disease. Physical Exam: Vitals: T 97.9 BP 90/57 HR 68 RR 18 O2sat 96% RA Wt 156lbs Gen: NAD, comfortable HEENT: PERRL. OP clear. Neck: Supple. JVD@5cm Cardio: RRR, nl S1S2, [**2-28**] sys murmur @ LLSB Resp: decreased air movement at bases BL, but otherwise CTAB Abd: soft, nt, nd, +BS. No rebound/guarding. Ext: no c/c/e. 2+ DP/PT pulses BL. Neuro: A&Ox3 Discharge Vitals 98.2, SR 80, 158.58, 18 RA sat 92% wt 73.5kg Neuro Alert and oriented x3, non focal Pulm: CTA Cardiac RRR no murmur/rub/gallop Sternal inc healing, midline, sternum stable no erythema/drainage L Leg EVH CDI with steris Ext warm palpable pulses trace edema Pertinent Results: [**2108-1-24**] 06:45AM BLOOD WBC-9.0 RBC-3.50* Hgb-10.5* Hct-31.9* MCV-91 MCH-30.1 MCHC-33.0 RDW-13.9 Plt Ct-300 [**2108-1-16**] 07:30PM BLOOD WBC-7.8 RBC-4.04* Hgb-12.7* Hct-36.2* MCV-90 MCH-31.4 MCHC-35.0 RDW-14.2 Plt Ct-239 [**2108-1-16**] 07:30PM BLOOD Neuts-71.6* Lymphs-20.8 Monos-4.4 Eos-2.7 Baso-0.5 [**2108-1-24**] 06:45AM BLOOD Plt Ct-300 [**2108-1-24**] 06:45AM BLOOD PT-13.3* PTT-27.0 INR(PT)-1.2* [**2108-1-16**] 07:30PM BLOOD PT-12.5 PTT-27.6 INR(PT)-1.1 [**2108-1-19**] 11:27AM BLOOD Fibrino-276 [**2108-1-24**] 06:45AM BLOOD Glucose-79 UreaN-13 Creat-0.9 Na-137 K-4.3 Cl-101 HCO3-24 AnGap-16 [**2108-1-16**] 07:30PM BLOOD Glucose-98 UreaN-23* Creat-1.0 Na-139 K-4.3 Cl-106 HCO3-25 AnGap-12 [**2108-1-17**] 08:55AM BLOOD ALT-28 AST-18 AlkPhos-60 TotBili-0.4 [**2108-1-22**] 03:27PM BLOOD Calcium-8.6 Phos-3.2 Mg-2.1 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 71335**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 71336**] (Complete) Done [**2108-1-19**] at 9:33:23 AM PRELIMINARY Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 177**] [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2037-9-13**] Age (years): 70 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Dilated cardiomyopathy. Left ventricular function. Myocardial infarction. Evaluate aortic atherosclerosis ICD-9 Codes: 402.90, 440.0 Test Information Date/Time: [**2108-1-19**] at 09:33 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2006AW4-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *4.4 cm <= 4.0 cm Right Atrium - Four Chamber Length: 4.4 cm <= 5.0 cm Left Ventricle - Diastolic Dimension: *6.6 cm <= 5.6 cm Left Ventricle - Peak Resting LVOT gradient: 10 mm Hg <= 10 mm Hg Aorta - Sinus Level: 3.3 cm <= 3.6 cm Aorta - Ascending: 2.7 cm <= 3.4 cm Aorta - Arch: 2.6 cm <= 3.0 cm Aortic Valve - Peak Gradient: 3 mm Hg < 20 mm Hg Aortic Valve - Valve Area: *2.0 cm2 >= 3.0 cm2 Mitral Valve - Peak Velocity: 0.7 m/sec Mitral Valve - Mean Gradient: 1 mm Hg Mitral Valve - E Wave: 0.7 m/sec Mitral Valve - A Wave: 0.5 m/sec Mitral Valve - E/A ratio: 1.40 Findings LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast is seen in the LAA. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. Prominent Eustachian valve (normal variant). LEFT VENTRICLE: Moderate symmetric LVH. Inferobasal LV aneurysm. Moderate global LV hypokinesis. Moderately depressed LVEF. RIGHT VENTRICLE: Borderline normal RV systolic function. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Simple atheroma in ascending aorta. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. There are complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. Conclusions PRE BYPASS: 1. The left atrium is mildly dilated. No spontaneous echo contrast is seen in the left atrial appendage. 2. No atrial septal defect is seen by 2D or color Doppler. 3. There is moderate symmetric left ventricular hypertrophy. There is an inferobasal left ventricular aneurysm. There is severe global left ventricular hypokinesis with minor regional variation (akinetic anterolateral and anterior walls, dyskinetic inferior base) . Overall left ventricular systolic function is severly depressed. (LVEF >20%) 4.Right ventricular systolic function is borderline normal. 5.There are simple atheroma in the ascending aorta. Epiaortic scan revealed no appreciable lesions at the point of crossclamp or aortic cannulation. There is simple atheroma in the aortic arch and complex (>4mm) atheroma in the descending thoracic aorta. 6. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. 7. The mitral valve leaflets are mildly thickened. The posterior leaflet is restricted in motion. Trivial regurgitation of mitral valve. There is a trivial/physiologic pericardial effusion. POST BYPASS (The patient is receiving epinephrine infusion at 0.02 ucg/kg/min) 1.LV systolic function is marginally improved (but still severly impaired) in the setting of low dose inotropes. 2.RV systolic function remains unchanged 3. Trace MR remains 4. Study otherwise unchanged from prebypass I certify that I was present for this procedure in compliance with HCFA regulations. Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting physician ?????? [**2104**] CareGroup IS. All rights reserved. Brief Hospital Course: 70 yo m with h/o EtOH abuse, who presented to OSH with CP and EKG changes. Cath shows 3VD with LM involvement. Referred to Dr. [**Last Name (STitle) 914**] for evaluation and underwent cabg x3 on [**1-18**]. Transferred to the CSRU in stable condition on epinephrine and propofol drips.Extubated later that afternoon and weaned off epinephrine the following morning. Transferred to the floor on POD #1 to begin increasing his activity level.ACE inhibitor titrated along with beta blockade and gentle diuresis.Chest tubes removed on POD #3. He had some rapid Afib overnight which converted to SR with IV lopressor. He continued to make good progress and was cleared for discharge to home with services on postoperative day 5 with VNA services. Patient is to make all follow-up appts. as per discharge instructions. Medications on Admission: MEDS (home): ASA 325mg qd Seroquel 50mg qhs Buproprion 75mg [**Hospital1 **] . MEDS (at OSH): integrillin gtt ASA 325mg qd Lovenox 70mg SC bid Protonix 40mg qd Metoprol 25mg PO tid Seroquel 50mg [**Hospital1 **] Buproprion 75mg [**Hospital1 **] Ativan per CIWA Tylenol prn 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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:*60 Tablet(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Bupropion 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 7. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:*60 Tablet(s)* Refills:*0* 8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*0* 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 11. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 12. Echo Echocardiogram to evaluate ventricular function with results to Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office # ([**Telephone/Fax (1) 5862**] and Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**] office # [**Telephone/Fax (1) 170**] Discharge Disposition: Home With Service Facility: tba Discharge Diagnosis: CAD s/p cabg x3 elev. chol. anxiety depression ETOH abuse Discharge Condition: Good Discharge Instructions: [**Month (only) 116**] shower, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns Followup Instructions: see Dr. [**Last Name (STitle) 8049**] in [**1-24**] weeks [**Telephone/Fax (1) 8036**] please call for appt see Dr. [**Last Name (STitle) **] in [**2-25**] weeks [**Telephone/Fax (1) 6197**] please call for appt see Dr. [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**] please call for appt see Dr [**Last Name (STitle) **] in 3 months [**Telephone/Fax (1) 285**] please call for appt - will need echocardiogram 1 week prior to appointment Echocardiogram in 3 months prior to appt with Dr [**Last Name (STitle) **] - call for appt [**Telephone/Fax (1) 128**] Completed by:[**2108-1-24**]

[ "435.2", "300.4", "303.90", "272.0", "414.01", "411.1", "428.42", "428.0", "427.31" ]

icd9cm

[ [ [] ] ]

[ "88.56", "36.13", "88.52", "39.61", "37.23" ]

icd9pcs

[ [ [] ] ]

10966, 11000

8083, 8899

306, 371

11103, 11110

2457, 8060

11576, 12185

1774, 1815

9223, 10943

11021, 11082

8925, 9200

11134, 11553

1830, 2438

241, 268

399, 1271

1293, 1455

1471, 1758

5,049

193,680

52479

Discharge summary

report

Admission Date: [**2131-5-22**] Discharge Date: [**2131-6-1**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5755**] Chief Complaint: fever; weakness Major Surgical or Invasive Procedure: ERCP: 7 cm by 7 Fr Cotton [**Doctor Last Name **] biliary stent was placed successfully into the bile duct. Prurlent bile and biliary sludge were seen draining into the duodenum subsequently. History of Present Illness: Pt is a [**Age over 90 **] yo man with h/o HTN, DM, who presented to the ED with chills and weakness. The patient reports that he has been in his USOH until evening of [**2131-5-21**] when he developed shaking chills and felt too weak to get out of bed. His wife called the ambulance. He did not check his finger stick glucose at the time of this episode. He denies any chest pain, nausea, vomiting, cough, upper respiratory symtpoms, abdominal pain, diarrhea, melena, hematochezia. He has chronic constipation, no recent changes. He also reports burning epigastric discomfort after meals for the last 2 days. No radiation to the back. In ED, VS on presentation T 105; HR 114; BP 108/46; RR 24; O2 sat 89% RA -> 98% on NRB then weaned to 4L NC. Blood cultures and urine cultures collected. In the ED, the patient received Tylenol supp, Anzemet, Levofloxacin 500mg IV once, Aspirin 325mg, Acetylcysteine, Sodium Bicarbonate 50 mEq once. While in the ED, the pateint became hypotenstive with BP 80/48 and started on Norepinephrine at 0.1 mcg/kg. Past Medical History: 1. Pacemaker placed [**2110**] for CHB 2. HTN 3. DM2 4. Hypothyroidism 5. Hyperlipidemia 6. s/p TURP Social History: Retired; worked for post office. Lives with wife of >50 years in [**Location (un) **]. No children. Originally from [**Location (un) 3156**]. Lifetime non smoker but occasional cigars many years ago; small amount of wine on Sabbath dinner every [**Location (un) **] but no other etoh use. He is DNR/DNI Family History: Both parents had DM Physical Exam: GENERAL: AAO x3; NAD; pleasant; talkative HEENT: NC, AT, PERRL, no scleral icterus, MM dry, OP w/o lesions NECK: supple, no LAD, no JVD CV: regular, nl S1S2, no m/r/g PULM: crackles throughout ABD: + BS, soft, NT, ND EXTR: no edema Pertinent Results: [**2131-5-22**] 06:00AM WBC-13.4*# RBC-3.36* HGB-11.0* HCT-32.3* MCV-96 MCH-32.7* MCHC-34.0 RDW-13.7 [**2131-5-22**] 06:00AM PLT COUNT-123* [**2131-5-22**] 09:41PM GLUCOSE-98 UREA N-35* CREAT-1.3* SODIUM-146* POTASSIUM-4.7 CHLORIDE-120* TOTAL CO2-12* ANION GAP-19 [**2131-5-22**] 09:41PM ALT(SGPT)-539* AST(SGOT)-386* LD(LDH)-363* CK(CPK)-178* ALK PHOS-312* AMYLASE-540* TOT BILI-3.4* [**2131-5-22**] 09:41PM LIPASE-940* [**2131-5-22**] 09:41PM CK-MB-13* MB INDX-7.3* cTropnT-0.19* [**2131-5-22**] 09:41PM ALBUMIN-3.1* CALCIUM-6.7* PHOSPHATE-3.8 MAGNESIUM-2.4 [**2131-5-22**] 06:28AM URINE BLOOD-LGE NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2131-5-22**] 06:28AM URINE RBC-256* WBC-5 BACTERIA-RARE YEAST-NONE EPI-0 [**2131-5-22**] 06:00AM CORTISOL-42.7* CT head [**2131-5-24**]: No evidence of intracranial hemorrhage or edema. ECHO [**2131-5-23**]: Conclusions: The left atrium is moderately dilated. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is moderately depressed with mid to distal septal, distal LV and apical akinesis. The anterior wall is not well seen but appears hypokinetic. No LV thrombus is seen. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**11-27**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. ERCP [**2131-5-22**]: Five fluoroscopic images were obtained in the ERCP suite without the presence of a radiologist. The first demonstrates opacification of the distal portion of the pancreatic duct, with a subsequent image showing a stent placed across it. There is opacification of the common bile duct, common hepatic and intrahepatic biliary ducts, the cystic duct and gallbladder also filled with contrast. Left hepatic distal duct has smooth tapering with mild proximal dilatation. The final image shows a stent across the common bile duct; the pancreatic duct has been removed. Pancreatic duct stent has been removed. The common bile duct by report drained purulent material. CTA chest [**2131-5-22**]: IMPRESSION: 1. Atherosclerotic ulcers of the aortic arch and descending aorta. 2. No evidence of PE. 3. 10 mm gallstone as well as smaller gallbladder neck stone. Possible gallbladder wall edema may be secondary to pancreatitis. 4. Finding consistent with pancreatitis. Abd u/s [**2131-5-22**]: IMPRESSION: 1. Cholelithiasis without evidence of acute cholecystitis. 2. 3.2 cm cyst within the lower pole of the right kidney. bld cx [**2131-5-22**]: [**11-29**] E coli (pansensitive) bld cx [**5-23**], [**5-24**]: no growth urine cx [**5-22**]: no growth Brief Hospital Course: A/P: [**Age over 90 **] yo man w/ HTN, DM presents with fever, hypotension and epigastric discomfrot. . #. E coli septicemia: Initially required ICU stay for pressors. Likely source was ascending cholangitis. LFTs were elevated to ALT:777 AST:924 AlkPhos:367 Amylase:873. GI performed an ERCP on [**2131-5-22**] and though no duct stone was found a CBD stent was placed with subsequent purulent bile drained. E.coli grew out of [**11-29**] of the original blood cultures and based on sensitivities Unasyn was switched to levofloxacin ([**2131-5-24**]). The patient's LFTs have trended down to normal since the ERCP. Subsequent surveillance blood cultures negative. On [**2131-5-24**] the diet was advanced to solids, and the patient is tolerating this well. He is to follow-up with Dr. [**Last Name (STitle) **] in [**12-29**] months for a repeat ERCP for stent replacement. Other potential sources of infection were ruled out, including no infiltrate on chest CTA and negative urinalysis and urine culture. No other signs/symptoms of infection identified. . #. NSTEMI: In setting of hypoxia and hypotension, patient had troponin peak with anterior ischemic changes on EKG. Peak Troponin([**2131-5-23**]) 1.59 Peak CK-MB:46 Index:11.5 has since trended down. Cardiology was consulted and assisted with anticoagulation during the ACS. Patient was treated with heparin x 72 hours. Plavix was d/c due to falling platelets. Final recommendation to consider catheterization once medical issues improved, but currently patient refusing. I have scheduled follow-up with his primary care doctor so that he can discuss this further. . ## CHF: Flash pulmonary edema during ICU stay which improved with diuresis. ECHO [**2131-5-23**] shows EF 30-35%, no LV thrombus, and with only [**11-27**]+ MR. Discharged on ASA, statin, BB (changed from atenolol to metoprolol XL), and ACEI. . # Pancreatitis: Lipase peaked at 1538 and has subsequently trended down to 938. Tolerating po with no pain. . # Rash: Preliminary path c/w hypersensitivity reaction, likely due to unasyn but possible levofloxacin. Improving off antibiotics. Managed with triamcinolone 0.1% cream [**Hospital1 **] (avoid face, axilla, groin) x 2 weeks only. . # Seborrheic dermatitis: Started on nizoral 2% cream daily to face and shampoo 3 times per week. . # Facial Droop: Developed in ICU. Neuro consulted. Stat head CT showed no bleed. On statin. Glucose and bp well controlled (hemoglobin A1c 6.2%). . #. Chronic renal insufficiency. Creatinine stable. No issues. . #. DM. Patient eventually restarted on glyburide prior to discharge with good control of blood sugars. Hgb A1c < 7%. . #. HYPOTHYROIDISM. TSH WNL. Patient continued on his home dose of levothyroxine. . #. FEN. Low sodium, diabetic, low fat diet. . #. COMMUNICATION: Pt and his wife. [**Name (NI) **] [**Telephone/Fax (1) 108393**]. . #. CODE. DNR/DNI but pressors OK (discussed with patient). . # Dispo: No family support other than elderly wife. SW consulted and put wife in contact with SW from [**Name (NI) **] Council on Aging. PT consulted and recommend home with PT. Patient discharged with VNA for medication assistance. Early PcP [**Name9 (PRE) 702**] arranged to readdress whether more services need to be in place for the couple long term. . # Follow-up: [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 2472**] and Dr. [**Last Name (STitle) **] (for ERCP). Medications on Admission: 1. Atenolol 25 mg po qd 2. Levothyroxine 100 mcg po qd 3. Pantoprazole 40 mg po qd 4. Glyburide 1.25 mg po qd 5. Aspirin 81 mg po qd 6. Lisinopril 5 mg po qd 7. Atorvastatin 5 mg po qd Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2* 7. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day). 8. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): DO NOT CONTINUE USE OF THIS CREAM BEYOND 10 DAYS. AVOID USE ON FACE, ARMPITS, AND GROIN. Disp:*1 TUBE* Refills:*0* 9. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: ascending cholangitis E. coli bacteremia with sepsis non ST elevation MI congestive heart failure pancreatitis drug hypersensitivity reaction hematuria secondary: anemia diabetes chronic renal insufficiency hypothyroidism Discharge Condition: good, afebrile, tolerating po, voiding without foley Discharge Instructions: Please call your doctor or go to the emergency room if you experience temperature > 101, difficulty urinating, chest pain, worsening rash, or any other concerning symptoms. Please take all of your normal medications but be sure to: 1. Increase your aspirin to 325 mg per day. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 2472**] on Thursday, [**6-7**] at 2:45 PM. Please follow-up for your follow-up ERCP for stent removal on [**Last Name (LF) 2974**], [**8-10**] at 9AM by Dr. [**Last Name (STitle) **] (phone [**Telephone/Fax (1) 1983**]).

[ "250.00", "272.4", "593.9", "410.71", "693.0", "244.9", "576.1", "428.0", "599.7", "401.9", "690.10", "V45.01", "584.9", "038.42" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04", "51.87" ]

icd9pcs

[ [ [] ] ]

10093, 10151

5396, 8818

277, 470

10418, 10473

2297, 5373

10798, 11071

2007, 2028

9054, 10070

10172, 10397

8844, 9031

10497, 10775

2043, 2278

222, 239

498, 1545

1567, 1670

1686, 1991

69,585

148,741

50161

Discharge summary

report

Admission Date: [**2177-10-14**] Discharge Date: [**2177-10-22**] Date of Birth: [**2123-9-19**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Weakness, fainting Major Surgical or Invasive Procedure: Bronchial stenting of left lower bronchus [**2177-10-20**] Intubation History of Present Illness: 51 year-old man with recent discharge on [**2177-9-24**] with a new diagnosis of NSCLC. He has a LUL mass and recent post-obstructive PNA. Biopsy by IP revealed NSCLC. While at home he felt weak and had a recent fall. He has had 4 "fainting" spells over the last month which prompted head imaging. MRI shows metastatic lesions. Vital signs on arrival to [**Hospital1 18**]: T 97.9, P 108, BP 112/72, 98% RA. His evaluation in the ED was notable for a CXR and head CT with numerous lesions. In the ED he received Dilaudid and IV fliuds. He is being admitted for evaluation of weakness and sinus tachycardia. He denies fevers, chills, or night sweats. Notes a [**9-3**]# weight loss over the last 1-2 months. Denies any headache, visual changes, slurring of speech, numbness, weakness, loss of coordination, dizziness, vertigo, or confusion. Denies shortness of breath or chest pain. Denies dysphagia. He does complain of moderate low back pain. [**Month (only) 116**] be mildly depressed. Review of Systems: (+) Per HPI (-) Denies oral ulcers, bleeding nose or gums, palpitations, orthopnea, PND, lower extremity edema, cough, hemoptysis, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, BRBPR, dysuria, hematuria, easy bruising, skin rash, myalgias, joint pain. Past Medical History: - Non-small cell lung cancer, diagnosed [**9-/2177**] - Post-obstructive pneumonia Social History: Works as a police officer in [**Location (un) 86**]. Married with with 2 children, ages 19 and 8. Denies current tobacco use. Previously smoked until 2 years ago, and had been smoking various amounts since his teens - no more than [**11-16**] ppd. No alcohol use. No drug use. Family History: Mother and brother with diabetes. Reports a paternal aunt with a malignancy but he does not know which one. Father with liver (or colon) cancer. Physical Exam: VS: 98.2, 107/65, 104, 20, 96% on RA GEN: NAD HEENT: EOMI, MMM, no oral lesions NECK: Supple, +large firm left supraclavicular LAD CHEST: No air movement in left upper/middle lung fields CV: Tachycardia, regular, normal S1 and S2, no murmurs ABD: Soft, nontender, nondistended, bowel sounds present SKIN: Normal EXT: No lower extremity edema NEURO: Alert, oriented x3, CN 2-12 intact, sensory intact throughout, strength 5/5 BUE/BLE, fluent speech, normal coordination PSYCH: Calm, appropriate Pertinent Results: [**2177-10-14**] 01:50AM BLOOD WBC-9.2 RBC-4.20* Hgb-9.8* Hct-30.0* MCV-72* MCH-23.5* MCHC-32.8 RDW-15.4 Plt Ct-494* [**2177-10-14**] 01:50AM BLOOD Neuts-78.4* Lymphs-15.6* Monos-5.3 Eos-0.2 Baso-0.6 [**2177-10-14**] 01:50AM BLOOD PT-16.1* PTT-29.8 INR(PT)-1.4* [**2177-10-14**] 01:50AM BLOOD Glucose-104* UreaN-26* Creat-0.9 Na-132* K-4.6 Cl-93* HCO3-26 AnGap-18 [**2177-10-13**] 11:15PM BLOOD ALT-21 AST-49* LD(LDH)-572* AlkPhos-124 TotBili-0.9 [**2177-10-14**] 05:40AM BLOOD cTropnT-0.09* [**2177-10-13**] 11:15PM BLOOD cTropnT-0.09* [**2177-10-14**] 01:50AM BLOOD Calcium-9.4 Phos-3.0 Mg-2.1 [**2177-10-14**] 01:50AM BLOOD D-Dimer-6377* [**2177-10-14**] 01:54AM BLOOD Lactate-2.3* K-4.4 [**2177-9-19**] CT Chest with contrast: 1. Large left upper lobe consolidation which appears to extend into the mediastinum and concurrent post-obstructive left upper lobe and lingular collapse. Above findings, in conjunction with massive left supraclavicular and mediastinal lymphadenopathy, raise the concern for underlying mass. Complete obstruction of left upper lobe and lingular bronchi could be due to a combination of compression and endobronchial tumor. Marked attenuation of the left upper lobe segmental pulmonary arteries. Bilateral smaller pulmonary nodules. Overall appearance is suspicious for neoplasm, primary lung cancer versus metastasis, also consider lymphoma. Post-obstructive pneumonia can not be excluded. Recommend correlation with bronchoscopy and tissue sampling. [**2177-9-23**] Mediastinal mass, biopsy/cytology: Most consistent with poorly differentiated non-small cell carcinoma. [**2177-10-1**] PET: IMPRESSION: 1. Large mass involving the left upper lobe causing lingular and segmental collapse. 2. Bulky supraclavicular, mediastinal lymphadenopathy, FDG avid. 3. Left lower lobe and right upper, middle and lower lobe FDG avid pulmonary nodules seen. 4. Multiple small celiac and left gastric nodes with FDG uptake seen. 5. Solitary focus of increased uptake in the inferior pole of the spleen. [**2177-10-2**] MRI Head: 1. Relatively large 2.3-cm hemorrhagic metastatic lesion centered in the mid-right cerebellar hemisphere with surrounding edema, but little mass effect on the fourth ventricle and no obstructive hydrocephalus. 2. At least one 6.5-mm metastatic lesion at the right paramedian parietal [**Doctor Last Name 352**]-white matter junction with two minute lesions in the region of the right pre- and post-central gyrus, with no appreciable surrounding edema. 3. Numerous, predominantly punctate foci of restricted diffusion in both cerebral and cerebellar hemispheres, in a pattern suggestive of a "shower" of acute emboli; these could represent either bland emboli from a cardiac or other central source, e.g., in a patient with an arrhythmia, or alternatively NBTE (so-called "marantic" endocarditis) in a patient with advanced malignancy and low-grade DIC. [**2177-10-13**] CT Head: Comparison is made to head MRI with and without contrast dated [**2177-10-2**], performed to evaluated for lung cancer metastases. The right cerebellar lesion corresponds to a known hemorrhagic metastasis, grossly unchanged allowing for differences in technique. Smaller right frontal and parietal lesions seen on the MRI are not appreciated on the CT. [**2177-10-13**] CXR: Left upper lung is completely airless and expanded displacing the mediastinum, particularly the trachea to the right. Severe narrowing of the left main bronchus as well as a large subcarinal mass projecting to the right of the midline is due to adenopathy, causing obstruction of the left upper lobe bronchus. Left lower lobe is aerated but small. Multiple nodules present throughout both lungs are manifestation of metastases, presumably due to a large central bronchogenic carcinoma. There is no appreciable pleural effusion. [**2177-10-16**] CT CHEST: 1. Interval increase in size of large LUL mass and obstructive consolidation/collapse due to increasing bronchial obstruction. 2. Increased size and number of hemorrhagic pulmonary metastasis and supraclavicular, and mediastinal, and possibly celiac and gastric adenopathy. 3. New small left pleural effusion. [**2177-10-17**] CT T-SPINE: No evidence for thoracic spinal metastasis. Massive left neck lymphadenopathy with laryngeal deviation to the right. # Microbiology [**2177-10-20**] URINE URINE CULTURE-FINAL INPATIENT [**2177-10-20**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT [**2177-9-21**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT [**2177-9-21**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2177-9-21**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2177-9-19**] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY [**Hospital1 **] [**2177-9-19**] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY [**Hospital1 **] Brief Hospital Course: 54 year-old man presented after fainting. He was recently diagnosed with NSCLC with brain mets and the fainting is likely from seizures. The tumor is extensive and causing complete obstruction of LUL and encasing pulmonary arteries. He is also having severe thoracic spine area pain and CT T-spine negative for mets (MRI not done [**12-17**] claustrophobia). Tachycardia is from tumor encasing pulmonary arteries. Has had scant hemoptysis. Bronchial stenting on [**2177-10-20**]. Patient suffered respiratory distress in PACU and was intubated. Despite mechanical ventilation, he had significant hypoxemia. In discussion with family, decision was made for comfort care in setting of poor prognosis. Patient expired on [**2177-10-22**] with primary cause of non-small cell lung cancer over a month leading to respiratory failure within days. PROBLEM LIST: # NSCLC with brain mets and very large LUL tumor causing obstruction of LUL and endangering LLL and causing trachea shift to the right. - Bronchial stenting by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] on Monday [**10-20**] - Keppra and dexamethasone for seizure prophylaxis # Hypoxemic respiratory failure: In setting of significant tumor burden with airway compression, recent Y stent may have caused irritation and patient has little to no reserve. Already failed extubation once in PACU. Prognosis discussed with patient's step-father/HCP [**Name (NI) **], and he understands that the patient's condition is terminal and he is unlikely to be able to survive off a ventilator. He was covered with vancomycin/cefepime empirically in the setting of leukocytosis for any possible HCAP contributing to his distress. Patient was subsequently transitioned to supportive care with extubation per family decision on [**10-22**] resulting in death. . # NSCLC: With brain mets and significant L lung tumor burden. Patient was continued on levetiracetam and dexamethasone for seizure prophylaxis. Medications on Admission: Initial inpatient medications: INPATIENT MEDICATIONS: DVT Prophylaxis: Heparin 5000 UNIT SC TID Seizure/PAIN: LeVETiracetam Oral Solution 500 mg PO/NG [**Hospital1 **] Lidocaine 5% Patch 1 PTCH TD DAILY For Back Pain Dexamethasone 2 mg PO/NG Q12H Fentanyl Patch 50 mcg/hr TP Q72H HYDROmorphone (Dilaudid) 0.12 mg IVPCA Lockout Interval: 6 minutes Basal Rate: 0 mg(s)/hour 1-hr Max Limit: 1.2 mg(s) PRN Dilauded IV Aspirin 81 mg PO/NG DAILY ANTIEMETIC: Ondansetron 4 mg IV Q8H:PRN nausea BOWEL REGIMEN: Docusate Sodium 100 mg PO BID Polyethylene Glycol 17 g PO/NG DAILY:PRN constipation Senna 2 TAB PO/NG [**Hospital1 **]:PRN constipation Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: - Lung cancer, non-small cell, metastatic to brain - Hypoxic respiratory failure Discharge Condition: Expired Discharge Instructions: NA Followup Instructions: NA [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "348.5", "197.7", "198.3", "519.19", "197.0", "162.8" ]

icd9cm

[ [ [] ] ]

[ "31.99", "96.05" ]

icd9pcs

[ [ [] ] ]

10368, 10377

7681, 8527

332, 404

10502, 10512

2817, 5739

10564, 10706

2141, 2288

10339, 10345

10398, 10481

9677, 10316

10536, 10541

2303, 2798

1452, 1725

274, 294

432, 1433

5748, 7658

8542, 9651

1747, 1831

1847, 2125

14,197

104,162

27547

Discharge summary

report

Admission Date: [**2171-9-15**] Discharge Date: [**2171-9-19**] Date of Birth: [**2111-2-14**] Sex: M Service: MEDICINE Allergies: Cephalosporins Attending:[**First Name3 (LF) 1257**] Chief Complaint: 60 year old male complaining of lightheadedness and weakness. Major Surgical or Invasive Procedure: Packed red blood cell transfusion Endoscopy History of Present Illness: Mr. [**Known lastname 12056**] is a 60 yo M with history of HTN, DM II, aortic valve endocarditis s/p replacement with a mechanical valve and atrial fibrillation who presented to the ED because of lightheadedness and low BP (at home) for 4 days. Patient reports that he was in his usual state of health until last Thursday when he noticed he was becoming lightheaded upon standing and he was getting short of breath with minimal acitvity and sometimes at rest, and his physical therapist took his blood pressure and it was ~90/50. He called his cardiologist who told him to stop his lasix which he did. He had persistent symptoms throughout the weekend. He reports having ~3 black, loose stools/day for one week but he attributes this to eating more fruit. . In the ED, initial vs were: T 99.4, HR 70, BP 118/53, RR 17, 100% O2 sat. Patient was found to have a Hct of 19.4, be guaiac (+) brown stools and an NG lavage showed coffee grounds that cleared after 500 mL. He was given 1L NS, IV pantoprazole 80 mg x2 and transfused 1 unit PRBC's. He was seen by GI in the ED. . On the floor, the patient states he is feeling better but persistently weak. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, rhinorrhea or congestion. Denies cough, or wheezing. Denies chest pain, chest pressure. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. . Past Medical History: Hypertension Diabetes Mellitus Type II Anxiety Peripheral Neuropathy Aortic Valve Replacement ([**First Name8 (NamePattern2) **] [**Male First Name (un) 923**]) secondary to endocarditis Atrial fibrillation Diastolic CHF EF - 55% Anxiety Social History: Mechanical engineer, [**Location (un) 67351**], MA, Married, EtOH "3 beers a day" but has trouble cutting back. Remote history of tobacco, currently smokes cigars, denies illicits. Family History: Mother pancreatic CA, deceased Father alcoholism, deceased Brother with CABG, CVA. Physical Exam: Physical Exam: Vitals: T: 96.4 BP: 123/69 P: 70 R: 18 O2: 96% on RA FS: 171 6 am, 274 noon, 261 6 pm, 214 midnight General: Obese, man laying propped up in bed, alert, oriented, no acute distress HEENT: Sclera anicteric, DMM, oropharynx clear Neck: supple, JVP not appreciable, no LAD, no carotid bruit Lungs: Bilateral inspiratory crackles [**2-3**] way up, no wheezes or ronchi CV: Regular rate and rhythm, normal S1, pronounced mechanical S2, flow systolic murmur loudest at USB, no rubs, gallops Abdomen: Obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, palpable liver edge 2 in below liver, palpable spleen GU: no foley Ext: warm, well perfused, 2+ pulses, trace edema to ankles, no clubbing, cyanosis Psych: Mood "tired," affect sad Pertinent Results: [**2171-9-15**] 06:15PM WBC-4.6 RBC-2.71*# HGB-6.4*# HCT-19.7*# MCV-73*# MCH-23.8* MCHC-32.8 RDW-20.2* [**2171-9-15**] 06:30PM PT-23.7* PTT-25.9 INR(PT)-2.3* [**2171-9-15**] 06:15PM cTropnT-< 0.01 [**2171-9-15**] 06:15PM proBNP-1270* . Labs on Callout: . [**2171-9-16**] 06:07AM BLOOD Hct-24.5* [**2171-9-16**] 06:07AM BLOOD PT-21.1* PTT-24.7 INR(PT)-2.0* . Labs on Discharge: [**2171-9-19**] 06:50AM BLOOD Hct-30.7* MCV-80* MCH-25.6* MCHC-31.9 RDW-19.0* Plt Ct-110* [**2171-9-19**] 06:50AM BLOOD PT-22.4* PTT-25.6 INR(PT)-2.1* . Imaging: RUQ US [**2171-9-16**]: 1. Echogenic liver consistent with fatty infiltration. Other forms of liver disease and more advanced liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded on this study. 2. Splenomegaly. . Studies: EGD: Findings: Esophagus: Mucosa: Area of linear erythema without bleeding noted at GE junction potentially related to NG tube trauma. of the mucosa was noted throughout the esophagus. Protruding Lesions 1 cords of grade I varices were seen in the lower third of the esophagus and gastroesophageal junction. The varices were not bleeding. Stomach: Protruding Lesions What appeared to be large gastric varices were seen in the cardia without stigmata of recent bleeding. Duodenum: Normal duodenum. Impression: Gastric varices Area of linear erythema without bleeding noted at GE junction potentially related to NG tube trauma. in the esophagus Varices at the lower third of the esophagus and gastroesophageal junction Otherwise normal EGD to second part of the duodenum Recommendations: Given computer difficulty images not retained. Area of erythema at GE junction likely from NG trauma though unclear. [**Name2 (NI) **] active bleeding.What appeared to be a grade 1 varix distal esophagus without cherry red spot. What appeared to be gastric varices at the fundus without active bleeding. No hx of cirrhosis or portal hypertension in the past. Recommend imaging of abdomen, assessment of portal and splenic vasculature. LFTS, albumin. Heparin gtt. If active bleeding, liver team for potential injection of varices. Brief Hospital Course: # Acute blood loss: Presented with symptomatic acute blood loss and signs/history consistent with upper GI etiology. EGD demonstrated gastric varices (not actively bleeding) and grade 1 esophageal varices. Hct on admission was 19.7 from 30 @ baseline and lactate was 3.3. Lactate normalized to 1.1 after 3 units of pRBCs, but Hct showed an incomplete response to 24.5, prompting an additional unit, after which Hct remained stable for the duration, at ~27 on call-out from ICU, which then increased to 30 upon discharge. - Though not actively bleeding at time of EGD source felt to be gastric varices but to rule out lower etiology patient was recommended to follow-up with pcp for colonoscopy [**Name9 (PRE) 13511**]. # Gastric Varices / Portal HTN work-up / lower GI bleed work-up: Varices found on EGD prompted an RUQ US, which showed fatty liver and splenomegaly. Cirrhosis work-up included negative Hep serologies, GGT, AFP, and Fe studies. Further outpatient work-up with hepatology will include alpha-1 antitrypsin and US with doppler. Pt was prescribed low dose nadolol 20 mg to help reduce splanchnic blood flow and reduce risk of variceal bleed. - Patient should receive Hepatitis B and A vaccine - Patient scheduled with liver for follow-up and further work-up # Mechanical valve: Coumadin was held in the setting of an acute bleed while pRBCs were transfused until Hct stabilized HD2. It was re-initated at dose of 10 mg daily and pt's INR was monitored up to discharge at 2.1. Pt was counseled that therapeutic range of INR for him is 2.5 to 3. # A-Fib / [**Last Name (LF) 9215**], [**First Name3 (LF) **] 55%: Coumadin was held as described above until Hct stabilized on HD2 and restarted HD3. Showed signs of left heart failure with wet adventitial sounds on exam; diuresed with IV Lasix, titrated to -1L daily and clinically improved. Remained hemodynamically stable without RVR and without signs of R heart failure; discharged in hemodynamically stable condition and normalized volume status. Restarted on home [**Hospital1 **] 80 Lasix PO. Discharged on dronedarone and metoprolol per home meds. Will to continue to follow with cardiology as an outpatient. # Alcohol abuse: Patient declined intervention offered by social work. Consoled on risk of alcohol use especially with new diagnosis of liver disease. Medications on Admission: Januvia 100mg daily Metformin 500mg [**Hospital1 **] Metoprolol Succinate 100mg daily Furosemide 80mg [**Hospital1 **] Warfarin 10mg daily Lisinopril 40mg daily Cymbalta 30mg daily Lantus 100u HS Humalog ISS Aspirin 81mg daily Dronedarone 400mg [**Hospital1 **] Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 2. Dronedarone 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lantus 100 unit/mL Cartridge Sig: One (1) 100 Subcutaneous at bedtime. 6. Humalog KwikPen Subcutaneous 7. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 9. Warfarin 10 mg Tablet Sig: One (1) Tablet PO once a day. 10. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 11. Cymbalta 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 12. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: Gastric varices Acute blood loss Steatohepatitis/cirrhosis Alcohol dependence Secondary diagnoses: Diastolic congestive heart failure Mechanical aortic valve Atrial fibrillation Type II Diabetes Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for lighteadeness and weakness which we think was due to a significant drop in your hematocrit and loss of blood in your stool. The endoscopy found varices (swollen veins) in your stomach which probably were bleeding into your stomach. We transfused you by giving you back red blood cells which stabilized your hematocrit. We are discharging you on a new medication called Nadolol to control the varices. You will need to discuss with your primary care doctor having a colonoscopy. Please monitor your stool, and if you see black-colored stool, call your primary care doctor. Please continue the metoprolol and the dronedarone, as well as the lasix, as prescribed by Dr [**Last Name (STitle) 911**], and weigh yourself every morning. Please [**Name8 (MD) 138**] MD if your weight goes up more than 3 lbs or if you get very dizzy or lightheaded. We encourage you to avoid drinking alcohol in order to stop the damage of your liver and reduce your chances of having a major bleed in your stomach. We offered help to quit alcohol from our social worker. In terms of medications we STOPPED your Metformin. We have HELD your Januvia please discuss re-starting with your doctor that controls your diabetes due to your liver disease. We are continuing your warfarin. It is very important to follow your INR with your primary care doctor to ensure goal INR 2.5-3.5. We ADDED nadolol to help prevent the chance of a bleed in your stomach. Otherwise we made no changes to your medication. Followup Instructions: You have the following appointments for follow-up with your primary care doctor, the liver specialists, and the gastrointestinal doctors. Department: [**State **] SQ When: TUESDAY [**2171-10-8**] at 1:15 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8428**], MD [**Telephone/Fax (1) 2205**] Building: [**State **] ([**Location (un) **], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: On Street Parking You need to discuss having a colonoscopy with your primary care doctor. Department: LIVER CENTER When: TUESDAY [**2171-10-15**] at 10:00 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 We have adjusted your diabetes medications. We STOPPED Metformin and HELD your Januvia. Please schedule an appointment with your diabetic doctor to discuss your management. Completed by:[**2171-9-21**]

[ "356.9", "571.5", "250.00", "V58.61", "456.0", "V43.3", "427.31", "285.1", "276.2", "428.30", "303.91", "578.9", "571.8", "456.8", "789.2", "428.0", "401.9", "300.00" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

9017, 9023

5399, 7733

337, 383

9295, 9295

3257, 3623

10977, 11988

2351, 2435

8045, 8994

9044, 9142

7759, 8022

9446, 10954

2465, 3238

9163, 9274

1582, 1875

236, 299

3642, 5376

411, 1563

9310, 9422

1897, 2137

2153, 2335

50,285

154,880

38181

Discharge summary

report

Admission Date: [**2104-5-11**] Discharge Date: [**2104-5-28**] Date of Birth: [**2050-7-1**] Sex: F Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 11415**] Chief Complaint: L [**2-25**] rib fxs Right [**1-26**] rib fractures Open left supracondylar femur fracture Right distal tib/fib ankle fracture Right patellar fracture Major Surgical or Invasive Procedure: [**2104-5-12**]: s/p Left femur ORIF, Left patella ORIF, Right ankle ex-fix. [**2104-5-22**]: s/p Right distal tibia ORIF with removal of ex fix. History of Present Illness: 53 year old woman with a history seizure disorder s/p motor vehicle crash after a seizure. She was taken to [**Hospital 8641**] Hospital and found to have multiple injuries including a right patella fracture, R pilon fracture, L open intra-articular distal femur. Also with bilateral pneumothoraces, rib fractures, and pulmonary contusions. She was then transferred to the [**Hospital1 18**] for further evaluation and care. Past Medical History: Hypertension, seizures, hypothyroidism, rheumatoid arthritis Social History: + tobacco, denies EtOH or illicits Family History: Non-contributory Physical Exam: Upon discharge Alert and oriented Cardiac: Regular rate rhythm Chest: Lungs clear Abdomen: Soft non-tender non-distended Extremities: BLE: L knee inicison clean and dry, RLE splint intact/knee incision intact. +sensation/movement, +pulses. Pertinent Results: Imaging (see below for details): [**2104-5-16**] Bilateral Lower Extremity Dopplar - Negative for DVT [**2104-5-14**] CXR - Minimal changes, L pleural effusion and tiny apical PNX [**2104-5-12**] ECHO - LVEF >55%, ? VSD, Mod Pulmonary HTN [**2104-5-11**] CT head - negative for fracture or intracranial hemorrhage [**2104-5-11**] CT c-spine - negative for fractures [**2104-5-11**] CT torso - L [**2-25**] rib fractures, R [**1-26**] rib fractures, bilateral extensive pulmonary contusions, bilateral small pneumothoraces Lab results: [**2104-5-22**] 02:57PM BLOOD WBC-6.0 RBC-3.99* Hgb-11.6* Hct-35.7* MCV-90 MCH-29.1 MCHC-32.6 RDW-15.6* Plt Ct-438# [**2104-5-22**] 02:57PM BLOOD Plt Ct-438# [**2104-5-22**] 02:57PM BLOOD Glucose-99 UreaN-7 Creat-0.5 Na-142 K-4.0 Cl-105 HCO3-31 AnGap-10 [**2104-5-14**] 06:05AM BLOOD CK(CPK)-256* [**2104-5-14**] 06:05AM BLOOD cTropnT-<0.01 [**2104-5-22**] 02:57PM BLOOD Mg-1.8 [**2104-5-11**] 09:43PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG TELEMETRY: no episodes of SVT present ECG [**2104-5-13**]: SVT at 180 bpm. L axis. Possible retrograde P wave in lead II after QRS indicating that AVNRT is a likely etiology. LVH present. Diffuse ST depressions likely secondary to LVH and rapid rate. TRANSTHORACIC ECHOCARDIOGRAM [**2104-5-13**]: The left atrium is elongated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is a restrictive paramembranous ventricular septal defect with a large proximal septal aneurysm measuring 1.5 x 1.0 cm. There is a turbulent jet. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No aortic regurgitation is seen. There is no mitral valve prolapse. No mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal biventricular systolic function. Paramembranous ventricular septal aneurysm with restrictive ventricular septal defect. Mild pulmonary hypertension. Biatrial dilation. CT CHEST/ABD/PELVIS [**2104-5-11**]: CHEST CT WITH CONTRAST: Partially imaged thyroid gland is unremarkable. There is small amount of fluid within the pericardial recess, demonstrating Hounsfield units of up to 18. Aorta, pulmonary artery, heart, and pericardium are unremarkable. Heart is not enlarged. There is no mediastinal, hilar, or axillary lymphadenopathy. There are bilateral anterior ground-glass opacities throughout both lungs, most compatible with contusion in setting of trauma. Multiple left-sided rib fractures with surrounding hematoma and air are noted on the left side. A tiny right basilar pneumothorax is present with a tiny focus of air in the right pleural space inferiorly (3:55). There is also a tiny left pneumothorax with a trace amount of hemothorax. There is also some subcutaneous emphysema and air along the lateral thorax musculature. Bilateral dependent atelectatic changes are seen. There is no mediastinal shift. Airways are grossly patent. Small amount of fluid within the esophagus can place the patient at risk for aspiration. ABDOMINAL AND PELVIC CT WITH CONTRAST: Focal area of decreased enhancement adjacent to the falciform ligament in the liver likely represents focal fat infiltration. There is no evidence of liver injury. Mild periportal edema is seen. The gallbladder, spleen, pancreas, adrenals, kidneys are unremarkable with no evidence of trauma. The aorta and iliac vessels are unremarkable. There is no lymphadenopathy. There is no retroperitoneal hematoma. Reflux of contrast in the left gonadal vein ending in pelvic varices can be seen in pelvic congestion syndrome. The uterus is lobulated containing fibroids. The urinary bladder is grossly unremarkable. There is no bowel obstruction or evidence of bowel wall trauma. There is no mesenteric hematoma or evidence of mesenteric injury. Rectum is unremarkable. OSSEOUS STRUCTURES: There are displaced fractures of the third, fourth, fifth, sixth, seventh, eight left ribs. There are also non-displaced fractures of the right second, third, fourth, sixth ribs. Fifth rib fracture on the right side is displaced. IMPRESSION: 1. Multiple bilateral rib fractures with bilateral pulmonary contusions, tiny bilateral pneumothoraces. 2. Fibroid uterus. 3. Reflux of contrast in a dilated left gonadal vein ending in pelvic varices is a nonspecific finding, but can be seen in pelvic congestion syndrome. LEFT FEMUR/ KNEE/ HIP FILM [**2104-5-11**]: Comminuted and displaced distal femoral and patellar fractures, with knee dislocation CT HEAD [**2104-5-11**]: There is no evidence of intracranial hemorrhage, mass effect, or [**Doctor Last Name 352**]-white matter differentiation abnormality. The ventricles and extra-axial spaces are within normal limits for age. There is no fracture. Left vertex subgaleal hematoma is moderate-sized. Imaged paranasal sinuses and mastoid air cells are grossly clear. There is partial ossification of the left maxillary sinus. IMPRESSION: Left parietal subgaleal hematoma. No acute intracranial abnormality. Brief Hospital Course: [**Known firstname **] [**Known lastname 54184**] is a 53 year old woman with a self reported history of an unspecified seizure disorder as well as a history of congenital VSD, SVT/palpitations, RA, hypothyroidism and anxiety who presented after a motor vehicle accident on [**2104-5-11**] after having a seizure while driving her car. She sustained left [**2-25**] rib fractures, right [**1-26**] rib fxs, open L supracondylar femur fx, right distal tib/fib ankle fx, and a right patellar fx. Her ribs were managed nonoperatively and she was taken to the OR on [**2104-5-12**] for repair of her orthopaedic injuries and again on [**2104-5-22**]. Etiology of pt accident is unclear as pt does not recall any aspect of the incident. Pt has history of fainting and both cardiac and questionable neurologic work up sin the past. Thus as part of her syncope work up cadiology and neurology consults were called. Neuro: During her hospital stay the patient was evaluated for her self reported history of seizures. The work-up was unremarkable and there were no further "seizures". Per neurology - the patient does not have documented hx of seizures and prior work-up has been negative including MRI of brain with and without contrast and EEG. LOC episodes most likely cardiac but given family reporting episodes witnessing LOC an EEG was repeated and shows mildly slow rhythm of 7Hz likely due to pain meds but also intermittent, focal L anterior slowing. No indication of seizures hence Keppra/AED not indicated. ****Please do not include seizures as patient's PMH**** Given slow rhythm seen on EEG, will recommend repeat EEG as outpatient to PCP, [**Name11 (NameIs) 3548**] [**Name12 (NameIs) **], NP. On discharge she was fully neurologically intact with no focal deficits. Pain was well controlled with PO and IV pain medications. Cardiac: Pt has PMHx of "hole in heart", SVT/ syncope in past and palpitations. Cardiology consulted as for question of cardiac etiology behind symptoms as well as episode of SVT with hypotension on [**5-13**]. pt has known congenital heart disease, the patient was followed at [**Hospital3 **] for quite some time. From our echo we believe her to have a paramembranous ventricular septal aneurysm and this would not cause an paradoxical emobli or be a reason why she would have had a fainting spell. However, she needs out patient follow up - specifically an EP study to look for arrhythmias. If none are found then she will need a Reveal device implanted. This should be done as an outpatient as the patient has had recent LE trauma and is currently s/p surgery. She should be scheduled to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**12-22**] weeks (would prefer 1wk) after discharge. The phone to his clinic is ([**Telephone/Fax (1) 20575**]. It is known that the patient has an SVT (likely AVNRT based on the EKG in the chart), and that she was hypotensive with this arrhytymia. Her SVT was in the post-op setting and this is the likely etiology behind it. However, if she is having this SVT while driving and became hypotensive that may have caused her syncope. For suppression of her SVT she was placed on beta blockade (metoprolol 25mg [**Hospital1 **]). Pulm: Patient sustained small bilateral apical pneumothoraces and pulmonary contusions. Patient was slowly weaned from supplemental O2 over the course of her hospitalization. At the time of discharge, the pain from her bilateral rib fractures was well controlled. She was able to maintain her O2 sats > 92% on room air and she was not splinting with deep respiration. GI: The patient had no active GI issues during this hospitalization. At the time of discharge she was tolerating a regular diet without any nausea or vomiting. GU: The patient had no active GU issues during this hospitalization. The foley catheters placed during surgery were discontinued on POD1 and the patient passed her voiding trial without any complications. At the time of discharge she was making adequate urine. MSK: The patient recovered well from her orthopaedic injuries. Her pain was well controlled with oral pain medication. PT consults were obtained and rehabilitation for her injuries was recommended. On discharge, the patient was neurovascularly intact in all 4 extremities, compartments were soft, she had palpable pulses in all extremities. Medications on Admission: Metoprolol 25mg [**Hospital1 **], celexa 40mg qd, levoxyl 75mcg qd, klonopin 2mg qd, methotrexate 2.5mg qd, folic acid 1mg qd Discharge Medications: 1. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 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). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constip. 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constip. 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for sleep. 9. Hydromorphone 2 mg Tablet Sig: 1-4 Tablets PO Q3H (every 3 hours) as needed for pain. 10. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily). 11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 12. Hydromorphone (PF) 1 mg/mL Syringe Sig: 0.25-0.5mg Injection Q3H (every 3 hours) as needed for breakthrough pain. Discharge Disposition: Extended Care Facility: [**Hospital **] Rehab - [**Location (un) **], NH Discharge Diagnosis: 1. Right distal tibia fracture 2. Right patella fracture. 3. Left open distal femur fracture. 4. Pulmonary contusion 5. Bilateral pneumothoraces 6. Multiple rib fractures. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Wound Care: -Keep Incisions dry. -Do not soak the incisions in a bath or pool. -Sutures/staples will be removed at your first post-operative visit. Activity: -Continue to be non weight bearing on both legs. -Elevate both legs to reduce swelling and pain. -Do not remove splint & brace. Keep splint & brace dry. Other Instructions - Resume your regular diet. - Avoid nicotine products to optimize healing. - Resume your home medications. Take all medications as instructed. - Continue taking the Lovenox to prevent blood clots. -You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2. We are not allowed to call in narcotic (oxycontin, oxycodone, percocet) prescriptions to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. - Narcotic pain medication may cause drowsiness. Do not drink alcohol while taking narcotic medications. Do not operate any motor vehicle or machinery while taking narcotic pain medications. Taking more than recommended may cause serious breathing problems. If you have questions, concerns or experience any of the below danger signs then please call your doctor at [**Telephone/Fax (1) 1228**] or go to your local emergency room Physical Therapy: Activity as tolerated Right lower extremity: Non weight bearing, [**Doctor Last Name **] locked in extension RLE Left lower extremity: Non weight bearing, ROM L knee 0-65 degrees in [**Doctor Last Name 6587**] Encourage turn, cough and deep breathe q2h when awake Treatments Frequency: Site: Incision Type: Surgical Dressing: Gauze - dry Comment: daily by RN; please overwrap any dressing bleedthrough with ABDs and ACE Followup Instructions: 2 weeks in the [**Hospital **] clinic with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP. PLease call [**Telephone/Fax (1) 1228**] to make this appointment. Follow up with PCP, [**Name11 (NameIs) 3548**] [**Name12 (NameIs) **], NP [**Telephone/Fax (1) 84709**] in [**12-22**] weeks (once you are off narcotics) for neurology assessment and a repeat EEG as outpatient with your Follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 20575**], in [**12-22**] weeks for cardiac and EP evaluation. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**] Completed by:[**2104-5-29**]

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icd9cm

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icd9pcs

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19028+57009

Discharge summary

report+addendum

Admission Date: [**2131-2-21**] Discharge Date: [**2131-3-8**] Date of Birth: [**2057-12-10**] Sex: M Service: SURGERY Allergies: Zosyn Attending:[**First Name3 (LF) 1481**] Chief Complaint: Toxic megacolon, Sepsis Major Surgical or Invasive Procedure: [**2-22**] Total abdominal colectomy, lysis of adhesions, and ileostomy PICC placement History of Present Illness: Pt is a 73M well known to Dr. [**Last Name (STitle) **] who was transferred to his care tonight from [**Hospital3 35813**] Center in RI. He presented there on on [**2131-2-18**] with weakness and lower abdominal pain. By report CT scan showed evidence of colitis. Stool was positive for C Diff. WBC was 44,000. He was admitted, hydrated, and started on PO vanco. No discharge summary was sent with him. In speaking with the outside physician, [**Name10 (NameIs) **] had improved after starting PO vanco. His WBC & diarrhea decreased. He was tolerating diet and had minimal abdominal pain. However, last night developed ARF and was making minimal urine with Cr newly elevated to 3.5. Then today he developed significant abdominal distension and SOB. Over a short periord this afternoon he quickly decompensated becoming hypotensive with respiratory distress. He was transfered to the ICU, intubated, had a central line placed, started on vasopressors, and was given 3L IVF and meropenem/flagyl IV. Arrangements were then made for transfer here. Of note patient was also admitted to [**Hospital3 **] center w/ a COPD exacerbation & PNA approx 2 weeks prior to this presentation. He has failed outpatient treatmend with augmentin; then received levofloxacin an as inpatient. It is unclear, but he may have been discharged home to complete a 14-day course of Ampicillin. Past Medical History: 1. HTN 2. perforated Diverticulitis [**6-/2125**] c/b sepsis, respiratory failure, ARF, A Fib [**Hospital **] transferred from OSH to Dr.[**Name (NI) 1482**] care after initial colectomy/[**Doctor Last Name 3379**]. 3. s/p colectomy/Hartmann for perforated diverticulitis [**6-/2125**] at an OSH c/b intra-abdominal abscess treated by IR drain 4. s/p colostomy takedown/[**Doctor Last Name 3379**] reversal [**12/2125**] ([**Doctor Last Name **]) 5. ?recurrent diverticulitis [**2128**] 6. SBO [**11/2129**] - managed non-operatively 7. ex-lap, small bowel resection and lysis of adhesions. [**4-/2130**] ([**Doctor Last Name **]) for recurrent SBO caused by an inflammatory mass 8. s/p left inguinal hernia repair 9. Prostate Ca [**31**]. COPD 11. h/o CVA hernia repair Social History: Lives with wife in [**Name (NI) **]. quit smoking 40+ years Family History: emphysema in his father and brain cancer in his mother Physical Exam: Upon Admission: PE: Currently on Propofol and Levophed VS: 97.8 101 95/48 19 97% CMV 0.5 500x16 +5 Intubated, sedated. Upon arrival with sedation off, moved all extremities, did not follow commands No jaundice or icterus breath sounds diminished B/L Abd: healed midline scar. massively distended. tympanitic. grimaces to light palpation No LE edema Upon Discharge: VS: 99.9, 78, 128/62, 16, 93% RA NAD NCAT RRR, S1S2 CTAB, minor wheezes Soft, NTND, Ostomy is C/D/I. Staples are still in place and are C/D/I. There is a small defect at the inferior portion of the incision site that is packed with saline soaked gauze. There is mild erythema, but no induration. There is minor serous drainage. No purulence. Pertinent Results: [**2131-2-21**] 08:19PM BLOOD WBC-10.1# RBC-4.49* Hgb-14.7 Hct-42.9 MCV-96 MCH-32.6* MCHC-34.2 RDW-13.2 Plt Ct-161 [**2131-2-22**] 02:03AM BLOOD WBC-10.8 RBC-4.15* Hgb-13.3* Hct-39.2* MCV-95 MCH-32.2* MCHC-34.0 RDW-13.8 Plt Ct-180 [**2131-2-22**] 10:57AM BLOOD WBC-12.4* RBC-3.57* Hgb-11.7* Hct-34.8* MCV-98 MCH-32.9* MCHC-33.8 RDW-13.2 Plt Ct-179 [**2131-2-22**] 04:19PM BLOOD WBC-7.4 RBC-3.22* Hgb-10.7* Hct-30.7* MCV-96 MCH-33.4* MCHC-34.9 RDW-13.3 Plt Ct-136* [**2131-2-22**] 09:33PM BLOOD WBC-8.6 RBC-2.82* Hgb-9.2* Hct-26.5* MCV-94 MCH-32.6* MCHC-34.7 RDW-13.7 Plt Ct-139* [**2131-2-23**] 02:07AM BLOOD WBC-10.0 RBC-2.89* Hgb-9.6* Hct-27.2* MCV-94 MCH-33.2* MCHC-35.2* RDW-13.3 Plt Ct-151 [**2131-2-23**] 02:36PM BLOOD WBC-11.3* RBC-3.15* Hgb-10.2* Hct-29.0* MCV-92 MCH-32.3* MCHC-35.2* RDW-14.0 Plt Ct-157 [**2131-2-24**] 01:59AM BLOOD WBC-11.2* RBC-2.95* Hgb-9.6* Hct-26.9* MCV-91 MCH-32.6* MCHC-35.8* RDW-14.6 Plt Ct-141* [**2131-2-25**] 01:22AM BLOOD WBC-14.3* RBC-3.04* Hgb-10.1* Hct-27.8* MCV-91 MCH-33.2* MCHC-36.3* RDW-13.5 Plt Ct-200 [**2131-2-26**] 02:01AM BLOOD WBC-12.1* RBC-2.86* Hgb-9.7* Hct-26.6* MCV-93 MCH-33.7* MCHC-36.3* RDW-13.6 Plt Ct-232 [**2131-2-27**] 01:57AM BLOOD WBC-14.0* RBC-3.00* Hgb-10.0* Hct-28.2* MCV-94 MCH-33.2* MCHC-35.4* RDW-13.8 Plt Ct-262 [**2131-2-28**] 05:21AM BLOOD WBC-12.1* RBC-2.99* Hgb-9.4* Hct-28.5* MCV-95 MCH-31.4 MCHC-33.0 RDW-13.8 Plt Ct-329 [**2131-3-1**] 06:25AM BLOOD WBC-12.3* RBC-2.90* Hgb-9.5* Hct-27.8* MCV-96 MCH-32.6* MCHC-34.1 RDW-13.2 Plt Ct-342 [**2131-3-2**] 07:00AM BLOOD WBC-13.1* RBC-3.05* Hgb-9.6* Hct-29.2* MCV-96 MCH-31.6 MCHC-32.9 RDW-13.3 Plt Ct-466* [**2131-3-3**] 04:15AM BLOOD WBC-9.7 RBC-2.73* Hgb-8.5* Hct-25.7* MCV-94 MCH-31.2 MCHC-33.2 RDW-13.4 Plt Ct-414 [**2131-3-4**] 04:38AM BLOOD WBC-8.0 RBC-2.52* Hgb-8.3* Hct-23.8* MCV-95 MCH-32.8* MCHC-34.7 RDW-13.2 Plt Ct-425 [**2131-3-5**] 05:21AM BLOOD WBC-6.6 RBC-2.65* Hgb-8.6* Hct-25.2* MCV-95 MCH-32.6* MCHC-34.4 RDW-13.4 Plt Ct-497* [**2131-3-6**] 06:18AM BLOOD WBC-7.3 RBC-2.71* Hgb-8.7* Hct-25.6* MCV-94 MCH-32.2* MCHC-34.1 RDW-13.2 Plt Ct-566* [**2131-3-7**] 04:41AM BLOOD WBC-6.2 RBC-2.75* Hgb-8.7* Hct-25.7* MCV-93 MCH-31.5 MCHC-33.8 RDW-13.3 Plt Ct-509* [**2131-3-2**] 07:00AM BLOOD Neuts-89.6* Lymphs-8.0* Monos-1.4* Eos-0.8 Baso-0.2 [**2131-3-5**] 05:21AM BLOOD Neuts-78.8* Lymphs-13.7* Monos-5.2 Eos-2.0 Baso-0.3 [**2131-2-21**] 08:19PM BLOOD PT-13.69* PTT-25.9 INR(PT)-1.2* [**2131-2-22**] 02:03AM BLOOD PT-14.6* PTT-29.4 INR(PT)-1.3* [**2131-2-22**] 10:57AM BLOOD PT-15.8* PTT-32.0 INR(PT)-1.4* [**2131-2-22**] 04:19PM BLOOD Plt Ct-136* [**2131-2-23**] 02:07AM BLOOD PT-15.9* PTT-34.4 INR(PT)-1.4* [**2131-2-24**] 01:59AM BLOOD PT-15.5* PTT-33.7 INR(PT)-1.4* [**2131-2-25**] 01:22AM BLOOD PT-16.5* PTT-34.1 INR(PT)-1.5* [**2131-2-27**] 01:57AM BLOOD PT-20.1* PTT-51.8* INR(PT)-1.9* [**2131-2-28**] 05:21AM BLOOD PT-19.1* PTT-35.3* INR(PT)-1.8* [**2131-2-21**] 08:19PM BLOOD Glucose-128* UreaN-70* Creat-4.8*# Na-131* K-4.3 Cl-99 HCO3-20* AnGap-16 [**2131-2-22**] 02:03AM BLOOD Glucose-119* UreaN-70* Creat-4.5* Na-131* K-4.3 Cl-100 HCO3-18* AnGap-17 [**2131-2-22**] 10:57AM BLOOD Glucose-139* UreaN-61* Creat-4.1* Na-133 K-4.5 Cl-108 HCO3-18* AnGap-12 [**2131-2-22**] 04:19PM BLOOD Glucose-131* UreaN-63* Creat-4.1* Na-133 K-4.8 Cl-106 HCO3-17* AnGap-15 [**2131-2-22**] 11:29PM BLOOD Glucose-114* UreaN-60* Creat-3.8* Na-135 K-4.6 Cl-107 HCO3-19* AnGap-14 [**2131-2-23**] 02:07AM BLOOD Glucose-124* UreaN-63* Creat-3.8* Na-133 K-4.5 Cl-106 HCO3-18* AnGap-14 [**2131-2-23**] 02:36PM BLOOD Glucose-108* UreaN-60* Creat-3.2* Na-134 K-4.5 Cl-107 HCO3-17* AnGap-15 [**2131-2-24**] 01:59AM BLOOD Glucose-104 UreaN-63* Creat-2.9* Na-136 K-4.4 Cl-106 HCO3-20* AnGap-14 [**2131-2-24**] 03:07PM BLOOD Glucose-92 UreaN-57* Creat-2.1* Na-139 K-4.0 Cl-108 HCO3-21* AnGap-14 [**2131-2-25**] 05:52PM BLOOD Glucose-101 UreaN-45* Creat-1.2 Na-145 K-4.2 Cl-109* HCO3-27 AnGap-13 [**2131-2-26**] 02:01AM BLOOD Glucose-126* UreaN-41* Creat-1.1 Na-147* K-4.1 Cl-113* HCO3-30 AnGap-8 [**2131-2-28**] 05:21AM BLOOD Glucose-132* UreaN-28* Creat-0.8 Na-143 K-4.3 Cl-107 HCO3-33* AnGap-7* [**2131-3-1**] 06:25AM BLOOD Glucose-90 UreaN-26* Creat-0.9 Na-144 K-5.0 Cl-107 HCO3-31 AnGap-11 [**2131-3-2**] 07:00AM BLOOD Glucose-108* UreaN-28* Creat-1.0 Na-141 K-4.9 Cl-105 HCO3-28 AnGap-13 [**2131-3-3**] 04:15AM BLOOD Glucose-132* UreaN-25* Creat-0.9 Na-141 K-3.8 Cl-107 HCO3-29 AnGap-9 [**2131-3-4**] 04:38AM BLOOD Glucose-113* UreaN-23* Creat-0.8 Na-140 K-4.0 Cl-108 HCO3-29 AnGap-7* [**2131-3-5**] 05:21AM BLOOD Glucose-114* UreaN-20 Creat-0.7 Na-138 K-4.0 Cl-107 HCO3-28 AnGap-7* [**2131-3-6**] 06:18AM BLOOD Glucose-111* UreaN-17 Creat-0.8 Na-142 K-3.8 Cl-107 HCO3-28 AnGap-11 [**2131-3-7**] 04:41AM BLOOD Glucose-96 UreaN-16 Creat-0.7 Na-142 K-3.7 Cl-108 HCO3-26 AnGap-12 [**2131-2-21**] 08:19PM BLOOD ALT-26 AST-37 CK(CPK)-645* AlkPhos-73 TotBili-0.6 [**2131-2-22**] 02:03AM BLOOD ALT-30 AST-37 AlkPhos-75 TotBili-0.6 [**2131-2-22**] 11:29PM BLOOD CK(CPK)-274* [**2131-2-23**] 08:03AM BLOOD CK(CPK)-329* [**2131-2-23**] 05:21PM BLOOD CK(CPK)-265* [**2131-2-27**] 01:57AM BLOOD ALT-29 AST-21 AlkPhos-54 TotBili-0.5 [**2131-2-21**] 08:19PM BLOOD CK-MB-32* MB Indx-5.0 cTropnT-0.02* [**2131-2-22**] 11:29PM BLOOD CK-MB-10 MB Indx-3.6 cTropnT-0.04* [**2131-2-23**] 08:03AM BLOOD CK-MB-7 cTropnT-0.03* [**2131-2-23**] 05:21PM BLOOD CK-MB-5 cTropnT-0.03* [**2131-2-21**] 08:19PM BLOOD Albumin-2.4* Calcium-7.4* Phos-7.1*# Mg-3.2* [**2131-2-22**] 10:57AM BLOOD Calcium-5.8* Phos-6.8* Mg-2.5 [**2131-2-22**] 11:29PM BLOOD Calcium-7.5* Phos-6.3* Mg-2.4 [**2131-2-24**] 01:59AM BLOOD Calcium-8.1* Phos-5.8* Mg-2.5 [**2131-2-25**] 01:22AM BLOOD Calcium-7.8* Phos-4.4 Mg-2.1 [**2131-2-26**] 02:01AM BLOOD Albumin-1.9* Calcium-7.5* Phos-3.9 Mg-1.9 [**2131-2-27**] 01:57AM BLOOD Albumin-1.9* Calcium-7.6* Phos-2.8 Mg-1.7 [**2131-3-1**] 06:25AM BLOOD Calcium-7.3* Phos-3.7 Mg-1.7 [**2131-3-4**] 04:38AM BLOOD Calcium-7.1* Phos-3.7 Mg-1.8 [**2131-3-5**] 05:21AM BLOOD Calcium-7.1* Phos-3.6 Mg-2.2 [**2131-3-6**] 06:18AM BLOOD Calcium-7.3* Phos-3.9 Mg-1.8 [**2131-3-7**] 04:41AM BLOOD Calcium-6.9* Phos-3.5 Mg-1.9 [**2131-2-24**] 07:59AM BLOOD Vanco-6.1* [**2131-2-22**] 10:57AM BLOOD Cortsol-40.6* [**2131-2-25**] 10:33AM BLOOD freeCa-1.09* CT abd/pelvis [**2131-2-21**]: 1. High-grade bowel obstruction with transition point at the descending colon/sigmoid junction secondary to stricture at site of prior inflammation. 2. Right lower lung ground-glass opacity is stable since [**2124**] and does not require followup. CXR [**2-22**]: No pulmonary edema. Bibasilar atelectasis and moderate left pleural effusion. CXR [**2-24**]: FINDINGS: As compared to the previous radiograph, the monitoring and support devices are in unchanged position, except for the nasogastric tube that hasbeen slightly pulled back and could be advanced by several centimeters. The extent of the pre-existing left-sided pleural effusion is unchanged. Also unchanged is the left retrocardiac atelectasis. On the right, the pre-existing small pleural effusion has cleared, a small discoid atelectasis persists at the right lung base. There is no evidence of focal parenchymal opacities suggestive of pneumonia, no evidence of overhydration. CXR [**2-26**]: The cardiomediastinal silhouette and hilar contours are normal, the lungs are clear. The elevated left hemidiaphragm is unchanged since [**2124**]. Previously mentioned possible effusion and consolidation within the left lung base are related to the elevated left hemidiaphragm. There has been interval removal of endotracheal tube, NG tube. The left subclavian central line is unchanged. Brief Hospital Course: The patient was transferred from an OSH. He arrived at [**Hospital1 18**] and after a short period of supportive care with pressors and antibiotics it was decided that he was clinically deteriorating and was taken to the OR for total colectomy and end ileostomy. He tolerated the procedure well and was taken to the SICU. He remained in the ICU with supportive care. Major events and there dates in the ICU: [**2-21**]: resuscitation, intubation, Levophed, CT abd [**2-22**]: OR, vasopressin added, [**Last Name (un) **], resuscitation, bicarb, albumin, amio for RVR [**2-23**]: Off Levo, esophageal balloon placed [**2-24**]: Off vasopressin, esophageal balloon d/c'd, Lasix, restarted amio for AF w/RVR, CPAP/PSV, ileostomy matured [**2-25**]: extubated, Dilaudid PCA, Lasix gtt, started sips, started PO Lopressor & amio, amio gtt d/c'd, [**Last Name (un) **] d/c'd [**2-26**]: Nystatin S&S for thrush, d/c'[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2830**], started cipro for wound infection The patient was then transferred to the floor on [**2131-2-27**]. On the floor, he started tolerating a regular diet and PO pain medications. However, on [**2-28**] his abdomen became more distended and the patient became nauseous. He was reverted back to NPO status. He was also noted to have some drainage from the lower portion of his abdominal wound. A PICC line was placed for TPN use and TPN was started on [**2131-3-2**]. He began tolerating clear liquids again on [**3-4**], and then a regular diet on [**3-5**]. TPN was discontinued on [**3-6**] as he was tolerating a full regular diet. A nutrition consult was also initiated for the use of yogurt/probiotics, which he began eating in the evening of [**3-6**]. His PICC was removed prior to discharge. Urinary Retention: The patient had his foley catheter removed on [**3-4**]. However, he failed to void appropriately and was straigh-catheterized. After failing to void a second time, the foley was replaced and remained in place upon discharge. He was also restarted on his home flomax dose. Peripheral Edema: The patient was noted to have peripheral edema on the post-op state and was started on IV and then PO lasix. He actively diuresed significantally and began to return to his pre-op weight. However, he was still requiring PO lasix at dishcarge. Ostomy: His ostomy remained clean, dry and intact. Wound care: The inferior portion of his wound was draining serosanguinous fluid and was opened and probed. It did not appear infected, but cultures grew out yeast and he was started on Fluconazole. He completed a 7 day course. Small amounts of feculent drainage appeared in the wound , treated with dry packing. C. Diff colitis: after the operation, the patient remained on IV flagyl until [**3-7**] when it was stopped. He completed a 14 days course of antibiotics. A-fib: The patient was found to be in afib postoperatively on POD 1. He was started on an amio drip and converted to NSR. He was transitioned to PO amio when tolerating PO. Daily EKG's were checked to ensure that his QT interval was not lengthening. The patient was discharged to a rehab facility on [**2131-3-7**] with his staples, foley, and ostomy all in place. He was ambulatory and tolerating PO. His pain was well controlled. Medications on Admission: advair 500'', atenolol 25', ASA 325', Flomax 0.4' Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) inj Injection TID (3 times a day). 2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed. 3. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig: One (1) Inhalation B ID (). 4. Insulin Regular Human 100 unit/mL Solution Sig: One (1) injection Injection ASDIR (AS DIRECTED). 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 7. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO at bedtime. 14. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: Rehab Hospital Of [**Doctor Last Name **] Discharge Diagnosis: Toxic Megacolon secondary to Clostridium dificile colitis Septic Shock secondary to above Enterocutaneous fistula- low output Wound seroma Postoperative Atrial Fibrillation Peripheral edema - started lasix as inpatient Discharge Condition: Good Discharge Instructions: 1. Take your medicines as prescribed. 2. Diet: Regular, as tolerated, with ensure supplements at all meals, and Yogurt supplementation at all meals 3. Activity: as tolerated 4. Wound care: The ostomy should be changed as instructed by ostomy care nursing. The midline abdominal wound should be packed with wet-to-dry dressings twice a day. 5. If you develop any fever, chills, shortness of breath, abdominal distension, redness or swelling around your wound, abdominal pain, foul-smelling output from your wound, then please call our office or come to the Emergency Room. 6. The Foley catheter may be removed at rehab and the patient followed with bladder scans as deemed necessary. Followup Instructions: 1. Urology: You need to follow-up with your urologist given your difficulties urinating 2. Primary Care: You need to follow-up with your primary care doctor to determine whether to continue the amiodarone (started for postop AFib). 3. Dr. [**Last Name (STitle) **]: Please call his office to schedule a follow-up appointment. Completed by:[**2131-3-7**] Name: [**Known lastname 9663**],[**Known firstname **] J Unit No: [**Numeric Identifier 9664**] Admission Date: [**2131-2-21**] Discharge Date: [**2131-3-8**] Date of Birth: [**2057-12-10**] Sex: M Service: SURGERY Allergies: Zosyn Attending:[**First Name3 (LF) 203**] Addendum: Mr. [**Known lastname **] did not get discharged until [**2131-3-8**]. He remained at [**Hospital1 8**] for an additional day because there was feculent material leaking from his wound. It is believed that he has a fistula draining into his wound. His wound was observed and cared for as previously described in his discharge summary. His PICC line was removed prior to discharge. He was also continued on Flagyl 500mg PO q8hrs, which should be continued for a total of 7 more days. Discharge Disposition: Extended Care Facility: Rehab Hospital Of [**Doctor Last Name 5041**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 206**] MD [**MD Number(1) 207**] Completed by:[**2131-3-8**]

[ "112.0", "785.52", "998.6", "568.0", "557.0", "E878.3", "V15.82", "285.1", "V12.54", "401.9", "998.31", "788.20", "008.45", "496", "427.31", "038.3", "427.89", "518.81", "584.9", "995.92", "782.3" ]

icd9cm

[ [ [] ] ]

[ "99.15", "96.71", "38.93", "45.82", "46.20", "54.59" ]

icd9pcs

[ [ [] ] ]

18144, 18370

11135, 13520

289, 378

16192, 16199

3479, 11112

16940, 18121

2677, 2733

14523, 15838

15950, 16171

14449, 14500

16223, 16406

2748, 2750

226, 251

16419, 16917

3116, 3460

406, 1789

2765, 3100

1811, 2583

2599, 2661

70,832

183,102

41055

Discharge summary

report

Admission Date: [**2180-12-8**] Discharge Date: [**2180-12-21**] Date of Birth: [**2097-6-8**] Sex: M Service: MEDICINE Allergies: Oxycodone Attending:[**First Name3 (LF) 7299**] Chief Complaint: Transfer from OSH for gallstone pancreatitis Major Surgical or Invasive Procedure: ERCP with CBD dilatation, balloon extraction of a small stone, and sphincterotomy on [**2180-12-11**]. History of Present Illness: 83 year-old male with a history of ischemic cardiomyopathy (EF 10-20%), s/p mechanical AVR on coumadin [**2152**], s/p biventricular ICD, HTN, HL, thrombocytosis, s/p CCY in the [**2162**] who transferred from [**Hospital6 33**] with gallstone pancreatitis. The patient states that 2 days prior to admission he developed 5 episodes of soft, semi-formed, dark brown bowel movements. He then developed epigastric abdominal pain without radiation. The pain was rated [**5-11**], constant "irritating" pain that was worse with movement. He denied worsening with food. He stated he felt warm on occasions and some chills, but no fevers. He also had some nausea, but no vomiting. He presented to [**Hospital **] ED today. At the OSH labs were remarkable for a lipase in the 6566 and CT that showed gallstone pancreatitis. He was given IVF at 150cc/hr, morphine & zofran and transferred to [**Hospital1 18**] for further management. His INR was 2.5. In the ED, 97.1 68 95/64 16 98%. The patient's labs were significant for lipase of 2688, TBili 2.8 with otherwise normal LFT. His Hct was 33.1, WBC 9.9 with normal differential and lactate of 1.2. He was empirically covered with Zosyn in the ED. His creatinine was 1.3 on arrival. The OSH CT abd/pelvis was re-read and showed a 6mm x 8mm calcified stone at the ampulla of Vater resulting in dilation of the intra & extrahepatic ducts and pancreatic duct. There was also a 24mm cystic lesion of the uncinate process of the pancreas as well as a 8mm lesion in the proximal body. He was given morphine & zofran for his pain and nausea. He was given 1L IVF in the ED. ERCP was contact[**Name (NI) **] and plan for ERCP when INR is 1.5 unless develops signs of cholangitis at which point they would take him emergently. Past Medical History: Mechanical Aortic Valve on coumadin since [**2152**] Ischemic Cardiomyopathy (EF 10-20%) BiVentricular ICD [**2177**] Atrial Fibrllation HTN/Hyperlipid Thrombocytosis on hydroxyurea BPH s/p Cholecystectomy [**2162**] Social History: He is a retired postal worker, widow and lives alone in a Senior Center. He has one daughter. Performs all his ADLs. 1ppd x 15yrs and quit at age 30. 2 drinks per week. No IVDU Family History: Brother and daughter with DM Father with HTN Physical Exam: Vitals: 97.1 68 95/64 16 98% GEN: non-toxic appearing, comfortable, no acute distress HEENT: EOMI, PERRL, sclera mild icterus, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, mechanical heart sounds, III/VI SEM normal S1 S2 PULM: slight crackles at the bases, but otherwise clear ABD: Soft, + epigastric tenderness, no RUQ pain -[**Doctor Last Name 515**] sign. NT, ND, +BS, EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Patellar DTR +1. Plantar reflex downgoing. No gait disturbance. No cerebellar dysfunction. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: . Radiology CT ABD & PELVIS WITH CONTRAST Study Date of [**2180-12-8**] 8:09 AM IMPRESSION: 1. 8-mm stone in the ampulla of Vater with dilation of the common bile duct and both pancreatic ducts, suggestive of obstruction at the ampulla of Vater. 2. Multiple pancreatic cysts, which given size should be evaluated with follow-up ultrasound in 6 months. 3. Splenomegaly 4. Right 2.3-cm parapelvic renal cyst which could be further evaluated with ultrasound if it has not been evaluated previously. 5. Right bladder diverticula. 6. Colonic diverticulosis without evidence for inflammation. . ERCP Impression: Cannulation of the biliary duct was performed with a sphincterotome using a free-hand technique A moderate diffuse dilation was seen at the biliary tree with the CBD measuring 14 mm. There was a filling defect in the distal CBD. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. A small stone was extracted with a balloon catheter. Excellent drainage of bile and contrast was noted [**2180-12-8**] 07:10AM BLOOD WBC-9.9 RBC-4.19* Hgb-10.7* Hct-33.1* MCV-79* MCH-25.6* MCHC-32.4 RDW-17.6* Plt Ct-365 [**2180-12-18**] 07:15AM BLOOD WBC-10.4 RBC-3.06* Hgb-7.9* Hct-24.5* MCV-80* MCH-25.7* MCHC-32.2 RDW-18.8* Plt Ct-399 [**2180-12-21**] 08:05AM BLOOD WBC-7.7 RBC-3.05* Hgb-8.0* Hct-24.7* MCV-81* MCH-26.2* MCHC-32.4 RDW-18.1* Plt Ct-432 [**2180-12-21**] 08:05AM BLOOD PT-22.2* PTT-34.8 INR(PT)-2.1* [**2180-12-20**] 07:35AM BLOOD Glucose-94 UreaN-23* Creat-1.6* Na-137 K-3.3 Cl-102 HCO3-27 AnGap-11 [**2180-12-17**] 07:10AM BLOOD ALT-49* AST-47* AlkPhos-183* TotBili-2.6* [**2180-12-20**] 07:35AM BLOOD ALT-26 AST-23 AlkPhos-122 TotBili-1.9* [**2180-12-8**] 07:10AM BLOOD Lipase-2688* [**2180-12-15**] 06:55AM BLOOD Lipase-76* [**2180-12-8**] 07:10AM BLOOD Albumin-4.0 Iron-29* [**2180-12-8**] 07:10AM BLOOD calTIBC-343 Hapto-99 Ferritn-81 TRF-264 [**2180-12-21**] 04:52PM BLOOD Hgb-8.8* calcHCT-26 Brief Hospital Course: Mr. [**Known lastname 65584**] was admitted with gallstone pancreatitis and was treated with IV antibiotics and bowel rest while his INR came down over 48hrs. He was taken for ERCP with stone extraction & sphincterotomy on [**12-11**]. 24 hours after his procedure he was restarted on anticoagulation given his mechanical aortic valve and his post-procedure course was complicated by a slow GI bleed and bile duct obstruction thought to be a post-sphincterotomy site hematoma. Pt was treated with IV unasyn and supportive care. He had spontaneous resolution of bleeding after stopping Aspirin and only required a single prbc transfusion. He developped volume overload after initial fluid resucitation due to his baseline systolic CHF (EF 15%) and required IV diuresis. He was maintained on carvedilol and a decreased dose of lisinopril. His INR was maintained between [**1-4**] for his mechanical valve and it was 2.1 on the day of discharge, hct was 26. Pt was instructed to continue Coumadin 2.5mg daily with the plan for follow up labs to be drawn on [**12-25**]. He was instructed to stop taking Aspirin until he is seen in follow up by his primary care physician. . # Pt was monitored on telemetry due to his ICD and baseline ischemic CMP. He was noted to be having abnormal pacer spikes. This was reviewed by EP consult team on [**12-8**] and they felt that there was nothing to worry about but some adjustments were made to sensing parameters on his device. . #Incidental findings on CT that will need follow-up, a letter has been sent to PCP 1) Multiple pancreatic cysts - recommend f/u in 6 months 2) right parapelvic renal cyst, incompletely characterized but likely simple cyst Medications on Admission: Coumadin 2.5mg daily Hydroxyurea 500mg daily ASA 81mg daily Carvedilol 3.125 [**Hospital1 **] Finasteride 5mg daily Fluticasone 2 sprays daily Folic Acid 1mg daily Lasix 40mg daily Lisinopril 20mg daily Loratadine 10mg daily Simvastatin 40mg qhs Tamulosin 0.4mg daily Albuterol/Ipratropium 2 puff q4:prn . Discharge Medications: 1. hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 3. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 8. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day. 11. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 12. Combivent 18-103 mcg/Actuation Aerosol Sig: [**12-3**] Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 13. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day: DO NOT RESTART UNTIL YOU ARE SEEN BY YOUR PCP [**Last Name (NamePattern4) **] [**2180-12-26**]. 14. Outpatient Lab Work Please draw CBC, PT & INR on [**2180-12-25**] and forward results to Dr. [**Last Name (STitle) 89521**] at fax # [**Telephone/Fax (1) 39969**] 15. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Primary: Gallstone Pancreatitis Acute systolic CHF Post sphincterotomy bleed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. No pain with eating a regular diet and no abdominal tenderness on physical exam. Discharge Instructions: You were admitted with abdominal pain and found to have gallstone pancreatitis. You were transferred to [**Hospital1 18**] on IV antibiotics and taken for ERCP with stone removal and stenting on [**12-11**]. Due to your mechanical heart valve we needed to restart your anticoagulation after the procedure. Unfortunately, you developed bleeding after your procedure and we had to keep you hospitalized for a few more days. Eventually your bleeding resolved but you did require a transfusion and we have started you on Iron replacement to help rebuild your blood counts. You will need to monitor your stools daily and return to the hospital if you note any significant bleeding. Please continue taking the Coumadin 2.5mg daily and you will have labs drawn on Monday [**12-25**] and the results will be forwarded to Dr.[**Name (NI) 89522**] office. . We have made the following changes to your medications: 1. Do not take Aspirin until you are seen by your primary care physician next week 2. We have decreased your Lisinopril to 5mg daily 3. Start taking Ferrous Sulfate 325mg daily Otherwise, you should resume taking your medication as you were taking it prior to admission. Please make sure to call your PCP tomorrow morning to reschedule your appointment with him Followup Instructions: Please call Dr.[**Doctor First Name 89523**] office tomorrow morning at [**Telephone/Fax (1) 89524**]. We had scheduled an appt for your on Tuesday [**12-19**] at 12:15pm but this will need to be rescheduled for early next week. Address: [**Location (un) **], [**Apartment Address(1) 1427**], [**Location (un) **],[**Numeric Identifier 31449**] Phone: [**Telephone/Fax (1) **]

[ "V43.3", "401.9", "599.0", "787.91", "238.71", "414.8", "285.1", "428.23", "998.11", "577.0", "584.9", "428.0", "276.0", "V53.32", "427.31", "593.2", "E878.8", "272.4", "577.2", "576.2", "V58.61", "600.00", "574.50", "998.12" ]

icd9cm

[ [ [] ] ]

[ "89.49", "51.88", "51.85" ]

icd9pcs

[ [ [] ] ]

9027, 9078

5545, 7241

315, 420

9199, 9199

3559, 5522

10727, 11108

2661, 2708

7598, 9004

9099, 9178

7267, 7575

9431, 10309

2723, 3540

10338, 10704

231, 277

448, 2209

9214, 9407

2231, 2450

2466, 2645

19,104

146,788

53185+59505

Discharge summary

report+addendum

Admission Date: [**2112-7-13**] Discharge Date: [**2112-7-22**] Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Known firstname 11415**] Chief Complaint: Right hip failed hardware Major Surgical or Invasive Procedure: [**2112-7-18**]: Removal of hardware right hip, cemented hemiarthroplasty History of Present Illness: Mr. [**Known lastname **] is an 85 year old man who suffered a right hip fracture [**2111-9-1**]. Unfortunately this went on to cut out and he presented to the [**Hospital1 **] [**Location (un) 620**] for evaluation. Due to his vascular history he was transferred to the [**Hospital1 18**] for further care and surgery. Past Medical History: History of alcoholism type 2 diabetes with neuropathy colonic polyps hypertension BPH s/p TURP GERD coronary artery disease GI bleed in [**12-10**] diverticulosis High cholesterol Right hip fx [**8-11**] MRSA skin ulcer [**10-11**] R femoral artery bypass to dorsalis pedalis [**7-11**] c/b stenosis in setting of R hip ORIF s/p revision bypass by Dr. [**Last Name (STitle) 1391**] in [**9-11**] Social History: EtOH abuse Tob - 40 pack year history d/c'ed in [**2088**] Lives alone; his wife died approximately one year ago Used to be an airline pilot, has flown all over the world Family History: n/a Physical Exam: Upon discharge: Alert and oriented, NAD 99 130/72 74 18 97% RA RRR no m/r/g split S2 vs S3? CTAB soft NT/ND + BS right thigh incision c/d/i unable to palpate DP b/l pt is unable to flex at his R ankle no sensation at webspace R, medial R foot left foot sensation intact, able to flex/extend ankle Pertinent Results: [**2112-7-19**] 06:27AM BLOOD WBC-13.5* RBC-2.86* Hgb-9.3* Hct-26.3* MCV-92 MCH-32.6* MCHC-35.5* RDW-21.6* Plt Ct-286 [**2112-7-13**] 06:32PM BLOOD WBC-5.6 RBC-2.84* Hgb-10.0* Hct-29.9* MCV-105*# MCH-35.1*# MCHC-33.3 RDW-17.6* Plt Ct-238 [**2112-7-22**] 05:15AM BLOOD Glucose-145* UreaN-20 Creat-0.8 Na-141 K-3.9 Cl-107 HCO3-28 AnGap-10 [**2112-7-18**] 03:50PM BLOOD Glucose-238* UreaN-30* Creat-1.5* Na-144 K-5.1 Cl-107 HCO3-24 AnGap-18 [**2112-7-13**] 06:32PM BLOOD Glucose-161* UreaN-22* Creat-0.9 Na-140 K-4.2 Cl-103 HCO3-29 AnGap-12 [**2112-7-22**] 05:15AM BLOOD Albumin-3.0* Calcium-8.5 Phos-2.3* Mg-1.8 Pertinent XR data: NCHCT: no acute hemorrhage or infact CXR [**7-20**]: Cardiac size is normal. The aorta is elongated. Mild bibasilar interstitial opacities have increased from prior study ([**2112-7-18**]) greater on the left side, most likely correspond to atelectasis. There is no pneumothorax. Pelvic XR [**7-13**]: There is a short intramedullary rod with proximal gamma nail within the proximal right femur. There is a fracture through the right femoral head and neck and the superior portion of the gamma pin is inside of the right hip joint space and resting upon the acetabular roof. The fracture involving the lesser trochanter as well as subcapitally within the right femur. The rest of the right femur is unremarkable without acute fractures. There is no knee joint effusion. Extensive vascular calcifications of the femoral vessels. The left hip is intact. Degenerative changes of the lower lumbar spine are visualized. XR [**7-18**]: A single intraoperative radiograph of the right hip demonstrates placement of a right hip prosthesis. The prosthesis appears to be a bipolar prosthesis. There is a long femoral stem. A lesser trochanteric fracture fragment is seen adjacent to the proximal aspect of the femur. Arterial Duplex R leg: Tight stenosis in the proximal right femoral to dorsalis pedis bypass graft. The degree of stenosis appears to be worse as compared to the Doppler scan obtained a year ago. Brief Hospital Course: Mr. [**Known lastname **] presented as a direct admit to the [**Hospital1 18**] on [**2112-7-13**] via transfer from [**Hospital1 **] [**Location (un) 620**]. He was found to have a right hip hardware that had failed. Due to his vascular history of losing pulses in the right leg after the initial right hip surgery plans were made to have the surgery at the [**Hospital1 18**]. Given his comorbidities, the medicine team was consulted prior to surgery. They recommended that the patient have a persantine stress MIBI, which revealed a mild partially reversible myocardial perfusion defect in the inferior wall, and with global hypokinesis with LVEF 44%. With these results, as per medicine the patient was seen by cardiology, who felt that his exercise capacity was sufficient for surgery. They maximized his betablocker, ace-inhibitor, and started him on simvastatin. On [**2112-7-18**] he was taken to the operating room and underwent a removal of hardware of the right hip and right cemented hemiarthroplasty. He tolerated the procedure well, was extubated, transferred to the recovry room, and then to the floor. On the floor, however, he was noted to have an altered mental status and was hypotensive with an elevated lactate of 6.4, and noted to be in acute renal failure with a creatinine of 1.5 up from 0.9. ECG did not reveal any ST elevations or depressions, and his troponin bumped to 0.02. The patient's mental status improved with .4 mg of narcan. He was transferred to the trauma intensive care unit for further care. He was transfused with 1 unit of packed red blood cells due to acute blood loss anemia in the setting of acute renal failure. His labs returned to baseline (Creatinine to 0.8, lactate to 1.3) and on [**2112-7-19**] he was transfused from the trauma intensive care unit. On [**2112-7-19**] he was again transfused with 2 units of packed red blood cells due to acute blood loss anemia. On [**2112-7-20**] he was again transfused with 2 units of packed red blood cells due to acute blood loss anemia; his H/H on the day of discharge was 10.7 and 31.0. In the setting of his hypotension and lactic acidosis the patient was noted to be poorly perfusing his extremities. Vascular surgery was again consulted, and a arterial duplex study of the right lower extremity was repeated. This revealed worsening stenosis in the proximal right femoral to dorsalis pedis bypass graft. The patient will be followed by vascular as an outpatient for a likely repeat angiogram of the right leg. The patient was again noted to be disoriented upon return to the floor from the ICU. Medicine saw the patient, and recommended discontinuing the metformin in the setting of acute renal failure. He also received a urine analysis, chest x-ray, and non-contrast head CT for the work-up of his delerium, all of which were negative. His narcotics were discontinued, he was given more IVF, and in the setting of the above his mental status returned to baseline, the delerium thought secondary to a combination of narcotics and hypotension. He was also seen by physical therapy to improve his strength and mobility. Of note, the patient remains unable to flex his right ankle, and has a loss of sensation at the dorsal webspace and the medial side of his right foot, both thought secondary to nerve injury in the setting of the surgery. The patient was placed in protective, flexed boots bilaterally, for the above and as he is at high risk for ulcers. The rest of his hospital stay was uneventful with his lab data and vital signs within normal limits and his pain controlled. He is being discharged today in stable condition. Medications on Admission: lisinopril 20mg daily gabapentin 300mg daily Prilosec 20mg daily ASA 81mg daily Toprol XL 25mg daily Vit B12 100 mcg daily glipizide metformin 500mg [**Hospital1 **] oxycodone, docusate, valium prn Regular insulin sliding scale Discharge Medications: 1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily) as needed for GERD. 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily) as needed for CAD. 4. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 8. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily) for 4 weeks. 9. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 14. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Location (un) 1036**] - [**Location (un) 620**] Discharge Diagnosis: Failed right hip hardware s/p removal of hardware with cemented hemiarthoplasty Acute blood loss anemia Acute renal failure Lactic acidosis Post operative delerium - resolved Inability to flex right foot (likely nerve damage) Discharge Condition: Stable Discharge Instructions: Continue to be weight bearing as tolerated on your right leg Continue your lovenox as instructed for a total of 4 weeks after surgery Please resume all your home medications as prescribed by your doctor If you notice any increased redness, drainage, or swelling, or if you have a temperature greater than 101.5, please call the office or come to the emergency department. Physical Therapy: Activity: Activity as tolerated Right lower extremity: Full weight bearing Left lower extremity: Full weight bearing antereior hip precautions Treatments Frequency: Staples/sutures out 14 days after surgery Dry sterile dressing daily or as needed for drainage Followup Instructions: Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in orthopaedics in 2 weeks, please call [**Telephone/Fax (1) 1228**] to schedule that appointment. Please follow up with Dr. [**Last Name (STitle) 1391**] of vascular surgery, [**Telephone/Fax (1) 109494**] for a repeat angiogram and evaluation of your right leg. [**Known firstname **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**] Completed by:[**2112-7-22**] Name: [**Known lastname 17957**],[**Known firstname 651**] W. Unit No: [**Numeric Identifier 17958**] Admission Date: [**2112-7-13**] Discharge Date: [**2112-7-22**] Date of Birth: [**2027-5-18**] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Known firstname 7332**] Addendum: Pt must wear foot brace on right when walking to prevent falling. Pt should have boots on in bed to prevent ulcer formation. Pt needs encouragement to move to prevent ulcer formation. Discharge Disposition: Extended Care Facility: [**Location (un) 1132**] - [**Location (un) 407**] [**Known firstname 651**] [**Last Name (NamePattern1) 7334**] MD, [**MD Number(3) 7335**] Completed by:[**2112-7-22**]

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icd9cm

[ [ [] ] ]

[ "81.52", "99.04" ]

icd9pcs

[ [ [] ] ]

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3753, 7410

292, 369

9223, 9232

1685, 3730

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227, 254

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397, 720

742, 1139

1155, 1327

2,457

135,882

54065

Discharge summary

report

Admission Date: [**2139-10-29**] Discharge Date: [**2139-11-1**] Date of Birth: [**2060-2-16**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 56114**] Chief Complaint: Endometrial cancer Major Surgical or Invasive Procedure: Total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, pelvic lymph node dissection History of Present Illness: 79-year-old gravida 3, para 2-0-1-2 who presents following referral by Dr. [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) **] following a [**2139-10-2**] endometrial biopsy confirming a grade 1 endometrial cancer. She was seen in the emergency department [**2139-9-30**] for an episode of postmenopausal bleeding. The patient reports that this is the first time she has had any vaginal bleeding since the age of 40 when she reports she underwent spontaneous menopause. An ultrasound at that time revealed a uterus measuring 7.7 x 4.3 x 4.8 cm with a thickened endometrial cavity heterogenous in appearance measuring up to 26 mm. Ovaries were not seen bilaterally. Past Medical History: GYN HISTORY: LMP age 40. Menarche age 13. Reports never having had a Pap smear. Last mammogram [**2136-12-20**], [**Hospital1 **]-RADS 1. OB HISTORY: G3, P2-0-1-2. SVD x2, no complications. SAB x1. PAST MEDICAL HISTORY: 1. COPD. 2. Type 2 diabetes. 3. Hypertension. 4. History of pulmonary embolism in [**2129**]. 5. Peripheral vascular disease. PAST SURGICAL HISTORY: 1. Brain aneurysm clipping in [**2113**]. 2. Four-vessel CABG in [**2128**]. 3. Cataract surgery. Social History: The patient lives with her husband and her daughter. She moved from her native [**Country 5976**] in [**2093**]. She speaks both Spanish and English. She reports having smoked since the age of 20 and currently smokes four to five cigarettes per day. She denies alcohol or drug use of any kind Family History: The patient reports a mother and a sister with breast cancer. There is some question as to whether another sister had uterine cancer Physical Exam: On [**2139-10-16**] by Dr. [**First Name (STitle) **]: Physical Exam: GENERAL: She is in no acute distress. Her affect is appropriate. NECK: Supple. There is no cervical/ supraclavicular lymphadenopathy. HEART: Regular rate and rhythm. ABDOMEN: Abdomen is soft, nontender, nondistended No masses/ hernias. EXTREMITIES: Lower extremities without edema. PELVIC: External genitalia unremarkable. Introitus smooth. Vaginal mucosa smooth. Parous cervix, no lesions. Normal size uterus, no adnexal masses.Normal rectal tone, no rectal masses. Exam on discharge: Physical Exam: GENERAL: She is in no acute distress. Her affect is appropriate. HEART: Regular rate and rhythm. LUNGS: decreased breath sounds but clear to auscultation b/l ABDOMEN: +BS, abdomen is soft, appropriately tender, mildly distended. EXTREMITIES: Lower extremities without edema. Nontender. Pertinent Results: [**2139-10-31**] WBC-9.8 RBC-3.14* Hgb-9.2* Hct-28.3* MCV-90 MCH-29.3 MCHC-32.6 RDW-16.1* Plt Ct-146* [**2139-10-30**] WBC-12.1* RBC-3.37* Hgb-9.9* Hct-30.5* MCV-91 MCH-29.4 MCHC-32.4 RDW-16.0* Plt Ct-168 [**2139-10-29**] WBC-17.6*# RBC-4.04* Hgb-11.6* Hct-36.8 MCV-91 MCH-28.7 MCHC-31.5 RDW-16.0* Plt Ct-175 [**2139-10-29**] Neuts-96* Bands-1 Lymphs-1* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2139-10-31**] Glucose-103* UreaN-19 Creat-1.0 Na-140 K-3.9 Cl-104 HCO3-31 AnGap-9 [**2139-10-30**] Glucose-133* UreaN-26* Creat-1.1 Na-144 K-4.4 Cl-106 HCO3-28 AnGap-14 [**2139-10-29**] Glucose-210* UreaN-25* Creat-1.2* Na-143 K-4.7 Cl-102 HCO3-32 AnGap-14 [**2139-10-31**] Calcium-8.7 Phos-2.4*# Mg-2.7* [**2139-10-30**] Calcium-8.3* Phos-4.3 Mg-2.9* [**2139-10-29**] Calcium-9.1 Phos-4.6* Mg-3.1* [**2139-10-29**] BLOOD Type-ART pO2-205* pCO2-56* pH-7.37 calTCO2-34* Base XS-5 [**2139-10-29**] BLOOD Type-[**Last Name (un) **] pO2-43* pCO2-76* pH-7.27* calTCO2-36* Base XS-4 [**2139-10-29**] Lactate-0.9 [**2139-10-29**] Urine Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.022, Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG, URINE RBC-9* WBC-2 Bacteri-FEW Yeast-NONE Epi-0 CXR, [**2139-10-29**]: Subcutaneous emphysema in the upper right abdominal wall and lower chest is decreasing. Contour of the right lung base suggests at least a small right subpulmonic effusion or given the appropriate clinical circumstances a subphrenic collection. Lungs are clear. Heart is top normal size. No pneumothorax. Brief Hospital Course: Ms. [**Known lastname **] was underwent total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, pelvic lymph node dissection for endomterial cancer on [**2139-10-29**]. Please see Dr.[**Doctor Last Name 90756**] operative note for full details. Post-operatively she was noted to have increased work of breathing while and was hypoxic after extubation. An ABG was attempted in the PACU and failed. She was placed on BiPap with excellent oxygenation. She came to the ICU where she was conversant and comfortable with the mask on. Within 30 minutes she was transitioned from 4L to 2L NC to RA with excellent Sats throughout. ABG revealed intact oxygen exchange. She was observed overnight and called out to the floor on POD #1. . She was discharged from the [**Hospital Unit Name 153**] on POD#1. Once arriving on the floor she was able to tolerate a regular diet, ambulate and control her pain with oral pain medications. She was able to void and returned to her baseline incontinence once her foley catheter was removed. On POD2 she it was attempted to wean her off of O2 unsuccessfully. She would desaturate on room air to 89%. This was likely secondary to her COPD, for which she is not on home oxygen. She was not having any subjective shortness of breath or chest pain and would improve with nebulizers. On POD3 she was successfully weaned off of oxygen to room air with O2 saturation >94%. She was discharged in good condition on POD3 with follow-up. Medications on Admission: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*60 Capsule(s)* Refills:*2* 2. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [**12-21**] Inhalation Q6H (every 6 hours). 6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. simvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 9. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*60 Capsule(s)* Refills:*2* 2. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [**12-21**] Inhalation Q6H (every 6 hours). 6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. simvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 9. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Tylenol Extra Strength 500 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain: do not exceed 4000 mg daily. Disp:*50 Tablet(s)* Refills:*1* 11. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*45 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Endometrial cancer, final pathology pending Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call [**Telephone/Fax (1) 2806**]. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], [**First Name3 (LF) **] Phone:[**Telephone/Fax (1) 5777**] Date/Time:[**2139-11-27**] 11:00 [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DO 16-ADL Completed by:[**2139-11-3**]

[ "403.90", "285.9", "585.9", "496", "V45.81", "272.4", "414.00", "250.00", "182.0" ]

icd9cm

[ [ [] ] ]

[ "40.29", "54.25", "65.63", "68.41" ]

icd9pcs

[ [ [] ] ]

8085, 8091

4621, 6098

338, 435

8179, 8179

3032, 4598

9424, 9793

1990, 2124

6963, 8062

8112, 8158

6124, 6940

8330, 9020

9035, 9401

1558, 1661

2721, 3013

280, 300

463, 1152

2706, 2706

8194, 8306

1403, 1535

1677, 1974

63,116

118,462

52208

Discharge summary

report

Admission Date: [**2102-10-16**] Discharge Date: [**2102-10-18**] Date of Birth: [**2045-6-4**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2782**] Chief Complaint: Symptomatic bradycardia Major Surgical or Invasive Procedure: None History of Present Illness: 57 y/o w/ dilated cardiomyopathy, afib, alcoholic cirrhosis, COPD, ESRD, presented from hemodialysis with shortness of breath. EMS was called and ECG showed wide complex bradycardia w/ bifascicular block without p waves. He denied chest pain. . In the ED labs were notable for K 6.5, HCO3 20 and lactate 2.3. Heart rates were initially 30-40 bpm with SBP >100. They gave him 2gm calcium, atropine 1mg and glucagon 1mg without effect. They then repeated calcium 2gm x2, with improvement in heart rate to 70s. SBP >100. 10 units of regular and 1 unit d50 also given. 1L of NS was given. The renal fellow was contact[**Name (NI) **] and there are plans to initiate urgent hemodialysis. Vitals prior to transfer were 71, 111/65 20 94% on RA, afebrile. Access includes 18 and 20G and tunneled line. . On arrival to the MICU, started on dialysis. . 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: - CKD - baseline unclear ?in [**3-23**].5 range - Afib usually on coumadin. - COPD on 2-4L O2 at rehab - EtOH cirrhosis. History of hepatic encephalopathy. Had transjugular liver biopsy at [**Hospital1 112**] on [**11-23**]. - Congestive heart failure - R heart failure with TR (?due to pericardial disease) - recurrent LE cellulitis; recently on a course of IV vancomycin through [**2100-11-17**]. Had a hematoma evacuated on [**2100-11-21**]. - HTN - Morbid obesity - Lymphedema of lower extremities - h/o idiopathic constrictive pericarditis s/p pericardial stripping in [**2083**] - Psoriasis - History of MRSA cellulitis Social History: Currently living with mother and sister in [**Location **]. On disability. Smoker- 1/2-1 pack daily. denies EtOH/drug use Family History: noncontributory Physical Exam: ADMISSION EXAM: Vitals: T-96.7, HR-71, BP-119/35, RR-28, 94% on 2L. General: Alert, oriented, no acute distress 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: bilateral 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 Pertinent Results: ADMISSION LABS: [**2102-10-16**] 04:20PM BLOOD WBC-9.3 RBC-3.79* Hgb-12.3*# Hct-36.6* MCV-97# MCH-32.5*# MCHC-33.6# RDW-15.1 Plt Ct-158 [**2102-10-16**] 04:20PM BLOOD Neuts-78.5* Lymphs-12.4* Monos-5.2 Eos-3.2 Baso-0.7 [**2102-10-16**] 04:20PM BLOOD Glucose-147* UreaN-96* Creat-8.9*# Na-131* K-9.9* Cl-94* HCO3-20* AnGap-27* [**2102-10-16**] 04:20PM BLOOD cTropnT-0.15* [**2102-10-16**] 04:20PM BLOOD Calcium-10.1 Phos-10.8*# Mg-2.8* [**2102-10-16**] 04:20PM BLOOD Digoxin-2.6* [**2102-10-16**] 04:28PM BLOOD pH-7.32* Comment-GREEN TOP [**2102-10-16**] 04:28PM BLOOD freeCa-1.04* CXR [**10-16**]: Moderate pulmonary edema, which may be cardiogenic or uremic in etiology. TTE [**10-17**]: The left atrium is markedly dilated. The right atrium is markedly dilated. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be excluded. Overall left ventricular systolic function may be mildly depressed but views are suboptimal for assessment of wall motion. The right ventricular cavity is mildly dilated with depressed free wall contractility. The aortic valve leaflets (3) are mildly thickened. Probably at least moderate (2+) eccentric aortic regurgitation is seen (views suboptimal). The aortic regurgitation jet is eccentric. The mitral valve leaflets are mildly thickened. There is moderate thickening of the mitral valve chordae. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2100-12-11**], the aortic regurgitation is new. Discharge labs: [**2102-10-18**] 06:13AM BLOOD WBC-6.9 RBC-3.47* Hgb-11.4* Hct-33.3* MCV-96 MCH-32.7* MCHC-34.1 RDW-15.0 Plt Ct-112* [**2102-10-18**] 06:13AM BLOOD Glucose-68* UreaN-30* Creat-4.5* Na-132* K-4.2 Cl-91* HCO3-29 AnGap-16 [**2102-10-18**] 06:13AM BLOOD Calcium-9.0 Phos-5.9*# Mg-2.0 Brief Hospital Course: This is a 57 year old male with a history of dilated cardiomyopathy, afib, alcoholic cirrhosis, COPD, ESRD, presented from hemodialysis with SOB and symptomatic wide-complex bradycardia from hyperkalemia. . #.severe hyperkalemia. Wide complex bradycardia with no P-waves. He was at dialysis on the day of admission, but before dialysis EM was called due to SOB and weakness. The hyperkalemia is most likely due to ESRD and poor dietary compliance, but other less likely causes include MI and rhadomyolysis. Was given insulin, glucagon, D50 with improvement in the ED and transfered to the MICU for urgent dialysis. Repeat potassium after dialysis was 5.0. The patient refused repeat EKG. Upon transfer to the floor, K stable approximately 4 x 2 with plan for d/c to dialysis. . #. CKD. Unclear etiology, but possibly due to HTN and poor compliance. No h/o DM. Appeared fluid overloaded on exam and by CXR. Underwent urgent HD on [**10-16**], and had HD again on [**10-17**]. Discharged to dialysis. . #.EKG changes: Likley related to hyperkalemia, also dig level slightly elevated to 2.6. Patient underwent urgent dialysis, with improvement in potassium and cardiac rhythm. Dig held. On discharge digoxin was restarted at lower dose of 0.125 mg Monday, Wednesday, and Friday. . #. Dilated cardiomyopathy: Unclear etiology. History of HTN and non-compliance, and could be the etiology of ESRD. TTE showed possible mildly depressed LV systolic function, but views were suboptimal. Did show RV dilation with depressed free wall contractility, RA and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1915**]. Patient has at least moderate (2+) eccentric AR, which is new. Given recent line infection at OSH, would have some concern for prior vegetation leading to new onset AR. Patient afebrile, and blood cultures from admission were pending upon call out. . #. h/o afib-on metoprolol: Held metoprolol in the setting of bradycardia. Also held amiodarone. Plan to restart as BP will allow, as patient required metoprolol, amiodarone, and digoxin for very difficult to control Afib. Per nephrologist Dr. [**Last Name (STitle) 4883**], patient should be continued on digoxin, but at decreased dose (3x/week rather than daily). On discharge amiodarone was discontinued and metoprolol was continued. Also started aspirin 81 mg daily. . #. COPD: Continue Advair, nebs prn. Medications on Admission: metoprolol succinate XL 25mg amiodarone 200mg daily Advair ProAir digoxin 125 mcg daily Discharge Medications: 1. Aspirin Low Dose 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:*2* 2. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 3. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**1-22**] Puffs Puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 5. digoxin 125 mcg Tablet Sig: One (1) Tablet PO Monday, Wednesday, Friday. Discharge Disposition: Home Discharge Diagnosis: Hyperkalemia with EKG changes, ESRD requiring dialysis 3 times a week. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 108014**], You were admitted to the [**Hospital1 18**] from dialysis for shortness of breath, lightheadedness, and a cardiac arrhythmia on EKG. Labs revealed an elevated potassium level and you underwent two rounds of emergent dialysis in the medical ICU. Your potassium level normalized. At the time of discharge, you felt back to your baseline with no symptoms of lightheadedness and shortness of breath and your potassium level was normal. Upon discharge, you had resumed your normal dialysis schedule starting today at 3:30pm. We made the following changes to your medications: Continued: Metoprolol succinate XL 25 mg Advair Proair Fluticasone-Salmeterol Diskus (250/50) 1 Inh [**Hospital1 **] Switched: Digoxin 125 mcg daily to Digoxin 125 mcg 3 times a week (Monday, Wednesday, Friday) Added: Aspirin 81 mg PO daily Stopped: Amiodarone 200 mg daily Followup Instructions: We have scheduled a follow up appointment with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 36055**], for Thursday, [**2102-10-26**] at 11:40am. Your nephrology doctors [**Name5 (PTitle) **] follow-up with you at your dialysis sessions. Completed by:[**2102-10-18**]

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icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

8323, 8329

5064, 7446

329, 336

8444, 8444

2988, 2988

9502, 9811

2489, 2506

7585, 8300

8350, 8423

7472, 7562

8595, 9172

4760, 5041

2521, 2969

9201, 9479

1235, 1683

266, 291

364, 1216

3005, 4743

8459, 8571

1705, 2333

2349, 2473

69,546

104,287

35724

Discharge summary

report

Admission Date: [**2154-3-5**] Discharge Date: [**2154-3-26**] Date of Birth: [**2079-12-4**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4365**] Chief Complaint: s/p Cardiac Arrest Major Surgical or Invasive Procedure: diagnostic thoracentesis History of Present Illness: The pt is a 74y/o F with a PMH of CAD, DM, CVA with recent diagnosis of cholangiocarcinoma with metastasis to the transverse colon, presenting s/p cardiac arrest. Pt sent from NH to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for evaluation of altered mental status. Per report the pt was recently started on bactim on [**2-22**] for PNA. Today she became letharic with no verbal response. T 96.5. Sat 94-96% on 4L NC. FS 325. . At OSH, the patient presented in cardiac arrest. Per report inital BP at 850 unable to obtain, given 1amp atropine and transcutaneous pacing started. She was intubated and dopamine started. Given additional 1amp atropine and 1 amp epi, 1am calcium gluconate and 2mg glucagon with return to perfusing rhythm at approx 915. Per ER physician report CT head with w/o bleed, abd with free fluid, no free air, + gallbladder stent, and right sided effusion. No formal read available at time of transfer. Per report she also received "broad spectrum antibiotics" . In the ED, initial vs were: T 98.2 P 82 BP 122/77 R 17 O2 sat 100%. On levophed 0.03mcg/kg/min. CT Torso demonstrated large right pleural effusion with right lower lobe collapse, RML atelectasis, and possible superimposed pneumonia. Patient was given albuterol neb. Sedation with fentanyl and versed. . On arrival to the ICU, the patient was intubated and sedated with stable hemodynamics. . Review of sytems: Unable to obtain . Past Medical History: Cholangiocarcinoma with metastasis to the transverse colon, unresectable - diagnosed [**1-25**] complicated by post ERCP pancreatitis MRSA bacteremia - received course of Vancomycin Bowel obstruction s/p R colectomy c/b wound dehiscence - received course of linezolid, ceftazidime and flagyl R pleural effusion G tube placement CAD s/p CABG [**2147**] Diabetes Mellitus HTN PVD R femoral tibial grast CVA [**2137**] with residual R sided weakness Hyperlipidemia Osteoarthritis . Social History: The patient is originally from [**Country 5976**], moved to US 30 years ago. Spanish speaking. She previously lived with her husband, daughter and [**Name2 (NI) 81260**] in JP, most recently in NH. No tobacco/etoh history. Family History: Father - CAD Physical Exam: Vitals: T: 99.8, HR 93, BP 115/72, RR 25, Sat 100% General: Intubated, sedated, chronically ill-appearing HEENT: Sclera anicteric, MMM, oropharynx clear, NGtube and ET tube in place Neck: supple, JVP 10, no LAD, L SC Lungs: Clear to auscultation anteriorly, decreased R base to [**1-18**] up lung field, dull to percussion, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, midline inscision well healed, PEG tube site C/D/I, ostomy with liquid stool, guaiac +, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: cool, 1+ pulses, no edema, multiple scars lower ext b/l . Pertinent Results: [**Hospital3 **]: WBC 19.0 HCT 37.9 Plt 238 BNP 4330 Trop 0.61 INR 2.05 Na 136 K 6.0 Cl 107 HCO3 16 BUN 35 Cr 1.2 ABG 7.18/39/181/15 . CT Torso [**3-5**] - Large right pleural effusion with right lower lobe collapse, RML atelectasis, and possible superimposed pneumonia. Endotracheal tube terminates just < 1 cm above carina, requires retraction. Ascites. No evidence of bowel obstruction. Atherosclerotic disease . EKG: OSH: [**3-4**] - R 96bpm, nl intervals, nl axis, ST dep II, AVF, V3-V6 [**3-5**] - NSR 81bpm, nl axis/nl interval, TWI I, II, AVF, V3-V6 . [**3-8**] Neck U/S HISTORY: Soft tissue calcifications noted on video swallow. FINDINGS: Calcifications are seen in the soft tissues of the left neck measuring up to 11 mm in greatest diameter. These are separate from the spine and are of unclear etiology. Degenerative changes are noted of the cervical spine, most marked at C5-6 with sclerosis, disc space narrowing, and anterior osteophytes. . [**2154-3-26**] 06:55AM BLOOD WBC-8.9 RBC-3.29* Hgb-10.3* Hct-31.5* MCV-96 MCH-31.3 MCHC-32.6 RDW-15.8* Plt Ct-276 [**2154-3-25**] 06:00AM BLOOD WBC-9.1 RBC-3.20* Hgb-9.9* Hct-30.6* MCV-95 MCH-30.9 MCHC-32.4 RDW-15.6* Plt Ct-233 [**2154-3-24**] 07:30AM BLOOD WBC-11.2* RBC-3.39* Hgb-10.6* Hct-32.8* MCV-97 MCH-31.1 MCHC-32.2 RDW-15.9* Plt Ct-264 [**2154-3-23**] 06:45AM BLOOD WBC-9.6 RBC-3.11* Hgb-9.7* Hct-30.0* MCV-96 MCH-31.2 MCHC-32.4 RDW-15.9* Plt Ct-193 [**2154-3-22**] 10:25AM BLOOD WBC-9.3 RBC-3.27* Hgb-10.2* Hct-31.9* MCV-98 MCH-31.3 MCHC-32.1 RDW-15.7* Plt Ct-169 [**2154-3-21**] 07:40AM BLOOD Neuts-82.0* Lymphs-13.1* Monos-3.7 Eos-1.1 Baso-0.2 [**2154-3-20**] 06:15AM BLOOD Neuts-87.5* Lymphs-6.4* Monos-5.2 Eos-0.3 Baso-0.5 [**2154-3-19**] 05:22AM BLOOD Neuts-84* Bands-5 Lymphs-4* Monos-5 Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2154-3-26**] 06:55AM BLOOD Plt Ct-276 [**2154-3-25**] 06:00AM BLOOD Plt Ct-233 [**2154-3-24**] 07:30AM BLOOD Plt Ct-264 [**2154-3-26**] 06:55AM BLOOD Glucose-222* UreaN-14 Creat-0.6 Na-132* K-4.9 Cl-100 HCO3-26 AnGap-11 [**2154-3-25**] 06:00AM BLOOD Glucose-246* UreaN-15 Creat-0.6 Na-133 K-5.2* Cl-101 HCO3-23 AnGap-14 [**2154-3-24**] 07:30AM BLOOD Glucose-158* UreaN-17 Creat-0.6 Na-133 K-5.0 Cl-99 HCO3-21* AnGap-18 [**2154-3-23**] 06:45AM BLOOD Glucose-115* UreaN-18 Na-132* K-5.1 Cl-101 HCO3-23 AnGap-13 [**2154-3-21**] 07:40AM BLOOD ALT-17 AST-23 AlkPhos-272* TotBili-0.5 [**2154-3-19**] 05:22AM BLOOD ALT-18 AST-29 AlkPhos-324* TotBili-0.7 [**2154-3-11**] 06:21AM BLOOD ALT-45* AST-28 LD(LDH)-237 AlkPhos-279* TotBili-0.7 [**2154-3-10**] 05:15AM BLOOD ALT-57* AST-33 LD(LDH)-236 AlkPhos-278* TotBili-0.6 [**2154-3-26**] 06:55AM BLOOD Mg-2.2 Brief Hospital Course: The pt is a 74y/o F with a PMH of CAD, DM, recent diagnosis of cholangiocarcinoma with metaseses to the transverse colon s/p resection and PEG placement admitted s/p PEA arrest. . # PEA Arrest: Unclear precipitating event. Possible causes of PEA included pneumonia +/- mucuous plug causing transient hypoxemia or possible primary cardiomyopathy. Patient has decreased EF to 15-20% unlcear primary or secondary to recent code. Patient also had hyperkalemia (K 6) on presentation, another possible factor. Ruled out PE with negative PE-CTA. She was promptly extubated without complication. . # healthcare-associated pneumonia: On admission, patient had leukocytosis and RLL effusion. She was afebrile, and blood cultures were negative. She was initially treated with vanc/zosyn. Diagnostic thoracentesis demonstrated a transudative process, thought to be parapneumonic vs CHF-related. Mini-BAL grew ESBL-producing klebsiella. Antibiotics were changed to meropenem, and she received 7 days or meropenem. On [**3-19**], nearly one week after completing Meropenem therapy, patient was found to have an elevated WBC count. Patient's PICC line was discontinued and cultures periperally and from PICC were obtained. Cultures on [**3-21**] grew out GNR, eventually speciated to Klebiella pneumoniae. Patient was started again on Meropenem on [**3-22**]. Paitent's WBC count has been trending down since. Paitent remained afebrile throughout the second course and vitals were stable. - Continue Meropenem 500mg IB q6hrs for total 14 day course . # Acute renal failure: Creatinine on admission was 1.1 and rose to 2.0 in the days after the arrest. Most likely prerenal due to poor forward flow in the pericode period. FeNa was 0.6% initially. There was likely also a component of ATN secondary to contrast. Urine output also decreased to ~10 cc/h with poor response to IV lasix. The renal consult service was involved and recommended conservative management. Urine output increased, and creatinine fell back to baseline .8-1.0. . # acute on chronic systolic congestive heart failure: EF 15-20%, newly decreased this admission. After resuscitation patient appeared total body overloaded. Diuresis was limited by ARF, as above. Despite CXR findings of significant pulmonary edema and bilateral pleural effusions, her O2 Sat was 98% on RA. Her outpatient dose of furosemide 20 mg daily was restarted and she was kept net negative daily. Effusions and peripheral edema decreased. . # Pleural Effusion: Diagnostic thoracentesis showed a transudative process. Differential included parapneumonic process, metastatic disease, and/or effusion secondary to cardiomyopathy. Now resolving. . # Metastatic Cholangiocarcinoma: Patient with recent diagnosis and complicated course including mets to transverse colon s/p resection. Tumor unresectable, felt to have poor likelihood of tolerating chemotherapy per OSH oncology notes. LFTs were stable. . # Guaiac + stools: The pt was found to have grossly bloody stool from ostomy site. Hct was stable. PPI was continued. . # Bowel obstruction s/p R colectomy ?????? Tube feeds were continued. S&S evaluation was done and diet advanced to ground solids and subsequently to regular. Tube feeds were held for 3 days to do a calorie count. Because she was only taking ~500 calories daily, tube feeds were re-instituted. . # CAD s/p CABG [**2147**] - Beta blocker was continued, ACEI held given ARF, lasix given as above, statin held. ACEI was restarted prior to discharge. Patient started on ASA 81mg . # Diabetes Mellitus - Lantus and RISS were continued. Lantus was decreased for hypoglycemia in the setting of holding tube feeds. This will need to be titrated. . # Nutrition - Patient was getting tube feeds. These were stopped temporarily and a calorie count demonstrated inadequate intake. Tubefeeds were re-instituted. Speech and swallow saw her and cleared her initially for pureed solids and later for regular solids as mental status improved. She was also cleared for thin liquids but preferred to continue nectar-thickened. . # Access: Patient is being discharged with a PICC line in place, placed by IR on [**2154-3-26**]. Medications on Admission: Tylenol 650mg Q 4 PRN Milk of Magnesia 30ml po daily PRN Bisacodyl Arixtra 2 gram daily Lantus 24U QHS RISS Colace Atarax 10mg 1 tab Q 8 PRN Senna Duragesic 25mcg Q 72 Bactrim DS 2 tab daily X 10 days stop [**3-9**] Promod [**1-18**] oxycontin 10mg po BID Reglan Lopressor 50mg [**Hospital1 **] MVI Prilosec 20mg daily Zocor 40mg daily Zestril 40mg daily Lasix 20mg daily Discharge Medications: 1. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 3. insulin Please given lantus 10 units and humalog insulin sliding scale, attached. 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO three times a day. 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 8. Tylenol 325 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for fever or pain. 9. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours). 12. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. 15. Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous four times a day: per sliding scale . 16. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: Please do not exceed 4g/24hrs. Discharge Disposition: Extended Care Facility: [**Hospital **] Health Care - [**Hospital1 **] Discharge Diagnosis: primary: cardiac arrest, hospital acquired pneumonia, acute renal failure, congestive heart failure secondary: metastatic cholangiocarcinoma, coronary artery disease, diabetes Discharge Condition: stable Discharge Instructions: You were admitted to the hospital after a cardiac arrest. CPR was given, and you were revived. It is thought that you cardiac arrest was secondary to hypoxia from pneumonia. You were also treated for a pneumonia. You were found to have bateremia a week prior to discharge and are going to a rehab facility with plan for continued meropenem for a full 14 day course. . Many of your medications were changed, please take as directed. . . Please return to the hospital or call your doctor if you experience chest pain, shortness of breath, high fevers and chills, or other symptoms that are concerning to you. Followup Instructions: Please follow up with the physician at your rehabilitation faciity. Completed by:[**2154-3-27**]

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icd9cm

[ [ [] ] ]

[ "96.71", "38.93", "34.91", "33.24", "96.6" ]

icd9pcs

[ [ [] ] ]

12200, 12273

6001, 10200

333, 360

12494, 12503

3325, 5978

13163, 13262

2587, 2601

10622, 12177

12294, 12473

10226, 10599

12527, 13140

2616, 3306

275, 295

1806, 1827

388, 1788

1849, 2330

2346, 2571

28,457

142,843

8791

Discharge summary

report

Admission Date: [**2153-2-22**] Discharge Date: [**2153-3-2**] Date of Birth: [**2106-5-1**] Sex: M Service: MEDICINE Allergies: Codeine / Penicillins / Haldol / Cellcept / Vancomycin / Amitriptyline / Iron / Reglan / Amikacin Attending:[**First Name3 (LF) 783**] Chief Complaint: urosepsis Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 46 yo man with MMP including Alports' sydrome, ESRD s/p renal transplant X4 currently on HD (via tunnelled line), Hep C, h/o aortic valve endocarditis, recently admitted to [**Hospital1 18**] [**Date range (1) 30706**] w/ polymicrobial bacteremia (MRSA, enterococcus, [**Female First Name (un) **]) who presented from rehab w/ c/o abdominal pain and fevers, found to be hypotensive. . In [**Name (NI) **], pt with SBP 60's-80's, other VSS. Labs notable for elevated WBC 13.8, lactate 2.9, elevated BNP. ED w/u included CXR that demonstrated CHF, U/A positive, CT scan initially concerning for pneumotosis, but rpt negative. He was given IVF (2L NS) and developed some respiratory distress due to presumed CHF (seen on CXR), transiently requiring non rebreather. O2 weaned down and able to tolerate nasal cannula. Pt also given Vanc, CTX, flagyl and levofloxacin in ED. Renal was also consulted and recommended he get steroids for ?adrenal insufficiency, so he received dexamethasone 10mg x 1 in ED. Pt had R fem line placed for central access, and initially required levophed for BP support, but that is now weaned off with stable BP. Of note, pt had extensive hospital course [**Date range (3) 30707**] with sepsis and polymicrobial bacteremia w/ MRSA, enterococcus, [**Female First Name (un) **], with many complications as described: 1) Due to constillation of organisms, concern for GI source. He had U/S on [**1-18**] had noted dilation of biiliary ducts, although RUQ u/s neg for this on rpt on [**2-8**]. GI consulted, given above, who recommended MRCP and colonoscopy, which the pt refused. Pt had numerous abx during hospital course and was eventually d/ced on fluconazole and linezolid to complete course through [**2-24**]. 2) access issues, as the pt had his porta-cath removed given his bacteremia. He has old fistula on R arm and L arm and R leg. Eventually had R IJ placed via IR under fluoroscopy, which was changed to R tunneled cath (in IJ) when pt required dialysis. 3) Pt had developed recurrent renal failure during hospital course requiring dialysis and has been dialysis dependent since. As above, via R IJ tunneled cath. 4) MRI demonstrating C5/6 cord compression from large paracentral disc protrusion. No neurological defecits noted and plans for outpt f/u w/ neurosurg w/ plans for [**Doctor First Name **] in future. 5) RLE DVT. Pt w/ h/o of DVT, but this was new noted during hospital course. Treated w/ hep gtt bridge to coum 6) Hypercarbic respiratory failure requiring intubation, felt to be due to oversedation. 7) Difficult to control HTN 8) Anemia - treated with iron and epo. As above, pt refused colonoscopy. 9) Pseudomonas UTI Most importantly, as stated in problem 1) above, pt had numerous abx during hospital course and was d/ced on fluconazole and linezolid to be continued through [**2-24**]. Pt also w/ h/o pseudomonas in his urine [**1-29**], treated initially w/ aztreonam, then cxs returned insensitive, so switched to amikacin, but developed ?dizziness (?true allergy). Currently appears comfortable. Past Medical History: 1. End-stage renal disease [**2-17**] Alport's. 2. Alport's syndrome. 3. Kidney transplant times four (most recently in [**2145**], recently re-started on dialysis) 4. Hepatitis C. 5. Seizure disorder. 6. Right lower extremity phlebitis. 7. Right eye blindness. 8. Right ear hearing loss. 9. Peripheral vascular disease. 10. Small-bowel obstruction. 11. Osteoporosis. 12. Hypertension. 13. Gastrointestinal bleed in [**2147-4-17**]. 14. Aortic stenosis. 15. Endocarditis 16. DVT [**2148**], new RLE DVT 17. Gout 18. h/o abnormal chest x-ray with multiple lung nodules last year [**64**]. Cavitary lung lesion noted [**1-23**] Social History: Lives w/ parents in [**Location (un) 1456**]. single, no kids. Occasional ethanol use. One pack per day of tobacco >20packyear smoking hx. Past cocaine abuse (none since fall, [**2151**]). Family History: Father had prostate cancer. Physical Exam: Vitals - T 95.7, HR 68, BP 108/50, RR 16, O2 100% on **NC Gen - sleeping but arousable, NAD HEENT - OP dry MM CVS - RRR, grade III/VI SEM Lungs - scattered crackles b/l Abd - soft, + tender to palpation diffusely, no rebound/gaurding, + bowel sounds Ext - No LE edema b/l, R LE > L LE, b/l edema of upper extremities Neuro - alert Pertinent Results: LABORATORIES: [**2153-2-22**] WBC-13.8 (NEUTS-93.2 BANDS-0 LYMPHS-3.9 MONOS-2.7 EOS-0.2 BASOS-0) HGB-8.5 HCT-27.0 MCV-92 PLT COUNT-154 [**2153-2-22**] PHENYTOIN-<0.6 [**2153-2-22**] proBNP-[**Numeric Identifier 17307**] [**2153-2-22**] ALT(SGPT)-15 AST(SGOT)-18 ALK PHOS-99 TOT BILI-0.4 LIPASE-7 [**2153-2-22**] SODIUM-137 POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-32 GLUCOSE-71 UREA N-19 CREAT-2.3 CALCIUM-6.9 PHOSPHATE-2.9 MAGNESIUM-1.5 [**2153-2-22**] LACTATE-2.9 [**2153-2-22**] PT-44.3 PTT-112.2 INR(PT)-4.9 [**2153-2-22**] TYPE-[**Last Name (un) **] PO2-49 PCO2-63 PH-7.31 TOTAL CO2-33 BASE XS-2 COMMENTS-GREEN TOP . MICROBIOLOGY: [**2153-2-22**] URINE RBC-[**12-6**] WBC->50 BACTERIA-MOD YEAST-NONE EPI-0-2 BLOOD-MOD NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-MOD COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.015 . [**2153-2-22**] URINE CULTURE (Final [**2153-2-25**]): PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | AMIKACIN-------------- 16 S CEFEPIME-------------- 16 I CEFTAZIDIME----------- 16 I CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM------------- 4 S PIPERACILLIN---------- =>128 R PIPERACILLIN/TAZO----- =>128 R TOBRAMYCIN------------ =>16 R ___________________________________________________________ . [**2153-2-22**] BLOOD CULTURE X4 BOTTLES-FINAL NO GROWTH [**2153-2-23**] BLOOD CULTURE X4 BOTTLES-FINAL NO GROWTH [**2153-2-26**] STOOL FECAL CULTURE-FINAL NO GROWTH; CAMPYLOBACTER CULTURE-FINAL NO GROWTH; OVA + PARASITES-FINAL NEGATIVE [**2153-2-27**] CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT . IMAGING: [**2153-2-22**] CXR: IMPRESSION: Mild CHF with bilateral pleural effusions. . [**2153-2-22**] CT Abd/Pelvis: IMPRESSION: 1. Extremely limited evaluation due to lack of IV and oral contrast, and patient arm positioning over the abdomen. Possible trace pockets of free air anterior to the stomach. Tiny pockets of air outlining the course of the bowel lumen. Although this may be a normal finding due to the non-dependent nature of the layering, given the extensive vascular calcifications, clinical history and possible free air, pneumatosis should be a consideration. There is no portal venous gas or overtly thickened loops of bowel. 2. Bladder intraluminal air, likely iatrogenic, but could represent infection if the patient has not been catheterized recently. . [**2153-2-22**] Repeat Abd/Pelvis CT: IMPRESSION: 1. Study limited by motion, but no definite intra-abdominal free air, pneumatosis, or evidence of ischemic bowel. 2. Bilateral pleural effusions with atelectasis unchanged. Ascites and anasarca. . [**2153-2-22**] Portable CXR: IMPRESSION: Mild increase in mild CHF with bilateral pleural effusions and associated atelectasis. . [**2153-2-23**] Portable CXR: Portable AP chest radiograph compared to [**2153-2-22**]. The dialysis catheter tip is about 2.5 cm below the cavoatrial junction. The mild cardiomegaly is unchanged. Mediastinal contours are stable. The moderate pulmonary edema persists, accompanied by increased bilateral pleural effusions, left more than right, partially loculated. Diffuse dense appearance of the bones is unchanged dating back to [**2145**], most likely due to known Alport syndrome. . [**2153-2-23**] BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**] of bilateral internal jugular, subclavian, axillary, brachial, cephalic, and basilic veins were performed. Focal occulusive thrombus is identified within the left subclavian vein. The remainder of the upper extremity veins remain patent. Note is made of a 2.9 x 4.8 x 2.3 cm hemtoma in the region of the left subclavian vein. IMPRESSION: Deep venous thrombosis of the left subclavian vein. 2.9 x 4.8 x 2.3 cm hematoma in the region of the left subclavian vein. . [**2153-2-23**] TRANSPLANT ULTRASOUND The transplanted kidney is seen within the left lower quadrant measuring 11.4 cm in length, previously was 12.6 cm. There is normal renal corticomedullary differentiation. No hydronephrosis or perinephric fluid collection is identified. A small hypoechoic lesion in the mid-pole consistent with a cyst is without interval change. Resistive indices in the upper, mid-, and lower poles measure 0.76, 0.65 and 0.68, respectively, and are grossly unchanged from those of 0.81, 0.72 and 0.63, respectively on the previous study. The main renal artery and vein are patent with normal waveforms. The bladder is non-distended and poorly visualized. IMPRESSION: Normal renal transplant ultrasound. No evidence for hydronephrosis or perinephric fluid collection. . ANKLE (AP, MORTISE & LAT) RIGHT [**2153-2-28**] FINDINGS: No prior studies of the ankle available for a direct comparison. There is a sclerotic lesion in the distal tibia which has peripheral calcification and is compatible with a bone infarct. There is no cortical destruction or pathologic fracture at this location. Additionally, there is an area of cystic change in the talar dome measuring 2.4 cm which extends to the joint surface. This likely represents sequela from avascular necrosis. There is no gross articular collapse at this time. However, imaging with MRI may better characterize this abnormality. The ankle mortise is preserved. There is no discrete fracture. There is some mild soft tissue swelling. IMPRESSION: 1. Cystic area within the talar dome, extending to the articular surface, likely due to avascular necrosis. This could be further evaluated with MRI imaging. 2. Bone infarct within the distal tibial metaphysis. . ANKLE (AP, MORTISE & LAT) LEFT [**2153-3-1**] FINDINGS: Comparison is made to the previous study of the right ankle from [**2153-2-28**]. There is a well demarcated area of sclerosis in the distal left tibial metaphysis consistent with a bone infarct. There are no acute fractures. The talar dome is unremarkable. The ankle mortise is preserved. Vascular calcifications are present. IMPRESSION: Bone infarct in the distal left tibial metaphysis. . Brief Hospital Course: #. RESOLVED HYPOTENSION/SEPSIS Mr. [**Name14 (STitle) 30708**] presented with hypotension, leukocytosis, elevated lactate, consistent with sepsis. In ED, U/A was positive. Urosepsis was presumed. The patient was aggressively volume resuscitated in the unit and supported with levophed. Given history of pseudomonas UTI, the patient was begun on cefepime. However, when sensitivities returned, he was switched to meropenem with dialysis as peripheral access was difficult. He was given dexamethasone 10mg IV x 1 in ED, but further steroids were not given as the patient showed no signs of adrenal insufficiency. He was transfered to the floor when hemodynamically stable and continued to be hemodynamically stable upon discharge. . Positive urine culture showed Pseudomonas infection (10K-100K) which could signify colonization rather than a true infection especially as the patient was on hemodialysis. Blood cultures from admission ([**2-22**] and [**2-23**]) and catheter tip culture show no growth (final). Abdominal CT (X2 on this admission) unremarkable for GI infection; outpatient colonoscopy recommended as the patient had a recent history of enterococcus bacteremia. Further GI workup for biliary source (eg MRCP) not indicated at this time as LFTs showed decreased alk phos and repeat RUQ last admission showed resolved biliary dilitation. Upon discharge, patient continued to be hemodynamically stable on current antibiotics. Meropenem should be continued for 14 day course (day 1: [**2153-2-25**]), dosed after hemodialysis as prescribed. Antibiotics course to be given at dialysis per the following regimen: Meropenem 1000 mg IV EVERY MONDAY AND WEDNESDAY AFTER HEMODIALYSIS; Meropenem 1500 mg IV EVERY FRIDAY AFTER HEMODIALYSIS. . The patient had a recent history of polymicrobial infxn (MRSA, enterococcus, [**Female First Name (un) **]). The patient completed his prescribed antibiotics of linezolid and fluconazole on [**2-24**] for this polymicrobial infection during this hospital stay. . # END STAGE RENAL DISEASE The patient is status post transplant x 4, on hemodialysis on every Monday, Wednesday, Friday. He underwent dialysis on the day of discharge with next hemodialysis on [**2153-3-5**]. Continued Prednisone 5 mg daily as immunosuppressant regimen. This should be titrated off as an outpatient. Cyclosporin discontinued per transplant recommendations. Outpatient transplant followup was scheduled. . # RIGHT LOWER EXTREMITY DEEP VENOUS THROMBOSIS The patient was recently diagnosed with a RLE DVT on his previous hospital course. His home dosage of coumadin was held for several days after arrival as he was supratherapeutic. He was discharge on warfarin 1 mg daily, lower than home dose of 2 mg daily as patient was supratherapuetic on arrival. INR should be monitored closely at rehab and warfarin dosage adjusted to obtain an INR therapeutic range between [**2-18**]. INR was 2.1 on the day of discharge. . # BILATERAL UPPER EXTREMITY EDEMA His upper extremity edema was likely due to aggressive fluid overload in sepsis protocol; his upper extremity edema improved with dialysis. Bilateral upper extremity noninvasive ultrasounds showed evidence of left subclavian DVT (see above report); no changes in management were made as the patient was already therapeutic on coumdin for lower extremity DVT. SVC syndrome was possible considering history of multiple other thrombi; however, CT chest was not able to be obtained to futher explore this diagnosis. The patient refused peripheral access (for contrast), which and also refused the study. A diagnosis of SVC syndrome was felt to be less likely and would not change management as the patient was anticoagulated. . # Cord compression: Noted on MRI C5/6 disc protrusion during previous hospital course. No focal neuro defecits. Pt has f/u with Dr. [**Last Name (STitle) 548**] from neurosurg on [**3-7**]. [**Location (un) 2848**] J-soft collar was provided for transport and when patient out of bed. Please continue usage of soft collar at rehabilitation. . #. Right ankle pain: Pain is chronic per family and patient. Plain films of bilateral ankles showed bilateral tibial metaphysis infarcts. Also right ankle showed evidence of cystic changes possibly secondary to AVN. Pain was unchanged in quality per patient, and he had a history of ankle surgery [**55**] years prior at an OSH (records unavailable). He was advised to wear the brace which he has at home. He was instructed to bring this brace to rehabilitation to assist in his physical therapy. . # PUD/Abdominal pain: Mother reported history of peptic ulcer disease and history of PPI use with symptomatic relief of abdominal pain. Of note, the patient's abdominal pain resolved with PPI. Please continue PPI as an outpatient. . # HTN: Held labetolol and amlodipine initially when hypotensive. However, restarted labetolol 5 days prior to discharge as patient was consistently hemodynamically stable at this point. Restarted home dosage of amlodipine 5 mg upon discharge as patient to better control systolic hypertension. . # Seizure disorder: Continued keppra. . # Anemia: Stable HCT per review of OMR since [**2145**]. Renal team increased epopoeitin dosage on this admission. Followup of HCT recommended as outpatient. . # FEN: Regular diet, low salt prescribed. Albumin was low and nutrition consulted. Started TID Ensure supplement with protein per nutrition recommendations. Please continue Ensure supplement at rehabilitation. . # PPX: Coumadin for DVT prophylaxis was provided as patient had recent lower extermity DVT. . # Access: Right tunneled cath dialysis catheter was in place. Femoral line placed in the emergency department but was discontinued several days prior to discharge. Femoral line catheter tip was cultured and was negative upon discharge. . #. Family contact: [**Telephone/Fax (1) 30709**] (Mother and father) Updated prior to discharge. . Medications on Admission: 1. Fluconazole 200 mg PO Q24H through [**2153-2-24**]. 2. Linezolid 600 mg PO Q12H through [**2153-2-24**]. 3. Warfarin 2 mg daily 4. Cyclosporine 25 mg PO Q12H 5. Oxycodone 2.5 mg PO Q8H PRN 6. Labetalol 200 mg PO TID 7. Amlodipine 5 mg PO DAILY 8. Prednisone 5 mg PO DAILY 9. Epoetin Alfa 10,000 unit/mL 1mL q HD 10. Levetiracetam 500 mg PO MON WED FRI 11. Levetiracetam 250 mg PO SUN, TUES, THURS. 12. Duloxetine 20 mg PO BID 13. Acetaminophen 500 mg 1-2 Tablets PO Q6H as needed. 14. Simethicone 80 mg Chewable PO QID as needed. 15. Hydrocortisone 0.5 % Ointment Topical TID as needed. 16. Bisacodyl 10 mg PO DAILY as needed. . Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). 3. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 5. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 6. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO Q SUN, TUES, THURS (). 7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-17**] Puffs Inhalation Q6H (every 6 hours) as needed. 10. Labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Meropenem 1000 mg IV EVERY MONDAY AND WEDNESDAY AFTER HEMODIALYSIS D1: [**2153-2-25**]. Continue for 14 day course; completion of antibiotics on [**2153-3-11**]. 13. Meropenem 1500 mg IV EVERY FRIDAY AFTER HEMODIALYSIS D1 of antibiotics [**2153-2-25**], Continue for 14 day course; completion of antiobiotics on [**2153-3-11**]. 14. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**First Name9 (NamePattern2) 30710**] [**Hospital1 **] Discharge Diagnosis: Primary Urosepsis Hypotension Left subclavian deep venous thrombosis . Secondary End-stage renal disease Alport's syndrome Hearing loss Hepatitis C Seizure disorder Right eye blindness Peripheral vascular disease Osteoporosis Hypertension Deep venous thrombosis Gout Discharge Condition: Hemodynamically stable, afebrile Discharge Instructions: You were admitted to the hospital with low blood pressure thought to be due to sepsis from an underlying urinary tract infection. You were supported with intravenous fluids and antibiotics and improved. Your antibiotics were dosed with dialysis. Your blood pressure stabilized, and you were clinically stable. . Please wear soft collar upon discharge until otherwise directed by neurosurgery followup. . Please keep all followup appointments. . 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. . =============== NEW MEDICATION: =============== 1. Meropenem to be dosed with dialysis. 2. Pantoprazole . ================== MEDICATION CHANGES ================== 1. Cyclosporin was discontinued. 2. Epopoeitin (given was dialysis) dosage was increased. 3. Warfarin dosage was decreased to 1 mg daily. INR should be followed and dosage adjusted as needed for INR goal of [**2-18**]. Followup Instructions: 1. Neurosurgery: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6214**], MD Phone:[**Telephone/Fax (1) 1669**] Date/Time:[**2153-3-7**] 11:00 . 2. Renal transplant clinic/Nephrology: Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]. Friday, [**2153-3-30**] at 9:30AM. [**Last Name (NamePattern1) 439**], [**Hospital Unit Name **], [**Hospital1 **] [**Last Name (Titles) 517**]. . 3. Follow up with PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 10508**] within 1 week of discharge from rehabilitation. . 4. Followup as needed with orthopedic surgery at [**Hospital3 **] [**Hospital 1225**] Hospital (Phone=([**Telephone/Fax (1) 2007**]) for ankle pain. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

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