ChanBeDu/relevant_section_length · Datasets at Hugging Face

81,728

179,517

37708+37709

Discharge summary

report+report

Admission Date: [**2138-9-27**] Discharge Date: [**2138-9-30**] Date of Birth: [**2087-4-10**] Sex: F Service: ORTHOPAEDICS Allergies: Morphine Attending:[**Doctor Last Name 1350**] Chief Complaint: Neck pain Major Surgical or Invasive Procedure: C6-c7 laminectomy, C5-6, c6-7 foraminotomies and c4-T1 posterior instrumented spinal fusion. History of Present Illness: History of rollover motor vehicle accident with trauma to neck. History of tingling in ulnar nerve distribution bilaterally. past history of neck pain. Past Medical History: History of lumbar spine surgery done in the past. Social History: Occasional smoker Physical Exam: Neuro [**6-3**] in both upper and lower extremities. SILT Tenderness over neck. Tenderness over left sided toes. Pertinent Results: [**2138-9-27**] 03:31AM PH-7.41 COMMENTS-GREEN TOP [**2138-9-27**] 03:31AM HGB-13.0 calcHCT-39 O2 SAT-96 CARBOXYHB-3 MET HGB-0.3 [**2138-9-27**] 03:31AM GLUCOSE-98 LACTATE-2.1* NA+-138 K+-3.3* CL--98* TCO2-24 [**2138-9-27**] 03:31AM HGB-13.0 calcHCT-39 O2 SAT-96 CARBOXYHB-3 MET HGB-0.3 [**2138-9-27**] 03:31AM freeCa-1.10* [**2138-9-27**] 03:30AM URINE HOURS-RANDOM [**2138-9-27**] 03:30AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2138-9-27**] 03:30AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.002 [**2138-9-27**] 03:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2138-9-27**] 03:20AM UREA N-10 CREAT-0.6 [**2138-9-27**] 03:20AM estGFR-Using this [**2138-9-27**] 03:20AM LIPASE-28 [**2138-9-27**] 03:20AM ASA-NEG ETHANOL-143* ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG [**2138-9-27**] 03:20AM WBC-15.2* RBC-3.71* HGB-11.6* HCT-33.8* MCV-91 MCH-31.4 MCHC-34.4 RDW-12.8 [**2138-9-27**] 03:20AM PLT COUNT-358 [**2138-9-27**] 03:20AM PT-13.2 PTT-25.5 INR(PT)-1.1 [**2138-9-27**] 03:20AM FIBRINOGE-285 Brief Hospital Course: Patient was admitted to the [**Hospital1 18**] Spine Surgery Service and taken to the Operating Room for the above procedure. Refer to the dictated operative note for further details. The surgery was without complication and the patient was transferred to the PACU in a stable condition. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were continued for 24hrs postop per standard protocol. Initial postop pain was controlled with a PCA. Diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. Foley was removed on POD#1. Physical therapy was consulted for mobilization OOB to ambulate. Hospital course was otherwise unremarkable. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. Discharge Medications: 1. Acetaminophen 650 mg Tablet Sig: One (1) Tablet 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). Disp:*60 Capsule(s)* Refills:*2* 3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:*90 Tablet(s)* Refills:*0* 4. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itchy. Disp:*20 Capsule(s)* Refills:*0* 5. Estrogens Sig: One (1) Tablet DAILY (Daily): home med. 6. Valium 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for muscle spasms. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: C6 left side lamina and pedicle fracture with floating lateral mass. left 2nd toe proximal phalanx fracture. Discharge Condition: Stable. Discharge Instructions: You have undergone the following operation: Posterior Cervical Decompression and Fusion Immediately after the operation: - Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit in a car or chair for more than ~45 minutes without getting up and walking around. weightbearing as tolerated left foot with post-op shoe and buddy tape for 2nd toe fracture. - Rehabilitation/ Physical Therapy: o 2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. You can walk as much as you can tolerate. o Isometric Extension Exercise in the collar: 2x/day x 10 times perform extension exercises as instructed. - Cervical Collar / Neck Brace: You need to wear the brace at all times until your follow-up appointment which should be in 2 weeks. You may remove the collar to take a shower. Limit your motion of your neck while the collar is off. Place the collar back on your neck immediately after the shower. - Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Call the office at that time. If you have an incision on your hip please follow the same instructions in terms of wound care. - You should resume taking your normal home medications. - You have also been given Additional Medications to control your pain. . Please allow 72 hours for refill of narcotic prescriptions, so please 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 prescriptions (oxycontin, oxycodone, percocet) to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. - Follow up: o Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. o At the 2-week visit we will check your incision, take baseline x rays and answer any questions. o We will then see you at 6 weeks from the day of the operation. At that time we will most likely obtain Flexion/Extension X-rays and often able to place you in a soft collar which you will wean out of over 1 week. Please call the office if you have a fever>101.5 degrees Fahrenheit, drainage from your wound, or have any questions. Followup Instructions: follow up with Dr [**Last Name (STitle) 1007**] in 2 weeks following discharge. Please call [**Telephone/Fax (1) 9769**] to make an appointment. follow up in ortho trauma clinic in [**3-4**] weeks for left 2nd toe fracture. call [**Telephone/Fax (1) 1228**] for appt. Completed by:[**2138-9-30**] Admission Date: [**2138-10-5**] Discharge Date: [**2138-11-6**] Date of Birth: [**2087-4-10**] Sex: F Service: ORTHOPAEDICS Allergies: Morphine Attending:[**First Name3 (LF) 3645**] Chief Complaint: fever and drainage from posterior c-spine incision Major Surgical or Invasive Procedure: [**2138-10-6**]: I&D of posterior c-spine wound infection with retention of bone graft and hardware by Dr. [**Last Name (STitle) 1007**]. [**2138-10-17**]: repeat I&D of posterior c-spine wound infection with removal of bone graft, retention of hardware, and placement of wound VAC by Dr. [**Last Name (STitle) 1007**]. [**2138-10-20**]: repeat I&D of posterior c-spine wound infection with retention of hardware and placement of wound VAC by Dr. [**Last Name (STitle) 1352**]. [**2138-10-23**]: repeat I&D of posterior c-spine wound infection with retention of hardware and placement of incisional VAC by Dr. [**Last Name (STitle) 1007**]. [**2138-10-31**]: repeat I&D of posterior c-spine wound infection with removal of bilateral T1 screws and revision fusion with ICBG and extension of posterior instrumented fusion from C3-T2 by Dr. [**Last Name (STitle) 1352**]. History of Present Illness: 51yo F s/p C4-T1 PSF with ICBG on [**2138-9-28**] by dr. [**Last Name (STitle) **] for frx disloc, C6 floating lateral mass from MVC. Fevers/chills x 1 day, serosang drainage from incision. c/o some "numbness" in hands bilaterally but had this before. Neuro exam intact, including sensation. Not systemically septic. transferred from [**Hospital **] hosp ER. T100.2 in ER. WCC 23.5 w/L shift. Past Medical History: as above History of lumbar spine surgery done in the past. Social History: Occasional smoker Physical Exam: on admission. well-appearing female. mod distress. BUE: good strength/sensation, still some loss of distal fine motor skills. BLE: good strength/sensation. posterior c-spine incision with breakdown of inferior incision, erythema and purulent drainage. Pertinent Results: [**2138-10-5**] 04:50PM GLUCOSE-98 UREA N-7 CREAT-0.6 SODIUM-130* POTASSIUM-3.7 CHLORIDE-89* TOTAL CO2-28 ANION GAP-17 [**2138-10-5**] 04:50PM CRP-164.6* [**2138-10-5**] 04:50PM WBC-23.5*# RBC-3.50* HGB-10.7* HCT-32.8* MCV-94 MCH-30.6 MCHC-32.7 RDW-12.9 [**2138-10-5**] 04:50PM NEUTS-92.3* LYMPHS-5.0* MONOS-1.6* EOS-0.9 BASOS-0.2 [**2138-10-5**] 04:50PM PLT COUNT-472*# [**2138-10-5**] 04:50PM SED RATE-59* Brief Hospital Course: Patient was admitted to the [**Hospital1 18**] Spine Surgery Service from the ER on [**2138-10-5**] she was taken to the Operating Room on the above dates by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**]. Refer to the dictated operative notes for further details. The surgeries were without complication and the patient was transferred to the PACU in a stable condition, except as noted below. TEDs/pnemoboots were used for postoperative DVT prophylaxis and subcutaneous heparin was added following her last surgery. Initial postop pain was controlled with a PCA. Diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. Foley was removed. Physical/occupational therapy was consulted for mobilization OOB to ambulate. preop and post-op blood cultures showed MRSA. OR tissue cultures also showed MRSA. she was continued on vanco and ID was consulted. she was intermittently febrile. blood cultures were positive until [**10-8**] and then negative until [**10-12**] when a single set showed enterobacter. ceftriaxone started for this and switched to PO cipro on [**10-14**]. TTE on [**10-7**] and TEE on [**10-9**] showed no endocarditis. vanco doses were frequently titrated due to variability from trough goals. HV drains and incisional VAC were removed on [**10-10**]. PICC placed on [**10-15**] after no growth for 48hrs from blood cultures. ESR, CRP and WBC improving. [**10-7**], [**10-8**] and [**10-9**] blood cx's with MRSA (treated with vanco). [**10-11**] blood cx with enterobacter (started ceftaz, later switched to cipro on [**10-14**]). [**10-13**] CXR neg for PNA. UA/urine cx neg. got PICC [**10-15**] once blood cx's were negative for 48h. wound drainage restarted [**10-14**]. taken to OR on [**10-17**]: significant seropurulent fluid above and below fasica. all bone graft was removed. hardware retained. [**10-17**] cx's: MRSA, enterobacter, e. coli. added ceftaz 2gm q8h to cipro on [**10-18**]. [**10-20**] cx's: MRSA from deep tissue. [**10-23**] cx's: gram positive bacteria. [**10-24**] ceftaz stopped, plan to continue PO cipro for several weeks along with vanco. further testing of cultures on [**10-29**] showed staph to be insensitive to vancomycin, so this was stopped and daptomycin was started on [**10-29**]. rifampin was started on [**11-3**]. plan to continue these antibiotics and cipro for at least 6-8 weeks. she may require long-term oral suppressive therapy due to presence of hardware. the [**Hospital1 18**] ID service will follow her as an outpatient and make these decisions. she will have weekly labs followed by them. patient returned to the OR on [**10-31**] for revision/extension of posterior c-spine fusion. she tolerated the surgery well, but upon exam in the PACU, was noted to have increased bilateral upper extremity weakness and frank left lower extremity paralysis. stat c-spine MRI demonstrated some increased cord contusion/edema at C5-C7. she was transferred to the TSICU for monitoring. c-spine CT scan showed hardware to be in good alignment. c-spine MRI with contrast on [**11-2**], again showed cord signal change at C5-C7. patient was transferred to the floor on [**11-2**]. patient continued to work with PT/OT and appropriate splints for bilateral wrists and left foot/ankle were provided. she is regaining proximal strength in BUE (about [**5-4**] with EF/EE/WE), but still with weak finger abduction and flexion (left weaker than right). she continues to have some decreased sensation in both hands and had fine motor problems dating back to her original injury. her left leg has also improved. she has min HF, trace great toe extension/flexion and no ADF, but [**5-4**] hip adduction/knee extension/ankle plantar flexion. RLE has good strength throughout. her neck incision is healing well with sutures in place. her left posterior hip incision is also healing. her right posterior hip incision has healed. given these strength/functional limitations, she is an appropriate candidate for acute/[**Hospital **] rehab before being transitioned home. On the day of discharge the patient was afebrile with stable vital signs, posterior c-spine incision is intact and dry, comfortable on oral pain control and tolerating a regular diet. Medications on Admission: dilaudid, tylenol, valium. 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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*2* 3. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: Three (3) ML Intravenous Q8H (every 8 hours) as needed for line flush. Disp:*50 flushes* Refills:*2* 4. Outpatient Lab Work weekly labs to be drawn while on IV abx. labs: cbc with diff, chem 8, LFTs, CPK. ESR, CRP. results faxed to [**Hospital 18**] [**Hospital **] clinic at [**Telephone/Fax (1) 432**]. 5. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): plan for 6-8weeks of treatment. 8. Diazepam 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for anxiety. 9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 10. Est Estrogens-Methyltest 0.625-1.25 mg Tablet Sig: One (1) Tablet PO daily (). 11. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day): for DVT prophylaxis until ambulating independently, regularly. 13. Rifampin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours): plan for 6-8wks of treatment. 14. Daptomycin 500 mg Recon Soln Sig: Three [**Age over 90 **]y Five (325) mg Intravenous Q24H (every 24 hours) as needed for propylaxis: plan for 6-8wks of treatment. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: postoperative wound infection of posterior c-spine fusion. cervical spinal cord injury. left 2nd toe proximal phalanx fracture. Discharge Condition: stable Discharge Instructions: You have undergone the following operation: Posterior Cervical Decompression and Fusion and irrigation/debridement for infection. Immediately after the operation: - Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit in a car or chair for more than ~45 minutes without getting up and walking around. - Rehabilitation/ Physical Therapy: o 2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. You can walk as much as you can tolerate. - Cervical Collar / Neck Brace: You need to wear the brace at all times until your follow-up appointment which should be in 2 weeks. You may remove the collar to take a shower. Limit your motion of your neck while the collar is off. Place the collar back on your neck immediately after the shower. - Wound Care: If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Call the office at that time. If you have an incision on your hip please follow the same instructions in terms of wound care. - You should resume taking your normal home medications. - You have also been given Additional Medications to control your pain. . Please allow 72 hours for refill of narcotic prescriptions, so please 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 prescriptions (oxycontin, oxycodone, percocet) to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. - Follow up: o Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. o At the 2-week visit we will check your incision, take baseline x rays and answer any questions. o We will then see you at 6 weeks from the day of the operation. Please call the office if you have a fever>101.5 degrees Fahrenheit, drainage from your wound, or have any questions. Physical Therapy: WBAT BLE. no heavy lifting with BUE. c-collar can be off for hygiene. continue WBAT left foot with postop shoe/buddy tape as needed for comfort for 2nd toe fracture (it is essentially healed). use left multipodus boot when in bed. use wrist splints when sleeping/not doing therapy. Treatments Frequency: daily DSD changes until fully healed. Followup Instructions: call [**Telephone/Fax (1) 3736**] to schedule follow up appt with dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in about 2 weeks. follow up appt with [**Hospital **] clinic: Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2138-11-19**] 10:50. you need to have weekly labs drawn and faxed to [**Hospital 18**] [**Hospital **] clinic at [**Telephone/Fax (1) 432**]. Completed by:[**2138-11-6**]

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icd9pcs

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14790

Discharge summary

report

Admission Date: [**2147-6-8**] Discharge Date: [**2147-6-10**] Date of Birth: [**2095-3-22**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4760**] Chief Complaint: Hypoxemia Major Surgical or Invasive Procedure: none. History of Present Illness: 52M with 3-vessel CAD s/p MI & BMS to OM1, COPD, DMII, HTN, hyperlipidemia transferred from [**Hospital3 7571**]Hosp. to [**Hospital1 18**] MICU [**6-9**] with fever, hypoxemia, and bandemia attributed to PNA. At [**Location (un) **], V/S 99.5 125 RR 24 81% RA 93% 2L NC. WBC# 25.4 with 23% bands, lactate 1.3. ABG 7.34/45/57 87% on 2LNC. Given CTX/azithro for presumed PNA. CK 143, MB 6.1, tropI 0.65 - given ASA 325. Upon arrival to [**Hospital1 18**] V/S 98 117/85 HR 120 RR 20 96% 4L. Spiked to 101.9 in ED. WBC# 26.4 w/ 92% PMN. Given levofloxacin and 2L NS. Portable CXR showed a subtle retrocardiac opacity. Treated with CTX/levo in MICU. Fever defervesced. CTA chest ordered to evaluate for PE but patient declined due to orthopnea. O2 weaned to 1L NC. Presently denies fever, chills, URI Sx, CP, palp, cough, wheezing, SOB, DOE, heartburn, abd pain, N/V/D, edema, calf pain. Past Medical History: 3VD CAD s/p MI with BMS to OM1 in [**2140**] DMII COPD HTN Hyperlipidemia Social History: Smokes 6 cigars daily. No ETOH, IVDU. Works at patient check-in at JP VA in patient check in. Lives with his sister in [**Name (NI) **], MA. Family History: unknown Physical Exam: ADMISSION PHYSICAL EXAM Vitals: T: 98.7 BP: 111/76 P: 99 R: 17 O2: 96% on 4L General: Obese, gruff, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, widdened neck with no apparent JVP, no LAD Lungs: Diffusly ronchous b/l CV: tahcycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2147-6-8**] 09:10PM BLOOD WBC-26.4*# RBC-4.48* Hgb-13.5* Hct-39.1* MCV-87 MCH-30.1 MCHC-34.5 RDW-14.4 Plt Ct-302 [**2147-6-8**] 09:10PM BLOOD Neuts-91.7* Lymphs-5.5* Monos-2.5 Eos-0.1 Baso-0.1 [**2147-6-9**] 04:26AM BLOOD WBC-19.4* RBC-4.15* Hgb-12.2* Hct-36.6* MCV-88 MCH-29.5 MCHC-33.4 RDW-13.8 Plt Ct-305 [**2147-6-10**] 07:20AM BLOOD WBC-10.8 RBC-4.01* Hgb-12.1* Hct-35.2* MCV-88 MCH-30.2 MCHC-34.3 RDW-14.0 Plt Ct-327 [**2147-6-8**] 09:10PM BLOOD Glucose-210* UreaN-38* Creat-1.0 Na-131* K-4.5 Cl-99 HCO3-21* AnGap-16 [**2147-6-9**] 04:26AM BLOOD Glucose-149* UreaN-30* Creat-0.8 Na-137 K-4.3 Cl-105 HCO3-23 AnGap-13 [**2147-6-10**] 07:20AM BLOOD Glucose-97 UreaN-15 Creat-0.5 Na-136 K-4.2 Cl-101 HCO3-26 AnGap-13 [**2147-6-8**] 09:10PM BLOOD ALT-14 AST-14 CK(CPK)-139 AlkPhos-113 TotBili-0.5 [**2147-6-9**] 04:26AM BLOOD CK(CPK)-139 [**2147-6-9**] 12:44PM BLOOD CK(CPK)-92 [**2147-6-8**] 09:10PM BLOOD CK-MB-5 proBNP-2162* [**2147-6-8**] 09:10PM BLOOD cTropnT-0.09* [**2147-6-9**] 04:26AM BLOOD CK-MB-5 cTropnT-0.06* [**2147-6-9**] 12:44PM BLOOD CK-MB-NotDone cTropnT-0.06* [**2147-6-9**] 04:26AM BLOOD %HbA1c-9.3* [**2147-6-8**] 09:21PM BLOOD Lactate-1.3 . [**2147-6-9**] 8:01 am URINE Source: CVS. **FINAL REPORT [**2147-6-10**]** Legionella Urinary Antigen (Final [**2147-6-10**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). . [**2147-6-9**] CXR FINDINGS: Cardiac silhouette is mildly enlarged. Straightening of left mediastinal border is present with loss of the normal aorticopulmonary window contour. Confluent opacity is present in the left retrocardiac region projecting posteriorly on the lateral view. Peripherally there is an either pleural or extrapleural opacity present but no blunting of the costophrenic angles. Skeletal structures reveal degenerative changes in the spine. IMPRESSION: 1. Confluent left lower lobe opacity suspicious for pneumonia. 2. Widening of left mediastinal contour and loss of normal aorticopulmonary interface. Consider chest CT to differentiate prominent mediastinal fat from lymphadenopathy or a discrete mass Brief Hospital Course: #Community-acquired pneumonia - Treated with 7 days of levofloxacin. Blood cultures remained negative. Urinary legionella antigen was negative. Displayed normal ambulatory oxygen saturation prior to discharge. Recommended 4 week follow-up CXR to ensure resolution. . #Abnormal CXR - [**2147-6-9**] exam revealed widening of the left mediastinal contour and loss of the normal aorticopulmonary interface. Chest CT was recommended to differentiate a prominent mediastinal fat from lymphadenopathy or mass, but, despite acknowledging that this radiographic finding could represent malignancy, the patient declined CT due to significant discomfort and orthopnea while supine in the scanner. . #Coronary artery disease - Mild troponin leak attributed to strain/subendocardial ischemia in the setting of febrile illness. Flat CK without acute ischemic EKG changes. Continued aspirin, beta-blocker statin. . #Diabetes mellitus type II - Well-controlled on glipizide and sliding scale insulin. Metformin held on admission but was restarted upon discharge. . #Chronic obstructive pulmonary disease - Continued advair and bronchodilator nebs as needed. . #Hypertension - Well-controlled on beta-blocker and ACE inhibitor. . #Hyperlipidemia - Continued statin. Medications on Admission: Advair 1 puff [**Hospital1 **] Glipizide 10mg daily Metformin 1g daily Lipitor 40mg daily Potassium 20mEQ daily Metoprolol 200mg daily Lasix 20mg daily Asa 325mg daily Albuterol qid Lisinopril 20mg daily Humulin 25 units qam and 28units qpm Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 2. Glipizide 10 mg Tablet Extended Rel 24 hr (2) Sig: One (1) Tablet Extended Rel 24 hr (2) PO DAILY (Daily). 3. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO once a day. 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 4 days. Disp:*4 Tablet(s)* Refills:*0* 9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 11. Humulin N 100 unit/mL Suspension Sig: Twenty Five (25) units Subcutaneous QAM. 12. Humulin N 100 unit/mL Suspension Sig: Twenty Eight (28) units Subcutaneous QPM. Discharge Disposition: Home Discharge Diagnosis: Primary 1) Community-acquired pneumonia Secondary 1) Coronary artery disease 2) Diabetes mellitus type II 3) Chronic obstructive pulmonary disease 4) Hypertension 5) Hyperlipidemia Discharge Condition: Clinically improved with stable vital signs. Discharge Instructions: You were admitted to the hospital with pneumonia which was partially treated with antibiotics. Please continue taking the antibiotics through [**Last Name (LF) 2974**], [**6-14**]. No changes were made to your other medications. Please arrange a follow up appointment with your PCP [**Name Initial (PRE) 176**] 1 week. Please discuss having a repeat chest x-ray in 4 weeks' time to ensure resolution of your pneumonia. Please call your physician or return to the Emergency Department if you experience fever, chills, sweats, dizziness, lightheadedness, chest pain, palpitations, cough, shortness of breath, abdominal pain, vomiting, diarrhea, leg swelling, rash or other concerning symptoms. Followup Instructions: Please call the office of Dr. [**Last Name (STitle) 17029**] at [**Telephone/Fax (1) 17030**] for an appointment within 1 week. Please discuss having a repeat chest x-ray in 4 weeks' time to ensure resolution of your pneumonia. Completed by:[**2147-6-12**]

[ "250.00", "414.01", "496", "401.9", "272.4", "486", "V45.82" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6914, 6920

4229, 5483

324, 332

7146, 7193

2056, 4206

7936, 8195

1518, 1527

5775, 6891

6941, 7125

5509, 5752

7217, 7913

1542, 2037

275, 286

360, 1245

1267, 1343

1359, 1502

51,275

167,352

34085+57892

Discharge summary

report+addendum

Admission Date: [**2106-3-18**] Discharge Date: [**2106-3-31**] Date of Birth: [**2021-11-18**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 3913**] Chief Complaint: Sepsis. Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. [**Known lastname **] with lymphoplasmocytic lymphoma complicated by aplastic anemia secondary to fludarabine based therapy, h/o colon cancer s/p colectomy, and HTN who has had multiple recent admissions for bleeding from colostomy secondary to thrombocytopenia and recurrent infections (most recently resistant pseudomonas right groin abscess) who presentes today with GI bleeding and fever. . She presented to [**Hospital 16843**] hospital with 200 cc of BRBPR in the setting of undetectable platelet levels. She was also febrile upon presentation. She given 2 units of platelets and 2 units of PRBCs. For her fever, she was given zosyn and imipenem and then transferred to [**Hospital1 18**]. . In the ED, vitals were T 101.6, HR 114, BP 117/75, RR 24, 96% on RA. A CXR showed a retrocardiac opacity. She was given levaquin, imipenem, zosyn. She was also given 2L NS for dehydration. She was given another unit of platelets. The patient's son was notified of her arrival, but he expressed concern that she had been rapidly declining over the past few weeks and was uncertain if he should continue with this level of care. . On arrival to the [**Hospital Unit Name 153**], patient reported intermittent non-productive cough for months. She reported several days of fevers. She denied abdominal pain. She could not recall what brought her to the hospital and was unclear about the reasons for her recent hospitalizations. Her speech was slurred. While in the [**Hospital Unit Name 153**], she remained hemodyncially stable and never required blood transfusions, but was given platlets x 4. She had + blood cultures for pseudomonas from the OSH, but no sensitivities as of yet. She remained stable, and was called out to the floor where she had no complaints. Past Medical History: Colon cancer [**2099**] s/p diverting colostomy reversed [**2100**], loop colostomy for large bowel obstruction [**10-25**] Lymphoplasmacytic lymphoma diagnosed [**10/2103**] Aplastic anemia Hypertension Iron overload (heterozygous for hemochromatosis gene) h/o C. diff colitis h/o large bowel obstruction s/p appendectomy s/p tonsillectomy s/p tubal ligation s/p cholecystectomy Social History: Widow, has five children Lives alone in [**Name (NI) 16843**], MA - son has been staying with her recently Denies tobacco, alcohol, or illicit drug use Family History: Father died of stroke at age 77 Mother had CAD and renal failure No family history of malignancy or hematologic disorder Physical Exam: Vitals: T: 97.6 BP: 118/72 P: 113 R: 26 O2: 100% on 3LNC General: ill appearing, slowed speach, HEENT: Sclera icteric, dry mucous membranes Lungs: Clear to auscultation bilaterally anteriorly CV: irregularly irregular, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly, + colostomy with old liquid blood (no clots, no bright red blood) GU: + foley Ext: warm, 1+ edema of LE bilaterally, bruising of both arms Pertinent Results: [**2106-3-31**] 05:55AM BLOOD WBC-0.3* RBC-3.38* Hgb-9.7* Hct-29.5* MCV-87 MCH-28.8 MCHC-33.0 RDW-13.8 Plt Ct-7*# [**2106-3-30**] 07:40AM BLOOD WBC-0.3* RBC-2.82* Hgb-8.0* Hct-24.3* MCV-86 MCH-28.4 MCHC-33.1 RDW-13.8 Plt Ct-20* [**2106-3-20**] 06:00AM BLOOD WBC-0.7* RBC-3.29* Hgb-9.6* Hct-27.8* MCV-85 MCH-29.2 MCHC-34.5 RDW-15.1 Plt Ct-27* [**2106-3-19**] 07:06PM BLOOD WBC-0.8* RBC-3.47* Hgb-10.1* Hct-29.4* MCV-85 MCH-29.2 MCHC-34.5 RDW-15.1 Plt Ct-28* [**2106-3-18**] 06:45PM BLOOD WBC-1.0* RBC-3.54*# Hgb-9.9*# Hct-29.0* MCV-82 MCH-28.1 MCHC-34.3 RDW-15.7* Plt Ct-30* [**2106-3-30**] 07:40AM BLOOD Neuts-43* Bands-0 Lymphs-38 Monos-19* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2106-3-18**] 06:45PM BLOOD Neuts-73* Bands-11* Lymphs-7* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 [**2106-3-31**] 05:55AM BLOOD Gran Ct-200* [**2106-3-31**] 05:55AM BLOOD Glucose-109* UreaN-28* Creat-0.8 Na-143 K-3.5 Cl-104 HCO3-33* AnGap-10 [**2106-3-30**] 07:40AM BLOOD Glucose-87 UreaN-25* Creat-0.7 Na-142 K-3.6 Cl-105 HCO3-30 AnGap-11 [**2106-3-18**] 11:44PM BLOOD Glucose-242* UreaN-30* Creat-1.0 Na-144 K-3.7 Cl-112* HCO3-24 AnGap-12 [**2106-3-18**] 06:45PM BLOOD Glucose-178* UreaN-29* Creat-1.0 Na-147* K-2.8* Cl-110* HCO3-27 AnGap-13 [**2106-3-31**] 05:55AM BLOOD ALT-64* AST-36 LD(LDH)-107 AlkPhos-174* TotBili-1.5 [**2106-3-18**] 06:45PM BLOOD ALT-61* AST-61* LD(LDH)-146 CK(CPK)-100 AlkPhos-178* TotBili-1.7* [**2106-3-19**] 05:33AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Test [**2106-3-19**] 04:06AM BLOOD B-GLUCAN-Test . OSH Blood cxs: 4/4 bottles positive for Pseudomonas pan-resistant except to tobramycin Repeat surveillance cultures: [**3-18**], [**3-22**], [**3-24**]: negative growth . CT abdomen: 1. evaluation limited due to lack of IV contrast (IV infiltrated after 20cc, no access). small amount of free fluid in the abdomen. No evidence of abscess. no free air. 2. moderate bilateral pleural effusions, left greater than right, with adjacent compressive atelectasis. Brief Hospital Course: Ms [**Known lastname **] was admitted for sepsis, with initial presentation of fevers, leukocytosis and [**3-21**] blood cultures from OSH positive for Pseudomonas resistant to imipinem, quinolones and sensitive only to tobramycin. She has a history of multiple resistant infections including MRSA/VRE abscesses in thigh, Clostridium difficile infection, Klebsiella, and prior Imipenem sensitive pseudomonas. She was initially in the ICU, where she received fluid resuscitation; her other infectious workup was negative. After observation of continued hemodynamic stability, she was transferred to the floor, where surveillance cultures were negative X 3. Her port-a-cath that she had in for a one year period for her chronic blood transfusions was removed as this could have been seeded with pseudomonas. Culture of the tip was negative. A midline was placed in her left arm. On the floor, she was afebrile and normotensive. After determining culture sensitivities, tobramycin and cefepime were initiated. Repeat surveillance cultures again remained negative. Given the initial report of blood noted in ostomy, she was continued on IV PPI, but once her hematocrits were seen to be stable, she was switched to PO PPI. Secondary to her aplastic anemia, she was continued on cyclosporine but the dose was reduced to 75 mg [**Hospital1 **] given high trough levels. Her neupogen was titrated up given persistent neutropenia. Her desferroxime was continued. Her coumadin, which was initially started several weeks prior to admission and then discontinued at time of GI bleed, was not restarted although she did have a CHADS score of 2 with her atrial fibrillation history, given that she was deemed too high risk for anticoagulation. Her atenolol was discontinued and she was switched to metoprolol TID. Her lymphoplasmocytic lymphoma continued to be in remission. She did initially have an O2 requirement however this was weaned; she was found to have small, stable pulmonary effusions likely secondary to fluid administration. At time of discharge, she was saturating well on room air although had mild dyspnea on exertion. She was afebrile and normotensive. She is due to continue her tobramycin q48 and cefepime 2 gm q8 up through [**4-4**]. She will need troughs checked prior to each q48 dose with goal trough < 1.0. She will have follow up with Dr [**Last Name (STitle) **] next week. Medications on Admission: Atenolol 25 mg daily Folic Acid 1 mg daily Multivitamin daily Acyclovir 400 mg [**Hospital1 **] Deferoxamine 500 mg twice weekly Calcium Carbonate 500 mg QID prn Amlodipine 10 mg daily Filgrastim 300 mcg/0.5 mL twice weekly Omeprazole 20 mg daily Cyclosporine Modified 125 mg [**Hospital1 **] Hydrochlorothiazide 25 mg daily Atrovent prn Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 2. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Deferoxamine 500 mg Recon Soln Sig: One (1) Recon Soln Injection 2X/WEEK (WE,SA). 6. Calcium Carbonate 500 mg (1,250 mg) Capsule Sig: One (1) Capsule PO four times a day. 7. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 8. Filgrastim 480 mcg/1.6 mL Solution Sig: One (1) Injection Q24H (every 24 hours). Disp:*qs month supply* Refills:*2* 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 10. Cyclosporine Modified 25 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). Disp:*180 Capsule(s)* Refills:*2* 11. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler Sig: [**12-19**] Inhalation once a day. 12. Cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection Q8H (every 8 hours). Disp:*qs (last day [**4-4**]) Recon Soln(s)* Refills:*0* 13. Tobramycin Sulfate 40 mg/mL Solution Sig: One (1) Injection Q48H (every 48 hours). Disp:*qs (last day [**4-4**]) * Refills:*0* 14. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Location (un) **] Nursing & Rehabilitation Center - [**Location (un) **] Discharge Diagnosis: 1) Pseudomonas bacteremia 2) Lower GI bleed 3) Aplastic Anemia 4) Lymphoplasmacytic Lymphoma Discharge Condition: Stable, ambulating on room air, clear mental status, normotensive, in atrial fibrillation with normal ventricular rate. Discharge Instructions: Dear Ms [**Known lastname **], It was a pleasure caring for you while you were at [**Hospital1 18**]. You were admitted because you had positive blood cultures growing out a bacteria called Pseudomonas. To treat you, we removed the Port on your right side and placed a new line in your left arm so you could continue to receive antibiotics. We removed the Port because its possible it could have been infected. We then started two antibiotics (tobramycin and cefepime) which you will need to take for a total of 2 weeks. . At the time of admission, you also had some lower GI bleeding, however this resolved. At time of admission, you had no evidence of continued GI bleed. . We made the following medication changes during this hospitalization: (1) Please discontinue atenolol. (2) We started you on metoprolol 50 mg three times a day. (3) We increased your filgastrim (NEUPOGEN) to 480 mg injected subcutaneously daily. (4) We decreased your cyclosporine dose to 75 mg twice a day. (5) We started you on two antibiotics (Cefepime) and (tobramycin) which you will continue to get intravenously until [**4-4**], to complete a two week course. Name: [**Known lastname 12658**],[**Known firstname **] [**Last Name (NamePattern1) 2803**] Unit No: [**Numeric Identifier 12659**] Admission Date: [**2106-3-18**] Discharge Date: [**2106-3-31**] Date of Birth: [**2021-11-18**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 3328**] Addendum: Ms [**Known lastname **] will be started on levaquin 500 mg daily starting on [**4-5**] at time of discontinuation of tobramycin and cefepime. Discharge Disposition: Extended Care Facility: [**Location (un) 12660**] Nursing & Rehabilitation Center - [**Location (un) 12660**] [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 994**] MD [**MD Number(1) 1001**] Completed by:[**2106-3-31**]

[ "578.9", "200.80", "427.31", "V10.05", "275.0", "428.0", "285.1", "401.9", "999.31", "038.43", "276.8", "511.9", "288.00", "276.1", "284.89", "E933.1", "E879.8", "995.91" ]

icd9cm

[ [ [] ] ]

[ "38.93", "86.05" ]

icd9pcs

[ [ [] ] ]

11625, 11895

5367, 7778

290, 297

9777, 9899

3357, 5344

2695, 2817

8166, 9514

9660, 9756

7804, 8143

9923, 11602

2832, 3338

243, 252

325, 2106

2128, 2509

2525, 2679

30,817

145,451

12719

Discharge summary

report

Admission Date: [**2117-10-27**] Discharge Date: [**2117-10-28**] Date of Birth: [**2045-7-14**] Sex: F Service: NEUROSURGERY Allergies: Morphine Attending:[**First Name3 (LF) 1854**] Chief Complaint: Intraparenchymal bleed Major Surgical or Invasive Procedure: None History of Present Illness: 72 F, found minimally responsive at home by husband. She was sent to OSH, initial assessment she was moving right side but not left side. CT OSH showed large right temporal lobe bleed and pt was intubated and transferred to [**Hospital1 18**] for further management. She was reportedly hemodynamically stable, pupils unequal but reactive during [**Location (un) **] transfer. Opon arrival in [**Hospital1 18**] ED, her pupils are unequal and unreactive. Past Medical History: HTN, COPD, MI s/p triple bypass 10yrs ago with bowel complications needing colostomy and trach. Social History: lives independently at home with husband; has 15 children; heavy smoker. Family History: NC Physical Exam: PHYSICAL EXAM: per Admit H&P O: T: afebrile BP: 154/93 HR:44 R 20 O2Sats 100% Gen: intubated and unresponsive. positive cornea reaction bilaterally and positive cough. HEENT: Pupils: L 1mm /R 5mm, both unreactive to light. Neck: intubated; old trach scar Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: colostomy at LLQ; Soft, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: unresponsive and intubated. Cranial Nerves: I: Not tested II: Pupils L 1mm /R 5mm, both unreactive to light. Unable to test the rest of CNs. Motor: both LE extensor posturing. No abnormal movements, tremors. No movement of both UE to noxious stimuli; minimal withdrawal of both LE to noxious stimuli. Sensation: No movement of both UE to noxious stimuli; minimal withdrawal of both LE to noxious stimulibilaterally. Reflexes: diminished throughout. Toes mute bilaterally Coordination: unable to assess. Pertinent Results: Diffuse subarachnoid hemorrhage centered in the right sylvian fissure with intraparenchymal extension into the temporalparietal lobe, most likey a sequelae of ruptured aneurysm. There is extensive mass effect secondary to the hemorrhage with resultant subfalcine and uncal herniation. LARGE HEMORRHAGE CENTERED WITHIN THE RIGHT SYLVIAN FISSURE WITH INTRAPARENCHYMAL EXTENSION MEASURING 4.1 X 5.5 CM . LARGE LOBULATED RIGHT MCA ANEURYSM MEASURING 2.7 X 2.1CM. LOW ATTENUATION LINEAR STRUCTURE IS SEEN IN THE RIGHT SUPRACLINOID ICA AND EXTENDING INTO THE CLINOID AND CAVERNOUS PORTION CONCERNING FOR DISSECTION. LINEAR LOW ATTENUATION STRUCTURE IS ALSO SEEN IN THE LEFT MCA, PROXIMAL TO THE TRIFURCATION, WHICH [**Month (only) **] REPRESENT DISSECTION. THE DISTAL LEFT MCA REMAINS PATENT DISTALLY AS ARE THE BILATERAL ACA. DIFFUSE SUBARACHNOID BLOOD IN THE RIGHT SYLVIAN FISSURE, BIHEMISPHERIC SULCI AND ALONG ANTERIOR LONGITUDINAL FISSURE, IS NOT SIGNIFICANTLY CHANGED. THERE IS EXTENSIVE MASS EFFECT AND EDEMA SECONDARY TO THE LARGE HEMORRHAGE WITH 1.5CM OF LEFTWARD SHIFT OF NORMALLY MIDLINE STRUCTURES, EFFACEMENT OF THE SULCI/RIGHT LATERAL VENTRICLE AND BASAL CISTERNS WITH SUBSEQUENT SUBFALCINE AND UNCAL HERNIATION. NOTE IS [**Last Name (un) 39247**] OF MILD ANEURYSMAL DILATATION OF THE DISTAL RIGHT VERTEBRAL ARTERY. THE PCA APPEARS PATENT BILATERALLY, HOWEVER WOULD BE WORRIED ABOUT IMPENDING COMPRESSION OF THE RIGHT PCA BY RIGHT CERBRAL PEDUNCLE. [**Doctor Last Name 7410**] [**Numeric Identifier 7414**] Brief Hospital Course: The patient was admitted to Neurosurgery in the SICU for management of her intraparenchymal bleed and uncal herniation. CT showed a large R temp hemo/diffuse SAH/uncal herniation and CTA demonstrated a large aneurysm. Discussions were made with the family about prognosis and that surgery was not indicated in her case. The husband gave decision making powers to the patient's and his daughter. The decision was made as a family for CMO. Upon extubation, the patient did not initiate a single breath and was eventually called dead at 9:57 am. Breath and heart sounds were ascultated for for 1 minute for confirmation. The patient was not an organ donor, the family refused autopsy, and the Medical Examiner waived the right to examine the patient. Medications on Admission: None; she had self d/ced all her medication for several months Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: n/a Discharge Condition: n/a Discharge Instructions: n/a Followup Instructions: n/a

[ "V45.81", "496", "348.4", "305.1", "430", "412", "401.9" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

4392, 4401

3496, 4251

298, 304

4448, 4453

1955, 3473

4505, 4511

1013, 1017

4364, 4369

4422, 4427

4277, 4341

4477, 4482

1047, 1411

236, 260

332, 787

1470, 1936

1426, 1454

809, 906

922, 997

9,905

130,273

22194

Discharge summary

report

Admission Date: [**2186-3-21**] Discharge Date: [**2186-4-9**] Date of Birth: [**2121-2-16**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 3984**] Chief Complaint: Bone marrow Transplant Major Surgical or Invasive Procedure: Insertion of Hickman central line Ultrasound guided cholecystotomy History of Present Illness: A 65-year-old gentleman with a history of recurrent non-Hodgkin's lymphoma who is being admitted today for his non-myeloablative allogeneic transplant from a sibling donor. Past Medical History: Non-Hodgkin's lymphoma (s/p autologous BMT in [**7-10**] with recurrance, s/p multiple chemotherapy regimens including [**Hospital1 **],CHOP/Rituxan,DHAP, Gemzar, Velcade) Hepatitis B - HepBcore Ab positive on pretransplant workup (currently on lamivudine) Hypertension Hyperlipidemia Silent MI (found on EKG 12 years ago) Basal cell carcinoma Macular degeneration Social History: Originally from the [**State 21008**]. Self-employed as a machinist, lives at home with his wife, who has MS. [**Name13 (STitle) **] has six children, all whom are supportive and helpful. Ambulates easily on his own. Past h/o tobacco 3ppd x 8-10 years, quit 30 years ago. Drinks only socially. No recreational/IV drug use. Family History: FH - HTN, CAD, no history of cancers or any bleeding disorders Physical Exam: VS- Ht 62in Wt 123.2 97.0 18 81 122/72 100%RA LINES- Right triple lumen port, no tenderness or erythema GEN- Bald male, pleasant, sitting up in bed in NAD HEENT- MMM, EOMI, PERRLA, OP clear, edentulous, no lesions, no sinus tenderness NECK- supple, no LAD, no bruits, equal carotid pulses CV- RRR, soft I/VI HSM loudest along LSB, no gallops CHEST- CTA and percussion bilatterally ABD- soft, NT, ND, pos BS x 4 EXT- No c/c/e, 2+ DP pulses bilaterally, no pelvic LAD NEURO- AAOx3, CN intact, no focal findings SKIN- Radiation markings, dry skin along denuded shins Pertinent Results: [**2186-3-20**] 08:50AM PLT SMR-RARE PLT COUNT-17* [**2186-3-20**] 08:50AM HYPOCHROM-NORMAL ANISOCYT-3+ POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-2+ POLYCHROM-NORMAL [**2186-3-20**] 08:50AM NEUTS-63 BANDS-0 LYMPHS-14* MONOS-21* EOS-1 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 [**2186-3-20**] 08:50AM WBC-1.8* RBC-3.04* HGB-9.8* HCT-27.0* MCV-89 MCH-32.2* MCHC-36.3* RDW-19.1* [**2186-3-20**] 08:50AM ALT(SGPT)-42* AST(SGOT)-47* LD(LDH)-285* ALK PHOS-253* TOT BILI-0.7 DIR BILI-0.2 INDIR BIL-0.5 [**2186-3-20**] 08:50AM GLUCOSE-126* UREA N-17 CREAT-0.8 SODIUM-136 POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-30 ANION GAP-10 [**2186-3-20**] 11:50AM PLT COUNT-48*# [**2186-3-21**] 12:03PM PT-13.3* PTT-24.8 INR(PT)-1.2* [**2186-3-21**] 12:03PM PLT COUNT-39* [**2186-3-21**] 12:03PM WBC-2.1* RBC-3.00* HGB-9.8* HCT-27.3* MCV-91 MCH-32.6* MCHC-35.9* RDW-20.4* [**2186-3-21**] 12:03PM WBC-2.1* RBC-3.00* HGB-9.8* HCT-27.3* MCV-91 MCH-32.6* MCHC-35.9* RDW-20.4* [**2186-3-21**] 12:03PM ALBUMIN-3.7 CALCIUM-9.1 PHOSPHATE-3.9 MAGNESIUM-1.9 URIC ACID-4.4 [**2186-3-21**] 12:03PM ALT(SGPT)-44* AST(SGOT)-51* LD(LDH)-396* ALK PHOS-224* TOT BILI-0.6 [**2186-3-21**] 12:03PM GLUCOSE-97 UREA N-19 CREAT-0.8 SODIUM-138 POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-27 ANION GAP-17 . RIGHT UPPER QUADRANT ULTRASOUND: The gallbladder is slightly distended with some gallbladder wall edema. Mobile sludge is seen within the lumen of the gallbladder. No shadowing stones are identified. The liver parenchyma appears unremarkable. There is no evidence of intra- or extra-hepatic biliary ductal dilation. The hepatic veins, hepatic arteries and portal veins are patent, with flow in appropriate directions, and normal waveforms. The right kidney appears unremarkable. There is no evidence of ascites. . IMPRESSION: Slightly distended gallbladder with gallbladder wall edema could be consistent with acalculous cholecystitis. Recommend correlation with HIDA scan if clinical concern exists. . Brief Hospital Course: ASSESSMENT AND PLAN: Mr. [**Known lastname 57923**] is a 65-year-old gentleman who was admitted for stem cell transplant and developed overwhelming sepsis 2 weeks into his hospital stay and ultimately passed away with multi-organ failure. . 1. Heme/Onc: He has a history of diffuse large B-cell lymphoma which has been recurrent/refractory following his autologous stem cell transplant and is being admitted today for his non-myeloablative allogeneic stem cell transplant from a sibling donor with Cytoxan/Fludarabine conditioning regimen. He was started on a cytoxan/fludarabine conditioning regimen, which he tolerated quite well. Prior to starting he had a pMIBI for some concerning finding on screening echo, which showed some fixed inferoapical scars, nothing reversible. He was able to proceed with transpalnt. On [**3-28**] he received his sister's stem cells (a nun and never been pregnant), and tolerated this well. He was treated with methotrexate after the transplant of cells. He was started on continuous CSA as [**Doctor Last Name **] as empiric antibiotics per protocol. He was started also on GCSF on day 5 of transplant. . 2. Sepsis: On [**2186-4-5**], day 8 post-transplant, the pt was noted to be hypotensive. He got out of bed to go to the restroom and after exiting the restroom was noted to have a fall that was witnessed by his nurse. He later recalled feeling light-headed while standing up just before falling. After a few moments of unresponsiveness, he regained alertness although was noted to have sbp in the 70's to 80's. He was afebrile at that time, it was thought that he may be vasovagal, although he was sent to the MICU for closer monitoring. By the time he arrived at the MICU, his bp remained persistently low despite fluids, he was noted to be febrile and was found to have elevated lacate. He was treated per sepsis protocol, given multiple liters of IV NS, given stress dose steroids, started on levophed. He was started empirically on very broad spectrum abx coverage including fungal coverage given his immunosuppressed state. He was given blood for low hct in the setting of septic shock. An arterial bp line was attempted in the femoral artery but was unsuccessful. His bp remained tenuous even with the support. An a-line was placed by anesthesia the following morning. He was intubated by anesthesia as well for shortness of breath in the setting of CHF with massive IVF infusion. He required increasing level of pressor suppport and was on high doses of three pressors. Over the following several days, the pt developed progressively worsening multiple organ dysfunction. Renal failure, coagulopathy reflected by elevated INR, metabolic acidosis became worse. The pt was requiring maximal doses of 3 pressors, levophed, dopamine, and phenylephrine to maintain map around 60. Broad spectrum abx coverage was continued, vital signs were supported. Ultrasound guided cholecystotomy was performed to drain a suspected source of infection. Blood cultures were found to be positive for E. coli and viridans strep, which were sensitive to the antibiotics which he was on. On [**4-8**] in the evening the pt became progressively unstable, the pt developed rapid tachycardia at 160 bpm. The ECGs were faxed to EP fellow on call. The rhythm was noted to be reverting from atrial flutter to atrial tachycardia, and atrial fibrillation. Amiodarone was infused IV with the plan to cardiovert, although the pt spontaneously returned to NSR at roughly 130 bpm. Amio was continued as a drip. Given the downward trend in the course, a discussion was held with the family regarding pt's critical condition. The following morning, on [**4-9**], the pt was found to be on an irreversible course toward passing away. His bp was dropping below life sustaining levels despite maximal pressor support, liver tests indicated hepatocellular damage likely from hypoperfusion, acidemia was becoming more severe. Discussions were held with the family by multiple physicians including the oncologist. The pt was made CMO and was extubated at around 10am. Shortly thereafter, he was found to have ceased spontaneously respiratory effort and was without a pulse and he was pronounce deceased. . Medications on Admission: Aerosolized pentamidine each monthly, last given on [**2186-3-6**], magnesium oxide 1 tablet b.i.d., Klonopin 0.5 mg b.i.d., Valtrex 500 mg b.i.d., atenolol 100 mg daily, folic acid 1mg daily, Epivir 100 mg daily, fluconazole 200 mg daily. Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: septic shock Discharge Condition: deceased Discharge Instructions: none Followup Instructions: none [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

[ "570", "038.42", "070.30", "401.9", "286.6", "202.88", "575.0", "427.31", "584.9", "284.8", "518.81", "287.31", "428.0", "724.5", "785.52", "038.0", "276.1" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.05", "96.72", "96.04", "00.92", "38.91", "99.28", "99.15", "86.05", "51.01", "41.05", "99.07", "99.04", "00.17", "99.25" ]

icd9pcs

[ [ [] ] ]

8526, 8535

3975, 8206

294, 362

8591, 8601

1982, 3952

8654, 8787

1313, 1377

8497, 8503

8556, 8570

8232, 8474

8625, 8631

1392, 1963

232, 256

390, 566

588, 955

971, 1297

80,536

128,948

35311

Discharge summary

report

Admission Date: [**2159-11-26**] Discharge Date: [**2160-3-18**] Date of Birth: [**2090-3-4**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 668**] Chief Complaint: acute renal failure Major Surgical or Invasive Procedure: [**2159-12-3**] Liver transplant [**2159-12-5**] Splenectomy and closure [**2159-12-16**] Ex lap, washout ERCP x4 Thoracentesis Tunneled HD line, L [**2159-12-18**] Trache History of Present Illness: Ms. [**Known lastname **] is a 69yo F with PMH Hep C cirrhosis currently on the tranplant list recently admitted [**Date range (1) 80525**] for SBP who is being admitted after her Cr in clinic was found to be 2.8 from 1.9. Of note, pt has been on diuretic as well as a fluid restriction since her last admission. . She was recently discharged on [**2159-11-12**] after an 11-day hospitalization for ischemic bowel and SBP, responsive antibiotics and volume resuscitation. She also had a urine culture that initially grew VRE and was treated with a 3-day course of linezolid. Upon discharge, her diuretic doses were doubled (lasix 20mg --> 40mg and spironolactone 50mg --> 100mg). Baseline creatinine appears to be 1.8-2.0. . She has been very compliant with her fluid restriction of 1L + Ensure, but her appetite continues to be poor. She denies any issues with medication compliance. She feels well overall, without any acute concerns. Her abdomen has not increased in size lately. Past Medical History: Chronic C hepatitis genotype 1 and cirrhosis as above Cirrhosis - complicated by volume overload, grade 1 esophageal varaces, never had encephalopathy or ascites requiring paracentisis. History of positive PPD - evaluated by transplant ID and will undergo INH/B6 therapy post-transplant. Osteopenia - DEXA [**1-/2159**] Hypothyroidism Vitamin D deficiency Orthotopic liver transplant [**2159-12-2**] Exploratory laparotomy, splenectomy, and choledochocholedochostomy [**2159-12-5**] Social History: She does not smoke. She does not drink. Denies drug use. She is married with five children. She used to works as a nurse, but hasn't been able to work for 3 years. She misses being a nurse and being active. Family History: Non-contributory. Physical Exam: Admission Physical Exam: Vitals: 98.1, 136/87, 85, 18 and 98% on RA General: NAD, pleasant and conversant HEENT: NC/AT, PERRL, EOMI, mild scleral icterus, oropharynx clear without sublingual jaundice Neck: supple, no appreciable JVD Heart: RRR, nl S1/S2, no m/r/g Lungs: crackles at right base, otherwise CTA Abdomen: distended but soft, non-tender; + fluid wave and shifting dullness Extremities: 2+ radial and DP pulses, 1+ edema in LE bilaterally; no cyanosis/clubbing; no palmar erythema Neurological: AAOx3, no asterixis, CN II-XII grossly intact, [**3-22**] in UE and LE bilaterally, gait deferred Skin: no e/o spider angiomata, no rashes Pertinent Results: [**2160-3-15**] 10:47AM BLOOD WBC-11.4* RBC-3.22*# Hgb-9.7*# Hct-32.9* MCV-102* MCH-30.0 MCHC-29.4* RDW-20.0* Plt Ct-468* [**2160-3-17**] 05:35AM BLOOD WBC-10.6 RBC-3.01* Hgb-9.1* Hct-30.4* MCV-101* MCH-30.1 MCHC-29.8* RDW-18.9* Plt Ct-395 [**2160-3-14**] 12:45PM BLOOD Glucose-145* UreaN-72* Creat-5.1*# Na-139 K-4.4 Cl-97 HCO3-23 AnGap-23* [**2160-3-15**] 10:47AM BLOOD Glucose-134* UreaN-93* Creat-6.4*# Na-141 K-5.0 Cl-98 HCO3-20* AnGap-28* [**2160-3-17**] 05:35AM BLOOD Glucose-132* UreaN-51* Creat-3.9*# Na-138 K-4.7 Cl-99 HCO3-22 AnGap-22* [**2160-3-13**] 05:25AM BLOOD ALT-9 AST-32 AlkPhos-362* TotBili-0.4 [**2160-3-15**] 10:47AM BLOOD ALT-9 AST-31 AlkPhos-361* TotBili-0.5 [**2160-3-17**] 05:35AM BLOOD ALT-14 AST-61* AlkPhos-393* TotBili-0.4 [**2160-3-17**] 05:35AM BLOOD Calcium-9.5 Phos-3.5 Mg-2.2 [**2160-3-14**] 12:45PM BLOOD TSH-1.1 [**2160-3-10**] 06:12AM BLOOD tacroFK-10.4 [**2160-3-13**] 05:25AM BLOOD tacroFK-10.3 [**2160-3-17**] 05:35AM BLOOD tacroFK-8.5 Brief Hospital Course: 69F with HCV cirrhosis recently admitted with acute on chronic kidney injury concerning for HRS and hyponatremia. Hyponatremia resolved with hydration. She became oliguric with rising Cr despite this octreotide/midodrine and was initiated on dialysis [**12-1**]. LFTs worsened. Liver ultrasound revealed new non-occlusive portal vein thrombosis. Liver function continued to worsen. Heparin drip was started after an EGD was performed to establish risk of bleeding varices. Grade [**11-19**] varices with no signs of bleeding were noted. On [**2159-12-2**], an ABO incompatible donor liver offer was accepted and she underwent orthotopic liver transplant from donor with blood type A (she is Type B). Plasmapheresis was done prior to OR. She had a significant coagulopathy and abdomen was unable to be closed. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please refer to operative notes for complete details. She was sent intubated to the SICU for management postop. Plasmapheresis was performed on postop day 1. Liver duplex exam was limited, but demonstrated patent vasculature within the right lobe of liver. Left lobe hepatic vasculature and extrahepatic vessels could not be assessed. LFTs increased. JP drainage was bilious. Anti A titers were in the 1-4 range and plasmapheresis was stopped. A total of 7 doses of ATG were given. Immunosuppression consisted of Cellcept, Solumedrol and Prograf per trough levels. She was taken back to the OR on [**12-4**], for exploratory laparotomy, splenectomy, and choledochocholedochostomy. Blood cultures were sent for serum WBC elevation. Enterococcus faecium was isolated from blood on [**12-10**]. Vancomycin was initially started then switched to Daptomycin when sensitivities isolated VRE. Dapto continued until [**1-10**] then was switched to Linezolid on [**1-10**]. LFTs improved, but bilirubin remained elevated. On [**12-12**], a liver duplex was done to evaluate for hyperbilirubinemia noting large peri- and subhepatic collection which appeared to be a partially liquefied and partially organized. On [**12-13**], an ERCP was performed for evaluation of bacteremia in setting of large peri-hepatic / subhepatic fluid collection seen on ultrasound. The biliary anastomosis was angulated but appeared patent. No intervention was done. Alk phos increased and liver biopsy was done on [**12-16**] which showed bile duct proliferation. Bilious drainage was noted in JP. On [**2159-12-18**], she was taken to the OR for liver transplant for exploratory laparotomy, evacuation of hematoma and washout liver biopsy. A tracheostomy was also performed as she had been intubated for 15 days. She remained vented and repeat ERCP was performed on [**12-31**] with finding of anastomotic stricture in the mid bile duct and moderate bile extravasation of the level of the stricture confirming bile leak. A sphincterotomy was performed with placement of a 7cm by 10FR biliary stent. Good bile flow was noted after stent placement. Feeding tube was placed and feeds were continued. She transferred out of the SICU after 26 days. She was febrile on [**1-2**] and was transferred back to the SICU for hypotension. Blood cultures isolated fairly resistant Klebsiella. CVL tip culture isolated VRE. Zosyn was started then was switched to Colistin after 3 days. Colistin continued for 4 more days when sensitivities revealed [**Last Name (un) **] sensitivity. Meropenum was started on [**1-8**] and continued for a total of 2 weeks. Repeat blood cultures were negative. Bilious JP output diminished. However, this increased again as well as serum WBC. ERCP was done again on [**1-15**]. Extravasation was noted at the main biliary tree, at or just below the anastomosis. Otherwise, biliary tree was normal. Two 7cm by 10FR Plastic stents biliary stents and [**Last Name (un) **]-gastric feeding tube were placed under Fluoro. She remained in the SICU for 10 days. She was anuric and CVVHD continued until [**1-10**] when she was switched to intermittent HD. On [**1-2**] thoracentesis was done for large pleural effusion with 1200cc removed. Culture was negative. A pigtail catheter was placed on [**1-10**] for re accumulation. Pigtail was removed on [**2-10**]. On [**1-18**], CXR demonstrated recurrent right pleural effusion. Interventional pulmonary performed a thoracentesis and placed a pigtail that was placed suction for small apical pneumothorax. Subsequently, daily CXR s showed near resolution of pneumothorax. Pigtail was removed. For most of her postoperative course, she was delirious/paranoid. Delirium was felt to be multifactorial (uremia, bacteremia, Prograf, sleep deprivation and steroids). Psyche was consulted and recommended low dose Haldol. Scheduled HS Haldol seemed to be beneficial with less confusion and paranoia. She became oriented, but had intermittent episodes of anxiety. Episodes of anxiety resolved. Speech evaluated and declared her safe for diet. Tube feeds continued secondary to inability to consume enough kcals to meet needs. Trache cannula was down sized to a # 5 with intermittent use of passy muir valve. She had episodes of feeling like she was suffocating. This seemed to occur with passy muir valve. A 24 hour trial of cuff deflation was done demonstrating appropriate oxygenation. She was decannulated on [**1-31**] and continued to do well from a respiratory stand point. On [**1-14**] , a left tunneled line was placed for hemodialysis. HD continued on a Tues-Thurs-Sat schedule as she remained anuric. Bladder scan was negative on multiple occasions. Physical therapy found her to be extremely debilitated requiring [**Doctor Last Name **] lift and max assist. Rehab was recommended. However, discharge to rehab was suspended given lack of approval for LTAC coverage from her insurer. She remained in hospital. Physical stamina improved over subsequent weeks to where she was able to stand and walk with assist with walker. Abdominal JP drain remained in place with outputs decreasing to a low of 11cc/day. Incision was intact with small area at apex that had been opened and a 2x2 gauze was placed. Of note, she had persistent vaginal bleeding over most of hospital stay. This was worked up in [**Month (only) 1096**] admission with endometrial Bx with finding of no-malignancy, but showed increased endometrial stripe. She continued to have vaginal spotting. Eventually, this stopped. She should f/u with GYN. On [**2-21**], she was hypotensive and felt unwell. Blood cultures were drawn and were positive for Daptomycin resistant VRE. She was initially started on Dapto, but then switched to Linezolid. Surveillance cultures remained negative. She completed a 2 week course. On [**3-7**], f/u ERCP was done (last ERCP [**1-15**] with biliary stent placement for leak). No leak was noted and stent was removed. Over subsequent days, she had malaise with intermittent nausea and small amount of vomiting. Tube feeds were held. Blood cultures were sent on [**3-10**] and have remained negative to date. On [**3-12**], she desat'd while ambulating. CXR revealed a moderate sized right pleural effusion. On [**3-13**], IP performed a right thoracentesis draining 800 ml. Pleural culture was negative . Post procedure CXR revealed a small apical pneumothorax. She became hypotensive with decreased right breath sounds. Chest pigtail catheter was placed to a pleura vac and attached to suction. It became obvious that she had an air leak. On [**3-15**], chest pigtail catheter was removed and CXR demonstrated small right-sided pleural effusion. Of note, feeding tube was noted to be in stomach. Hemodialysis schedule was switched to Monday-Wednesday-Friday. She recquired low dose Midodrine 2.5mg 1 hour prior to HD for on going hypotension during HD. Last HD was [**3-17**] which she tolerated well. CODE: Full EMERGENCY CONTACT: [**First Name4 (NamePattern1) **] [**Name (NI) **] (husband, [**Telephone/Fax (1) 80526**]) . Transitional Issues: - Gyn follow-up for h/o vaginal bleeding Medications on Admission: - ciprofloxacin 500 mg Tablet 1 Tablet(s) by mouth every twenty-four(24) hours - furosemide 40 mg Tablet 1 Tablet(s) by mouth once a day - lactulose [Constulose] 10 gram/15 mL Solution 15-30 ml(s) by mouth three times a day - levothyroxine 50 mcg Tablet 1 Tablet(s) by mouth daily - megestrol 400 mg/10 mL (40 mg/mL) Suspension 20 ml by mouth once a day - rifaximin [Xifaxan] 550 mg Tablet 1 Tablet(s) by mouth twice a day - spironolactone 100 mg Tablet 1 Tablet(s) by mouth q am - calcium carbonate-vitamin D3 600 mg (1,500 mg)-400 unit Tablet 1 Tablet(s) by mouth twice a day - cholecalciferol (vitamin D3) 400 unit Tablet 2 Tablet(s) by mouth once a day Discharge Medications: 1. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for SOB/wheeze. 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain: no more than 2000mg per day. 4. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2 times a day). 5. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. insulin regular human 100 unit/mL Solution Sig: follow printed scale units Injection ASDIR (AS DIRECTED). 7. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 8. ipratropium bromide 0.02 % Solution Sig: One (1) inh Inhalation Q6H (every 6 hours) as needed for wheezing. 9. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 10. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 11. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): decrease to 7.5mg on [**3-29**] x 10 days then decrease to 5 mg x10. 12. sulfamethoxazole-trimethoprim 200-40 mg/5 mL Suspension Sig: Ten (10) ML PO DAILY (Daily). 13. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours): Provide elixer. 14. Outpatient Lab Work stat labs every Monday and Thursday for cbc, chem 10, ast, alt, alk phos, t.bili, albumin and trough prograf with results faxed to [**Hospital1 18**] transplant coordinator [**Telephone/Fax (1) 697**] 15. mycophenolate mofetil 200 mg/mL Suspension for Reconstitution Sig: Five (5) ml PO BID (2 times a day). 16. isoniazid 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 17. pyridoxine 50 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily): while taking INH. 18. midodrine 5 mg Tablet Sig: 0.5 Tablet PO 3X/WEEK (MO,WE,FR): give 1 hour prior to dialysis. 19. B-complex with vitamin C Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. mirtazapine 15 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 21. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a day). 22. tacrolimus 2 mg PO Q12H (every 12 hours). Takes as elixir 23. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg Injection Q8H (every 8 hours) as needed for nausea. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: acute on chronic kidney injury HCV cirrhosis S/p liver transplant, splenectomy Biliary anastomoses stricture, leak malnutrition VRE catheter tip/VRE bacteremia Right pleural effusion s/p thoracentesis x2 Pneumothorax h/o +ppd on INH Delirium Hypothyroin Vaginal bleeding Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Fall risk Discharge Instructions: You will be transferring to [**Hospital 100**] Rehab Hemodialysis will continue 3 times per week Blood work will be drawn every Monday and Thursday for lab monitoring Tube feedings will continue Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14955**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2160-3-24**] 11:30 Completed by:[**2160-3-18**]

[ "571.5", "038.9", "995.92", "585.6", "512.1", "584.9", "998.59", "572.4", "452", "511.9", "070.54", "263.9", "486", "E879.8", "286.9", "572.2", "996.82", "560.1", "V45.11" ]

icd9cm

[ [ [] ] ]

[ "96.6", "38.95", "99.71", "50.12", "45.13", "50.59", "96.72", "50.0", "00.93", "51.36", "51.10", "41.5", "51.87", "31.1", "51.85" ]

icd9pcs

[ [ [] ] ]

15010, 15076

3957, 11935

322, 496

15391, 15391

2956, 3934

15798, 15982

2256, 2276

12706, 14987

15097, 15370

12024, 12683

15579, 15775

2316, 2937

11956, 11998

263, 284

524, 1508

15406, 15555

1530, 2015

2031, 2240

4,017

194,472

19170

Discharge summary

report

Admission Date: [**2196-7-14**] Discharge Date: [**2196-8-2**] Date of Birth: [**2161-12-25**] Sex: M Service: Trauma HISTORY OF PRESENT ILLNESS: The patient is a 35-year-old man who was working underneath a car supported by a car [**Doctor Last Name **] that became unstable, fell and crushed the patient in the right decubitus position. He remained underneath for approximately 10 minutes. When he was freed he was found to be unresponsive with agonal breathing. EMS arrived and on the scene the patient was found to be in pulseless electrical activity. He was intubated, needle decompressed bilaterally, and resuscitation was begun. He was emergently brought to the [**Hospital1 69**] where he was found to have a GCS of 3, was intubated and unresponsive. In the field systolic blood pressure was in the 120-170 range per report. Heart rate was in the 130s. PAST MEDICAL HISTORY: Unknown. MEDICATIONS: Unknown. ALLERGIES: Unknown. PHYSICAL EXAMINATION: Upon entry to the trauma bay the patient was intubated, heart rate 110, blood pressure 186/90, saturation was 81%. On initial examination he was markedly cyanotic. Pupils were 3 mm, nonreactive, tympanic membranes were clear bilaterally. Neck was with trachea midline, cervical collar in place, no crepitus. Chest had breath sounds bilaterally with needles in the bilateral second intercostal spaces anteriorly. Heart was regular, tachycardic. Abdomen was soft, with O- fast. Pelvis was stable. Rectal was normal tone, guaiac negative. The patient had no deformities of the extremities. They were warm, 2+ radial pulses, and 2+ dorsalis pedis pulses bilaterally. LABORATORY DATA: On admission his hematocrit was 36, platelet count of 259, BUN of 5, creatinine of 0.9. Arterial blood gases were 7.20, 48, 70, 20 and -9. Toxicology screen was negative. RADIOLOGIC FILMS: AP Chest showed bilateral pneumothoraces, subcutaneous emphysema, multiple rib fractures. The head CT showed no intracranial hemorrhage. A chest CT did not demonstrate any PE, but did show the multiple rib fractures of the right third, fourth, and fifth ribs. A CT of the abdomen demonstrated no intra-abdominal injury. CT of the cervical spine showed no evidence of acute fracture or subluxation. CT of the talus demonstrated no fracture or subluxation. HOSPITAL COURSE: In the trauma bay the patient was resuscitated. Bilateral chest tubes were placed. The endotracheal tube was repositioned, and the patient was brought to the trauma intensive care unit for monitoring and resuscitation. A pulmonary artery catheter was placed in the intensive care unit for optimization of the hemodynamics to ensure good cerebral perfusion. Cardiology was consulted and they performed a transthoracic echocardiogram that demonstrated no pericardial effusion and declined left ventricular function, which appeared global, with an ejection fraction of 30%. Neurosurgery was consulted. They opted to monitor the patient with frequent neurological checks. Over the next several days the patient remained hemodynamically stable but became increasingly difficult to monitor secondary to sedation requirements. On hospital day two neurosurgery placed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] bolt with an opening pressure of [**12-12**] cm of water. Over the next several days the patient's management was optimized to maintain an ICP of less than 20 cm of water. This was achieved using Mannitol as needed, paralytics and sedation. He remained hemodynamically stable and after close monitoring with the bolt, by hospital day four, neurosurgery removed the bolt and recommended lightening sedation. At the same time the patient's hemodynamics remained stable and the patient's PA catheter was changed to a triple-lumen catheter. The patient's intensive care unit course has otherwise been significant for the following: The patient has had ventilator-dependent respiratory failure and MRSA pneumonia for which he has been on vancomycin. Due to difficulty of weaning the ventilatory support, the patient underwent percutaneous tracheostomy tube placement that he tolerated well. He has been undergoing a slow vent wean, and will require further vent and respiratory care in a rehabilitation facility. His MRSA pneumonia has been treated with eight days of vancomycin for which he is going to complete a 14-day course. Pulmonary toilet is being achieved via tracheostomy tube suction. The patient also underwent a percutaneous gastrostomy tube placement, for which he is receiving tube feeds at goal. The patient also had bilateral chest tubes removed with no residual pneumothorax or effusion and stable respiratory status. The patient's neurologic status has slowly improved. He currently spontaneously opens his eyes and has some purposeful movement of his left lower extremity. He will intermittently appear to follow commands but not consistently so. At this point the patient will require neurological rehabilitation secondary to what is likely an anoxic brain injury from his arrest at the time of the trauma. The patient otherwise has remained stable and is ready for discharge to rehabilitation for a slow ventilatory wean and neurological rehabilitation. DISCHARGE DIAGNOSES: 1. Status post chest crush injury. 2. Cardiopulmonary arrest. 3. Anoxic brain injury. 4. MRSA pneumonia/ventilator-dependent respiratory failure status post percutaneous tracheostomy. 5. Status post percutaneous gastrostomy tube. 6. Bilateral pneumothoraces status post bilateral chest tubes. 7. Sputum growing Citrobacter (on levofloxacin). DISCHARGE MEDICATIONS: 1. Prevacid per gastrostomy tube 30 mg q.d. 2. Lovenox 40 mg subcutaneous q.d. 3. Impact with fiber at 85 cc an hour. 4. Insulin sliding scale. 5. Clonidine patch. CARE RECOMMENDATIONS: Ventilatory wean and neurological rehabilitation. [**Name6 (MD) **] [**Name8 (MD) **], M.D. 2923 Dictated By:[**Last Name (NamePattern1) 3835**] MEDQUIST36 D: [**2196-8-1**] 09:26 T: [**2196-8-1**] 09:57 JOB#: [**Job Number 52292**]

[ "427.5", "348.1", "807.03", "482.41", "E918", "518.81", "860.0" ]

icd9cm

[ [ [] ] ]

[ "31.1", "96.6", "38.93", "89.64", "34.04", "96.72", "43.11", "38.91", "01.18", "96.04", "45.13" ]

icd9pcs

[ [ [] ] ]

5298, 5641

5664, 5829

2357, 5277

5852, 6126

993, 2339

168, 891

914, 970

31,198

131,827

33022

Discharge summary

report

Admission Date: [**2201-4-7**] [**Month/Day/Year **] Date: [**2201-4-14**] Date of Birth: [**2165-2-26**] Sex: M Service: MEDICINE Allergies: Iodine; Iodine Containing / Reglan / Morphine / Prochlorperazine / Doxycycline Attending:[**First Name3 (LF) 1115**] Chief Complaint: abdominal pain, nausea, fever Major Surgical or Invasive Procedure: none History of Present Illness: Mr [**Known lastname 76780**] is a 35 year old male with past medical history significant for chronic pancreatitis, with recurrent acute exacerbations, hidradenitis suppurativa, Fournier's gangrene in [**2199**], presenting from home with abdominal pain typical of pancreatitis flares. . Patient reports he has been compliant with all his medications including enzyme supplement, and maintaining a good diet. However he has been experiencing severe abdominal pain and nausea over the last 2 days. In spite of taking phenergan PR, his symptoms haver persistend to the point where he can no longer tolerate PO. He also notes some greenish diarrhea which is common for him during flares. He does not some rigors/chills last night but denies any cough, CP, SOB, dysuria, change in freqency, sick contacts, or changes in his hidraddenitis concerning for infection. . In the ED, initial VS were: 98.3 88 172/84 18 100 Pt. was given a total of 2mg IV Dilaudid and 4mg Zofran. Patient was admitted for further management. . Review of systems: (+) Per HPI (-) 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: # Diabetes Mellitus - insulin dependent # Hydradenitis Suppuritiva - frequent flares # Fournier's Gangrene, s/p Diverting Colostomy - [**2198**] @ [**Hospital1 2025**] # Colostomy Revision [**2199-6-23**] # Pulmonary Embolism [**6-/2199**] - post op, anticoagulated x 5.5 months # abdominal hernia # s/p cholecystectomy # s/p umbilical hernia repair # Depression - history of prior suicide attempt, though truthfulness of this attempt is in question per psychiatry # Primary Personality Disorder/concern for factitious or malingering disorder - raised in setting of psych hospitalization [**4-/2199**] for ?suicide attempt # Frequent missed [**Year (4 digits) 4314**]/poor follow up # Hyperlipidemia # h/o chronic pancreatitis [**2-24**] high triglycerides - first episode [**2199-12-23**], about 4 hospitalizations in [**2200**] Social History: Works as a mover, used to work in the kitchen of pizza restaurants. He lives alone. Mother, sister and friends are involved. Mother has medical problems, so he tries to help out with her. He denies tobacco or alcohol abuse. Currently has narcotic contract with PCP and he gets ~228 percocets per month for chronic pain r/t hydronitis. Family History: Relatives with COPD, MS, ovarian CA, uterine CA, bladder CA, mother and uncle with diabetes mellitus II, aunt with SLE, mother has hidradenitis suppurativa (severe, in axillae and groin). Mother also has multiple sclerosis. Great aunt has very high cholesterol and triglycerides and related complications. Physical Exam: On Admission: Physical Exam: Vitals: 100.7, 88, 162/108, 97% RA General: Obese young man in no acute distress, alert, oriented [**Year (4 digits) 4459**]: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD, obese neck Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Distant heart sounds, regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Obese, tender to palpation on epigastrium and bil Upper Quad, distended, bowel sounds present, hydradenetis lesions on RLQ/pelvis/groin, several of which appear to be draining Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro:A&Ox3, sensation and strength intact Pertinent Results: On Admission: [**2201-4-7**] 02:05AM WBC-7.7 RBC-4.17* HGB-12.0* HCT-34.3* MCV-82 MCH-28.8 MCHC-35.0 RDW-15.8* [**2201-4-7**] 02:05AM NEUTS-75.9* LYMPHS-17.4* MONOS-4.0 EOS-2.4 BASOS-0.3 [**2201-4-7**] 02:05AM PLT COUNT-286 [**2201-4-7**] 02:05AM PT-11.0 PTT-24.9 INR(PT)-0.9 [**2201-4-7**] 02:05AM ALT(SGPT)-21 AST(SGOT)-23 [**2201-4-7**] 02:05AM LIPASE-26 [**2201-4-7**] 02:05AM TOT PROT-6.9 ALBUMIN-3.6 GLOBULIN-3.3 CALCIUM-8.6 PHOSPHATE-2.3* MAGNESIUM-1.8 [**2201-4-7**] 02:05AM GLUCOSE-137* UREA N-17 CREAT-0.6 SODIUM-140 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-26 ANION GAP-14 [**2201-4-7**] 08:20AM ALT(SGPT)-17 AST(SGOT)-33 LD(LDH)-371* ALK PHOS-80 AMYLASE-31 TOT BILI-0.3 [**2201-4-7**] 04:48PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-300 GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2201-4-7**] 04:48PM URINE RBC-<1 WBC-<1 BACTERIA-NONE YEAST-NONE EPI-<1 . On [**Month/Day/Year **]: [**2201-4-14**] 09:15AM BLOOD WBC-5.8 RBC-3.85* Hgb-10.7* Hct-31.5* MCV-82 MCH-27.9 MCHC-34.0 RDW-15.6* Plt Ct-314# [**2201-4-14**] 09:15AM BLOOD Glucose-146* UreaN-6 Creat-0.9 Na-140 K-3.5 Cl-108 HCO3-20* AnGap-16 Calcium-8.0* Phos-2.9 Mg-1.8 [**2201-4-14**] 09:15AM BLOOD ALT-16 AST-25 AlkPhos-87 TotBili-0.4 . Lipids: [**2201-4-8**] 08:00AM Cholest-375* Triglyc-1423* HDL-42 CHOL/HD-8.9 LDLmeas-91 . IMAGING: ---------- . CXRAY PA/LAT ON [**2201-4-7**]: ======================= HISTORY: 36-year-old male with abdominal pain. COMPARISON: Multiple prior chest radiographs, most recently [**2200-11-26**]. The lungs are clear, without airspace consolidation, effusion or evidence of pulmonary edema. The cardiac silhouette remains normal in size. Mediastinal and hilar contours are normal. IMPRESSION: No acute cardiopulmonary abnormality. . RUQ U/S ([**2201-4-7**]): =================== 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. No biliary ductal dilation. The proximal common bile duct is not visualized. 3. Limited study as discussed above. . MR OF THE ABDOMEN WITH IV GADOLINIUM (MRCP) ([**2201-4-8**]): ======================================================= There is diffuse diminished signal intensity of the hepatic parenchyma on pre-contrast opposed-phase T1-weighted images relative to in-phase images, consistent with fatty infiltration. No focal hepatic lesions are seen. The patient is status post cholecystectomy. The biliary tree is normal in caliber without filling defects. The pancreas and pancreatic duct are within normal limits. There is no inflammatory change of the pancreas. The spleen, adrenal glands, kidneys, stomach, and loops of bowel are unremarkable. There is no lymphadenopathy or ascites. There is no focal bone lesion of concern. Multiplanar 2D and 3D reformations and subtraction images generated on an independent workstation were valuable in assessment of the biliary tree. IMPRESSION: 1. Fatty liver. 2. No evidence of acute or chronic pancreatitis. . US EXTREMITY NONVASCULAR RIGHT; DUPLEX DOP ABD/PEL LIMITED [**2201-4-8**]: = = = ================================================================ INDICATION: History of hidradenitis suppurativa; worsening pain and drainage from right scrotum and groin area. Comparison was made with ultrasound dated [**2200-12-16**]. Ultrasound of the testes demonstrates normal echogenicity bilaterally. The right testis measures 3.4 x 2.4 x 2.3 cm. The left measures 3.9 x 2.6 x 2.3 cm. A left epididymal head cyst is present measuring 4 x 3 x 3 mm. The right epididymis is unremarkable. Soft tissue thickening is noted in the scrotum, particularly on the right. Imaging of the right groin demonstrates a region of edema and increased vascularity measuring up to 4.9 x 5 cm. No discrete fluid collection, abscess formation or fistula is seen. IMPRESSION: Soft tissue thickening consistent with inflammation/infection. No discrete fluid collection or abscess formation. . . LEFT KNEE THREE VIEWS ON [**2201-4-8**]: ================================= No fracture or dislocation is detected about the left knee. No joint effusion is identified. Small marginal spurs are noted. A small focus of vascular calcification is seen along the lateral aspect of the distal femur. . LUNG SCAN [**2201-4-10**]: ================== Reason: 36 YEAR OLD MAN WITH NEW ACUTE HYPOXIA, HX OF PE, ALLERGY TO DYE, NOW IN MICU INTERPRETATION: Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in 8 views demonstrate Perfusion images in the same 8 views show normal perfusion Chest x-ray shows no focal consolidations. The above findings are consistent with no evidence of PE. IMPRESSION: Normal study. PORTABLE ABDOMEM ON [**2201-4-10**]: ============================= FINDINGS: A single supine abdomen radiograph was obtained. Radiograph is limited due to exclusion of the pelvis from the image. No significantly dilated small or large bowel loops are identified. Supine radiograph is limited for the evaluation of pneumoperitoneum. IMPRESSION: No radiographic evidence of small bowel obstruction or ileus. CHEST PORTABLE ON [**2201-4-10**]: =========================== FINDINGS: As compared to the previous radiograph, there is no relevant change. Due to positional differences, the mediastinum appears minimally denser. No pleural effusions, no focal parenchymal opacity suggesting pneumonia. Normal size of the cardiac silhouette. BIL LE VENOUS DOPPLER US ON [**2201-4-10**]: ==================================== INDICATION: Acute hypoxia with prior history of pulmonary embolism. Grayscale and Doppler son[**Name (NI) 1417**] of bilateral common femoral, superficial femoral, popliteal and posterior tibial veins were performed. There is normal compressibility, flow and augmentation. IMPRESSION: No evidence of DVT. Brief Hospital Course: 36M with diagnosis of chronic pancreatitis and frequent presentations of abdominal pain/N/V/D, hypertriglyceridemia, and hydradenitis suppurativa who presents with N/V/D, abdominal pain, and fever/chills/rigors. . # ABD PAIN / CHRONIC PANCREATITIS: Patient has the diagnosis of chronic pancreatitis and has consistently had hypertriglyceridemia, but there is no evidence of chronic pancreatitis changes on previous CT (without contrast); there was also no evidence on MRCP. Lipase levels have not been elevated. However, the patient's initial episode of acute pancreatitis in [**2198**] did present with a lipase of 2328, and it's possible to have chronic pancreatitis without ragiologic evidence. Pt presented with pain on epigastrium and bil upper quadrant pain radiating to back. He states that the epigastric and LUQ pain with radiation to his back are his usual presentation and that the RUQ is somewhat different than prior presentations. patient is status post cholecystectomy and on imaging his biliary tree appears normal. The patient has been evaluated as outpatient by Dr. [**Last Name (STitle) 174**] in GI, who was contact[**Name (NI) **] during this patient hospitalization and had previously recommended an MRCP. The MRCP was done on [**2201-4-8**] and showed fatty liver, but no evidence of acute or chronic pancreatitis. . Other possible explanations for patient's abdominal pain include gastroparesis and diabetic enteropathy. He was put on Reglan in the past, but reported anxiety and agitation on the medication, so discontinued it. This is also less likely given that his symptoms were not associated with eating. Chylomicronemia (with triglycerides over 1000), can be associated with abdominal pain from chylomicron organ deposition and stretch; as per MRCP and US of abd there are no organomegaly mentioned also making this less likely. We're treating hypertriglyceridemia as below. A right LL pneumonia could possibly present with RUQ pain, though he had no evidence of PNA on exam and cxray was clear. Another possibility is cardiac, given his hx and presentation. The patient's EKG was not indicative of ACS and CE was negative. In addition, given the hx of abdominal pain with occ. diarrhea, we also included IBD on the differential. Sent studies for Celiac Disease (IgA TTG) which was negative. Stool was sent for culture which was negative. He states that he had a colonoscopy last year, although there is no report, that was normal. Pt will need outpatiend f/u with GI. . He was treated with pain medication and he was kept NPO until nausea improved. He was initially treated with zofran, compazine and ativan. The nausea had somewhat resolved and he was then able to tolerate POs with no N/V. His pain was treated IV and then PO Dilaudid as needed. He frequently required high doses for adequate pain control, we discuss how this may also be contributory to his nausea. He was restarted on his pancreatic enzymes when he began eating again. . # HYPOXIC RESPIRATORY DISTRESS: Patient developed respiratory distress on the medicine floor. His O2sat dropped into the 80s and he was tachypneic and not moving air well. A code was called, and the patient was about to be intubated when he yelled that he did not want to be intubated. The patient was put on non-rebreather and transferred to the ICU. ABG showed 55 / 44 / 7.37 / 26, so patient had in fact been hypoxic. In the MICU, patient's breathing and O2sat stabilized without intubation. Blood cultures and urine cultures were sent, all had no growth. He had cxray and KUB which were also negative for acute process. He was put on Vancomycin/Cefepime/Flagyl for hydradenitis infection since the wound had increase drainage on the day this event. He was started empirically on IV heparin. He was evaluated for PE with LENI and V/Q scan which were negative. He remained stable and was transferred back to the floor. . # FEVER/HIDRADENITIS SUPPURATIVA: Fever was likely due to superinfection of hidradenitis suppurativa. Hidradenitis suppurativa lesions on groin and scrotum are draining purulent [**Date Range **]. Patient spiked fevers, as high as 102.7. Blood, urine, and stool Cxs, as well as C. Diff were sent; all were negative. US of groin and scrotum did not show an abscess or fluid collection. Surgery saw patient and recommended vancomycin and Unasyn for treatment of superinfection of hydradenitis. Those medications were started. Surgery did not recommended wound to be I&D at this time. We consulted ID to see if there's an appropriate oral regimen for this patient since he had previously been on Vanc, Levaquin, Zosyn, Augmentin. Review of OMR notes also shows that patient has been non compliant and easily lost to follow up while on IV antibiotics. There are also POE warning about the pt leaving the hospital with PICC lines in place and being lost to follow up. Patient was seen by ID and was initially placed on vanc/cefepime/Flagyl for broader coverage which was then narrowed to vancomycin as the pt clinically improved. The lesions looked better by the time of [**Date Range **] with decreased drainage from the site. He was sent out on oral linezolid for 5 more doses to complete a total of 10 course of antibiotics. He was also recommended to follow-up with dermatology. He refused for us to have the appointment set-up for him prior to [**Date Range **]. He was continued on his home dose of percocet since he already had Percocet prescription for hidradenitis at home. . # DMI: Patient is on high dose of insulin at home. Dose has been decreased while patient is NPO, and FSGs have been between 100 and 200. This patient reported his home regimen was 125 NPH Qam, 95 NPH QHS, and 30 Humalog TID without sliding scale. His PCP reported that he was on metformin, but patient reported that he didn't take it anymore as it gave him diarrhea. Patient was discharged on the regimen he was on in the hospital: 125 NPH Qam, 95 NPH QHS, and Humalog sliding scale. . # HYPERTENSION: Patient has had hypertensive crisis in the hospital in the past. Currently normotensive. When patient was in the ICU, his home metoprolol was stopped, and carvedilol was added. Patient was discharged on carvedilol, amlodipine, and valsartan. The patient was not given Lasix, as we were giving him IV fluids, and he reported he hasn't taken that medication in a while. Patient's home aspirin 81mg was continued during his hospital stay. . # HYPERTRIGLYCERIDEMIA: Chronic problem, poorly controlled. During this hospitalization, his triglycerides was 1423, total cholesterol 375, HDL 42. Patient's home statin, niaspan, fish oil, and fenofibrate were continued during this hospitalization. . # OBESITY: Chronic problem likely contributing to many of the problems above. [**Name2 (NI) **] has mentioned that he's spoken with his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 76783**] about gastric bypass surgery. . # DEPRESSION / ANXIETY: Patient has had psychiatric hospitalizations in the past; there's also been some documented concern for malingering and secondary gain during past hospitalizations. He appears to be having significant anxiety, but he did not want to see a psychiatrist. Unclear whether his anxiety caused his hypoxic respiratory distress. He saw social work and expressed being quite offended that one of the house officers suggested that many of his problems were likely related to his obesity. He was given PRN Ativan for anxiety. As per his PCP he was previously prescribed Cymbalta which he had not been taking this. After discussion with the patient, he has agreed to restart taking cymbalta a few days after he was done with antibiotics due to interaction. He will be following up with his PCP. . # FEN: No IVF, replete electrolytes, regular diet . # Prophylaxis: -DVT ppx with SC heparin -Bowel regimen -Pain management with . # Access: peripherals . # Code: full . # Communication: Patient . Medications on Admission: Patient's Report on Admission ([**2201-4-7**]): - amlodipine 10mg daily - metoprolol succinate XL 200mg daily - valsartan 160mg [**Hospital1 **] - simvastatin 40mg PO QHS - amylase-lipase-protease 60,000-12,000-38,000 unit capsule, [**5-28**] capsules/meal - niaspan 1,000mg [**Hospital1 **] - fenofibrate micronized 145mg daily - hibiclens 4 % [**Hospital1 **] - fish oil 4,000mg daily - insulin NPH 125units SC QAM and 95units SC QHS - insulin Lispro 30units SC TID prior to meals with no sliding scale . PCP's Report of (Obtained [**2201-4-13**]): - Percocet 5-325 (228 pills per month), [**1-24**] pills Q6H as needed for pain - amlodipine 10mg daily - metoprolol succinate XL 400mg daily - valsartan 80mg [**Hospital1 **] - simvastatin 80mg PO QHS - amylase-lipase-protease 60,000-12,000-38,000 unit capsule, [**5-28**] capsules/meal - niaspan 1,000mg [**Hospital1 **] - fenofibrate micronized 145mg daily - hibiclens 4 % [**Hospital1 **] - fish oil 4,000mg daily - insulin NPH 105units SC QAM and 95units SC QHS - metformin 500mg long-acting - Cymbalta 60mg daily [**Hospital1 **] Medications: 1. Valsartan 160 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. Lipase-Protease-Amylase 16,000-48,000 -48,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Niacin 500 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO BID (2 times a day). 5. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO once a day. 6. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY (Daily): 4000mg daily. 7. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 9. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): Please take twice a day through [**2201-4-16**]. Disp:*5 Tablet(s)* Refills:*0* 11. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 12. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: One [**Age over 90 **]y Five (125) Units Subcutaneous every morning. 13. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Ninety Five (95) units Subcutaneous at bedtime. 14. Humalog 100 unit/mL Solution Sig: sliding scale Subcutaneous with meals. 15. Hibiclens 4 % Liquid Sig: One (1) wash Topical twice a day. 16. Cymbalta 60 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day: Please begin taking this medication again on [**4-23**], to allow several days off of Linezolid before restarting the Cymbalta. 17. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* [**Month (only) **] Disposition: Home [**Month (only) **] Diagnosis: Primary Diagnoses: acute on chronic pancreatitis superinfection of hidradenitis suppurativa . Secondary Diagnoses: hypertriglyceridemia type II diabetes mellitus abdominal hernia [**Month (only) **] Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent [**Month (only) **] Instructions: You were admitted to the hospital for fever and worsening of your chronic abdominal pain. We treated the abdominal pain and nausea as acute pancreatitis, as you have a diagnosis of chronic pancreatitis with frequent flares that present with similar symptoms. This treatment included restricting food intake, giving IV fluids, and controlling pain with medication. With this treatment, your abdominal pain and nausea improved. You were able to tolerate regular diet. . The fever you had was likely related to an infection of the tissue on your groin and scrotum associated with the hidradenitis suppurativa. We treated this infection with IV and then oral antibiotics. Please continue to take these antibiotics as instructed below. . Medication changes: - Linezolid 600mg by mouth twice a day for the next 3 days - Cymbalta 60mg -- do NOT take this medicine until [**4-23**], so that you give your body time to clear the Linezolid, which can interact with the Cymbalta - Stopped Metoprolol -- do NOT take this medication any more - Carvedilol 25mg daily -- we added this medication (in place of the metoprolol) to your regimen for improved control of your blood pressure - You should continue to take NPH at the same doses in the morning and evening. You should not take the standing dose of lispro until you discuss your insulin mamagement with your primary care doctor. You should also monitor your glucose before meals and at bed time. Followup Instructions: You have an appointment scheduled with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 76783**], within a week of [**Last Name (STitle) **] on [**2201-4-23**] at 01:30PM. Office phone # [**Telephone/Fax (1) 25050**]. . We recommended that you see someone in the Department of Dermatology for the hidradenitis suppurativa. You did not want us to make an appointment for you, as you said you have an appointment with a specialist at [**Hospital1 2025**] in [**Month (only) 116**]. If you change your mind and would like to see a dermatologist at [**Hospital1 18**], please call ([**Telephone/Fax (1) 8132**] in order to schedule an appointment. . We recommended that you see someone at [**Last Name (un) **] for your diabetes. You did not want us to make an appointment for you, as you said you would like to manage your blood sugars with your primary care doctor; in addition you said that you plan on seeing someone at [**Hospital 3278**] Medical Center for gastric bypass surgery as a next step in your diabetes management. If you change your mind and would like to see an endocrinologist at [**Last Name (un) **], please call ([**Telephone/Fax (1) 17484**] in order to schedule an appointment. . We made an appointment for you at the [**Hospital **] Clinic here at [**Hospital1 18**] to for further evaluation and treatment of your hypertriglycerdiemia on [**2201-4-24**]. Please see below for appointment information. The appointment begins at 8:30 am and will last 2 hours, as you will be meeting with Dr. [**Last Name (STitle) **], as well as with a nutritionist. You should receive a packet in the mail with some forms to will out and bring with you to the appointment. The appointment is located in the [**Hospital Ward Name 23**] Building on the [**Hospital Ward Name 516**]. Provider: [**First Name8 (NamePattern2) 2890**] [**Last Name (NamePattern1) 2889**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2201-4-24**] 8:30 Provider: [**Name10 (NameIs) **] NUTRITIONIST Phone:[**Telephone/Fax (1) 2207**] Date/Time:[**2201-4-24**] 9:30

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Discharge summary

report

Admission Date: [**2170-5-7**] Discharge Date: [**2170-5-10**] Date of Birth: [**2140-6-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1850**] Chief Complaint: Toxic ingestion in suicide attempt Major Surgical or Invasive Procedure: Intubated and extubated History of Present Illness: 29 yo male with h/o depression and ADHD who presented to ED with ingestion of Nyquil and ibuprofen in suicide attempt. Patient notes history of depression secondary to recent death of sister and not taking his Paxil for past 2 months. Pt was on Mass Health but did not complete forms and lost coverage 2 months ago so had no way to pay for Paxil. Per pt's mother on night of admission, pt called her to tell her he took some pills. He drove to her house and she found him to be lethargic. In ED given Narcan with no result. Pt intubated for airway protection with dose of vercuronium for agitation. Pt given 1.2 grams of N-acetylcysteine and activated charcoal x1. EKG showed ST at 106, normal axis, normal intervals, TWI in III, AVF. Pt had mild transaminitis. Toxicology was consulted and recommended supportive care, including follow LFT's and re-checking EKG. Tox screen was only pos for amphetamines. Past Medical History: Depression -no previous psychiatric admission (PCP-[**Last Name (NamePattern4) **]. [**Last Name (STitle) 2903**] prescribes paxil) ADHD Social History: Lives with roommate in [**Location (un) 745**]. Plays piano, gives lessons. Sister died 2-3 months ago from crack overdose. No ETOH or drug use. Family History: ?Bipolar disorder Physical Exam: PE: 97, HR 80, BP 141/90, RR 18, Os sat 100% on vent (AC 500x18, PEEP 5, FiO2 0.5) GENL: intubated, sedated HEENT: Pupils sluggish 8-5 mm. no LAD, +profuse salivation CV: RRR no MRG Resp: CAT ABD: soft, NT, ND, +BS EXT: no edema, 2+ pedal pusles Neuro: sedated, no babinski, localizes to painful stimuli, moves all limbs Pertinent Results: [**2170-5-9**] 06:06AM BLOOD WBC-14.2* RBC-4.37* Hgb-13.0* Hct-36.0* MCV-82 MCH-29.8 MCHC-36.2* RDW-13.7 Plt Ct-205 [**2170-5-7**] 08:35PM BLOOD Neuts-73.6* Lymphs-19.3 Monos-5.7 Eos-0.9 Baso-0.6 [**2170-5-9**] 06:06AM BLOOD Plt Ct-205 [**2170-5-9**] 06:06AM BLOOD Glucose-94 UreaN-9 Creat-0.7 Na-141 K-3.8 Cl-106 HCO3-28 AnGap-11 [**2170-5-9**] 06:06AM BLOOD ALT-56* AST-20 LD(LDH)-165 AlkPhos-57 TotBili-0.6 [**2170-5-7**] 08:35PM BLOOD ALT-90* AST-41* AlkPhos-68 Amylase-64 TotBili-0.5 [**2170-5-7**] 08:35PM BLOOD Lipase-29 [**2170-5-9**] 06:06AM BLOOD Albumin-4.2 Calcium-9.3 Phos-3.1 Mg-2.0 [**2170-5-7**] 08:35PM BLOOD Osmolal-285 [**2170-5-8**] 05:35AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2170-5-7**] 08:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2170-5-8**] 01:12AM BLOOD freeCa-1.24 Brief Hospital Course: Patient was admitted to the [**Hospital Unit Name 153**] on [**2170-5-7**]. He was kept intubated and sedeated overnight. He was extubated without complications on [**2170-5-8**]. His LFT trended down. When he was extubated we confirmed with patient that he took liquid nyquil and ibuprofen. We restarted his Paxil at 40 mg per day. Psychiatry saw the patient and felt appropriate for in patient psychiatry evaluation. Pt does not want admission but [**Last Name (un) 5798**] criteria for involuntary admission. Social work was consulted for coping and for help with Mass Health and free care. He was refused by Mass Health so application accepted for Free Care at [**Hospital1 18**] so he can get his Paxil paid for. On day of discharge, pt complained of sore throat and myalgias. His temp was normal and WBC count slightly elevated. His WBC is likely related to stress response and sore throat is likely related to intubation. He was felt to be medically cleared for psychiatric hospitalization. Medications on Admission: Paxil 40 mg QD (not taken for past 2 mos) Adderal Discharge Medications: 1. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Cepacol 2 mg Lozenge Sig: [**2-4**] Lozenges Mucous membrane PRN (as needed). 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Discharge Disposition: Extended Care Discharge Diagnosis: Depression S/P toxic ingestion for suicide attempt Discharge Condition: Stable Discharge Instructions: Follow up with Dr. [**Last Name (STitle) 2903**]. Will be transferred to [**Hospital1 **] 4 for Inpatient Psychiatric eval Followup Instructions: Follow up with your Dr. [**Last Name (STitle) 2903**]. Take medications as prescribed. [**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**] MD [**MD Number(2) 5799**]

[ "963.0", "296.20", "794.8", "E950.0", "E858.1", "314.01", "965.61", "518.81" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

4285, 4300

2919, 3920

349, 374

4394, 4402

2022, 2896

4573, 4779

1647, 1666

4020, 4262

4321, 4373

3946, 3997

4426, 4550

1681, 2003

275, 311

402, 1309

1331, 1469

1485, 1631

18,094

183,206

45434+58818

Discharge summary

report+addendum

Admission Date: [**2113-2-2**] Discharge Date: [**2113-3-1**] Date of Birth: [**2039-8-6**] Sex: F Service: MEDICINE Allergies: Aspirin / Hydralazine / Ace Inhibitors / Diovan Attending:[**First Name3 (LF) 689**] Chief Complaint: fever, chills Major Surgical or Invasive Procedure: central line placement (change over a wire) central line removal x 2 femoral line placement History of Present Illness: 73 y.o. female with h/o DMII, ischemic CHF (EF ~30%), CAD s/p NSTEMI and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2 to RCA ([**11-26**]) c/b dye nephropathy and ESRD (hospitalized [**2112-12-9**] - [**2112-12-28**]), on HD with recent tunneled line and fistula creation, who presented [**2113-2-2**], 1 day after leaving [**Hospital3 **] (7 week stay, just discharged [**2113-2-1**]), with fevers to 104 C, rigors, and hypotension. She had just undegone placement of tunneled HD catheter (R IJ) and also had AV fistula placed ([**2113-1-26**]). ED course notable for initiation of vancomycin, levofloxacin and flagyl, and placement of femoral line. She was found to have a high grade MRSA bacteremia, with 7/8 bottles positive from [**2112-2-2**]. MICU course notable for clearance of blood cultures on vancomycin, with hemodynamic stabilization. Line changed over a wire, though catheter tip from original line then grew out MRSA. Past Medical History: hypercholesterolemia DM-2 HTN CAD - cath [**11-26**] with 3VD, s/p cypher [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2 to RCA. pulmonary HTN CHF (Ef 30%), afib, esrd on HD Severe lumbar spondylosis and spinal stenosis Social History: Denies tobacco, EtOH, IVDA. Ambulates with walking assist device (walker), which she has required since 'being dropped by EMTs' prior to her surgical repair for spinal stenosis. Uses also electronic wheelchair. Family History: Fhx: Father died of CVA at 64yo. Mother died of MI @ 86yo. Brother had CAD. Physical [**Last Name (Prefixes) **]: Gen: patient appears stated age, found lying flat in bed, talking with family, in NAD HEENT: Sclera anicteric, conjunctiva uninjected, PERL, EOMI, MMM, no sores in OP Neck: JVP difficult to assess, no LAD, nl ROM Cor: RRR nl S1 S2 no m/r/g Chest: clear to percussion and asculation Abd: soft, NT/ND, +BS. No HSM appreciated. EXT: no calf tenderness. 2+ edema to mid tibia. Also with sacral edema. 2+DP, 1+ PT pulses Neuro: MS [**First Name (Titles) **] [**Last Name (Titles) **], CN II-XII in tact, UE/LE strength 5+ bilaterally, 2+ DTRs, toes [**Name2 (NI) 14451**], nl cerebellar [**Name2 (NI) **]. Gait not tested. Pertinent Results: [**2113-2-2**] 10:22PM LACTATE-1.5 [**2113-2-2**] 10:22PM HGB-10.0* calcHCT-30 [**2113-2-2**] 09:27PM LACTATE-1.5 [**2113-2-2**] 08:05PM LACTATE-1.7 [**2113-2-2**] 07:04PM LACTATE-1.7 [**2113-2-2**] 06:33PM LACTATE-2.3* [**2113-2-2**] 06:00PM GLUCOSE-215* UREA N-50* CREAT-3.5* SODIUM-138 POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-27 ANION GAP-14 [**2113-2-2**] 06:00PM ALT(SGPT)-4 AST(SGOT)-12 CK(CPK)-67 ALK PHOS-81 AMYLASE-49 TOT BILI-0.3 [**2113-2-2**] 06:00PM LIPASE-27 [**2113-2-2**] 06:00PM CK-MB-NotDone cTropnT-0.32* [**2113-2-2**] 06:00PM ALBUMIN-3.4 CALCIUM-8.6 PHOSPHATE-3.1 MAGNESIUM-1.3* [**2113-2-2**] 06:00PM CORTISOL-30.0* [**2113-2-2**] 06:00PM CRP-8.69* [**2113-2-2**] 06:00PM WBC-28.5* RBC-3.33* HGB-10.2* HCT-29.5* MCV-89 MCH-30.6 MCHC-34.6 RDW-14.9 [**2113-2-2**] 06:00PM NEUTS-73* BANDS-25* LYMPHS-0 MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 YOUNG-1* [**2113-2-2**] 06:00PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+ TEARDROP-1+ [**2113-2-2**] 06:00PM PLT COUNT-178 [**2113-2-2**] 06:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.021 [**2113-2-2**] 06:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2113-2-2**] 06:00PM URINE RBC-[**11-12**]* WBC-0-2 BACTERIA-MOD YEAST-NONE EPI-[**6-2**] [**2113-2-2**] 06:00PM URINE AMORPH-MOD [**2113-2-2**] 04:12PM TYPE-[**Last Name (un) **] [**2113-2-2**] 04:12PM LACTATE-2.2* [**2113-2-2**] 12:35PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.020 [**2113-2-2**] 12:35PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-500 GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2113-2-2**] 12:35PM URINE RBC-[**2-25**]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [**2113-2-2**] 12:35PM URINE GRANULAR-<1 HYALINE-<1 [**2113-2-2**] 12:35PM URINE AMORPH-FEW [**2113-2-2**] 12:01PM LACTATE-2.7* [**2113-2-2**] 11:50AM GLUCOSE-196* UREA N-48* CREAT-3.4*# SODIUM-141 POTASSIUM-5.4* CHLORIDE-102 TOTAL CO2-29 ANION GAP-15 [**2113-2-2**] 11:50AM ALT(SGPT)-6 AST(SGOT)-11 CK(CPK)-46 ALK PHOS-98 AMYLASE-60 TOT BILI-0.4 [**2113-2-2**] 11:50AM cTropnT-0.11* [**2113-2-2**] 11:50AM CK-MB-NotDone [**2113-2-2**] 11:50AM ALBUMIN-3.8 CALCIUM-9.0 PHOSPHATE-3.6 MAGNESIUM-1.4* [**2113-2-2**] 11:50AM WBC-19.9*# RBC-3.64*# HGB-11.2*# HCT-32.4* MCV-89 MCH-30.6 MCHC-34.5 RDW-14.7 [**2113-2-2**] 11:50AM NEUTS-92* BANDS-5 LYMPHS-2* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2113-2-2**] 11:50AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2113-2-2**] 11:50AM PLT SMR-NORMAL PLT COUNT-159 [**2113-2-2**] 11:50AM PT-13.7* PTT-25.4 INR(PT)-1.2 Brief Hospital Course: A/P: 73 yo F with CAD, CHF, ESRD, HTN, hyperlipidemia, spinal stenosis who p/w high grade MRSA bacteremia after recent placement of HD line. (1) MRSA bacteremia - Initial source for infection was likely the Tunneled HD catheter. The catheter was removed, and a temporary line was placed over a wire at the same site initially. However, as her blood cultures failed to clear, the temporar HD line was removed [**2113-2-7**], and a new L-sided temporary HD line was placed. Nonetheless, her blood cultures remained positive, despite apparently therapeutic levels of vancomycin, with worsening leukocytosis, and gentamycin was added for synnergy. TTE and TEE did not reveal evidence of endocarditis, though Chest CT suggested probable MRSA pneumonia. Diagnostic thoracentesis was performed [**2-10**] and negative for infection. US of the R sided arm and neck veins was negative for clot as a source of infection. Blood cultures remained positive until [**2-12**]. On [**2-15**] she was started on daptomycin iv 6 mg/kg q 48 hours and on [**2-16**] the temporary dialysis catheter was changed over a wire and the tip cultured with no growth. CT of the entire spine with contrast and of the torso was also performed with the following results: CT RESULTS [**2-16**]: * CHEST AND ABDOMEN * 1. No discrete abscesses or abnormal fluid collections are seen aside from right-sided pleural effusion and associated atelectasis. 2. Markedly distended gallbladder, with gallstones. This can be seen in the setting of prolonged fasting, although if there are symptoms referrable to this region, right upper quadrant ultrasound could be performed. 3. Marked coronary artery calcifications. 4. Equivocal soft tissue filling defect adjacent to the left IJ central venous catheter, which could represent adherent thrombus at the tip. Note that CT is neither sensitive nor specific for detection of adherent thrombus. 5. Two or three areas of focal consolidation in subpleural locations within the right upper lobe as described above. * SPINE * CT OF THE CERVICAL SPINE: Evaluation of the soft tissue windows demonstrates no evidence of abnormal fluid collection or bony destruction. There is no cervical lymphadenopathy present. There is a 7 mm low density right thyroid nodul, which can be evaluated by ultrasound if clinically indicated. Also, right-sided pleural effusion is seen, indeterminately evaluated on this examination. Evaluation of the coronally and sagittally reformatted images demonstrates appropriate alignment of the cervical spine, without significant abnormal soft tissue swelling. Degenerative narrowing of the disc spaces at C6-7, C7-T1, are seen without significant facet changes at these levels. Note is made of marked vascular calcifications involving the cavernous internal carotid arteries as well as a left-sided internal jugular central venous catheter. CT OF THE THORACIC SPINE: Scans are marred by artifact and of limited diagnostic quality. No fracture is identified. Alignment is normal. The vertebral body heights are normal, however there is marked diffuse disc space narrowing. There are a few small areas of decreased attenuation in somee of the vertebral bodies. This is of uncertain nature. No endplate cortical destruction is seen. Vertebral bodies have bridging osteophytes. There is poor visualization of the intraspinal structures. There are no gross abnormalities observed in the perivertebral soft tissues. There is a moderate-sized right pleural effusion. CT LUMBAR SPINE: Again seen is grade 1 anterolisthesis of L4 in relation to L5 and new grade 1 to 2 anterolisthesis of L5 on S1. The remaining vertebral bodies are well aligned. There is vacuum disc phenomenon at L5-S1. There is disc space narrowing at T12-L1, L1-L2, L2-L3, likely L3-L4, L4-L5, and L5-S1. Again noted are pedicle screws and posterior rods transfixing L3 through L5. There is associated laminectomy at these vertebral levels. The neural foramina in the lower lumbar region are difficult to assess secondary to hardware artifact. No vertebral fractures or hardware loosening is appreciated. There are no destructive changes of the endplates to indicate osteomyelitis. The prevertebral soft tissues appear morphologically normal. The posterior soft tissues are obscured by artifact from the fusionhardware. The intraspinal contents are not well seen. She was unable to fit into an MRI scanner for evaluation of possible osteomyelitis or epidural abscess given persistent postitive cultures and back pain. CT scan was done as above and plan for open MRI as an outpatient. She remained culture negative despite daily surveillance cultures until [**2-20**]. She was switched back to vancomycin. From [**2-13**] to [**2-27**] her blood cultures (collected at each dialysis) were negative. Should they have vecome positive again, plan was to pursue a white blood cell tagged scan to identify a source of infetion. Due to mechanical falure of the line her dialysis catheter was changed over a wire on [**2-21**] and then a tunneled catheter was placed [**2-24**]. She has been awaiting placement with no events occurring since [**2-24**]. (2) CRI/ESRD - Upon admission, it was hoped that the patient's renal function had recoverd to the extent that HD could be delayed for several months. However, attempts to achieve fluid balance with diuretics, including lasix and metalozone, were unsuccessful, and given worsening Cr, the decision was made to proceed with hemodialysis. Phoslo was titrated. She has been on T/Th/Saturday dialysis since admission. Ultrafiltration has been pursued to remove fluid. On one occasion [**2-24**], she experienced hypotension with nausea after dialysis. The hypotension responded to 1L fluids. Given this was like her presentation with NSTEMI, a set of cardiac enzymes was checked (troponin still trending down from previous event) and an EKG (no changes). The nausea resolved with the hypotension. Likely etiology was too much fluid removal with ultrafiltration. (3) Anemia - Patient required several units of PRBC transfusions, and was started on erythropoietin 8000U thrice weekly. This is most likely because of chronic kidney disease combined with extensive phlebotomy here (many many blood cultures and chem 10, cbc daily until [**2-21**] when they were changed to dialysis days only). (4) CHF - patient noted to have mildly decompensated heart failure,likely secondary to volume overload while dialysis was on hold. She was not started on an ACE or [**Last Name (un) **], given prior adverse reactions, but was maintained on low-dose beta-blocker. (5) Back pain - No clear etiology evident on CT scan, doubt abscess or osteomyelitis. This is may be from anterolisthesis of L5 on S1 as seen in CT scan. (6) A-fib - continued b-blocker. Re-starting anticoagulation with coumadin, please maintain INR between 2 and 2.5. On aspirin/plavix. (7) CAD - continued aspirin, plavix, statin, b-blocker. Medications on Admission: 1. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days: last dose is [**2112-12-31**]. 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 11. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 12. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY OTHER DAY (Every Other Day). 13. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 14. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 15. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 16. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation every 4-6 hours as needed for SOB. 17. insulin regimen NPH regimen of 4 units of NPH at breakfast and 6 units and dinner with sliding scale which is attached. thank you. Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 10. Zolpidem Tartrate 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime). 11. Epoetin Alfa 4,000 unit/mL Solution Sig: Two (2) injections Injection QMOWEFR (Monday -Wednesday-Friday): for a total of 8000 UNIT SC QMOWEFR . 12. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 15. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 17. Tramadol HCl 50 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 18. Vancomycin HCl 10 g Recon Soln Sig: One (1) gram Intravenous PRN (as needed) as needed for for level less than 15, dosed at dialysis. Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: sepsis MRSA bacteremia CHF CAD hypertension hypotension end stage renal disease on hemodialysis anemia atrial fibrillation hyperlipidemia Discharge Condition: fair Discharge Instructions: Please take all of your medications as instructed. Please return to the hospital or call you doctor if you have any further fever, chills, persistently low blood pressures that do not respond to fluids, racing heart or other symptoms. Followup Instructions: 1. Please follow up with your primary care doctor ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 410**] [**Telephone/Fax (1) 1144**]) one to two weeks after your discharge from the rehabilitation facility. 2. You have an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6173**] of the Infectious Disease department at [**Hospital1 1170**] on Tuesday, [**3-21**] at 11:00 am. His office is located in the [**Hospital **] Medical Office Building at 110 [**Location (un) 33316**] St. next to the medical center [**Hospital Ward Name 517**]. Phone:[**Telephone/Fax (1) 457**]. Name: [**Known lastname **],[**Known firstname 4348**] L Unit No: [**Numeric Identifier 15442**] Admission Date: [**2113-2-2**] Discharge Date: [**2113-3-1**] Date of Birth: [**2039-8-6**] Sex: F Service: MEDICINE Allergies: Aspirin / Hydralazine / Ace Inhibitors / Diovan Attending:[**First Name3 (LF) 161**] Addendum: Mr. [**Known lastname 13747**] was discharged on [**3-1**] after waiting for placement for several days. Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 2314**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 165**] MD [**MD Number(1) 166**] Completed by:[**0-0-0**]

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icd9cm

[ [ [] ] ]

[ "99.04", "39.95", "34.91", "88.72", "00.17", "38.95" ]

icd9pcs

[ [ [] ] ]

17471, 17702

5449, 12395

318, 411

16051, 16057

2656, 5426

16340, 17448

1898, 2637

14054, 15766

15890, 16030

12421, 14031

16081, 16317

265, 280

439, 1395

1417, 1651

1667, 1882

54,406

172,464

5659

Discharge summary

report

Admission Date: [**2133-3-25**] Discharge Date: [**2133-3-31**] Date of Birth: [**2068-7-3**] Sex: M Service: MEDICINE Allergies: Penicillins / Bactrim Attending:[**First Name3 (LF) 30**] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: Thoracentesis Endoscopy x2 History of Present Illness: Mr. [**Known lastname 22627**] is a 64 year-old man with a history of esophageal cancer, s/p resection, neoesophagus, radiation, and chemotherapy who presents with GIB. . Most recently admitted [**Date range (1) 22630**] with dyspnea and suboptimal stress test. Cardiac catheterization revealed moderate MR and two vessel CAD. He underwent a pericardectomy only as he had severe constrictive pericarditis related to his esophageal radiation. . Reports feeling well until evening prior to admission when he began to vomit blood. No nausea or vomiting before initial hemetemesis. Over the evening he vomited ~5 times, once with "jellyfish" appearance. Also with concurrent black stools (~5). Last episode of hemetemesis was at 7am on day of admission. . Initially presented to an OSH where BP was 109/68 with HR 129. HCT found to ve 22.1. 2 units of pRBC were given. . In the ED, initial BP 116/79 with HR 120, RR 20 and 100% on room air. BP fell to as low as 95/70 with HR in the 120s. Recieved 1+ liters of IVF. . ROS: (+) weight loss of 22lbs since [**11-15**]; thinks this is water weight (+) fatigue (-) fevers/chills (-) Chest pain (+) SOB with exertion (noted since before [**11-15**]) (-) nausea/abdominal pain (-) dysphagia/odynophagia Denies use of NSAIDs or other OTC meds Past Medical History: 1. Esophageal cancer - s/p resection ([**2123**]) - s/p radiation, chemotherapy and neoesophagus 2. Coronary artery disease - Cardiac cath ([**11-15**]) with --LMCA: eccentric 40% ulcerated plaquing with slight contrast staining --LAD: 50% stenosis just after a large D1; 50% mid LAD stenosis after a smaller D2; 60% distal LAD stenosis; slightly slow flow in the LAD consistent with microvascular dysfunction --LCx: mild diffuse plaquing, and supplied a tortuous LPL; distal AV groove LCx was occluded after the LPL and filled slightly by antegrade vasa and right-to-left collaterals; proximal LPL 40% stenosis --RCA: mild diffuse plaquing throughout --RCA-RV fistula 3. Hypertension Social History: Married with two grown children. Does not smoke and drinks [**1-9**] glasses of wine 3-4 times per week. Works as an insurance [**Doctor Last Name 360**]. Family History: Father had heart disease and a MI at age 59. Physical Exam: VITALS: BP 111/79, HR 126, RR 14, 100% on RA GEN: Lying in bed. In no distress. HEENT: Mild conjuctival pallor; no icterus CV: Tachycardic; no murmurs. PULM: Clear. ABD: Soft. NT/ND EXT: Warm. Mild edema. NEURO: Pupils 4mm-->2mm CN II-XII intact. Strength 5/5 in all four extremities; sensation grossly intact Pertinent Results: Admission Labs: [**2133-3-25**] 12:15PM BLOOD WBC-7.4 RBC-3.45* Hgb-8.7* Hct-27.3* MCV-79* MCH-25.1* MCHC-31.8 RDW-16.5* Plt Ct-194 [**2133-3-25**] 12:15PM BLOOD Neuts-77.5* Lymphs-16.5* Monos-5.1 Eos-0.6 Baso-0.2 [**2133-3-25**] 12:15PM BLOOD PT-16.8* PTT-27.2 INR(PT)-1.5* [**2133-3-25**] 12:15PM BLOOD Glucose-112* UreaN-41* Creat-0.8 Na-141 K-4.3 Cl-107 HCO3-28 AnGap-10 [**2133-3-25**] 12:15PM BLOOD ALT-20 AST-24 AlkPhos-81 TotBili-1.1 [**2133-3-25**] 12:15PM BLOOD Lipase-16 [**2133-3-25**] 12:15PM BLOOD Albumin-3.6 [**2133-3-25**] 02:18PM BLOOD Calcium-8.3* Phos-3.1 Mg-2.0 [**2133-3-25**] 12:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG . Studies: [**2133-3-25**] CXR - IMPRESSION: Increased right-sided pleural effusion and possible infiltrate in the right lower lung. Interval decrease in left-sided pleural effusion compared to [**2133-3-12**]. The study and the report were reviewed by the staff radiologist. . [**2133-3-25**] Endoscopy - Findings: Esophagus: Lumen: Evidence of a previous esophago-gastric anastomosis was seen at 23 cm from the incisors. There was no visible bleeding site in the esophagus or at the esophageal gastric anastomosis. However, there was sdherent coffee ground material not all of which could be washed away. Stomach: Contents: Clotted blood was seen in the stomach body and antrum. This obscured the greater curve of the antarl area and could not be completely cleared as the clots could not be suctioned. Other The stomach was s shaped. Duodenum: Other normal to d3 with out a bleeding site found Impression: Previous esophago-gastric of the esophagus Blood in the stomach body and antrum Normal to d3 with out a bleeding site found The stomach was s shaped. Otherwise normal EGD to second part of the duodenum Recommendations: If any questions or you need to schedule an [**Telephone/Fax (1) 682**] or email at [**University/College 21854**] The patient's bleeding site could not be ascertained due to blood in the stomach. Plan keep HCT above or at 27. He has already received two units PRBC. npo except for meds. IV Protonix. We will reavaluate patient in AM and likely rescope tomorrow. Discharge labs: [**2133-3-31**] 05:58AM BLOOD WBC-6.5 RBC-3.76* Hgb-10.5* Hct-31.2* MCV-83 MCH-27.9 MCHC-33.6 RDW-18.2* Plt Ct-193 [**2133-3-31**] 05:58AM BLOOD Glucose-113* UreaN-12 Creat-0.7 Na-138 K-4.1 Cl-102 HCO3-31 AnGap-9 [**2133-3-28**] 05:50AM BLOOD LD(LDH)-203 [**2133-3-28**] 05:50AM BLOOD TotProt-6.0* Brief Hospital Course: 64M with history of esophageal cancer, s/p resection and radiation, now with upper GIB. # Upper GIB: Pt had several episodes of hematemesis and was found to have HCT 22 at OSH. Hct increased to 27.3 after 2 units packed RBC's; overall down from 31 two weeks prior. He was initially admitted to MICU for management. GI scope upon arrival to ICU showed evidence of recent bleeding but no clear etiology and no active bleeding; no interventions were performed. He was continued on IV PPI and metoprolol, aspirin and plavix were held. He continued to have melanotic stools with gradually decreasing hematocrit. GI attempted repeat EGD however he spontaneously went into an SVT in the 220s. This resolved with IV lopressor, but the procedure was deferred until the following day. The following day however, his oxygen saturations in low 90's at rest and decreased below 90% while laying flat therefore the procedure was again postponed for gentle diuresis to improve oxygenation. Eventually after several days of slowing decreasing hematocrit but no overt bleeding events, he udnerwent repeat EGD with no evidence of active bleeding. He was discharged on PPI with GI follow-up. # Acute blood loss anemia: As above, [**2-9**] GI bleed which responded appropriately to blood tranfusion . # Coronary artery disease: Patient denied any chest pain though continued to have DOE. His aspirin and plavix were held given GI bleed. Aspirin was scheduled to be restarted after discharge and patient will discuss with his primary cardiologist risks vs benefits of restarting plavix # Tachycardia: Patient had persistent tachycardia despite adequate fluid and blood replacement. This was thought to be a physiological response from his known restrictive pcardiomyopathy. After remaining hemodynamically stable with no evidence of re-bleed, he was restarted on metoprolol with heart rate stable around 100. He diud have an episode of SVT as described above. # Acute CHF: Patient developed decreasing oxygen saturations, worsening dyspnea and orthopnea after initial volume and blood resuscitation. He has chronic bilateral pleural effusions that have not responded to diuresis and have required thoracentesis previously therefore it was decided to proceed with thoracentesis to improve oxygenation. Patient was symptomatically drastically improved after unilateral thoracentesis and was able to tolerate repeat EGD. Pleural fluid was sent for cytology and was negative for evidence of malignant cells. He was scheduled for outpatient appointment with interventional pulmonary to discuss utility of right-sided thoracentesis. # Hypertension: Anti-hypertensives were held initially and restarted as above. # History of esophageal cancer: Presentation initially concerning for recurrence given that he initially presented with hematemesis. No evidence of recurrence on repeat EGD. Thoracentesis with negative cytology. He will follow-up with outpatient providers as scheduled Medications on Admission: 1. Aspirin 81 mg daily 2. Clopidogrel 75 mg daily 3. Metoprolol 25 mg daily (used to take [**Hospital1 **]) 4. Lasix 40 mg daily 5. Spironolactone 12.5 mg daily 6. Simvastatin 40 mg daily 7. Omeprazole 20 mg daily Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Take twice daily on [**3-5**], [**4-2**], [**4-3**], [**4-4**] then resume once daily dosing. 3. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Hematemesis Acute Blood loss anemia Supraventricular tachycardia Diastolic Congestive Heart Failure Bilateral Pleural effusion . Secondary: Restricive pericarditis Discharge Condition: Good. Hemodynamically stable and afebrile. Blood counts stable with no evidence of active bleeding. Discharge Instructions: You were admitted to the hospital after an episode of vomiting blood. You received several blood tranfusions and your blood counts remained stable. We did a procedure called an endoscopy but did not find the source of the bleeding. You also some shortness of breath and low oxygen levels, likely related to the fluid in your lungs, so we did a procedure called a throacentesis to remove the fluid. The following changes were made to your medications: 1) HOLD aspirin for 7 days then restart on [**4-8**] 2) STOP plavix and discuss with your cardiologist whether this should be restarted 3) INCREASE pantoprazole to 40mg twice daily 4) INCREASE lasix to 40mg twice daily for 5 days, then resume 40mg daily until you see Dr. [**Last Name (STitle) 1911**] 5) INCREASE metoprolol to 50mg twice daily Please return to the emergency department if you experience an episode of bleeding, either vomiting blood or defecating, black or tarry stools, shortness of breath or any other symptoms that are concerning to you. Regarding your heart failure, please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Followup Instructions: The following appointments are scheduled after discharge: Interventional Pulmonary, Dr. [**Last Name (STitle) **] for right sided thoracentesis on Friday [**4-10**] at 2pm. Please report to Chest Disease Center in [**Hospital Ward Name 121**] building, room [**Hospital1 **] 116. Call [**Telephone/Fax (1) 3020**] with questions. . You have an appointment with Dr. [**First Name (STitle) **] [**Name (STitle) **] from Gastroenterology on [**4-17**] at 3:10 pm. Please call [**Telephone/Fax (1) 463**] with questions. . You have an appointment with your caridologist Dr. [**Last Name (STitle) **] [**Name (STitle) 1911**] on [**4-21**] at 4:40pm. Please call [**Telephone/Fax (1) 11767**] with questions There are still some test results pending including fluid from your lungs that is being evaluated for cancer cells. Please follow-up your PCP [**Last Name (NamePattern4) **] [**1-9**] weeks for these results. Completed by:[**2133-5-8**]

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Discharge summary

report

Admission Date: [**2169-8-1**] Discharge Date: [**2169-8-5**] Date of Birth: [**2117-8-31**] Sex: M Service: MEDICINE Allergies: Fish derived Attending:[**First Name3 (LF) 8388**] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: Upper Endoscopy with banding x2 [**2169-8-1**] Paracentesis [**2169-8-4**] History of Present Illness: 51M w/ childs C PSC/HCV/cirrhosis c/b ascites, esophageal varices w/ prior hemorrhage,HE, prior SBP, portal vein thrombosis on transplant list who presents from [**Hospital 794**] hospital with hematemesis. The pt was recently discharged from the hepatology service on [**2169-7-29**] after a similar episode, he had EGD showing varices and portal gastropathy at that time, s/p banding. He presents today from OSH with recurrent hematemesis. He underwent paracentesis earlier in the day then went home and had abdominal pain and 1 liter of hemaemesis. He went to the [**Hospital 794**] hospital ER where he was hemodynamically stable. While in the ER he had another episode of ~500cc of hematemesis. He was intubated electively and underwent endoscopy at OSH showing varices and large amount of clot in his stomach. His CBC 12.5>8.6/24.3<81. His INR was 2.0. He recieved 1PRBC 2FFP. He was bolused with protonix and started on octreotide gtt. He became hypotensive in transit and was given an additional 3PRBC. Past Medical History: - PSC Cirrhosis c/b ascites, encephalopathy SBP, and bleeding esophageal varices, on transplant list - Primary sclerosing cholangitis, dx [**2165-10-2**] - portal vein thrombosis - failed TIPS attempt [**12-12**] - History of UGIB in [**10-13**], [**5-29**], [**11/2168**], [**7-/2169**] - HCV: by history, had positive HCV with HCV VL in [**2157**], but on follow up cleared HCV spontaneously - Horseshoe kidney w/intermittent renal insufficiency - Distant history of polysubstance abuse - History of dysphagia with normal barium swallow on [**2167-11-24**] - Typical Angina - Chostrochondritis [**2-12**] - Depression - Back pain - Sleep apnea Social History: Lives with his eldest of 2 sons. [**Name (NI) **] lots of family support (mother, sisters, [**Name2 (NI) 12232**]) - requires 24 hour care at home. Not currently employed, on SSI. - Smoking: quit > 16 yrs ago, 25 pack year history - EtOH: history of abuse, last drink > 22 yrs ago - Drugs: history of polysubstance abuse including cocaine, crack, barbiturates, amphetamines, and marijuana. None for 20 years. Family History: No pertinent family history, including PSC, liver disease, or other gastrointestinal disease. (Has identical twin brother without above conditions). Grandfather with diabetes. Physical Exam: Admission Exam (on trasnfer from SICU): VS: 98.0 57 16 99% RA GENERAL: chronically ill appearign Hispanic male, jaundiced, in NAD HEENT: Sclera icteric. MMM. CARDIAC: RRR with no excess sounds appreciated LUNGS: CTA b/l with no wheezing, rales, or rhonchi. ABDOMEN: Distended, tender diffusely to palpation. No HSM or tenderness appreciated. No gaurding or rebound. EXTREMITIES: Edema half up shins. Warm and well perfused, no clubbing or cyanosis. NEUROLOGY: no asterixis, A1-B2-C3- correct. A+Ox3, executive function intact, moving all extremities. Discharge Exam: VS: 98.0/98.2 96-107/54-72 57-71 16 100% RA GENERAL: chronically ill appearing Hispanic male, jaundiced, in NAD HEENT: Sclera icteric. MMM. CARDIAC: RRR with no excess sounds appreciated LUNGS: CTA b/l with no wheezing, rales, or rhonchi. ABDOMEN: Distended, slightly tender to palpation. No HSM or tenderness appreciated. No guarding or rebound. EXTREMITIES: Edema half up shins. Warm and well perfused, no clubbing or cyanosis. NEUROLOGY: no asterixis, A1-B2-C3- correct. A+Ox3, executive function intact, moving all extremities. Pertinent Results: Admission Labs: [**2169-8-1**] 01:04AM BLOOD WBC-7.7 RBC-3.02* Hgb-9.4* Hct-28.1* MCV-93 MCH-31.1 MCHC-33.4 RDW-20.7* Plt Ct-35* [**2169-8-1**] 01:54AM BLOOD PT-19.3* PTT-33.1 INR(PT)-1.8* [**2169-8-1**] 01:54AM BLOOD Fibrino-85* [**2169-8-1**] 01:04AM BLOOD Glucose-130* UreaN-54* Creat-1.4* Na-133 K-5.4* Cl-97 HCO3-20* AnGap-21* [**2169-8-1**] 01:04AM BLOOD ALT-60* AST-60* AlkPhos-87 TotBili-18.0* [**2169-8-1**] 01:54AM BLOOD CK-MB-1 [**2169-8-1**] 06:31PM BLOOD CK-MB-1 cTropnT-<0.01 [**2169-8-1**] 01:04AM BLOOD Albumin-4.0 Calcium-8.6 Phos-4.5# Mg-2.2 [**2169-8-1**] 02:04AM BLOOD Type-ART pO2-213* pCO2-37 pH-7.46* calTCO2-27 Base XS-3 [**2169-8-1**] 01:14AM BLOOD Lactate-1.8 [**2169-8-1**] 02:04AM BLOOD freeCa-1.10* Paracentesis: [**2169-8-4**] 05:23PM ASCITES WBC-95* RBC-810* Polys-32* Lymphs-15* Monos-0 Plasma-2* Macroph-44* Other-7* Discharge Labs: [**2169-8-5**] 05:15AM BLOOD WBC-11.9* RBC-3.20* Hgb-9.7* Hct-30.3* MCV-95 MCH-30.4 MCHC-32.2 RDW-22.0* Plt Ct-34* [**2169-8-5**] 05:15AM BLOOD PT-20.5* PTT-45.8* INR(PT)-1.9* [**2169-8-5**] 05:15AM BLOOD Glucose-154* UreaN-33* Creat-1.2 Na-134 K-3.9 Cl-94* HCO3-27 AnGap-17 [**2169-8-5**] 05:15AM BLOOD ALT-98* AST-85* LD(LDH)-213 AlkPhos-111 TotBili-22.4* [**2169-8-5**] 05:15AM BLOOD Albumin-4.3 Calcium-9.0 Phos-1.9* Mg-2.2 Imaging: [**2169-8-1**] CXR: REASON FOR EXAMINATION: Assessment of ET tube placement. AP radiograph of the chest was reviewed in comparison to [**7-24**], [**2169**]. The ET tube tip is approximately 4 cm above the carina. Heart size and mediastinum are difficult to compare to the prior studies given the portable character of the study, low lung volumes. Right aortic arch is less distinguished on the current study as compared to multiple prior examinations. Right basal opacity is new, most likely representing atelectasis. Rest of the lungs are clear. [**2169-8-1**] EGD: Esophagus: Protruding Lesions 3 cords of grade II varices were seen in the lower third of the esophagus. The varices were not bleeding. 2 bands were successfully placed. Excavated Lesions Two non-bleeding 6-7mm ulcers were found in the lower third of the esophagus at the site of previous banding. Stomach: Other Old blood in fundus partially obscured view of mucosa - no obvious gastric varices but cannot exclude Severe portal gastropathy Duodenum: Other Duodenitis Old pills and old blood in duodenum Other procedures: 2 bands were successfully placed in the lower third of the esophagus. Impression: Varices at the lower third of the esophagus (ligation) Ulcers in the lower third of the esophagus Old blood in fundus partially obscured view of mucosa - no obvious gastric varices but cannot exclude Severe portal gastropathy Duodenitis Old pills and old blood in duodenum (ligation) Otherwise normal EGD to third part of the duodenum [**2169-8-2**] Echo: The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Compared with the prior study (images reviewed) of [**2169-2-8**], there is less mitral regurgitation visualized, though image quality is now suboptimal. [**2169-8-2**] ECG: Sinus bradycardia. Left atrial abnormality. Compared to the previous tracing of [**2169-7-27**] atrial ectopy is absent. Otherwise, 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 55 168 76 400/391 55 3 26 Brief Hospital Course: [**Known firstname 25368**] [**Known lastname 26438**] is a 51yoM with h/o PSC cirrhosis c/b ascites, esophageal varices w/ prior hemorrhage, hepatic encephalopathy, prior SBP, portal vein thrombosis, who p/w hematemsis/UGIB due to esoph varices after recent admission for the same [**2169-7-19**], now s/p banding [**8-1**], stabilized in the SICU, and called out to ET. . # Recurrent Variceal bleed: as evidenced by EGD [**2169-8-1**]. Currently hemodynamically stable, w/ stable hct. - HCT daily (32.4->33) - Switched from gtt PPI to [**Hospital1 **] 40mg Pantoprazole - Octreotide stopped today - continue sucralfate slurry 1g QID - may need repeat f/u EGD in several weeks - maintain active T&S: Ordered for [**8-5**] - telemetry for now, though likely can d/c soon if stable - continue nadolol, - continue SBP ppx w/ ceftriaxone 1g IV q24 x Last day tomorrow - Restart lactulose/rifaxamin for now but would restart prior to DC - hold heparin SQ fow now but consider restart . # SBP Prophylaxis - on cipro at home. pt has h/o SBP. - On CTX 1gm q 24 for 5d course D#1 [**8-1**] (last day tomorrow) - F/u ascites labs for todays tap ## ASCITES - bothersome to patient, requires frequent [**Doctor First Name 4397**] (more than Qweekly). 6L para done today - F/u ascites labs - monitor clinically - restart diuretics . # PSC cirrhosis: c/b ascites, esophageal varices w/ prior hemorrhage, hepatic encephalopathy, prior SBP, portal vein thrombosis - variceal care per above - restart lactulose and rifaxamin - continue cholestyramine and ursodiol on d/c - restart torsemide and spironolactone at home dose - 6L paracentesis done today with 50g Albumin after . # Pain control: - q6 oxycodone - Fentanyl patch . # Portal vein thrombosis - Tbili at 21.2 most recently. -Holding home warfarin for now, pending above. As unclear benefit of systemic anticoagulation for PVT, consider stopping coumadin altogether. - On hold since discharge on [**7-6**]. - would not restart until PLTs >50 - monitor LFTs daily . ## Leukocytoclastic vasculitis. Was improving on oral prednisone taper which was held on last admission and restarted with plan to taper prednisone by 5 mg every 4 days. Once reached 10 mg would continue 10 mg prednisone daily till he sees his rheumatologist Dr. [**Last Name (STitle) 4894**]. - restart pred taper: down to 20mg tomorrow if vasculitis symptoms stable/improving. - restart colchicine 0.6 mg daily . ## [**Last Name (un) **]: Cr 1.2 today (baseline 1.1) but has been at 1.4 during this admission. Off diuretics in setting of GIB. Last MRI ([**6-/2169**]) - horshoe kidney, no other abnormalities - restart diuretics at lower dose as Cr is stable - Given 50g Albumiin after todays tap . ## NSVT/BIGEMINY: asymptomatic, max 18 beats VTach. Cards states these are unconcerning. TTE wnl [**2169-8-3**]. # Esophageal candidiasis: was on 14 day course of fluconazole from last admit. Seems to have resolved, though would restart if symptoms re-appear as this may exacerbate esophageal issues. . # Depression: holding citalopram in SICU. Psych knows him well here and should be consulted if any problems. - consider restart of citalopram as outpatient. ## HCC Screening - U/S q6mo - MRI ABD [**2169-6-29**] - Next [**12-13**] . Transitional Issues: #CODE: Full #CONTACT: [**Last Name (LF) **],[**First Name3 (LF) **] sister [**Telephone/Fax (1) 82281**] Medications on Admission: 1. Cholestyramine 4 gm PO BID 2. Ciprofloxacin HCl 250 mg PO/NG Q12H 3. Citalopram 20 mg PO DAILY 4. Colchicine 0.6 mg PO DAILY RX *Colcrys 0.6 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Fentanyl Patch 50 mcg/hr TP Q72H 6. Gabapentin 300 mg PO Q8H 7. Lactulose 60 mL PO QID Titrate to [**3-5**] BMs daily. 8. Lidocaine 5% Patch 1 PTCH TD DAILY 9. Metoclopramide 10 mg PO QIDACHS prn nausea 10. Multivitamins 1 TAB PO DAILY 11. OxycoDONE (Immediate Release) 20 mg PO Q6H:PRN Pain >[**6-11**] 12. Pantoprazole 40 mg PO Q24H 13. Nadolol 20 mg PO DAILY hold for HR < 55 RX *nadolol 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 14. PredniSONE 25 mg PO DAILY Duration: 4 Days RX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*70 Tablet Refills:*0 15. Rifaximin 550 mg PO BID 16. Spironolactone 50 mg PO DAILY Hold for SBP<90. Notify HO if holding. 17. Torsemide 20 mg PO DAILY Hold for SBP<90. Let HO know if holding. 18. Ursodiol 500 mg PO BID 19. Vitamin D 800 UNIT PO DAILY 20. Haloperidol 1 mg PO HS:PRN insomnia 21. Acetaminophen 650 mg PO TID:PRN pain 22. Magnesium Oxide 400 mg PO BID 23. Simethicone 40-80 mg PO QID:PRN abd pain 24. Cyclobenzaprine 10 mg PO HS:PRN muscle spasms 25. Calcium Carbonate Suspension 500 mg PO BID Discharge Medications: 1. PredniSONE 20 mg PO DAILY Duration: 4 Days First dose [**2169-8-5**]. Start 15mg for 4 days on Wednesday [**8-9**] RX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*70 Tablet Refills:*0 2. Lactulose 60 mL PO QID titrate to 3-4BM daily 3. Fentanyl Patch 50 mcg/hr TP Q72H 4. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*3 5. Nadolol 20 mg PO DAILY hold for sbp<100 or hr <60 6. Spironolactone 50 mg PO DAILY hold for K>5.5 7. Torsemide 20 mg PO DAILY Hold for SBP<90 8. Rifaximin 550 mg PO BID 9. Cholestyramine 4 gm PO BID 10. Ciprofloxacin HCl 250 mg PO Q12H First dose [**2169-8-6**] 11. Citalopram 20 mg PO DAILY 12. Colchicine 0.6 mg PO DAILY 13. Gabapentin 300 mg PO Q8H 14. Lidocaine 5% Patch 1 PTCH TD DAILY 15. Metoclopramide 10 mg PO QIDACHS nausea 16. OxycoDONE (Immediate Release) 20 mg PO Q6H:PRN pain > [**6-11**] 17. Haloperidol 1 mg PO ONCE:PRN insomnia 18. Ursodiol 500 mg PO BID 19. Vitamin D 800 UNIT PO DAILY 20. Acetaminophen 650 mg PO TID:PRN pain 21. Simethicone 40-80 mg PO QID:PRN abd pain 22. Cyclobenzaprine 10 mg PO HS:PRN muscle spasms 23. Calcium Carbonate Suspension 500 mg PO BID 5 mL (1 tsp) = 1250 mg Calcium Carbonate = 500 mg of Elemental Calcium. DO NOT TAKE WHEN TAKING CIPROFLOXACIN 24. Magnesium Oxide 400 mg PO BID 25. Sucralfate 1 gm PO QID RX *sucralfate 1 gram/10 mL 1 Suspension(s) by mouth four times a day Disp #*120 Gram Refills:*0 Discharge Disposition: Home With Service Facility: VNA of RI Discharge Diagnosis: Primary Diagnosis: End stage liver disease with acute variceal bleed Secondary Diagnosis: Refractory Ascites Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 26438**], It was once again a pleasure taking care of you at [**Hospital1 771**]. You were admitted for an upper gastrointesintal bleed which was intervened upon by the gastroenterologists. Two esophageal varices were found and banded. Your blood counts remained stable and you were restarted on your home medications. You received a therapeutic paracentesis during this admission to keep you comfortable. We continued you on your current prednisone taper, however the taper was delayed by a couple days. This is your new steroid taper: Please make sure to follow this steroid tapering regimen to ensure your vasculitis does not flare up: TAKE Prednisone 20mg daily on [**7-1**] THEN TAKE Prednisone 15mg daily on [**2169-8-9**] THEN TAKE Prednisone 10mg daily until your follow up appointment with Rheumatology on [**9-18**]. We will give you an additional prescription for prednisone so that you don't run out of prednisone prior to this appointment. The stitches that were placed last admission should be removed on Monday [**8-7**]. You can present to your primary health care provider to have this done. Please continue your regularly [**Month (only) 1988**] lab draws and paracenteses, and plan to keep the follow up appointments detailed below. Followup Instructions: Department: TRANSPLANT When: WEDNESDAY [**2169-8-16**] at 2:20 PM With: TRANSPLANT [**Hospital 1389**] [**Hospital **], Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] Phone: [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: Internal Medicine, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 82282**] Office When: Monday [**2168-8-27**]:00 am With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 49957**], NP Address: [**Street Address(2) **]., E. [**Hospital1 789**], [**Numeric Identifier 82283**] Phone: [**Telephone/Fax (1) 82264**] Department: RHEUMATOLOGY When: MONDAY [**2169-9-18**] at 11:00 AM With: [**First Name8 (NamePattern2) 674**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2226**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

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Discharge summary

report

Admission Date: [**2129-1-21**] Discharge Date: [**2129-2-10**] Date of Birth: [**2060-11-20**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Fall Major Surgical or Invasive Procedure: Intubated/extubated, mechanical ventilation Lumbar puncture Arterial line placement Central venous line placement PICC line placement History of Present Illness: 68M with a history of afib s/p ablation on [**2129-1-14**], diabetes type II, HTN, OSA refusing CPAP, hiatal hernia, and alcohol abuse admitted for fall, ICH, and temporal bone fracture who developed acute hypoxia on the floor initially and was found to have aspiration PNA and then went into alcohol withdrawal. In brief, he was at a bar and fell in the parking lot due to a combination of intoxication and ice. He hit his head and lost consciousness. He woke up some time later and drove home. At home his wife noted he was bleeding from his ear, and called EMS. He was taken to an OSH then transfered here. In the ED here he was found to have a temporal bone fracture and a small ICH. ENT and Nsurg were consulted, and he was admitted to Nsurg for further management. . On Nsurg, he received a total of 30mg vitamin K and 5 units of FFP to reverse his INR (he is on warfarin for afib). His INR has remained elevated but his bleed is small and his neurologic exam is intact. During his second day of admission he became increasingly hypoxic. There was concern for a PE so he was sent to CTA chest yesterday. CTA showed no PE but ?aspiration pneumonitis. Medicine was consulted to assist with management. He was started on levofloxacin and metronidazole as well as standing nebs. His sats stabilized. Overnight he became increasingly hypertensive, tachycardic, and agitated consistent with etOH withdrawl. He was receiving lorazepam 0.5mg IV Q2H with little impact. In the AM he was re-evaluated by Med Consult, who started diazepam 5-10mg PO Q2H and Zyprexa for agitation. Nsurg has been giving his metoprolol overnight for HTN, but this was changed to hydralazine. He was increasingly SOB, so he received Lasix 20mg IV x1. Given his complex medical issues and ongoing alcohol withdrawl, he was transfered to the MICU for further management. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies sinus tenderness, rhinorrhea or congestion. Denies cough, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1. A-fib, on coumadin 2. Type II Diabetes 3. Hypertension 4. GERD 5. sleep apnea, noncompliant with CPAP 6. pseudotumor cerebri 7. recent cardiac ablation Social History: Married, works as a contractor. - Tobacco: smoked age 15 to 45 5 PPD, 200 pack years - EtOH: Per patient, social drinker only - Illicits: Denies Family History: Non-contributory Physical Exam: On admission: O: T: BP: 161/103 HR:102 R:17 O2Sats:99% 2L Gen: WD/WN, comfortable, NAD. HEENT: Normocephalic. L hemotympanum. No obvious CSF. Pupils: [**1-31**] bilaterally EOMs intact Neck: In C-Collar Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**3-2**] 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, 2 to 1 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-4**] 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 . On transfer to the MICU: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, 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: CT HEAD [**1-21**]: 1. Limited study due to motion. 2. Right frontal extra-axial hematoma, likely subdural, 2 mm in greatest transverse dimension. Probable subdural hematoma along the anterior falx. 3mm left frontal hyperdensity most likely subdural hematoma. 3. Bilateral inferior frontal and left frontal hyperdensities, which may be artifact or subarachnoid or intraparenchymal hemorrhage. 4. Nondisplaced temporal bone fracture, not well assessed due to motion. Partial opacification left mastoid air cells. 5. Soft tissue gas around the left mandibular condyle and ramus. . - CT HEAD W/O CONTRAST Study Date of [**2129-1-21**] 2:29 AM FINDINGS: Examination is degraded by motion artifact, which persisted despite repeating the examination. Hyperdensity overlying the right frontotemporal lobe (5:[**12-13**]) is consistent with acute blood, likely subdural hematoma, measuring 2 mm in greatest transverse dimension. Hyperdensity along the anterior falx (2:13-14) is concerning for subdural hematoma. A hyperdense 3 mm focus overlying the anterior left frontal lobe is consistent with acute blood, likely subdural. Bifrontal hyperdensities of the inferior frontal lobes (5:10) may be due to artifact, or subarachnoid or intraparenchymal hemorrhage. There is no intraventricular hemorrhage. There is no mass effect, shift of midline structures or edema. [**Doctor Last Name **]-white matter differentiation is preserved. There appears to be a nondisplaced left temporal bone fracture (3:16), although this is not well evaluated due to motion artifact. Left mastoid air cells are partially opacified. Soft tissue gas is identified around the left mandibular condyle and ramus. IMPRESSION: 1. Limited study due to motion. 2. Right frontal extra-axial hematoma, likely subdural, 2 mm in greatest transverse dimension. Probable subdural hematoma along the anterior falx. 3mm left frontal hyperdensity most likely subdural hematoma. 3. Bilateral inferior frontal and left frontal hyperdensities, which may be artifact or subarachnoid or intraparenchymal hemorrhage. 4. ondisplaced temporal bone fracture, not well assessed due to motion. artial opacification left mastoid air cells. 5. Soft tissue gas around the left mandibular condyle and ramus. . - CT HEAD W/O CONTRAST Study Date of [**2129-1-21**] 9:48 AM Again noted is small acute subdural hematoma in the bilateral inferior frontal egions along the gyri recti or straight gyrus, extending superiorly up the anterior falx. This is unchanged in size and appearance from prior as is the small associated subarachnoid hemorrhage. No new areas of hemorrhage are present. No areas of edema or large infarctions are noted either. The prior noted left nondisplaced temporal bone fracture is also unchanged. Partial opacification of the left mastoid air cells persists. The remaining paranasal sinuses and right mastoid air cells are well aerated. IMPRESSION: 1. Unchanged frontal subdural and subarachnoid hemorrhage. 2. No change in nondisplaced left temporal bone fracture. . - CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2129-1-21**] 2:29 PM There is no pulmonary embolism. Thoracic aorta is normal in caliber and contour throughout, with mild atherosclerotic calcification seen in the arch, and descending aorta. There is mild cardiomegaly. There are small bilateral pleural effusions, and small nonhemorrhagic pericardial effusions. Three-vessel coronary artery calcification is mild. The main pulmonary artery is prominent, measuring up to 4.0 cm in diameter, suggestive of pulmonary arterial hypertension. There is diffuse pneumonitis throughout dependent portions of both lungs, with relatively [**Name2 (NI) 15410**] consolidation at the lung bases. Central airways are patent to the subsegmental level. Mildly enlarged mediastinal lymph nodes are noted, measuring up to 28 x 11 mm in the prevascular space (2, 18). Mildly enlarged subcarinal and right hilar nodes are also noted, measuring 11 and 13 mm in short axis respectively. This study is not specifically tailored for subdiaphragmatic evaluation. Limited views of the upper abdomen demonstrate a moderately large axial hiatal hernia. Hepatic and left renal hypodense lesions are incompletely characterized as they are only visualized on non-contrast sequences, but statistically most likely represent simple cysts. There is no osseous lesion suspicious for malignancy. IMPRESSION: 1. No evidence of pulmonary embolism. 2. Widespread consolidation predominantly in dependent portions of both lungs, most consistent with a multilobar pneumonia, possibly secondary to aspiration. 3. Mediastinal and hilar lymphadenopathy is likely reactive, but if clinically warranted, a followup chest CT could be performed in three to six months to determine resolution. 4. Prominent main pulmonary artery, suggestive of pulmonary arterial hypertension. 5. Moderately large hiatal hernia. . EKG: First degree heart block (PR214), Q in 3, TWF laterally and inferiorlly. Noramal axis, sinus. . CT head non con [**1-23**]: 1. Expected interval evolution of bifrontal subdural and subarachnoid hemorrhage. No significant change in blood products in the bilateral occipital horns. 2. Interval development of hypodensity in the bilateral inferior frontal lobes may represent edema, but acute infarct is not excluded. If there is clinical concern for acute ischemia, MRI is recommended for further evaluation. 3. Unchanged nondisplaced left temporal bone fracture with opacification of some of the mastoid air cells. 4. Ethmoid and sphenoid sinus mucosal thickening. Clinical correlation recommended. . CT abd/pelvis: 1. Multiple mildly dilated loops of small and large bowel with areas of bowel wall thickening and mesenteric edema are concerning for mesenteric ischemia, especially given the patient's cardiac history. If there is increased clinical suspicion for ischemic bowel disease, a CTA of the abdomen could be considered. 2. A transition point at the proximal portion of the descending colon is present, but the proximal bowel pattern does not suggest a high grade obstruction. An underlying mass is not visualized, however further characterization is limited by lack of IV contrast. 3. Small perisplenic fluid collection. 4. Small pericardial effusion. . MRI head/MRA: 1. Post-traumatic changes with a right frontotemporal contusion, demonstrating expected evolution since the prior study. Areas of subdural and subarachnoid hemorrhage also demonstrate expected evolution. No new hemorrhage is identified. 2. Normal MRA of the head, without evidence of hemodynamically significant stenosis, dissection, or aneurysm. . MRI abd/pelvis: 1. Distension of the proximal loops of small bowel with relative collapse of distal loops of small bowel and no definite transition point identified. Abnormal configuration of several loops of small bowel in the left mid abdomen suggest tethering, but no transition point is seen at these regions. The presence of adhesions at this level is possible. 2. Proximal celiac and SMA axes are widely patent and unremarkable with no intraluminal filling defects. . EEG: This telemetry showed a slow encephalopathic background throughout. Medications, metabolic disturbances, and infection are among the most common causes. There were no prominent focal findings, but encephalopathies may obscure focal slowing. By routine sampling or by automated detection programs, there were no epileptiform features or electrographic seizures. A tachycardia was noted. . LENI bilateral: Non-occlusive thrombus in the right common femoral vein extending into the proximal superficial femoral vein. The proximal extent of clot is not visualized on this study. . ECHO: The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-10mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. with normal free wall contractility. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Tricuspid regurgitation is present but cannot be quantified. There is mild pulmonary artery systolic hypertension. Very small pericardial effusion. The effusion is echo [**Month/Year (2) 15410**], consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2129-1-27**], the pericardial effusion is smaller. Brief Hospital Course: 68M s/p fall with EtOH intoxication leading to skull fracture, SAH, SDH. Admission c/b intermittent ileus, acute on chronic renal failure, respiratory distress, atrial flutter and atrial fib, and altered mental status. . # Altered Mental status: Patient had extensive imaging (CT/MRI), blood/urine/sputum cultures, EEG and a lumbar puncture, all of which were unrevealing. Neurology also followed the patient during this hospitalization. Patient was initially withdrawing from alcohol, then it was unclear if his intracranial hemorrhages and initial head trauma had caused residual damage. By day of discharge, however, patient's mental status had improved dramatically. Patient was conversant, interactive and logical. - Please note that patient does have a tendency to wax and wane, and still has evidence of frontal brain contusion on imaging - Continue to work with Physical and Occupational therapy as much as posible - Maintain sleep/wake cycle, manage symptoms (pain), re-orient frequently and encourage family at bedside . # Gout: Patient was found to be grimacing in pain two days prior to discharge, especially with movement. The pain localized to patient's left elbow/forearm and xrays were unrevealing but an elbow effusion was found. Fluid aspirate from the elbow confirmed gout. - Continue Prednisone taper as follows: [**2-11**]: 60mg daily [**2-12**]-14: 50mg daily [**2-14**]-16: 40mg daily [**2-16**]-18: 30mg daily [**2-18**]-20: 20mg daily [**2-20**]-22: 10mg daily OFF [**2-22**] - Continue pain control as needed with tylenol . # DVT: Was found in patient's right lower extremity, which was felt to be contributing to his low grade fevers. Patient had previously been anticoagulated for his atrial fibrillation, reversed in the setting of his intracranial hemorrhages. Heparin gtt was restarted, in discussions with neurosurgery, with a lower goal of PTT 60-80 in the setting of his ICHs. Patient was restarted on Coumadin on day of discharge - Continue heparin gtt (currently 3000 units/hour) with lower goal PTT 60-80 in setting of his intracranial hemorrhages - Continue Coumadin at 4mg daily. It is important that patient get close (daily) PTT/INR checks as his goal INR should be lower, close to 2.0, in the setting of his head bleeds. . # A Fib/Flutter: Patient is known to be difficult to rate control as an outpatient. Serial EKG's showed borderline first degree AV block, which per his outpatient cardiologist, is what he exhibits when not in atrial fibrillation. Patient had been on coumadin for atrial fibrillation for 4-5 years with several ablations. Maximum sinus rhythm intervals has been a few weeks each time. Given his admission for cerebral contusion and multiple intracranial hemorrhages, his coumadin was initially stopped and his INR reversed with FFP and vitamin K. Patient's most recent ablation had been at [**Hospital6 1708**] by Dr. [**Last Name (STitle) **] on [**2129-1-15**] (ph: [**0-0-**]). He continued to be in Atrial Fibrillation throughout his hospital stay. Patient was initially started on Esmolol gtt which was weaned off. He was also started on Digoxin but per Cardiology recommendations, this was discontinued (patient's small left ventricle was felt to make Digoxin ineffective/potentially harmful in managing this patient's Afib/flutter). Also per their recommendations, his home Sotalol was held in the setting of recent INR reversal and risk of thromboembolic events with cardioversion from Sotalol. Patient's heart rate and blood pressures were relatively well controlled on Labetalol. Repeat ECHOs showed unchanged cardiac function and minimal pericardial effusion. - Continue Labetalol 800mg TID - If would like better heart rate control, can switch to Metoprolol Tartrate 50mg TID and titrate up to effectiveness - Patient has an appointment to see his outpatient cardiologist, Dr. [**Last Name (STitle) 4455**] for Wednesday, [**2-16**] at 1pm. He should discuss with him the possibility of restarting Sotalol, using Metoprolol for better rate control, as he is anti-coagulated again. * Dr.[**Name (NI) 51658**] office number: [**Telephone/Fax (1) 45578**]) . # Ileus: Patient initially developed an ileus, etiology not entirely clear. Patient was briefly on TPN instead of tube feeds and eventually redeveloped good stool output. As his ileus resolved, patient was resumed on tube feeds and by day of discharge, patient was swallowing well and tolerating PO diet - Continue PO diet - If patient is not taking in adequate caloric intake, can place Dobhoff for supplemental tube feeds . # Hypertension: Patient initially hypotensive, likely in the setting of sedation for intubation (fentanyl and versed). Eventually, as he was weaned and extubated, patient became hypertensive and was relatively difficult to control. His home ACE-inhibitors and ARBs were held given his rise in Creatinine. He was briefly on Nifedipine gtt, Esmolol gtt and received Hydralazine, Labetalol IV. Patient did not respond significantly to Metoprolol. - Continue Labetalol 800mg PO TID - Given stability of creatinine, can add Lisinopril if blood pressures are not well controlled - Continue to control gout pain with tylenol as needed . # Respiratory Failure: Patient was initially intubated for desaturation and tachypnea. He had a prolonged intubation course given altered mental status during spontaneous awakening trials that made it concerning that the patient would not be able to protect his airway and/or clear secretions. Patient was initially on Cefepime and Flagyl for aspiration pneumonia. He was later started on Vancomycin and completed a two week course for health-care acquired pneumonia given persistent fevers. He did have two sputum samples positive for Coagulase Positive Staph Aureus and he is MRSA colonized. Ultimately, patient was able to be extubated and tolerated it well. - Continue albuterol and ipratropium inhalers as needed . # Acute Renal Insufficiency: Patient's creatinine bumped up to 3.3, etiology likely multifactorial (drug induced, pre-renal, etc). By time of discharge, patient's creatinine had stabilized to 1.5-1.7, which is felt likely to be his new baseline. . # Skull fracture: Patient was seen by ENT and completed a full course of ciprofloxacin/dexamethasone ear drops. - Patient needs to see ENT, Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 2349**] in [**1-1**] weeks. He also needs an audiogram in 1 week. Please call ([**Telephone/Fax (1) 18008**] for an appointment . # Subarachnoid Hemorrhage/Subdural Hematoma: Patient was followed by neurosurgery and initially on their service. He underwent serial CT scans for worsening intracranial bleeds or new fractures, which were both negative. Ultimately, patient's mental status improved dramatically and final CT scan on [**2-8**] showed continued signs of frontal brain contusion from his fall but no acute processes. - Continue to monitor his mental status - Patient should call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name (STitle) **] in Neurosurgery, to be seen in 4 weeks . # EtOH: Patient started withdrawing from alcohol on [**1-23**], becoming diaphoretic, hypertensive and tachycardic. He was treated with valium 10mg IV every hour as needed for this initially, briefly transitioned to propofol given intubation. By the time of discharge, he had completed his alcohol withdrawal and not requiring any benzodiazepines. - Continue thiamine, folate and multivitamin - Patient should see social worker to discuss his alcohol use . # Diabetes: Patient was on an insulin sliding scale while in the hospital. He can resume his home glipizide upon discharge # Access: PICC line . # Communication: [**Doctor First Name **] and [**First Name8 (NamePattern2) **] [**Known lastname 20250**] (children) . # Code: Confirmed full Medications on Admission: 1. Lisinopril 40mg Daily 2. Glipizide ER 10mg [**Hospital1 **] 3. Nifedipine ER 90mg Daily 4. Sotalol 80mg 1.5 tablets Daily 5. Coumadin 5mg 1.5 tablets Daily 6. MVI 7. FIsh Oil 8. Viagra PRN Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for Fever. 3. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for dry eyes/irritation. 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for rash. 7. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 8. Labetalol 200 mg Tablet Sig: One (1) Tablet PO three times a day. 9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. 10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 11. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 12. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 14. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day: Please dose according to INR, with lower goal of ~2.0 given brain bleeds. 15. Prednisone 10 mg Tablet Sig: 1-5 Tablets PO once a day for 11 days: [**2-11**]: 60mg daily, [**2-12**]-14: 50mg daily, [**2-14**]-16: 40mg daily, [**2-16**]-18: 30mg daily, [**2-18**]-20: 20mg daily, [**2-20**]-22: 10mg daily. OFF [**2-22**]. 16. Heparin Drip Currently 3,000 units/hour . * Please titrate according to PTT with low goal of 60-80 given intracranial bleeds Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: Primary: Left Temporal Skull Fracture, Subdural Hematoma, Subarachnoid Hemorrhage, Gout, Deep Vein Thrombosis, Respiratory Failure w/ possible pneumonia, Acute Renal Insufficiency, Alcohol Withdrawal Secondary: Atrial fibrillation, Hypertension, Type 2 Diabetes Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Out of Bed with assistance to chair or wheelchair Discharge Instructions: -You were admitted after a fall and found to have a skull fracture (causing bleeding from your ear), multiple bleeds in your brain. Both have since stabilized with medications and close monitoring. Your hospital stay was complicated by inability to maintain your breathing/airway and you required intubation and a breathing machine for a while. You also developed symptoms of alcohol withdrawal, which was also managed by close monitoring and medications. You developed gout in your left albow and a deep vein thrombosis in your right leg which are being treated with steroids and blood thinners, respectively. . -It is important that you continue to take your medications as directed. Please find enclosed a list of your current medication regimen. Of note, --> STOP your home Sotalol, continue Labetalol 800mg three times daily for now --> START Coumadin 4mg daily with close INR monitoring (goal 2.0) . Neurosurgery Discharge Instructions: ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. Please work with Physical Therapy for optimal rehabilitation/strengthening ?????? Increase your intake of fluids and fiber, as you were constipated during this hospitalization due to your multiple medical issues. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. Followup Instructions: Follow-Up Appointment Instructions: * You have an appointment to see your cardiologist, Dr. [**Last Name (STitle) 4455**] for Wednesday, [**2-16**] at 1pm. He should discuss with him the possibility of restarting Sotalol, using Metoprolol for better rate control, as you are anti-coagulated again. Dr. [**Name (NI) 51659**] office number: [**Telephone/Fax (1) 45578**] * Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen in 4 weeks * You need to see ENT, Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 2349**] in [**1-1**] weeks. You need to have an audiogram in 1 wk. Please call ([**Telephone/Fax (1) 18008**] for an appointment * Please call your primary care doctor Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 51660**] for an appointment to see her in [**2-2**] weeks. You can reach her at: [**Telephone/Fax (1) 51661**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "585.9", "584.5", "348.2", "349.82", "804.22", "482.41", "790.92", "693.0", "E885.9", "496", "780.97", "427.31", "041.11", "453.42", "E934.2", "530.81", "790.7", "285.1", "507.0", "553.3", "403.90", "385.89", "276.0", "274.01", "V58.67", "560.1", "291.81", "327.23", "303.01", "V02.54", "458.29", "V15.82", "427.32", "518.81", "250.00", "E930.5" ]

icd9cm

[ [ [] ] ]

[ "96.72", "96.6", "94.62", "81.91", "46.85", "03.31", "38.91", "38.93", "96.04", "99.15" ]

icd9pcs

[ [ [] ] ]

23666, 23746

13743, 13974

285, 420

24052, 24052

4975, 13720

26088, 27144

3086, 3104

21802, 23643

23767, 24031

21585, 21779

25165, 26065

3119, 3119

2313, 2730

241, 247

448, 2294

3672, 4956

3133, 3380

24066, 24198

2752, 2908

2924, 3070

14,585

107,708

25981

Discharge summary

report

Admission Date: [**2150-7-29**] Discharge Date: [**2150-8-12**] Date of Birth: [**2110-1-11**] Sex: M Service: MEDICINE Allergies: Didanosine / Iodine; Iodine Containing Attending:[**First Name3 (LF) 8487**] Chief Complaint: transfer from floor (west) for hypotension Major Surgical or Invasive Procedure: None History of Present Illness: HPI: 40 yo Indian male with HIV/AIDs (CD4 17), chronic wasting/malnutrition on TPN, on treatment for cryptosporidium diarrhea, c. diff, who originally presented to [**Hospital1 **] On [**2150-7-29**] with worsening pancytopenia and epistaxis (plt 17 on admission). Hematology saw pt while hospitalized and differential for thrombocytopenia was drug induced from flagyl/gancyclovir/bactrim, myelosuppression from HIV, vs ITP. Bone marrow biopsy was performed and pt was started on IV steroids for presumed ITP. Additionally, pt has been having guaiac positive stools and GI saw pt though opted not to scope as pt likely bleeding in setting of thrombocytopenia. Mr. [**Known lastname 64553**] was also diagnosed with Norwegian scabies, thrush, and likely esophageal candidiasis. . Last night ~midnight, MICU green called for pt being hypothermic to 92.9, BP: 58/pal (100s prior), P: 88; RR: 26; O2: 2L with a new productive cough. He was given cefepime 2 g IV x 1, 4 L NS. Pt was started on a dopamine gtt for SBP in the 60s and transferred to [**Hospital Unit Name 153**] via ambulance. Past Medical History: PMHx copied per old note: 1) HIV: Diagnosed [**2138**]. Last CD4 17 on [**2150-6-3**] (45 on [**2150-3-27**]), VL 33,000 on [**2150-3-27**]. Last HAART regimen in [**3-23**] consisted of Kaletra/Trizivir/Viread; however, this regimen did not suppress his VL or raise his CD4 count. As his HAART meds were thought to be worsening his diarrheal symptoms and were unlikely to be absorbed, they were held at that time. . 2) Cryptosporidium: Positive [**2150-3-27**] and [**2150-5-4**], negative [**2150-6-2**]. Started treatment with paromycin and azithromycin on [**5-27**] for projected 18 week course. Terminal ileum biopsies taken, which was c/w cryptosporidiosis. . 3) CMV colitis: One cell suspicious for CMV on [**5-23**] terminal ileum biopsy, though staining was negative. CMV VL found to be 6830. He was started on ganciclovir 150mg IV bid on [**2150-6-23**] for 2wk induction period, then to qD maintenance dosing. . 4) C. diff colitis: Started treatment with flagyl 500mg IV tid on [**2150-7-24**] for 14 day course, holding antimotility agents that had been previously used. . 5) Esophageal candidiasis: Dx'ed on [**5-23**] EGD, s/p 14 days fluconazole. Recently diagnosed with thrush, started on another course of fluconazole 100mg IV qD x 14 days. . 6) Malnutrition: Likely [**2-19**] chronic diarrhea and AIDS. Receives chronic TPN . 7) Abnormal TFT's: TSH 4, FT4 0.7 in [**2150-6-9**]. Not repleted [**2-19**] sinus tach and diarrhea. Planned for recheck in 6 weeks. . 8) h/o pancreatititis [**2-19**] DDI c/b pseudocyst requiring drainage . 9) h/o scabies tx with permethrin . 10) Anal condylomata Social History: Indian born. Economic professor [**First Name (Titles) **] [**Last Name (Titles) 64552**]. No tobacco, alcohol, or IVDU. Family History: Grandmother with ovarian cancer Physical Exam: Physical Exam: 18mcg dopamine, SBP 85 VS: 92.9 I/O [**8-1**] 1550 / BR BM(1600) Gen: Mild distress, HEENT: PERRL, EOMI, nonicteric sclera, OP with extensive thrush, dry mm, JVD flat, CV: rrr no mrg Lungs: decrease bs, Abd: decrease BS, soft nt/nd Ext: no c/c/e Skin: hyperkeratotic scales on neck Neuro: aaox3 Pertinent Results: Radiology: [**2150-7-31**] Abdominal ultrasound- IMPRESSION: Minimal thickened gallbladder wall with intraluminal sludge and slightly dilated common bile duct. These constellation of findings are concerning for HIV cholangiopathy. . TTE [**2150-7-31**]-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%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. No vegetation seen (cannot definitively exclude). . [**2150-7-30**] CXR PA/LAT- no acute cardiopulm process [**2150-7-29**] 06:00PM GLUCOSE-84 UREA N-40* CREAT-1.6*# SODIUM-147* POTASSIUM-3.7 CHLORIDE-110* TOTAL CO2-23 ANION GAP-18 [**2150-7-29**] 06:00PM ALT(SGPT)-29 AST(SGOT)-48* LD(LDH)-261* ALK PHOS-854* AMYLASE-51 TOT BILI-1.0 [**2150-7-29**] 06:00PM GGT-446* [**2150-7-29**] 06:00PM CALCIUM-7.1* PHOSPHATE-4.0 MAGNESIUM-1.9 [**2150-7-29**] 06:00PM HAPTOGLOB-166 [**2150-7-29**] 06:00PM WBC-1.0*# RBC-2.46* HGB-7.9* HCT-22.7* MCV-92# MCH-32.0# MCHC-34.7 RDW-18.1* [**2150-7-29**] 06:00PM NEUTS-72* BANDS-0 LYMPHS-18 MONOS-10 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2150-7-29**] 06:00PM PLT COUNT-7*# [**2150-7-29**] 06:00PM PT-12.9 PTT-26.9 INR(PT)-1.1 [**2150-7-29**] 06:00PM GRAN CT-760* [**2150-7-29**] 06:00PM RET AUT-0.2* Head CT [**8-8**]: FINDINGS: There is no evidence of acute intra- or extra-axial hemorrhage. The [**Doctor Last Name 352**]-white matter differentiation appears grossly preserved. There is slight prominence of the ventricles and sulci that may be related to volume loss. The basal cisterns appear patent. Imaged paranasal sinuses appear clear. [**8-10**] Portable chest x-ray: The heart size is normal. There is a persistent area of opacity in the right lower lobe with associated displacement of the fissure suggestive of atelectasis. There is a new area of opacity in the left retrocardiac region with air bronchograms, concerning for infectious pneumonia or aspiration. There is a persistent small right pleural effusion and there is a new small left pleural effusion. IMPRESSION: Persistent right lower lobe opacity, most likely atelectasis. New left retrocardiac opacity, concerning for infectious pneumonia or aspiration. Brief Hospital Course: A/P: 40M with HIV/AIDS (CD4 17) with chronic diarrhea [**2-19**] cryptosporidium, c. diff, and CMV colitis, pancytopenia, electrolyte abnormalities, transfer from floor for hypotension, hypothermia, and new O2 requirement. . #) Septic shock: Likely due to Pseudomonas in blood +/- ? left lower lobe infiltrate He was started on Broad spectrum abx cefepime/levo to double cover for Pseudomonas. He was started on Levophed and dopamine was weaned off on [**8-3**] to maintain MAPs>60. He completed a 7 day course of stress dose steroids. Intravenous fluids and antibiotics were continued until [**8-11**] when patient was made comfort measures. . #) Pancytopenia : Multifactorial: Likely HIV + medication . a. Thrombocytopenia - ITP vs. medication (bactrim/ganciclovir/flagyl) vs. myelosuppression from HIV/AIDs. Also possible include infection with PCP, [**Last Name (NamePattern4) **]. s/p BMBx by heme on [**2150-7-30**]. . b. Anemia - Hct on admission 22.7. Likely from GIB and HIV. Peripheral smear did not show evidence of hemolysis and iron studies in [**5-23**] consistent with anemia of chronic disease. Pt also has been having guaiac positive stools. On [**8-3**] he was transfused 1U PRBCs and 2U PRBCs on [**8-4**] . c. Neutropenia and lymphopenia - marrow suppression likely [**2-19**] HIV, infection. GCSF was continued until blood counts increased and no longer neutropenic. . #) GIB/Coagulopathy: Likely from INR of 2.0 as well as low platelets. Patient has been putting out bloody watery BMs from mushroom cath. He was transfused with plts, PRBCs, received 10Sc of Vit K on [**8-3**] and FFP. GI was consulted regarding GI Bleed - no intervention because of low platelet count. . #) Access: Patient had double lumen PICC placed. . #) Diarrhea - Etiology multifactorial including crytosporidia and C.Difficile, but completed a 14 day course of flagyl treatment. He was started on opium tincture and loperamide. Patient had over 4L stool production. He had frequent labs checked to replete electrolytes and aggressive fluid resuscitation. This was stopped when he was made comfort measures only. . #) AIDS - CD4 of 17 in [**5-23**]. He was restarted on HAART medications but these were stopped when made comfort measures. . #) AIDS cholangiopathy - seen on RUQ u/s and pt with elevated AP. It is a biliary obstruction from infection associated strictures of biliary tract, most common being cryptosporidiumm as well as CMV, microsporidia, cyclospora. Followed LFTs. . #) Norwegian scabies-received ivermectin PO x 1 on [**2150-7-30**] and permethrin cream. He remained on contact precautions. . #) Esophageal candidiasis-originally dxd by EGD in [**5-23**] and he is s/p 14 day trt with fluconazole. Pt again dxd with thrush at [**Hospital1 **]. Was on fluconazole IV (started [**2150-7-26**]) but switched to Voriconazole until antibiotics were stopped. . #) Code Status - Patient was a DNR/DNI but initially was willing to have pressors. As treatments did not seem to be effective, GI losses remained great, and patient remained with low CD4 count despite HAART therapy a family meeting was held on [**8-10**] with patient's infectious disease doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] and the ICU team. The patient expressed his wishes to be comfort measures only. On [**8-11**] all iv fluids and antibiotics were stopped. He was transitioned to a morphine drip and passed away peacefully with his family at his bedside on [**2150-8-12**] at 7:25p.m. Medications on Admission: Medications on transfer: 1. RISS 2. Tylenol prn 3. Carmol topical 4. Methylprednisolone 40 mg IV q24 5. Nystatin Oral Suspension 10 ml PO TID 6. Fluconazole 100 mg IV Q24H ([**7-30**]-) 7. Paromomycin *NF* 750 mg Oral tid 8. Glutamine 10 gm PO TID 9. Hydrocerin 1 Appl TP TID 10. Cefepime x 1-7/15/06 . Outpatient medications: Azithromycin 500mg PO qD Flagyl 500mg IV tid (started [**7-24**]) Fluconazole 100mg IV qD (started [**7-26**]) Ganciclovir 150mg IV bid (started [**6-23**]) Bactrim DS 1 tab qD Paromycin 750mg PO tid Metoprolol 25mg PO bid SSI Glutamine 10gm packet tid c meals Nystatin 10mL PO tid Discharge Medications: Not applicable Discharge Disposition: Expired Discharge Diagnosis: AIDS/HIV Pseudomonas sepsis diarrhea: crytopsoridia, C.Difficile Discharge Condition: expired Discharge Instructions: none Followup Instructions: none Completed by:[**2150-8-13**]

[ "008.69", "078.5", "584.5", "133.0", "008.45", "787.91", "995.92", "284.8", "578.1", "007.4", "112.0", "038.43", "042", "261", "112.84", "785.52" ]

icd9cm

[ [ [] ] ]

[ "99.07", "99.04", "00.17", "41.31", "99.15", "99.05" ]

icd9pcs

[ [ [] ] ]

10416, 10425

6196, 9717

342, 349

10534, 10543

3645, 6173

10596, 10631

3257, 3290

10377, 10393

10446, 10513

9743, 9743

10567, 10573

3321, 3626

10070, 10354

260, 304

377, 1465

9768, 10046

1487, 3102

3118, 3241

29,892

147,678

31957

Discharge summary

report

Admission Date: [**2113-9-20**] Discharge Date: [**2113-9-28**] Date of Birth: [**2087-11-1**] Sex: M Service: PLASTIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5667**] Chief Complaint: left hand crush injury Major Surgical or Invasive Procedure: 1. Repair of index finger laceration with complex volar wound closure of central and middle portion of finger over the metacarpophalangeal joint and proximal phalanx, repair of long finger proximal volar laceration with complex wound closure, repair of ring finger complex volar laceration 2. Repair of extensor surface laceration with complex wound closure 3. Repair of flexor digitorum profundus of the index finger 4. Repair of flexor digitorum superficialis of the index finger 5. Digital radial artery exploration of the index finger 6. Repair/revascularization of the radial artery of the long finger with vein graft 7. Repair/revascularization of the radial artery of the ring finger with vein graft 8. Harvest of vein graft x2 9. Extensor tendon exploration 10. Digital nerve exploration of the index, long, and ring fingers, on both ulnar and radial surfaces 11. Closed reduction, percutaneous pinning of the left second finger 12. Closed reduction percutaneous pinning of the left long finger 13. Closed reduction percutaneous pinning of the ring finger 14. Complex wound closure 20 sq cm History of Present Illness: Asked to consult on this 25 yo otherwise healthy RHD laborer with a work-related L hand crush injury.His left fingers were swept into an industrial pressing machineapprox 2 hours PTA resulting in open wound with deformity. He was brought to [**Hospital1 18**] stable for further eval. + left hand pain,+numbness/tingling left hand Past Medical History: none Social History: factory worker No tobacco/No EtOH/No Drugs Family History: NC Physical Exam: General: no acute distress,Awake,Alert,& Oriented x 3 HEENT: normocephalic, atraumatic, anicteric, neck supple, no masses Heart: regular rate and rhythm, without murmurs, rubs, or gallops Lungs: clear to auscultation bilaterally, no wheezes, rales, or rhonchi Abdomen: soft, nontender, nondistended, +bowel sounds Left upper extremity:complex soft & bony tissue deformity at basal P1 level of Left IF/MF/RF. His fingertips appear perfused. His soft tissue is split apart at the web space level spanning the involved digits. His sensation is decreased along the ulnar aspect of IF, bilateral MF, and radial aspect of RF. His extensor mechanism is at least partially disrupted at P1 level of IF/MF. He has bony fractures with displacement of the IF/MF/RF. The remainder of his hand including his thumb and wrist appear atraumatic and are nontender. Pertinent Results: [**2113-9-25**] 04:00AM BLOOD WBC-9.7 RBC-3.14* Hgb-9.5* Hct-26.9* MCV-86 MCH-30.3 MCHC-35.4* RDW-17.2* Plt Ct-284 [**2113-9-21**] 04:30AM BLOOD WBC-15.9* RBC-4.52* Hgb-13.7* Hct-40.5 MCV-90 MCH-30.3 MCHC-33.8 RDW-12.3 Plt Ct-327 [**2113-9-25**] 04:00AM BLOOD Plt Ct-284 [**2113-9-21**] 04:30AM BLOOD Plt Ct-327 [**2113-9-25**] 04:00AM BLOOD Glucose-123* UreaN-7 Creat-1.0 Na-136 K-4.2 Cl-101 HCO3-30 AnGap-9 [**2113-9-22**] 03:00AM BLOOD Glucose-122* UreaN-11 Creat-0.9 Na-140 K-3.9 Cl-105 HCO3-28 AnGap-11 [**2113-9-25**] 04:00AM BLOOD Calcium-8.1* Phos-4.3 Mg-2.2 [**2113-9-22**] 03:00AM BLOOD Calcium-8.1* Phos-4.0 Mg-2.1 LEFT HAND (AP, LAT & OBLIQUE)[**2113-9-20**] 4:45 PM: Comminuted fractures with marked posterior displacement of the distal fragments involving the second through fourth proximal phalanges. No intra-articular extension is identified. Associated subcutaneous emphysema and soft tissue injury consistent with near- amputation. Brief Hospital Course: The patient was NAD, A/Sx3 remained on proper prophylaxis and his pain was well controlled throughout his hospital stay. He maintained good PO and UOP as well. Surgery: On [**9-21**] the patient was taken to the OR for left hand exploration, k-wiring and vascularization of 2,3, 4th, digits, specifics are described above. The EBL was 200cc, there were no complications and the patient remained stable throughout and in post-operatively. Post operative course: The patient remained stable and pain was controlled throughout his stay, he was anemic 2/2 blood loss and the decision to transfuse was made on [**9-22**], a RIJ was placed and he was transfused 1 unit. He had frequent hand checks including doppler, turgor, finger sticks/cap refill, and never did he have compromised arterial flow. His long finger had a few days of increased swelling, but no severe congestion ever developed. His hand remained elevated and splinted Dispo: Pt was d/c'd on POD 7 with VNA services and 1 week follow up. Medications on Admission: none Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Tablet, Chewable(s) 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever/pain. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 5. Duricef 500 mg Capsule Sig: One (1) Capsule PO twice a day for 7 days. Disp:*14 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Left hand crush injury in work related accident Discharge Condition: good Discharge Instructions: 1. Wound: You will be visited by a nurse daily to change your dressings and evaluate your hand. You should not bear any weight on that hand. Keep the dressing on at all times, and keep dry when you wash/shower. Also, keep the hand elevated throughout the day. 2. Medication: Please take the antibiotics as prescribed. You were given pain medicatin that may make you drowsy so no driving while on it. Also, it may make you constipated so you may take an over the counter laxative such as docusate for this. Please also continue to take the aspirin as prescibed. You may resume your home drug regimen. 3. Please follow up as directed. 4. Please call your doctor or come to the emergency room if you experience any of the following: Fever >101.4, chills, uncontrolled pain, cold/blue finger, increased redness/warmth/swelling/drainage/pus or any other symptoms that are worrisome to you. Followup Instructions: 1. Please follow up in the hand clinic of plastic surgery this coming Tuesday. Please call ([**Telephone/Fax (1) 7138**] to make an appointment. Completed by:[**2113-10-5**]

[ "882.2", "927.3", "955.7", "E849.3", "293.0", "780.6", "E919.8", "958.7", "285.9", "816.12", "903.5" ]

icd9cm

[ [ [] ] ]

[ "99.04", "79.14", "82.01", "04.04", "39.56", "82.44", "38.93", "99.15", "86.73", "86.59" ]

icd9pcs

[ [ [] ] ]

5375, 5433

3786, 4789

337, 1450

5525, 5532

2809, 3763

6465, 6641

1916, 1920

4844, 5352

5454, 5504

4815, 4821

5556, 6442

1935, 2790

275, 299

1478, 1812

1834, 1840

1856, 1900

27,588

151,888

4962

Discharge summary

report

Admission Date: [**2140-6-3**] Discharge Date: [**2140-6-17**] Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 552**] Chief Complaint: diarrhea Major Surgical or Invasive Procedure: 1. TTE [**2140-6-6**] " IMPRESSION: Normal global and regional biventricular systolic function. Mild aortic stenosis and regurgitation. At least moderate mitral regurgitation. Moderate pulmonary artery systolic hypertension. Biatrial enlargement." 2. Multiple CXRs 3. BLE US 4. R PICC placement, removal 5. L wrist Xray -[**2140-6-14**] "1. No acute fracture. 2. Widening of the scapholunate interval is compatible scapholunate ligamentous injury. 3. Severe degenerative changes of the STT and first CMC joints. Apparent collapse of the trapezoid and trapezium as described." History of Present Illness: 84 y/o F with CAD s/p stents, PAF on coumadin, HTN transferred from OSH for further management of C.diff sepsis and volume overload. The patient underwent elective left total hip replacement at [**Hospital1 2025**] on [**4-27**]. She developed diarrhea while at rehab post-operatively, however it is unclear from outside records whether this occurred in the setting of antibiotic therapy. After discharge from rehab she was prescribed PO flagyl and immodium for persistent diarrhea. She was subsequently admitted to [**Hospital3 **] on [**5-21**] for dehydration. She was treated with PO vancomycin, PO flagyl, and IV flagyl for C. diff colitis (positive toxin assay on [**5-21**]), and IVF for acute renal failure. WBC was [**Numeric Identifier 20597**]. Abd/pelvis CT on [**5-23**] revealed diffuse colonic wall thickening but no bowel obstruction, and moderate ascites with generalized mesenteric inflammation/edema. She was transfused on [**5-23**] U FFP on [**5-24**], and 1 U PRBC and 3 U FFP. She was loaded with amiodarone for AFib. Right IJ CVC was placed on [**5-26**] for massive volume resuscitation and pressors (it appears she received neosynephrine f/b dopamine prior to transfer) in the setting of hypotension. She was then treated with albumin and lasix. ABG the morning of transfer 7.17/73/81/26. At the time of transfer, she was receiving dopamine 2 mcg/kg/min and non-invasive mask ventilation, both of which were discontinued upon arrival. . ROS: + unproductive [**Month/Year (2) **], dry mouth, nausea with food/drink - fever, chills, sweats, HA, dizziness, lightheadedness, CP, SOB, vomiting, abd pain, hematochezia, melena, calf pain Past Medical History: CAD s/p stenting of LCx and RCA per OMR cath report [**12-4**] PAF LE DVT HTN hyperlipidemia urinary incontinence osteoporosis s/p ORIF and LTH s/p hepatobiliary surgery s/p hysterectomy s/p cholecystectomy s/p RTK x 1, LTK x 2 Social History: Lives in [**Location 7658**], MA with husband; 3 children live outside of MA; no ETOH, tobacco Family History: Non-contributory Physical Exam: PE - V/S: T99.2 HR 75 BP 120/66 RR 17 O2sat 99% on 4 L NC CVP 6 cmH20 GEN: Awake, alert elderly female comfortable HEENT: R > L pupil, reactive; sclera anicteric; very dry mucous membranes with crust-covered tongue; NECK: no bruit CV: irreg irreg nl S1S2 IV/VI cres-decres murmur at base, III/VI diastolic murmur at apex PULM: diffuse rhonchi, decr. breath sounds at bases, no wheezes ABD: distended, soft, NT +BS, no rebound, guarding EXT: warm, dry; trace pitting edema NEURO: A+O x 3 Pertinent Results: Admit EKG: EKG: AFib HR 73, LAD, nl intervals, diffuse TW flattening, unchanged c/w prior exam [**2140-5-31**] . Micro: C. diff toxin positive - [**5-21**] . Imaging: [**5-23**] OSH CT abd/pelvis - 1. Diffuse colonic wall thickening but no bowel obstruction. 2. Moderate ascites with generalized mesenteric inflammation/edema. 3. Surgical clips in the porta hepatis with some [**Last Name (LF) **], [**First Name3 (LF) **] represent reflux from the GI system. [**5-23**] and [**5-25**] bilateral LE duplex U/S - negative for DVT [**5-25**] V/Q - low prob for PE [**6-3**] CXR - bilateral pulmonary opacities, read pending . 149 115 37 --------------< 101 3.3 29 1.1 CK: 15 MB: 4 Trop-T: 0.10 Ca: 9.0 Mg: 2.0 P: 2.9 ALT: 9 AST: 12 LDH: 114 [**Doctor First Name **]: 42 Lip: 56 AP: 118 Tbili: 0.6 Alb: 2.9 TSH:4.4 Vit-B12:831 Folate:13.2 proBNP: [**Numeric Identifier **] . Iron: 21 calTIBC: 81 Ferritn: 518 TRF: 62 . WBC: 11.8 HCT: 30 PLT: 215 N:89.5 Band:0 L:6.6 M:3.6 E:0.2 Bas:0.1 . Ret-Aut: 0.9 . PT: 17.2 PTT: 36.9 INR: 1.6 . Echo: The left atrium is mildly dilated. The left atrial volume is markedly increased (>32ml/m2). Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) 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 mild aortic valve stenosis (area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. Mild aortic stenosis and regurgitation. At least moderate mitral regurgitation. Moderate pulmonary artery systolic hypertension. Biatrial enlargement. Brief Hospital Course: 84 y/o F with CAD s/p stents, PAF on coumadin, HTN transferred from OSH for management of C. difficile septic shock. She was profoundly volume overloaded but stable off pressors and non-invasive ventilation. . #C. diff - she was no longer septic upon arrival. Per ID recs, pt was treated w po Vancomycin, last day [**6-17**]. Pt does have diarrhea still but was seen by ID again, who felt that it is unlikely to be from Cdiff and recommended discontinuing vanc on [**6-17**]. Cdiff X3 on [**6-5**] and [**6-16**] have been neg. Diarrhea may be secondary to tube feeds. Should pt have any change such as fever, abdominal pain, worsening diarrhea, please check Cdiff toxins again . # CHF: Came in with acute on chronic diastolic CHF and profound fluid overload. Echo showed nl LVEF but Mild AR, mod MR, mod TR. Pt was placed on lasix gtt and diuresed aggressively. when transferred to the floor, pt did not have any edema on exam, she still had persistent but improving pleural effussions, and lasix had to be briefly held, as by labs she appeared volume contracted. Pt has now been restarted on lasix 20mg po BID, which should be adjusted based on clinical status. Please follow BMP periodically to ensure pt is not developing acute renal failure #AFib - In MICU, she developed afib with RVR. Received 5 IV lopressor then had HR in the 30s transiently. Pt had one other episode of transient asymptomatic bradycardia during sleep noted on tele. Pt was loaded with IV amio in MICU and now on amio 200mg QD. Oral metoprolol has slowly been titrated and pt has tolerated it well. On floor, pt's HR remained in 100-110's at baseline w/ occ 130-140's w/ actitivty. Metoprolol should be continued to be titrated as long as bp allows. Pt has both Afib and hx of DVT and is being transitioned w lovenox to coumadin. Coumadin was increased from 2 to 3mg QD on [**6-15**], INR yesterday was still 1.2. Please titrate coumadin for a goal INR of 2.0-3.0 and discontinue lovenox when INR therapeutic. . # LOWER GI BLEED: In the MICU, the patient was noted to have a small amount of blood clots and liquid blood in the rectal tube. Lovenox and coumadin were temporarily held, although aspirin was continued. NG lavage was performed and was negative. The GI service was consulted and deferred a colonoscopy. Ultimately, it was felt that her bleeding may have been from the rectal tube. Received 1u pRBC on [**6-8**]. Hct stable thereafter without any further GIB. Pt was restarted on lovenox and coumadin on [**6-11**]. Pt's H/H remained stable on the floor but gradually drifted down from 25 to 22. Given that pt has CAD, it was decided to transfuse 2 units pRBC the day before transfer to Acute Rehab hospital. Pt's HCT appropriately rose from 22 to 30 on day of discharge. #[**Name (NI) **] - Pt has productiver [**Name (NI) **] w/ whitish sputum but has remained afebrile w nl WBC. CXR continues to show stable B pleural effussions. Pt will need ipratropium (avoid albuteral given afib) nebs and frequent suctioning to clear secretions. Pt was needing 2L oxygen and sats were 96-99% on it. #CAD - many risk factors, but low clinical suspicion for an event. Trop only mildly elevated. She was on ASA. Lisinopril was discontinued to allow uptitration of metoprolol and should be started when bp allows. . #Hx of HTN - pt's bp gradually improving, was borderline in the 90-100's before. Pt on metoprolol and lasix. Once metoprolol has been titrated, if bp allows, ACE-I should be started given CAD . # Contact: [**Name (NI) **] [**Name (NI) 20598**], husband, [**Telephone/Fax (1) 20599**] (home) PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 1983**] . # Code: DNR DNI . Medications on Admission: Meds (on admission to OSH): coumadin 2.5 mg daily detrol [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 20600**] benazapril imdur toprol XL tricor HCTZ . Meds (on transfer): flagyl 500 mg PO q8 flagyl 500 mg IV q8 vanco 250 mg PO QID digoxin 0.25 mg PO daily amiodarone 400 mg PO daily albumin 25% 25 g IV q6 cholestyramine 1 packet QID dopamine gtt lasix 60 mg IV daily heparin 5000 U TID dilaudid 1 mg IV q4 lactinex reglan 10 mg IV q6 protonix 40 mg IV q12 ambien 5 mg qHS tylenol PRN . All: PCN Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed: to inguinal region. 3. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed: for sleep. 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever>101. 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. 6. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q4H (every 4 hours). 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed: for wheezing, sob, [**Last Name (Prefixes) **]. 12. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day. 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Cdiff colitis Anemia Atrial Fibrillation Hx diastolic heart failure Moderate MR CAD s/p stents Hx of L LE DVT DJD Hx of knee/hip replacements Hx of osteopenia Hx of Rheumatic Fever Hx of HTN Hx of Urge incontinence Discharge Condition: Good Discharge Instructions: You were admitted to this hospital from another hospital because you had severe infection w/ C.diff colitis. You were given fluids and developed fluid overload. You were admitted to the ICU and diuretics were given to remove the fluid. You were seen by ID and they decided to treat you with oral vancomycin. Your therapy is complete on [**6-17**] and although you are still having some diarrhea, it is thought to not be due to persistent infection by ID. Should you notice worsening or bloody diarrhea, abdominal pain, or fevers/chills, please return to ED You have atrial fibrillation and we have been adjusting medications to control your heart rate. You are also anemic. At one point, you did have some bleeding due to irritation from the rectal tube but your blood count remained stable and you were evaluated by GI doctors who did not want to do a colonoscopy. You did receive 2 units of blood because you were very anemic. Should you notice blood in stool, black stools or active bleeding anywhere, please see a doctor right away You will be working with therapists and nutritionists at the rehab facility Followup Instructions: Please make appointment with the following when pt is discharged from Acute Rehab hospital. Dr. [**First Name (STitle) 572**], PCP, [**Last Name (NamePattern4) **]: [**Telephone/Fax (1) 1983**], fax [**Telephone/Fax (1) 20601**], Address: [**Last Name (NamePattern1) 10357**], Suite 8E, [**Location (un) 86**], [**Numeric Identifier 718**] Dr, [**Name (NI) 20602**], Cardiologist, Ph:[**Telephone/Fax (1) 8543**] Fax [**Telephone/Fax (1) 20603**]. Address: [**Street Address(2) 20604**], [**Location (un) 86**], [**Numeric Identifier 8542**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

11067, 11139

5605, 9342

226, 805

11398, 11405

3426, 5582

12565, 13111

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11429, 12542

2919, 3407

178, 188

833, 2506

2528, 2758

2774, 2870

27,261

194,743

46419+58910

Discharge summary

report+addendum

Admission Date: [**2170-11-19**] Discharge Date: [**2170-11-24**] Date of Birth: [**2092-4-18**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5018**] Chief Complaint: R sided weakness, slurred speech Major Surgical or Invasive Procedure: IV TPA History of Present Illness: Pt. is a 78 year old with hx of CAD s/p stenting, HTN, hyperlipidemia, who presents with acute onset R sided weakness, slurred speech, and a fall. Code Stroke called at 12:31, Neurology at the bedside at 12:35. Daughter reports that she saw pt. at 10 AM before she got in to bed, and she was in her USOH. She heard her fall at 11:30 and rushed in to the bedroom. She found her lying across the door to her bedroom. She asked her what had happened, and she said "I don't know, I just fell." She asked how she fell, and she said "I don't remember." Daughter felt that her right hand was limp, the right side of her face was drooping, and she speech was slurred. She complained that the right side of her face "felt funny." Pt. reports that she was watching the Red Sox game and was feeling normal. She got up to go to the bathroom at 11:30. She doesn't think anything was wrong when she first got up. She describes that while she was walking she suddenly felt that she was "feeling a little different" and like she was going to fall. She says that "my legs felt like they weren't on my body." She's not entirely sure why she fell, and is unclear whether she lost consciousness for a minute. Afterwards she also noticed that her arm was weak, and that her right arm and leg "didn't exactly feel the same." She agrees her speech was slurred. She is pretty sure that these symptoms started while she was walking to the bathroom. On arrival to the ED they confirmed R facial droop and R hemiparesis. Code stroke was called. CT showed no acute signs of infarct, but CTA showed a cut off at P2. After discussing risks and benefits of tPA, and confirming that she had no contraindications to tPA, she received an IV bolus at 2:07. Her case was discussed with Dr. [**First Name (STitle) **] from Neurosurgery, who felt that she was not an iAtPA candidate as a P2 lesion was not likely accessible via angiography and risk of perforation was too high. Past Medical History: CAD s/p stenting HTN hyperlipidemia diverticulosis, diverticulitis renal a. stenosis s/p ccy, s/p hysterectomy peptic ulcer, gastritis Social History: lives in SC, here visiting her daughter, no tobacco, no EtOH Family History: sister had a stroke in her early 80s, brother with CAD, HTN Physical Exam: T- BP- 177/83 HR- 99 RR- 24 O2Sat- 98% on RA Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, no carotid or vertebral bruit Back: No point tenderness or erythema CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no edema 1a. Level of Consciousness: 0 1b. LOC questions: 2 1c. LOC commands: 0 2. Best gaze: 0 3. Visual: 2 4. Facial palsy: 1 5a. Motor arm, left: 0 5b. Motor arm, right: 2 6a. Motor leg, left: 0 6b. Motor leg, right: 2 7. Limb ataxia: 0 8. Sensory: 2 9. Best language: 0 10. Dysarthria: 1 11. Extinction and inattention: 0 NIHSS = 12 Neurologic examination: Mental status: Awake and alert, cooperative with exam, normal affect. Attentive, relays full history. Speech is fluent with normal comprehension and repetition; names 3 objects on card (glove, key, chair). No dysarthria. Reads R side of card well, not left. Cranial Nerves: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. + R homonymous hemianopsia. Extraocular movements intact bilaterally, no nystagmus. Sensation diminished to light touch V1- V3 on R. + R UMN facial droop. Hearing intact to finger rub bilaterally. Palate elevation symmetrical. Sternocleidomastoid and trapezius normal bilaterally. Tongue midline, movements intact Motor: Normal bulk bilaterally. Tone normal. No observed myoclonus or tremor. + R pronator drift [**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF R 3 4- 4 5- 4 4- 5 4 4- 4+ 4+ 5 4 5 L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 Sensation: diminished to light touch in R hemibody (just barely feels normal touch on R side, "less than 50%" compared to left) Reflexes: +2 and symmetric throughout. Toes downgoing bilaterally Coordination: finger-nose-finger normal on L, limited on R [**2-23**] weakness Gait: not assessed Pertinent Results: Na:142 K:3.8 Cl:104 TCO2:27 Glu:92 BUN 20 Cr 1.0 WBC 5.3 Hgb 12.7 Plt 229 Hct 36.8 MCV 92 PT: 12.2 PTT: 22.4 INR: 1.0 EKG ([**2170-11-19**]): Sinus rhythm. Non-specific ST segment changes. Imaging HEAD CT ([**2170-11-19**]): There is no evidence of hemorrhage, masses, mass effect, edema or infarction. HEAD/NECK CTA ([**2170-11-19**]): The vertebral arteries and their major branches in the neck are patent with diffuse atherosclerotic disease noted in the proximal basilar artery that does not cause significant stenosis. There is an abrupt cutoff of the P2 segment of the left PCA. CT PERFUSION ([**2170-11-19**]): There is increased transit time in the left PCA distribution. The blood volume map is within normal limits. IMPRESSION: 1. There is ischemia along the territory of the left posterior cerebral artery with an abrupt cutoff at the P2 segment. MRI BRAIN ([**2170-11-20**]): There are multiple areas of T2 and FLAIR hyperintensity with corresponding decreased diffusion in the left thalamus, temporal and occipital lobes as well as the both cerebellar hemispheres. The larger lesions measure approximately 2 cm in the left thalamic region, and 6.5 x 1.8 cm in the left temporal-occiiptal lobe with and scattered subcentimeter foci throughout the cerebellum noted. Susceptibility is seen in the left thalamic lesion, consistent with hemorrhagic component of the infarct. There is a small amount of edema and mass effect, but without shift of normally midline structures. MRA BRAIN ([**2170-11-20**]): Thre is a moderate stenosis of the basilar artery, a few millimeters above the junction with the vertebral arteries (1, 405), without evidence of aneurysm or occlusion in the visualized arteries. IMPRESSION: Multiple areas of acute infarction, with hemorrhagic conversion in the left thalamic region, as noted above, consistent with embolic phenomenon within the posterior circulation. CXR ([**2170-11-20**]): Generally widened and elongated thoracic aorta including innominate artery prominence. Borderline heart size but no evidence of acute CHF or infiltrates. THREE VIEWS OF THE RIGHT SHOULDER ([**2170-11-20**]): Study is limited. No definite fracture is seen. AC joint is intact. Glenohumeral joint is intact. Evaluation of the lungs is better assessed on the dedicated chest radiograph. IMPRESSION: No definite fracture on this limited study. ECHO ([**2170-11-21**]): The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler, but there is premature left atrial appearance of bubbles with cough (clip #[**Clip Number (Radiology) **]) c/w a patent foramen ovale. Overall left ventricular systolic function is normal (LVEF>55%). There are extensive simple atheroma in the arch and descending thoracic aorta to 40cm from the incisors. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Patent foramen ovale. Extensive simple plaque in thoracic aorta. MRV PELVIS FINDINGS ([**2170-11-22**]): The dynamic gadolinium sequences, 2D time-of-flight sequences, and FIESTA sequences demonstrate no evidence of deep venous thrombosis. There is conventional arterial and venous pelvic vascular anatomy. Patient is status post hysterectomy. There is a Foley catheter in place. Remaining visualized pelvic organs and soft tissue structures are within normal limits. Bone marrow signal within the visualized osseous structures is normal. IMPRESSION: No evidence of deep venous thrombosis. Brief Hospital Course: Pt. is a 78 year old with a history of HTN, hyperlipidemia, who presented with acute onset of R hemiparesis and R hemisensory loss at 11:30 on [**2170-11-19**]. Her NIHSS is 12, an on exam she had a R hemiparesis (3-4/5 in UMN pattern, arm = leg), R hemisensory loss, R hemianopsia, and R UMN facial droop. On imaging she had a left P2 cut off, which would correlate with her deficits. Given that she was within the 3 hour time window and had no contraindications, iVtPA was administered. She was admitted to the ICU for close monitoring. She remained stable for 24 hours and was transferred to the floors. The patient was admitted to neurology ICU for close monitoring s/p intravenous TPA administration. Initial home anti-hypertensives were held, goal BP's <185 systolic and <105 diastolic and she was written for PRN labetalol to achieve this goal as needed. Avoided instrumentation (foley, arterial puncture, NGT) x 24 hrs. No antiplatelet or anticoagulants x 24 hrs. Initial CT post TPA was without hemorrhage. MRI DWI suggested an embolic distribution with left basal ganglionic/thalamic, left medial parietal, and bilateral cerebellar hemispheric infarcts. She had no history of atrial fibrillation to suggest a proximal source, but a TTE revealed evidence of atheromas in the aschending aorta and a patent foramen ovale. Given the pfo and that the patient had presented recently with bilateral leg swelling and a positive d-dimer, there was concern for paradoxical embolus as well. Bilateral lower extremity ultrasound at that time was negative for DVT. Thefore, were performed an MRV of the pelvis on this admission to further rule out this possibility. Given the findings consistent with embolic disease and the possible source of atheroma in the aorta, we initiated coumadin without a heparin bridging. Plavix, which was initially resumed, was then discontinued given the increased risk of hemorrhage on both medications and the prolonged time since her cardiac stenting. The patient was risk stratified. She came in on zetia, which was discontinued and replaced with lipitor, given the need for more potent lipid-lowering therapy (LDL 138). Her A1C was 5.9. The patient had had several low grade fever overnight while in the hospital, but a fever work up including UA, CXR and pending blood cultures were unrevealing. She was afebrile on the day of discharge. The patient also complained of right arm pain that was thought to be related to her fall with the acute stroke. Shoulder and elbow plain films were unrevealing for fracture. By the day of discharge, the patient had made strides in gaining strength in her right side, which was generally 4-5/5 in strength. (However, deltoid strength was difficult to assess given her discomfort in the right arm.) The patient worked with PT and OT to regain her strength and function. Her right hemisensory loss persisted as did her right right hemianopsia. Her K was 3.0 on the day of discharge; this was repleted orally with 40 mEq KCl. We attempted to contact the patient's primary care physician in [**Doctor First Name 26692**], Dr. [**First Name8 (NamePattern2) 1692**] [**Last Name (NamePattern1) **], regarding her hospital course, but were unable to get through by phone. Medications on Admission: amlodipine 10 mg QD ASA 81 mg QD- recommended by Dr. [**Last Name (STitle) 2961**] on [**11-14**], hasn't started Plavix 75 mg QD Zetia 10 mg QD Toprol XL 100 mg QD Nitrodur 0.4 mg/hr QD NTG 0.4 mg SL PRN Protonix 40 mg QD Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once Daily at 16): Please dose the medication to an INR [**2-24**]. Continue to check the INR once daily until at a therapeutic level ([**2-24**]). 5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain, t> 100.4. 6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 8. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual once a day as needed for chest pain. 9. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Cerebral Infarction Discharge Condition: Stable. The right side was generally 4-5/5 in strength. (However, deltoid strength was difficult to assess given her discomfort in the right arm.) Has right hemisensory loss to soft touch and a right right hemianopsia. Discharge Instructions: Please take your medications as prescribed and follow up with your appointments as scheduled. You have had a stroke. It is important that you work with physical and occupational therapy so that you regain strength and function. We have started you on coumadin, a blood thinning medication, in order to prevent further strokes. Please continue to check the INR daily. The coumadin should be dosed such that the INR is kept in a range between 2 and 3. We have resumed your amlodipine, but have continued to hold your Toprol XL 100 mg QD and Nitrodur 0.4 mg/hr QD. These medications may be restarted in the near future as her blood pressure and heart rate tolerate. Followup Instructions: Please arrange to follow up with the [**Hospital3 **] [**Hospital 4038**] Clinic at ([**Telephone/Fax (1) 2528**] in the next 2-4 weeks with Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **]. When you return to [**Doctor First Name 26692**], you should schedule follow up with your primary care physician, [**First Name8 (NamePattern2) 1692**] [**Last Name (NamePattern1) **], at [**Telephone/Fax (1) 98614**]. [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**] Name: [**Known lastname **],[**Known firstname 3485**] Unit No: [**Numeric Identifier 15753**] Admission Date: [**2170-11-19**] Discharge Date: [**2170-11-24**] Date of Birth: [**2092-4-18**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3326**] Addendum: The patient was about to go to rehab on [**11-23**] but had a temperature of 100.7 and a heart rate of 111, with a systolic blood pressure of 160 manually. She thus remained in the hospital overnight and had a chest xray and UA that were negative for signs of infection; blood cultures were preliminarily negative, but urine grew >100,000 enterococcus. She was started on augmentin for a 7 day course at the time of discharge. She was feeling well and in good spirits. Discharge Disposition: Extended Care Facility: [**Hospital6 41**] - [**Location (un) 42**] [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 3327**] Completed by:[**2170-11-24**]

[ "E934.4", "434.11", "414.01", "V45.82", "272.4", "401.9", "440.1", "431", "599.0" ]

icd9cm

[ [ [] ] ]

[ "99.10" ]

icd9pcs

[ [ [] ] ]

15415, 15623

8435, 11689

352, 360

13044, 13267

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2604, 2666

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13001, 13023

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279, 314

388, 2350

3662, 4622

3399, 3646

3384, 3384

2372, 2509

2525, 2588

20,480

126,209

9612

Discharge summary

report

Admission Date: [**2169-12-29**] Discharge Date: [**2170-1-15**] Date of Birth: [**2125-3-6**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1781**] Chief Complaint: left ovarian remnant Major Surgical or Invasive Procedure: 1. Examination under anesthesia, exploratory laparotomy, lysis of adhesions, left ureterolysis, resection of ovarian remnant from the left pelvic sidewall, resection of ovarian remnant from the right pelvic sidewall, rigid proctosigmoidoscopy. 2. External iliac artery arteriotomy primary closure of iatrogenic laceration of external iliac artery. 3. Cystoscopy. 4. Left ureteral stent placement. 5. Right lower extremity 4-compartment fasciotomies. 6. Exploration of right groin, thrombectomy of right common femoral artery, superficial femoral artery, and profunda femoral artery, with bovine patch angioplasty History of Present Illness: This is a 44 year old female who is about to undergo an exploratory laparotomy and excision of left ovarian mass. The GYN/Onc service has requested a preoperative ureteral stent placement to aid with their dissection. The patient has signed a consent form saying she understands the risks and benefits involved with this procedure and wishes to proceed. Past Medical History: Past Medical History: - endometriosis - Ulcerative Colitis - asthma - allopecia Social History: SHx: single, never married, no kids, lives with her sister and 4 dogs, working on her 2nd graduate degree in regulatory affairs (she works in quality control with a company that makes surgical equipment). Quit tobacco 8 years ago, occ etoh, no drugs. Family History: FamHx: CAD in both parents, 3 sibs all healthy, no strokes, seizures. 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, surgical incision C/D/I EXT: rle - palp fem, [**Doctor Last Name **], pt, dp / fasciotomy surgical site wit vac / slight edema with slight erythema of RLE. lle - palp fem, [**Doctor Last Name **], pt, dp Pertinent Results: [**2170-1-13**] WBC-12.6* RBC-3.36* Hgb-10.1* Hct-29.5* MCV-88 MCH-30.0 MCHC-34.2 RDW-14.7 Plt Ct-753* [**2170-1-13**] PT-12.9 PTT-27.5 INR(PT)-1.1 [**2169-12-30**] Fibrino-158 [**2170-1-13**] Glucose-102 UreaN-12 Creat-0.8 Na-133 K-4.3 Cl-100 HCO3-23 AnGap-14 [**2170-1-13**] Calcium-8.9 Phos-4.5 Mg-1.9 [**2170-1-11**] Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014 [**2170-1-7**] 8:02 PM CT HEAD W/ & W/O CONTRAST HISTORY: Mental status change, thrombectomy and right lower extremity fasciotomy. NONCONTRAST HEAD CT: There are no comparisons. There is no intracranial hemorrhage, shift of normally midline structures, or mass effect. The [**Doctor Last Name 352**]- white matter differentiation remains intact. There is no evidence of a major vascular territorial infarct. There is no hydrocephalus. There is slight asymmetry of the occipital horns of the lateral ventricles, of uncertain significance. There is mucosal thickening within both maxillary sinuses. There is mucosal thickening within the sphenoid sinuses, with air-fluid levels. There is minimal mucosal thickening within the ethmoid air cells. IMPRESSION: 1. No intracranial hemorrhage or mass effect. 2. Sinus disease as described above [**2170-1-11**] EEG Study OBJECT: R/O EPILEPSY. FINDINGS: ABNORMALITY #1: A single sharp transient was seen in stage II sleep from the left anterior sylvian to mid-temporal region. BACKGROUND: Was a posterior 11 Hz rhythm that attenuated to eye opening. HYPERVENTILATION: Was contraindicated. INTERMITTENT PHOTIC STIMULATION: Was contraindicated. SLEEP: The patient drowsed frequently and progressed to stage II sleep on several occasions without further abnormalities seen other than Abnormality #1 above. CARDIAC MONITOR: Showed a tachycardia at times up to 120 bpm. IMPRESSION: Abnormal awake and light sleep EEG due to a single isolated sharp transient from the left anterior sylvian to mid-temporal region suggestive of an epileptiform abnormality. A repeat study with minisphenoidals may be of further diagnostic benefit to assess this abnormality. No other lateralizing abnormalities were seen. INTERPRETED BY: [**Last Name (LF) **],[**First Name3 (LF) 20**] C. [**2170-1-11**] URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2170-1-11**] URINE RBC-[**12-31**]* WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2 [**2170-1-12**]** WOUND CULTURE (Final [**2170-1-12**]): No significant growth. RADIOLOGY Final Report [**2170-1-10**] 1:21 PM UNILAT LOWER EXT VEINS RIGHT CLINICAL DETAILS: Lower limb edema, evaluate for DVT. FINDINGS: The right lower limb veins are patent and compressible with normal phasic venous flow and increased venous return with calf compression on color Doppler. The contralateral left common femoral vein is patent with normal venous flow. Some generalized edema noted along the proximal right thigh, no collection. CONCLUSION: No right lower limb deep venous thrombosis. RADIOLOGY Final Report [**2170-1-10**] CHEST (PA & LAT) INDICATION: Rising white blood cell count, question pneumonia. FINDINGS: No consolidations are present. No pleural effusions are present. There is persistent mild elevation of the right hemidiaphragm. Right subclavian catheter has been removed. The cardiac and mediastinal silhouettes are stable. IMPRESSION: No evidence for acute pulmonary disease. [**2170-1-7**] CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST CONTRAST: Oral contrast and 100 cc of IV Optiray contrast administered due to the rapid rate of bolus injection required for this study. CT OF THE ABDOMEN WITH IV CONTRAST: Focal atelectasis is noted at the right lung base. No pleural effusions or pulmonary nodules are identified. The liver, spleen, gallbladder, adrenal glands, right kidney, and pancreas are normal in appearance. A focal hypodensity which is too small to characterize was noted in the superior pole of the left kidney, which is otherwise normal in appearance. There is no hydronephrosis. The bowel is normal, without evidence of bowel wall thickening or dilatation. No free intraperitoneal air is seen. CT OF THE PELVIS WITH IV CONTRAST: There is free fluid noted within the pelvis, which appears simple, and likely represents post-surgical change. Some of this fluid tracks superiorly in the right colic gutter. There is no bowel wall thickening or dilatation of the rectum or distal colon. Foley catheter is seen within the bladder, which is otherwise normal in appearance. Small amount of stranding is noted anterior to the right common femoral vessels, perhaps possibly relating to recent intervention. BONE WINDOWS: No suspicious lytic or sclerotic lesions are identified. CT RECONSTRUCTIONS: Multiplanar reconstructions were essential in delineating the anatomy and pathology. IMPRESSION: 1. Free fluid is noted within the pelvis, which is likely post-surgical. No inflammatory phlegmon or more mature abscess collections are identified. 2. Focal hypodensity within the superior pole of the left kidney, which is too small to characterize. Brief Hospital Course: Ptad mitted on [**2169-12-29**] Pt brought to the OR underwent a procedure for removal of left ovarion remenant. During the procedure there was a complication of laceration of the external iliac artery. Vascular surgery was consulted. They repaired the external artery. Pt had signiciant blood loss. This was repleted. Pt brought to the ICU intubated. On arrival to the ICU. It was noticed that the pt had a swollen / pulseless left leg. Pt brought back to the or for emergent fasciotomy / with thrombectomy. Pt tolerated the procedure well. She was transfered to the ICU in stable condition. Intubated. [**2169-12-30**] - [**2170-1-4**] Pt remained intubated. Lytes replenished / IV antibotics / Foley cath. / SICU monitering / blood transfusions for decrese hct. TPN Anticoagulated with heparin [**2170-1-5**] Pt exctubated Diuresed Pt recieves CT scan for confusion ( neg ) CPK monitered for tissue necrosis Nutrition consult [**2170-1-6**] - [**2170-1-15**] Pt has increase temp. , has complete fever work-up, ID consulted. Pt recieves wound vac for fasciotomy site. Diet is advanced Pt transfered to the VICU in stable condition. Wound vac changed per protocol. [**2170-1-16**] Pt stable for discharge Taking PO / OOB to chair / urinating / pos BM Medications on Admission: - Ventalin - Flovent - [**Doctor First Name 130**] - estradiol Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 7. Metoprolol Tartrate 25 mg Tablet Sig: 1 Tablets PO BID (. 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at [**Hospital6 1109**] - [**Location (un) 1110**] Discharge Diagnosis: 1.Ischemic right lower extremity, status post repair of right external iliac artery transection. 2. Right leg compartment syndrome. 3. Left ovarian mass. 4.Lacerated the external iliac artery 5. Post operative agitation/altered mental status. 6. Post opeerative anemia Discharge Condition: Stable Discharge Instructions: 1. Wound Vac Care / change dressing every 4 days. Vac to be rermoved by Dr [**Last Name (STitle) **] on follow-up. Followup Instructions: Call Dr [**Last Name (STitle) **] office at [**Telephone/Fax (1) 2395**]. Schedule an appointment for 1 week. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] GYN ONC PPS (SB) Date/Time:[**2170-1-31**] 1:15 Completed by:[**2170-1-15**]

[ "614.6", "493.90", "584.9", "958.8", "997.4", "591", "728.88", "998.2", "996.62", "428.0", "736.79", "293.0", "518.5", "285.1", "556.9", "E878.6", "617.1" ]

icd9cm

[ [ [] ] ]

[ "83.09", "65.52", "38.93", "96.72", "39.98", "48.23", "54.59", "99.04", "96.22", "59.02", "38.08", "59.8", "39.31" ]

icd9pcs

[ [ [] ] ]

9715, 9860

7538, 8817

335, 957

10178, 10187

2403, 2939

10350, 10596

1732, 1803

8930, 9692

9881, 10157

8843, 8907

10211, 10327

1818, 2384

275, 297

985, 1341

2948, 7515

1385, 1445

1461, 1716

23,803

148,738

21872

Discharge summary

report

Admission Date: [**2140-8-8**] Discharge Date: [**2140-9-8**] Date of Birth: [**2083-8-1**] Sex: F Service: MED Allergies: Heparin Agents Attending:[**First Name3 (LF) 6114**] Chief Complaint: DKA and painful left knee Major Surgical or Invasive Procedure: [**2140-8-10**]: Incision and Drainage of Left Knee [**2140-8-19**]: Incision and Drainage of Left Knee History of Present Illness: 56 homeless female h/o CAD (cath s/p stentx2 with EF 30%), DMII (no outpt meds) HTN, ?personality disorder who was last hospitalized at [**Hospital1 336**] in [**2136**] for left knee pain and near DKA due to refusal to comply with medical management presented to [**Hospital1 18**] ED in DKA with simultaneous left knee pain. In the ED, the patient was fluid resuscitated 3L NS, started on an insulin drip, and potassium repleted. In the unit, patient further received phos, potassium, and more ivf as well as was continued on insulin drip. Past Medical History: htn, diabetes II, cad with stent x2, inf mi [**2126**], personality disorder, HIT syndrome. Social History: Lives in the Millineum House with 17 yo son, currently homeless. Family History: Non-contributory Physical Exam: 98.6 120/70 84 18 97%RA 195>209>74>154>228 Card: RRR no m/r/g Pulm: CTAB no w/r/c Abd: s/nt/nd BS+ x4 Extremity: Pedal pulses palpable, pt able to move LE on command, SPVPFT<3 secs, Knee incision appears stable and without erythema. Minimal joint effusion noted about the L knee. Pertinent Results: [**2140-8-9**] 03:25AM BLOOD WBC-15.1* RBC-4.16* Hgb-11.1* Hct-33.1*# MCV-80* MCH-26.6* MCHC-33.4 RDW-13.2 Plt Ct-517* [**2140-8-9**] 11:55AM BLOOD Hct-32.3* [**2140-8-9**] 03:25AM BLOOD Neuts-87* Bands-2 Lymphs-6* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2140-8-9**] 03:25AM BLOOD Plt Ct-517* [**2140-8-9**] 03:25AM BLOOD PT-13.4 PTT-27.1 INR(PT)-1.1 [**2140-8-9**] 11:55AM BLOOD Glucose-79 UreaN-24* Creat-0.3* Na-141 K-4.1 Cl-112* HCO3-18* AnGap-15 [**2140-8-9**] 11:55AM BLOOD Calcium-8.9 Phos-1.3* Mg-2.5 [**2140-8-8**] 05:25PM BLOOD %HbA1c-11.7* [**2140-8-8**] 07:04PM BLOOD TSH-0.29 [**Hospital1 18**] Radiologic Studies ([**2140-8-8**]): CXR: Left lower lobe pneumonia. CTA CHEST: No evidence of pulmonary embolism. LEFT KNEE, AP & LATERAL VIEW: There is normal bony mineralization and alignment. No fracture or dislocation. There is a moderate to large suprapatellar joint effusion. No focal bony destruction, lytic or blastic lesions. KNEE JOINT FLUID ([**2140-8-9**]) - Gram stain: 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. [**2140-8-11**] 09:00AM BLOOD WBC-23.5*# RBC-3.80* Hgb-9.8* Hct-29.5* MCV-78* MCH-25.9* MCHC-33.4 RDW-13.3 Plt Ct-408 [**2140-8-12**] 05:20AM BLOOD WBC-19.0* RBC-3.55* Hgb-9.3* Hct-28.2* MCV-79* MCH-26.2* MCHC-33.0 RDW-13.5 Plt Ct-401 [**2140-8-13**] 05:40AM BLOOD WBC-14.6* RBC-3.59* Hgb-9.3* Hct-28.8* MCV-80* MCH-26.0* MCHC-32.4 RDW-12.8 Plt Ct-390 [**2140-8-14**] 05:20AM BLOOD WBC-12.7* RBC-3.68* Hgb-9.5* Hct-30.0* MCV-82 MCH-25.8* MCHC-31.7 RDW-12.9 Plt Ct-444* [**2140-8-15**] 05:05AM BLOOD WBC-14.5* RBC-3.87* Hgb-9.9* Hct-31.6* MCV-82 MCH-25.7* MCHC-31.5 RDW-12.7 Plt Ct-553* [**2140-8-16**] 05:20AM BLOOD WBC-15.7* RBC-4.05* Hgb-10.8* Hct-32.9* MCV-81* MCH-26.7* MCHC-32.8 RDW-12.7 Plt Ct-582* [**2140-8-17**] 05:05AM BLOOD WBC-14.1* RBC-3.90* Hgb-10.4* Hct-31.5* MCV-81* MCH-26.8* MCHC-33.1 RDW-12.7 Plt Ct-578* [**2140-8-18**] 04:48AM BLOOD WBC-13.2* RBC-3.89* Hgb-10.2* Hct-31.4* MCV-81* MCH-26.3* MCHC-32.6 RDW-12.4 Plt Ct-616* [**2140-8-19**] 05:50AM BLOOD WBC-12.2* RBC-3.89* Hgb-10.1* Hct-31.2* MCV-80* MCH-25.9* MCHC-32.2 RDW-12.6 Plt Ct-595* [**2140-8-24**] 05:33AM BLOOD WBC-7.3 RBC-3.46* Hgb-8.8* Hct-28.4* MCV-82 MCH-25.4* MCHC-31.1 RDW-12.8 Plt Ct-549* [**2140-9-2**] 05:30AM BLOOD WBC-7.7 RBC-3.44* Hgb-8.6* Hct-26.9* MCV-78* MCH-25.0* MCHC-31.9 RDW-12.5 Plt Ct-662* [**2140-8-13**] 05:40AM BLOOD Neuts-81.8* Lymphs-11.5* Monos-5.1 Eos-1.3 Baso-0.2 [**2140-8-17**] 05:05AM BLOOD Neuts-78.9* Lymphs-12.8* Monos-6.6 Eos-1.2 Baso-0.4 [**2140-9-1**] 05:10AM BLOOD Neuts-57.4 Lymphs-27.6 Monos-8.4 Eos-5.6* Baso-0.9 [**2140-8-29**] 09:30AM BLOOD Plt Ct-581* [**2140-8-31**] 09:30AM BLOOD Plt Ct-619* [**2140-8-31**] 05:17PM BLOOD Plt Ct-726* [**2140-9-1**] 05:10AM BLOOD Plt Ct-614* [**2140-9-2**] 05:30AM BLOOD Plt Ct-662* [**2140-9-4**] 05:00AM BLOOD Plt Ct-582* [**2140-9-6**] 05:25AM BLOOD Plt Ct-577* [**2140-8-8**] 02:21AM BLOOD Glucose-333* UreaN-35* Creat-0.8 Na-146* K-3.2* Cl-108 HCO3-5* AnGap-36* [**2140-8-11**] 12:45AM BLOOD Glucose-205* UreaN-13 Creat-0.3* Na-136 K-4.3 Cl-105 HCO3-20* AnGap-15 [**2140-8-13**] 05:40AM BLOOD Glucose-193* UreaN-10 Creat-0.3* Na-133 K-4.2 Cl-94* HCO3-26 AnGap-17 [**2140-8-14**] 05:20AM BLOOD Glucose-202* UreaN-7 Creat-0.3* Na-135 K-4.6 Cl-93* HCO3-28 AnGap-19 [**2140-8-16**] 05:20AM BLOOD Glucose-246* UreaN-16 Creat-0.3* Na-133 K-4.4 Cl-91* HCO3-23 AnGap-23* [**2140-8-16**] 05:17PM BLOOD Glucose-264* UreaN-21* Creat-0.4 Na-131* K-4.4 Cl-91* HCO3-23 AnGap-21* [**2140-8-21**] 06:25AM BLOOD Glucose-222* UreaN-21* Creat-0.3* Na-133 K-5.5* Cl-96 HCO3-26 AnGap-17 [**2140-8-23**] 05:56AM BLOOD Glucose-229* UreaN-23* Creat-0.3* Na-132* K-4.5 Cl-91* HCO3-28 AnGap-18 [**2140-8-24**] 05:33AM BLOOD Glucose-229* UreaN-19 Creat-0.3* Na-132* K-4.2 Cl-94* HCO3-29 AnGap-13 [**2140-8-26**] 05:30AM BLOOD Glucose-183* UreaN-23* Creat-0.4 Na-133 K-4.2 Cl-94* HCO3-28 AnGap-15 [**2140-8-29**] 09:30AM BLOOD Glucose-148* UreaN-19 Creat-0.4 Na-137 K-3.9 Cl-96 HCO3-29 AnGap-16 [**2140-9-1**] 05:10AM BLOOD Glucose-172* UreaN-21* Creat-0.4 Na-135 K-4.6 Cl-97 HCO3-26 AnGap-17 [**2140-9-6**] 05:25AM BLOOD Glucose-170* UreaN-29* Creat-0.5 Na-137 K-5.0 Cl-99 HCO3-28 AnGap-15 [**2140-8-8**] 02:21AM BLOOD ALT-14 AST-15 CK(CPK)-51 AlkPhos-192* Amylase-54 TotBili-0.3 [**2140-8-11**] 12:45AM BLOOD Calcium-7.5* Phos-2.2* Mg-2.0 [**2140-8-8**] 02:21AM BLOOD Albumin-3.7 [**2140-8-11**] 07:19PM BLOOD calTIBC-117* VitB12-1732* Folate-9.0 Ferritn-976* TRF-90* [**2140-8-14**] 01:10AM BLOOD %HbA1c-11.1* [**2140-8-10**] 02:15AM BLOOD CRP-28.63* [**2140-8-8**] 02:51AM BLOOD Glucose-363* Lactate-2.7* Na-151* K-3.6 Cl-104 calHCO3-7* [**2140-8-8**] 02:51AM BLOOD Glucose-363* Lactate-2.7* Na-151* K-3.6 Cl-104 calHCO3-7* Brief Hospital Course: 1. Septic Knee: Following admission pt indicated L knee pain, which upon exam did not demonstrate erythema but was positive for joint effusion. Upon tapping the joint ~20cc pus drained with 100K wbc and GPC. Began abx and had serial tap the next day which had 5cc with 60K wbc. Ortho was consulted and took her to the OR to was out the joint [**8-10**]. Ortho followed pt daily and then took her back to the OR on [**2140-8-19**] for 2nd I and D. Pt on Amp and gent for less than 2 days then switched to Ceftriaxone, which she completed a 28 day course via PICC line. Pt encouraged for Physical therapy throughout admission with minimal compliance citing pain issues. Pt refused to participate as long as there was ANY pain in the joint. Explained to pt that some pain is normal and that meds and therapy would reduce these issues, pt still resistant. Physical symptoms as well as lab values improved througout course. 2. DM: Pt arrived at hospital in DKA, insulin drip, iv fluids, and lytes repletd. [**Last Name (un) **] consult placed for care and recs. They stated insulin medically necessary to sustain life & prevent DKA from reoccurring. Pt started on Lantus and HSS. Pt began refusing Lantus despite medical advice and then became agreeable to NPH [**Hospital1 **]. Pt would vasilate between taking NPH as ordered and refusing full dose. Subsequently adequate control was difficult to achieve. Pt has never taken the prescribed NPH dosing while in house, rather she dictates to the nursing staff what she will accept. The medical team advised againest this daily, but she would proceed to take lower than recommended doses. Given that guardianship is a complex and time consuming process, it was determined that compulsory dosing of insulin would only be mandated when an emergency would arise. She ultimately agreed to NPH 8 units twice daily and sliding scale insulin however refused dose titration to improve her glycemic control. 3. Anti-coagulation: Pt reported hx of HIT, documented in OSH records but no labs to back this up. Pt started on Herudin and Coumadin, then d/c'd as pharmacy department provided a new protochol for HIT DVT prophylaxis with fondaparinux 2.5 mg SQ qd. Pt refused all dosings as she believed they would endanger her life. INR was subtherapeutic throughout stay and but pt was OOB frequently. 4. Psych: Pt displayed delirium upon admission which resolved with DKA. Pt then was combative frequently regarding medications and medical status. DKA as well as the I and D of the Left knee were deemed medical emergencies and the pt was txt'd despite protest to save life and limb. Pt has severe misconceptions regarding her diabetes and the actions of medications. She was deemed medically incompetent in regards to medical decision making. Pt was written for Haldol prn but refused each dosing. Guardianship proceedings were initiated on [**2140-8-14**]. Final results pending. Pt needs health care proxy as she is a danger to herself. Pt refused almost all meds every day. Exceptions included Percocet until d/c'd, Senna until percocet d/c'd, NPH and Humalog. At the time of d/c pt agrees to only take her NPH with Humalog sliding scale as detailed and Ibuprophen. Given refusal of all other meds except these, she will be discharged on this regiment. 5. Hyperkalemia: 5.4->4.9, Pt ordered for Potassium Cholride post-operatively, medication was to be held with K or 5.0, pt given dose before lab results returned. Medication was d/c??????d with normalization noted quickly. Medications on Admission: Transfer Meds: Metoprolol 12.5 mg PO BID, Oxacillin 2 gm IV Q6H, Pantoprazole 40 mg PO Q24H, Aspirin 325 mg PO QD, Insulin SC (per Insulin Flowsheet), Senna 1 TAB PO BID, Docusate Sodium 100 mg PO BID, Acetaminophen 325-650 mg PO Q4-6H:PRN, Acetaminophen w/Codeine [**11-27**] TAB PO Q4H:PRN. Discharge Medications: 1. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO tid with meals. 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 3. Insulin NPH Human Recomb 100 unit/mL Syringe Sig: Ten (10) Units Subcutaneous twice a day. 4. Humalog Sliding Scale Pt may take Humalog sliding scale qid prn. Please see attached sliding scale. Discharge Disposition: Extended Care Facility: [**Location (un) **] Manor Discharge Diagnosis: 1. Diabetic Ketoacidosis 2. Septic joint left knee 3. Diabetes Mellitus Type 2 Discharge Condition: Good Discharge Instructions: Please return to emergency department in the event of chest pain, sob, fevers, chills, night sweats. Followup Instructions: Pt to follow up with PCP [**Name Initial (PRE) 176**] 1 month of discharge. Follow up with Ortho team, Dr. [**Last Name (STitle) 57373**] ([**Telephone/Fax (1) 2007**] within 1 week of discharge. Completed by:[**2140-9-8**]

[ "293.0", "V15.81", "V63.2", "707.15", "401.9", "250.10", "276.7", "711.06", "V60.0", "727.00", "041.02", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "81.91", "80.76", "80.16" ]

icd9pcs

[ [ [] ] ]

10561, 10614

6337, 9853

293, 398

10737, 10743

1516, 6314

10892, 11118

1183, 1201

10198, 10538

10635, 10716

9879, 10175

10767, 10869

1216, 1497

228, 255

426, 969

991, 1085

1101, 1167

41,976

153,826

34812

Discharge summary

report

Admission Date: [**2202-10-3**] Discharge Date: [**2202-10-11**] Date of Birth: [**2136-7-28**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 603**] Chief Complaint: Chief Complaint: Altered mental status, hypotension Major Surgical or Invasive Procedure: Midline insertion (removed prior to discharge) History of Present Illness: 65 M with a complicated PMH including CVA (non-verbal & quadriplegic at baseline) now s/p trach & PEG [**3-/2200**], atrial fibrillation on coumadin, chronic aspiration PNAs and recurrent UTIs with drug-resistant organisms, C Diff s/p colectomy, DM2, recent ICU admission for urosepsis who presents from his nursing home. Of note, the patient was discharged from [**Hospital1 18**] on [**2202-9-23**] to complete a course of IV antibiotics on [**2202-9-27**] for a presumed HCAP. Per report, the pt was diagnosed with a PNA on CXR yesterday at his [**Hospital1 1501**] & received IV antibiotics. Today, he was noted to have an alteration in his mental status so he was sent to the [**Hospital1 18**] ED for further evaluation. In the ED, initial VS were: 99.2 107 95/56 30 Initial labs in ED revealed peripheral lactate 2, creatinine 2.6 (from 0.3), potassium 7.3. An initial EKG revealed peaked-T waves. The patient was given insulin, 1 amp D50%, as well as 2 gm calcium gluconate. During the calcium infusion, the patient was noted to develop some erythema around his IV site. He was started on vanco, cefepime, & levofloxacin in the ED. His Foley catheter was replaced and it immediately drained roughly 2 L, suggesting an obstructive uropathy. After receiving the above therapies, the patient was admitted to the ICU for further evaluation and treatment. Unable to obtain ROS Past Medical History: - Hypertension - Hypothyroidism - H/o CVA (bilateral embolic cerebellar [**2188**], hemorrhagic left thalamic [**2190**]) - Type 2 Diabetes mellitus - Peripheral neuropathy - Depression - h/o DVT (? - no [**Hospital1 18**] records) - Atrial fibrillation (on coumadin) - Peripheral vascular disease - Hyperlipidemia - Tracheostomy and GJ tube for chronic aspiration ([**3-/2200**])- Portex Bivono, Size 6.0 - C.diff colitis in [**1-29**] requiring total abdominal colectomy with end ileostomy [**1-29**], repeat positive C diff toxin [**2200-5-20**](outside facility, [**12/2198**] here) Social History: Resident of [**Hospital 16662**] Nursing Home, previously at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]. Family very involved in care. Patient does not take anything by mouth due to history of aspiration. Spanish-speaking. Patient is a former 60 pack year smoker but quit in [**2183**]. Family History: Patient has a mother with diabetes and brother with heart disease Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98 94/50 65 18 100% GEN: Non-verbal, not responding to commands. HEENT: Edentulous. PERRL NECK: Trach in place PULM: Diminished expansion bilaterally, crackles worse at right base. [**Last Name (un) **]: + NABS in 4Q. Ostomy in right lower quadrant which is pink EXT: Cool, non-edematous, contracted. NEURO: Does not respond to commands, retracts upper extremities to pain. PERRL Discharge Physical Exam: VS: 98, 106/75, 72, 18, 99% TM GEN: Non-verbal, responds to commands and answer questions appropriately by nodding head HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear/mouth open, EOMI follows finger Neck: supple, JVP not elevated, no LAD, trach tube inplace, no erythema CV: Regular rate and rhythm, 2/6 systolic murmer heard best at apex PULM: Clear to auscultation bilaterally (but coarse breath sounds throughout), no wheezes, rales. [**Last Name (un) **]: soft, non-tender, non-distended, bowel sounds present, no organomegaly, large midline scar, PEG tube in place and ostomy in place EXT: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema NEURO: Non-verbal, responds to commands and answer questions appropriately by nodding head Pertinent Results: ADMISSION LABS [**2202-10-3**] 01:45AM BLOOD WBC-25.8*# RBC-5.28 Hgb-11.1* Hct-36.7* MCV-70* MCH-21.0* MCHC-30.2* RDW-17.6* Plt Ct-312 [**2202-10-3**] 01:45AM BLOOD Neuts-83.7* Lymphs-10.2* Monos-5.2 Eos-0.6 Baso-0.4 [**2202-10-3**] 01:45AM BLOOD PT-37.3* PTT-44.9* INR(PT)-3.4* [**2202-10-3**] 01:45AM BLOOD Plt Ct-312 [**2202-10-3**] 01:45AM BLOOD Glucose-343* UreaN-111* Creat-2.6*# Na-143 K-7.3* Cl-104 HCO3-24 AnGap-22* [**2202-10-3**] 01:45AM BLOOD Albumin-3.7 [**2202-10-3**] 04:50AM BLOOD Calcium-7.4* Phos-5.6*# Mg-2.3 [**2202-10-3**] 01:53AM BLOOD TypeVEN pO2-51* pCO2-44 pH-7.40 calTCO2-28 Base XS-1 [**2202-10-3**] 01:53AM BLOOD Lactate-2.0 [**2202-10-3**] 01:54AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.013 [**2202-10-3**] 01:54AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG [**2202-10-3**] 01:54AM URINE RBC-0 WBC-18* Bacteri-FEW Yeast-MANY Epi-0 Discharge Labs: [**2202-10-11**] 05:45AM BLOOD WBC-7.1 RBC-3.84* Hgb-8.3* Hct-26.4* MCV-69* MCH-21.6* MCHC-31.4 RDW-17.5* Plt Ct-238 [**2202-10-11**] 05:45AM BLOOD Glucose-89 UreaN-8 Creat-0.2* Na-137 K-3.4 Cl-101 HCO3-30 AnGap-9 [**2202-10-11**] 05:45AM BLOOD Calcium-7.7* Phos-2.4* Mg-1.5* IMAGING: CXR IMPRESSION: 1. Right base consolidative opacity and patchy left base opacity are compatible with pneumonia or aspiration. 2. Moderate cardiomegaly. MICRO: Blood cx x2 [**10-3**]: negative; [**10-8**]: pending Urine cx - Yeast Sputum cx- GRAM STAIN (Final [**2202-10-3**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [**2202-10-5**]): MODERATE GROWTH Commensal Respiratory Flora. PROTEUS MIRABILIS. MODERATE GROWTH. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS MIRABILIS | AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- 8 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I MEROPENEM-------------<=0.25 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R LEGIONELLA CULTURE (Final [**2202-10-10**]): NO LEGIONELLA ISOLATED. [**2202-10-8**] 1:20 pm BLOOD CULTURE #2. Blood Culture, Routine (Pending): Brief Hospital Course: 66 M with complicated past medical history most significant for multiple CVAs now with trach & PEG, also with h.o CDiff colitis s/p colectomy, recurrent aspiration PNA as well as UTIs in setting of chronic Foley presented with fever & altered mental status found to have HCAP. #HCAP: Pt initially presented meeting SIRS criteria (fever, leukocytosis, tachycardia) in the presence of two suspected sources (UTI, possible PNA based on U/A & CXR). CXR revealed "Right base consolidative opacity and patchy left base opacity are compatible with pneumonia or aspiration." He was transferred from the ER to the MICU and responded to fluid resuscitation. His mental status improved and he was treated with Linezolid and Cefepime. When he was more stable he was tranferred to the medicine floor where we continued antiboitics. ID was consulted and they recommended total of 8 days of cefapime and to discontinue the linezolid. As patient improved the plan was to give him a PICC and to discharge him home on cefapime however patient refused PICC. His family was contact[**Name (NI) **] and it was believed that he was competent enough to refuse the PICC. He stayed in the hospital till he finished his course of antibiotics. Patient is at risk for recurrent admissions for pneumonia because of his aspiration risk. # HYPERKALEMIA: Admission potassium elevated to 7.3; precipitant unclear. EKG demonstrated peaked T waves (new from prior). The patient did have an element of [**Last Name (un) **], but his hyperkalemia was out of proportion to his renal dysfunction. He received 10 units IV insulin in the ED as well as calcium gluconate and D50; his repeat potassium is 5.9. His hyperkalemia resolved while he was on the medicine floor. There were no more episodes of hyperkalemia while on the medicine floor. # ACUTE KIDNEY INJURY: The patient's admission creatinine was elevated to 2.6; the etiology for this is most likely a combination of prerenal [**Last Name (un) **] in the setting of hypotension as well as a post-obstructive uropathy given concern for blocked Foley in ED. The patient's Foley was replaced in the ED & it was immediately noted that the new catheter drained 1.8 L of urine. Creatinine improved after resuscitation. Discharge Cr 0.2. # CHRONIC PAIN: This was from his decubitus ulcers (which wound care had seen on prior admissions). We initially held fentanyl patch given AMS at admission. Fentanyl patch and morphine was restarted when his MS improved. Palliative care was consulted and they recommended increasing his PO morphine dose and exploring the option of methadone at some future time. We held off on changing his chronic pain management (eg: changing fentanyl to methadone), but rather increased his PRN morphine dosage (to 10-15 mg PO Q4h prn pain). While here, he tolerated 15 mg of morphine sulfate PO up to 2-4 times a day without issue. #Code status: DNR DNI. I called the family and talked to them about his code status and about the idea of do not re-hospitilize. The son [**Name (NI) 39522**] said that he recently had a discussion with pt 1 month ago and he wanted to continue the care he has been receiving currently. Palliative care was involved and spoke with patient and son and they were interested in palliative care services. They are not interested in discussing hospice, but interested in the idea of pain management through palliative care recommendations. #Hypocalcemia/Hypophosphatemia: Both Ca and Phos were low for several days requiring supplementation. Likely [**1-21**] Vit D def. His PTH was elevated (because of low Ca). We started him on PO vitamin D. THis is a new medication for him. #Hypomagnesemia: Repleted withIV MgSO4. As an outpatient, we hope he can have his lytes checked Q2-3 days for need of repletion as an outpatient. #Pain from indwelling foley: catheter was kinked on [**10-7**] and nurses flushed it with resolution of pain. Notably, we tried to upsize the foley, however this was not able to be done. Rather, our plan is for his caregivers at the nursing home to flush the foley with 100cc of sterile water or saline if urine output drops <30cc/hr. If this doesn't resolve the situation, we would recommend changing the foley. #[**Female First Name (un) 564**] in urine: not uncommon in frequently hospitilized patients. Typically only symptomatic patients (though it is difficult to assess if he is symptomatic) and pts with possible disseminated [**Female First Name (un) **] are treated. We decided not to treat. # HYPOTHYROIDISM: Continued home levothyroxine. # ATRIAL FIBRILLATION: INR 3.4 on admission and then 4. His coumadin was held until his INR became therapeutic. We trended his INR and it eventually trended down and his coumadin dose was increased to 5mg daily. Unfortunately, it dropped below 2, so we started heparin gtt, now lovenox so that he can be transitioned to warfarin as an outpatient. Notably, as an outpatient, he has been on ~4-5 mg /day doses in the past. # DM2: Continued home insulin scales. # DEPRESSION: Continued duloxetine. # CLogged g-tube: Resolved with flushes by nursing staff. TRANSITIONAL ISSUES: #Recurrent aspiration PNA #Chronic Pain: palliative care involved, see above #Requiring Mg, Phos and Ca supplementation #follow up vitamin D levels and depending on the value may need to increase dose of vitamin D. #Atrial fibrillation: on lovenox to bridge until coumadin therapeutic #Blood cultures from [**10-8**]- PND Medications on Admission: The Preadmissions Medication list may be inaccurate and require further investigation. 1. Baclofen 5 mg PO QID 2. Duloxetine 30 mg PO DAILY 3. Fentanyl Patch 50 mcg/h TP Q72H 4. Glargine 32 Units Bedtime Insulin SC Sliding Scale using Novolin R Insulin 5. Ipratropium Bromide Neb 1 NEB IH Q6H sob/wheezes 6. Levothyroxine Sodium 25 mcg PO DAILY 7. Mirtazapine 15 mg PO HS 8. Glucerna Hunger Smart *NF* (nut.tx.gluc.intol,lac-free,soy;<br>nut.tx.glucose intolerance,soy) 1 Liquid Oral Daily 85cc/hour for 20 hours, start at 2pm 9. Lactinex *NF* (lactobacillus acidoph & bulgar) 100 million cell Oral [**Hospital1 **] 10. Milk of Magnesia *NF* (magnesium hydroxide) 400 mg/5 mL ORAL DAILY PRN constipation 11. Acetaminophen 650 mg PO Q6H:PRN pain 12. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob/wheezes 13. Gabapentin 600 mg PO TID 14. Multivitamins 1 TAB PO DAILY 15. arginine (L-arginine) *NF* 500 mg Oral [**Hospital1 **] Powder Packet 16. Warfarin 3 mg PO DAILY16 Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob/wheezes 3. Baclofen 5 mg PO QID 4. Duloxetine 30 mg PO DAILY 5. Fentanyl Patch 50 mcg/h TP Q72H 6. Gabapentin 600 mg PO TID 7. Glargine 32 Units Bedtime Insulin SC Sliding Scale using Novolin R Insulin 8. Ipratropium Bromide Neb 1 NEB IH Q6H sob/wheezes 9. Levothyroxine Sodium 25 mcg PO DAILY 10. Mirtazapine 15 mg PO HS 11. Multivitamins 1 TAB PO DAILY 12. Warfarin 5 mg PO DAILY16 13. arginine (L-arginine) *NF* 500 mg Oral [**Hospital1 **] Powder Packet 14. Glucerna Hunger Smart *NF* (nut.tx.gluc.intol,lac-free,soy;<br>nut.tx.glucose intolerance,soy) 1 Liquid Oral Daily 85cc/hour for 20 hours, start at 2pm 15. Lactinex *NF* (lactobacillus acidoph & bulgar) 100 million cell Oral [**Hospital1 **] 16. Milk of Magnesia *NF* (magnesium hydroxide) 400 mg/5 mL ORAL DAILY PRN constipation 17. Vitamin D 400 UNIT PO DAILY 18. Morphine Sulfate (Oral Soln.) 10-15 mg PO Q4H:PRN pain 19. Enoxaparin Sodium 70 mg SC BID For bridging to warfarin. Can be stopped after INR is therapeutic (between [**1-22**]) for at least 48 hours, and coumadin is continued at that time. Discharge Disposition: Extended Care Facility: [**Hospital 16662**] Nursing and Rehab Center - [**Street Address(1) **] Discharge Diagnosis: Primary diagnosis hospital acquired and aspiration pneumonia Secondary diagnoses Sacral decubitus ulcer Atrial fibrillation History of stroke Discharge Condition: Mental Status: Confused - sometimes. Activity Status: Bedbound. Level of Consciousness: interactive at times. Discharge Instructions: You came to the hospital because you had a fever and change in mental status. You originally went to the MICU and were treated for hospital acquired and aspiration pneumonia. You were started on intravenous antibiotics and you came to the medical floor when you were improving. The infectious disease doctors saw [**Name5 (PTitle) **] and recommended you remain on one of your antibiotics for a total of 8 days. While you were here you had pain from your decubitus ulcer and we had the palliative care team come and see you and give recommendations for pain control. Because your G-tube was clogged, you couldn't take your warfarin and we had to start heparin because of your atrial fibrillation. You also needed to have your foley changed and flushed because it got clogged a few times. We have addressed this with your care team at the nursing facility where you live. We made the following changes to your medications: We INCREASED the dose of morphine 10-15mg q4H prn pain We INCREASED the dose of coumadin to 5mg daily please START lovenox 70 mg SQ [**Hospital1 **] to bridge to coumadin please START Vitamin D 400 UNIT PO DAILY Followup Instructions: Please follow up with your physicians at the extended care facility. Department: RADIOLOGY CARE UNIT When: TUESDAY [**2202-11-16**] at 10:00 AM [**Telephone/Fax (1) 446**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: RADIOLOGY When: TUESDAY [**2202-11-16**] at 11:30 AM With: XSP WEST [**Telephone/Fax (1) 590**] Building: CC [**Location (un) 591**] [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage

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icd9cm

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Discharge summary

report

Admission Date: [**2179-1-30**] Discharge Date: [**2179-2-2**] Date of Birth: [**2142-10-19**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3984**] Chief Complaint: Right Upper Extremity Swelling Major Surgical or Invasive Procedure: IR-guided Venous Catheter Placement and tPA infusion Multiple Venograms History of Present Illness: 36 y/o female with PMH sig for ADD, h/o L breast lipoma s/p resection, presents with 3-4 day h/o progressive RUE swelling. Denies any recent trauma and has no history of central venous cathether insertion. Denies OCP use. No personal h/o DVTs. Denies any fevers, chills, night sweats, chest pain, shortness of breath. RUE U/S showing axillary clot; patient was subsequently admitted to MICU s/p IR procedure for catheter guided TPA infusion. Past Medical History: 1. ADD; not currently on any medications. 2. H/O L breast mass (Lipoma); s/p resection. Social History: Psychiatry resident No tob/etoh/IVDA Family History: Father with h/o Pulmonary Embolism Aunt with several miscarriages No other FH of DVTs/PEs Physical Exam: AF VSS Gen: lying in bed, NAD HEENT: MMM Neck: suple Chest: CTAB CV: rrr no mrg Abd: soft, NABS Extrem: massive RUE swelling from shoulder to mid-forearm. No overlying erythema, mildly tender. 2+ radial pulse. Pertinent Results: [**2179-1-30**] 09:35AM AT III-84 PROT C-112 [**2179-1-31**] 05:45AM BLOOD CARDIOLIPIN ANTIBODY-PND [**2179-1-30**] 09:35AM BLOOD FACTOR V LEIDEN-PND [**2179-1-30**] 09:35AM BLOOD PROTEIN S,FUNCTIONAL-PND [**2179-1-31**] 05:45AM BLOOD Lupus-NEG Brief Hospital Course: 36 y/o female with PMH sig for ADD, L breast Lipoma, admitted with Paget Schroetter Disease (spontaneous upper extremity DVT). Patient underwent initial IR procedure which demonstrated: "The venogram demonstrates near complete occlusion of the proximal subclavian vein with surrounding collateral flow with reformation of the superior vena cava distally. These findings are compatible with effort induced venous thrombosis (Paget-Schroetter syndrome)." She was started on catheter-directed TPA and low-dose heparin infusion. This was perfomed on [**2179-1-30**]. Of note, a subsequent Venogram showed: Partial resolution of the thrombosis was shown by the venogram; however, a more proximal stenosed area could be identified ([**2179-1-31**]). The patient's tPA and heparin were continued until a final venogram on [**2-2**]. This showed resolution of subclavian vein thrombus along with two focal areas of high-grade stenosis identified in the right subclavian vein with subsquent angioplasty of the right subclavian stenoses with a 10 mm x 4 cm balloon. Post-angioplasty venogram demonstrated improved flow through the subclavian vein but some residual stenosis was still seen. The patient had a inherited thrombophilia panel send; most of the studies are either negative or pending to date. Her new PCP (Dr. [**Last Name (STitle) **] will follow up on these results. Two additional tests (which may be low yield given her anatomic abnormality) to complete the workout would be a Prothrombin Gene Mutation Test and a homocystiene level. She was discharged on 5 mg of Coumadin and Lovenox brige with plans to follow up with NP [**Doctor Last Name 3817**]. NP [**Doctor Last Name 3817**] or one of her colleagues will follow the patients INR until the patient is transferred to the [**Hospital 191**] [**Hospital3 271**] in the middle of [**Month (only) 958**]. Ms. [**Known lastname 55268**] will schedule an appointment with Dr. [**First Name (STitle) **] from IR in two weeks. Dr. [**First Name (STitle) **] will decide the exact length of AC and whether Ms. [**Known lastname 55268**] will need subsequent surgery for her underlying anatomic abnormality. Medications on Admission: None Discharge Medications: 1. Warfarin Sodium 2.5 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*2* 2. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 5 days. Disp:*10 Capsule(s)* Refills:*0* 3. Lovenox 60 mg/0.6mL Syringe Sig: .5 ml Subcutaneous twice a day for 7 days: 50 mg [**Hospital1 **]; please continue until your coumadin levels are therapeutic. Disp:*14 syringes* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Spontaneous Right Upper Extremity Deep Vein Thrombosis (Paget Schroetter Syndrome) Discharge Condition: Stable Discharge Instructions: Please contact your primary care provider should you develop any chest pain, shortness of breath, blood in your stools or black stools, worsening right arm swelling, or any other complaints. Please arrive early to your appointment on the 11th to get your blood drawn (for your Coumadin levels). You can simply proceed to the [**Hospital 191**] clinic on the [**Location (un) **] of the [**Hospital Ward Name 23**] Building and tell them you have lab work to be done (this has already been entered in the computer). Please continue to take your Lovenox shots twice a day until your coumadin levels are therapeutic. Followup Instructions: Please call to make an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] @ [**Telephone/Fax (1) 25094**]. She would like to see you in two weeks. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Where: [**Hospital6 29**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2179-2-5**] 10:00 Provider: [**First Name8 (NamePattern2) 3688**] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Where: [**Hospital6 29**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2179-2-23**] 1:30 (This is your new Primary Care Doctor) Your have been accepted to the [**Company 191**] anticoagulation service on Monday, [**3-8**]. On this day, someone will contact you and assume responsibility for your anticoagulation management. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

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icd9cm

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Discharge summary

report

Admission Date: [**2129-7-12**] Discharge Date: [**2129-7-29**] Date of Birth: [**2076-12-2**] Sex: F Service: Plastic Surgery CHIEF COMPLAINT: Fever and right leg pain. HISTORY OF PRESENT ILLNESS: This 52-year-old female presented to the [**Hospital1 69**] Emergency Room on [**7-12**] with fever and pain in the right thigh that had been getting progressively worse for 2-3 days. The patient had also noted significant swelling and redness in the involved region. The patient had undergone elective liposuction on that same thigh approximately 2 months earlier at an outside hospital. She was initially evaluated by the medical service in the Emergency Room with consultation to the plastic surgery service. PAST MEDICAL HISTORY: Significant for obesity, status post gastric bypass, status post liposuction, status post abdominoplasty and osteoarthritis. The patient took no medication, had no known drug allergies. PHYSICAL EXAMINATION: The temperature was 102.9, heart rate 138, blood pressure 92/60, respiratory rate 24, oxygen saturation 94% on room air. The patient was ill appearing, diaphoretic with dry mucus membranes. Her neck was supple with no meningeal signs and no lymphadenopathy. Her cardiac exam was regular rhythm, tachycardic with a 2/6 systolic murmur. She had decreased breath sounds bilaterally at her lung bases. Her abdominal exam, she was obese with multiple surgical scars. Her abdomen was soft and nontender. Her extremities, her right thigh was swollen and tense, red with some yellowish drainage from a small scar at a previous liposuction entry site. There was no well defined area of fluctuants. Neurological exam, she was alert and oriented times three, non focal. An ultrasound had been done on admission revealing a loculated area of fluid just deep to the site of the previously mentioned liposuction scar. LABORATORY DATA: On admission the patient's [**Known lastname **] blood cell count was 26.5 and hematocrit was 32.5. Cultures were sent from wound swab as well as from a tap of the loculated fluid when cultures were also sent. HOSPITAL COURSE: The patient was initially admitted to the medical service for cellulitis and started on IV Unasyn. The patient failed to improve by hospital day #2 with continued fevers up to 102 degrees and more pain and swelling in the right leg. Gram stain of the wound fluid revealed 4+ gram positive cocci and 2+ gram negative rods. The patient's [**Known lastname **] count remained elevated on hospital day #2 at 24.4 and thus the decision was made to transfer the patient to the plastic surgery service and take the patient to the operating room for debridement of the right leg. In the operating room the patient was found to have a large amount of infectious fluid in the leg and evidence of necrotizing fasciitis. The patient was hypotensive in the OR requiring addition of a Neo-Synephrine drip. The patient was admitted to the SICU postoperatively, started on IV Penicillin and Clindamycin and the infectious disease service was consulted. Cultures of the patient's wound fluid came back revealing infection with pseudomonas, group A strep as well as staph aureus. At the suggestion of the infectious disease service, the patient was started on Vancomycin, Cipro, Clindamycin and Zosyn on the evening of postoperative day 0, hospital day #2. The patient was weaned off Neo and on [**7-14**] returned to the operating room for a second debridement wash-out of the right leg. The patient remained in the SICU for several days post-operatively. The patient required [**Hospital1 **] dressing changes of her open wound. The patient was extremely uncomfortable during these wound dressing changes and required conscious sedation with Morphine and Versed. The patient's hematocrit dropped significantly to 24 on hospital day #4 and as a result the patient was transfused with two units of packed red blood cells. The patient remained stable in the SICU, remaining there for several days due to her requirement for conscious sedation with dressing changes. The Vancomycin was discontinued on [**7-15**] and the Cipro was discontinued on [**7-16**]. On [**7-18**] the patient was transferred to the VICU stable, on Zosyn and Clindamycin IV. On the VICU she continued requiring conscious sedation for dressing changes. As a result of the frequent painful dressing changes, the patient became increasingly tearful and frightened before dressing changes. She began having nightmares and ruminations, thus psych was consulted on [**7-18**] and the patient was diagnosed with acute stress disorder and started on Ativan po. On [**7-20**] the patient returned to the OR for a third debridement washout, partial wound closure and VAC dressing placement. The patient returned to the VICU but was soon discharged to a floor bed with brief transfers back to the unit as needed every four days for changes to the VAC dressing. The patient improved significantly after her third surgery. The patient was taking a full diet by [**7-23**] and began working with the physical therapy service. On [**7-24**], however, the nursing staff reported that the patient was expressing some suicidal ideation. Psychiatry was once again notified and the patient was placed on a 1:1 sitter. Psychiatry suggested starting the patient on Serzone and increasing her Ativan dose. Psychiatry continued following the patient whose mood improved. She contracted for safety and by [**7-27**] the 1:1 sitter was discontinued. Since [**7-27**] the patient's mood, diet and activity level have continued to improve. Her IV Clindamycin was stopped on [**7-27**] and the IV Zosyn was stopped on [**7-28**]. The patient was switched to po Dicloxacillin and Cipro. Discharge planning began and the patient expressed her desire to go to a facility near her home in [**Location (un) 669**]. The patient underwent a VAC dressing change on the morning of [**7-29**] and these dressing changes should be continued every four days. CONDITION ON DISCHARGE: Stable, to [**Hospital 100**] [**Hospital 107**] Rehab. DISCHARGE DIAGNOSIS: 1. Necrotizing fasciitis, status post three debridement and wash-outs. The patient is to continue taking po Dicloxacillin and Cipro for one month. The patient is instructed to follow-up with Dr. [**Last Name (STitle) **] the week of [**8-1**] and she should call his office to make an appointment. The patient is also instructed to follow-up in [**Hospital **] Clinic on [**8-4**] and the patient has been provided with a phone number for that. 2. Depression/acute anxiety disorder. DISCHARGE MEDICATIONS: Serzone 150 mg by mouth [**Hospital1 **], Ciprofloxacin 500 mg po bid for four weeks, Dicloxacillin 500 mg po qid for four weeks, Dilaudid 2-4 mg po q 3-6 hours prn pain, Ativan 1 mg po qid prn anxiety. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2647**], M.D. [**MD Number(1) 2648**] Dictated By:[**Doctor Last Name 23283**] MEDQUIST36 D: [**2129-7-29**] 20:07 T: [**2129-8-2**] 08:52 JOB#: [**Job Number 23284**]

[ "278.01", "682.6", "998.59", "300.4", "728.86" ]

icd9cm

[ [ [] ] ]

[ "38.93", "86.22" ]

icd9pcs

[ [ [] ] ]

6652, 7157

6139, 6628

2131, 6036

968, 2113

162, 189

218, 734

757, 945

6061, 6118

27,877

164,586

10255

Discharge summary

report

Admission Date: [**2166-4-16**] Discharge Date: [**2166-4-23**] Date of Birth: [**2122-11-4**] Sex: F Service: SURGERY Allergies: Penicillins / Codeine / Bactrim / Percocet / Morphine Attending:[**First Name3 (LF) 1384**] Chief Complaint: cholelithiasis Major Surgical or Invasive Procedure: [**2166-4-16**] lap cholecystectomy History of Present Illness: 43 y.o. female s/p kidney/pancreas transplant [**2164-1-27**] with recent RUQ pain. U/S showed stones and ERCP demonstrated common duct stone which was removed. Since that time she had vague RUQ complaints with n/v after eating fatty foods. Past Medical History: DMI, ESRD,Left AV graft, PAK ([**2164-1-27**]) s/p cholecystectomy Social History: Pt lives with boyfriend at nursing home where she resides [**Doctor Last Name **] in nursing home due to hypoglycemia pre transplant, disabled, college graduate. Her family, friends, and nursing home staff provide her with strong social support Family History: Non contributory Physical Exam: 99.2 101 126/61 14 97% RA wt 186 lbs, height 5'2" A&O RRR Lungs clear Abd soft, ND/NT, GB not palpated, well healed transplant incisions ext no edema Pertinent Results: On Admission: [**2166-4-16**] WBC-14.6*# RBC-4.04* Hgb-11.4* Hct-35.5* MCV-88 MCH-28.3 MCHC-32.1 RDW-12.6 Plt Ct-246 Glucose-125* UreaN-17 Creat-1.1 Na-139 K-5.1 Cl-106 HCO3-23 AnGap-15 ALT-28 AST-41* CK(CPK)-93 AlkPhos-87 Amylase-36 TotBili-0.3 Albumin-3.7 Calcium-8.8 Phos-3.2 Mg-1.5* FK506-9.0 On Discharge: [**2166-4-23**] WBC-5.2 RBC-3.75* Hgb-10.7* Hct-33.1* MCV-88 MCH-28.6 MCHC-32.4 RDW-13.2 Plt Ct-356 Glucose-101 UreaN-15 Creat-1.1 Na-140 K-4.4 Cl-107 HCO3-25 AnGap-12 ALT-26 AST-30 AlkPhos-74 Amylase-29 TotBili-0.5 Calcium-9.3 Phos-3.4 Mg-1.7 Brief Hospital Course: On [**2166-4-16**] she underwent laparascopic cholecystectomy. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. The case was uneventful. She was recovered in the PACU where pain was managed with pca dilaudid. She required O2 4Liters NC to maintain sats at 95-96% as she was unable to take deep breaths [**3-8**] pain. She was also tachycardic in the low 100s. Hct was stable. She was then transferred to the med-[**Doctor First Name **] floor where main complaint was RUQ lap site pain. PCA dilaudid was adjusted. She had mild nausea. On pod 1, diet was advanced as tolerated. She was still requiring O2 to keep sats >93%. Mid morning after bathing, she was found unresponsive, apneic and diaphoretic. O2 sat was 87% on RA and glucose was 236. Narcan was pushed given concern for narcotic respiratory depression with good response awakening the patient. O2 sats persisted to be in high 80's on nasal cannula requiring a non-rebreather with O2 maintained at 93-94%. ABG's revealed respiratory acidosis. A CTA was done to assess for PE and an abd fluid collection. This demonstrated no PE and bilateral pulmonary parenchymal consolidation, likely representing aspiration, as there is air-fluid level in the mid esophagus. She was transferred to the SICU. Levaquin and flagyl were started for aspiration. IV vanco was also given. She required O2 Non-rebreather to keep sats >90. She remained stable. CXR on [**4-19**] showed new bibasilar atelectasis, small bilateral pleural effusions with patchy infiltrates left mid lung zone and right upper lobe. On [**4-20**], she transferred out of the SICU. O2 sats were 96% on 4 liters. CXR demonstrated mild interval worsening with increased bibasilar consolidation and effusions with stable consolidation in right upper lobe. WBC was normal. Renal and pancreas function was normal. Oxygenation improved daily, and by day of discharge she was amintaining saturations in the high 90's off of O2. Immunosuppression was maintained and blood sugars normalized, creatinine at baseline 1.1 She will discharge back to her nursing home and have surgical followup with Dr [**Last Name (STitle) 816**] on [**4-28**]. Antibiotics through [**2166-5-2**]. Urinalysis sent on day of discharge due to patient complaint of frequency/urgency was negative. Medications on Admission: paroxetine 10', ASA 81', enalapril 5', cellcept [**Pager number **]", levothyroxine 50', prograft 1.5", timolol gtt, protonix 40', lipitor 10' Discharge Medications: 1. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic TID (3 times a day): Through [**2166-4-28**]. 2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 3. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Hold if having loose stool. 10. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 12. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 13. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 15. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): Through [**2166-5-2**]. 17. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Through [**2166-5-2**]. 18. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital **] HEALTH CARE CENTER Discharge Diagnosis: cholelithiasis s/p kidney/pancreas tx [**1-9**] narcotic oversedation aspiration pneumonia Discharge Condition: good Discharge Instructions: Please call the Transplant Office [**Telephone/Fax (1) 673**] if fever, chills, shortness of breath, nausea, vomiting, jaundice, decreased urine output or elevated glucoses. [**Month (only) 116**] shower, no heavy lifting Continue laboratory testing to follow transplant and immunosuppression as recommended by the transplant clinic Followup Instructions: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2166-4-28**] 8:00 [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2166-6-20**] 10:00 Completed by:[**2166-4-23**]

[ "574.10", "244.9", "250.01", "E937.9", "V42.0", "305.40", "507.0", "V42.83", "568.0" ]

icd9cm

[ [ [] ] ]

[ "51.23", "54.51" ]

icd9pcs

[ [ [] ] ]

5978, 6039

1793, 4115

328, 366

6174, 6181

1214, 1214

6562, 6850

1006, 1024

4308, 5955

6060, 6153

4141, 4285

6205, 6539

1039, 1195

1525, 1770

274, 290

394, 637

1228, 1511

659, 727

743, 990

20,256

112,832

49936

Discharge summary

report

Admission Date: [**2140-3-24**] Discharge Date: [**2140-4-4**] Date of Birth: [**2056-8-22**] Sex: F Service: SURGERY Allergies: Demerol / Droperidol / Penicillamine / Streptomycin / Ampicillin Attending:[**First Name3 (LF) 1**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: Exploratory laparotomy, extensive lysis of adhesions, small bowel resection with reanastomosis, repair recurrent ventral hernia. History of Present Illness: Mrs. [**Known lastname 104299**] is an 83yo female with [**Hospital 10224**] medical and surgical problems. She has a known h/o recurrent ventral hernia. She presented to [**Hospital1 18**] ED with complaints of abdominal pain, N/V x 3 hours. She reported the pain to be similar to the prior pain that she had with previous small bowel obstructions. She last reports passing flatus the night before presentation to the ED, but no flatus since. She was admitted to the surgery service for further evaluation. . During work-up in ED, the patient was found to have a prolonged QT interval near 600. Of note, patient had dose of Flecanide recently increased. She was also hypokalemic, KCL down to 2.9 on presentation Past Medical History: Hyperlipidemia: [**8-/2139**] LDL 114 HDL 73 Chol 209 TG 108 Hypertension, labile blood pressure Diastolic left ventricular dysfunction with EF >55% Renal Insufficiency: eGFR 50 Stage 3A (most likely [**1-25**] HTN) Chronic chest pain, clean coronary arteries by [**2127**] catheterization Paroxysmal AFib Esophageal spasm Gout Gastroesophageal reflux disease Status TAH-BSO in [**2121**] for menorrhagia. Chronic vaginal itching, now on Premarin cream. Small Bowel Obstruction in [**2123**], [**2126**] and [**2138**] s/p adhesion lysis in [**9-/2139**] Migraine headaches H/o hysterectomy (abdominal) H/o abdominal hernia with repair Gallstones Social History: Social history is significant for the absence of current tobacco use and patient states she has never smoked. There is no history of alcohol abuse or illegal substance use. Patient lives in [**Location 583**], MA. She is a retired dentist and immigrated from [**Country 532**] and [**Location (un) 3156**] in the [**2110**]. Family History: There is no family history of premature coronary artery disease or sudden death. [**Name (NI) **] mother had HTN. Physical Exam: At Discharge: Vitals: GEN: NAD, A/Ox3 CV: RRR, no m/r/g RESP: CTAB, decreased bases bilaterally. no w/r/r ABD: soft slightly distended, appropriately TTP Incision: midline abdominal OTA with staples, mild erythema at staples sites with scant dry blood, otherwise CDI GI/GU: diaper in place due to urinary frequency/incontinence. Rectal tube placed on [**2140-4-2**] for frequent loose brown stool. Intact. no rectal irritation/excoriation noted Skin: perineal skin free of rash and excoriation Extrem: B/L 1+ pedal edema. +DP's Pertinent Results: [**2140-3-23**] 09:05PM BLOOD WBC-8.1 RBC-4.22 Hgb-11.8* Hct-34.4* MCV-81* MCH-27.9 MCHC-34.2 RDW-15.5 Plt Ct-201 [**2140-3-25**] 04:43AM BLOOD WBC-7.7 RBC-3.74* Hgb-10.6* Hct-31.1* MCV-83 MCH-28.3 MCHC-34.1 RDW-15.9* Plt Ct-153 [**2140-3-27**] 04:11AM BLOOD WBC-11.2*# RBC-3.84*# Hgb-10.9*# Hct-33.2*# MCV-87 MCH-28.5 MCHC-32.9 RDW-15.2 Plt Ct-175 [**2140-3-29**] 02:18AM BLOOD WBC-8.5 RBC-3.11* Hgb-9.0* Hct-27.3* MCV-88 MCH-28.9 MCHC-32.9 RDW-15.3 Plt Ct-175 [**2140-4-1**] 04:49AM BLOOD WBC-7.0 RBC-3.13* Hgb-8.7* Hct-26.7* MCV-85 MCH-27.6 MCHC-32.4 RDW-15.3 Plt Ct-195 [**2140-4-3**] 03:34AM BLOOD WBC-10.2 RBC-3.49* Hgb-9.8* Hct-28.6* MCV-82 MCH-28.0 MCHC-34.2 RDW-15.7* Plt Ct-255 [**2140-4-4**] 05:50AM BLOOD WBC-12.0* RBC-3.75* Hgb-10.2* Hct-30.9* MCV-83 MCH-27.2 MCHC-33.0 RDW-15.9* Plt Ct-318 [**2140-3-23**] 09:05PM BLOOD PT-32.3* PTT-35.4* INR(PT)-3.4* [**2140-3-25**] 04:43AM BLOOD PT-42.0* PTT-44.0* INR(PT)-4.6* [**2140-3-26**] 06:20PM BLOOD PT-18.1* PTT-35.0 INR(PT)-1.7* [**2140-3-27**] 12:40AM BLOOD PT-17.3* PTT-32.7 INR(PT)-1.6* [**2140-3-28**] 02:03AM BLOOD PT-15.7* PTT-37.3* INR(PT)-1.4* [**2140-3-23**] 09:05PM BLOOD Glucose-109* UreaN-77* Creat-2.1* Na-137 K-2.9* Cl-90* HCO3-33* AnGap-17 [**2140-3-24**] 08:51PM BLOOD Glucose-118* UreaN-65* Creat-1.6* Na-144 K-4.0 Cl-105 HCO3-28 AnGap-15 [**2140-3-26**] 02:25AM BLOOD Glucose-104 UreaN-41* Creat-1.1 Na-150* K-3.3 Cl-109* HCO3-32 AnGap-12 [**2140-3-28**] 03:29PM BLOOD Glucose-106* UreaN-31* Creat-1.1 Na-152* K-3.7 Cl-114* HCO3-31 AnGap-11 [**2140-3-29**] 02:18AM BLOOD Glucose-105 UreaN-29* Creat-1.0 Na-153* K-3.7 Cl-116* HCO3-30 AnGap-11 [**2140-3-29**] 12:46PM BLOOD Glucose-128* UreaN-27* Creat-0.9 Na-152* K-3.8 Cl-116* HCO3-28 AnGap-12 [**2140-4-2**] 04:03AM BLOOD Glucose-94 UreaN-17 Creat-0.8 Na-141 K-3.5 Cl-104 HCO3-29 AnGap-12 [**2140-4-3**] 06:53AM BLOOD Glucose-80 UreaN-16 Creat-0.7 Na-141 K-3.5 Cl-103 HCO3-30 AnGap-12 [**2140-4-4**] 05:50AM BLOOD Glucose-101 UreaN-12 Creat-0.8 Na-140 K-4.2 Cl-104 HCO3-28 AnGap-12 [**2140-3-23**] 09:05PM BLOOD Albumin-4.1 [**2140-3-24**] 04:30AM BLOOD Calcium-8.5 Phos-6.2*# Mg-2.4 [**2140-3-24**] 08:51PM BLOOD Calcium-8.1* Phos-4.7* Mg-3.2* [**2140-3-27**] 12:13PM BLOOD Calcium-8.5 Phos-2.6* Mg-2.1 [**2140-3-28**] 02:03AM BLOOD Calcium-8.4 Phos-3.9 Mg-2.4 [**2140-3-28**] 03:29PM BLOOD Calcium-8.3* Phos-4.2 Mg-2.5 [**2140-4-2**] 04:03AM BLOOD Calcium-7.8* Phos-2.9 Mg-2.0 [**2140-4-3**] 06:53AM BLOOD Calcium-7.7* Phos-3.4 Mg-1.8 [**2140-4-4**] 05:50AM BLOOD Calcium-7.9* Phos-3.8 Mg-2.2 . CDIFF culture negative x 2 on [**4-3**] & [**2140-4-4**] . MRSA culture negative x 2 on [**3-24**] & [**2140-3-26**] . Urine culture negative on [**2140-3-23**] . CT ABDOMEN W/O CONTRAST Study Date of [**2140-3-24**] 12:43 AM IMPRESSION: 1. Findings consistent with small bowel obstruction at the level of the ventral abdominal wall outpouching (likely attenuation of peritoneum rather than true hernia), with distal decompression. No perforation. 2. Cholelithiasis without cholecystitis. 3. Atherosclerotic calcification. . Pathology Examination Procedure date [**2140-3-26**] DIAGNOSIS: Small bowel, segmental resection: Segment of small bowel with fibrous adhesions, one incorporating synthetic mesh material, and focus of ischemic necrosis. Tissue at margins appears viable. Clinical: Bowel obstruction. . CHEST (PA & LAT) Study Date of [**2140-3-31**] 4:16 PM IMPRESSION: New left perihilar region faint ground-glass opacity concerning for aspiration. Persistent bibasilar atelectasis with bilateral pleural effusions. . [**2140-4-1**]-Video swallow completed via CT scan Brief Hospital Course: Mrs. [**Known lastname 104299**] was underwent a CT scan in the ED for c/o abdominal pain. Her CT scan revealed a small bowel obstruction near her known ventral hernia which was reducible at the beside. General surgery was consulted, and she was admitted to the ICU found to have junctional brady rhythm with prolonged QT (QTc near 600) in context of recent increase in Flecainide dose per PCP. [**Name10 (NameIs) **] was monitored in the ICU for a few days. Cardiology was consulted, and recommended holding beta blocker, and flecanide. Coumadin was also held in case of need for surgical intervention. In addition, her Potassium of 2.9 and Magnesium were aggressively repleted. Her cardiac status stabilized after undergoing diuresis with Diamox, however, her abdominal exam worsened over the following 48 hours after a few days of conservative management with NPO/NGT for decompression and IV antibiotics. . She was taken to the OR, and underwent lysis of adhesions and small bowel resection. Her operative course was uncomplicated, routinely observed in the PACU, and transferred back to [**Hospital Unit Name 153**] where cardiac monitoring and electrolyte correction occurred. She was transfused post/op with 2 U PRBC. HCTs remained stable thereafter. She was extubated and wean off pressors, and transferred to Stone 5. . Physical therapy was consulted upon transfer to Stone 5 for expected discharge to REHAB due to physical deconditioning. Remained NPO until bowel function resumed. Electrolytes checked and repleted daily. Hyponatremia resolved gradually. Started on sips of water, advanced to clear liquids. Noted to have difficulty swallowing and clearing secretions. Bedside Swallow study conducted. She was taken for Video swallow, and cleared for regular diet with thick liquids, and whole pills in puree. Patient reported passing flatus, and incontinent of loose, brown stools. Rectal tube inserted on [**2140-4-2**] due to frequencey of bowel movements, and risk for compromise of perineal skin. Rectal tube should be removed by Friday [**2140-4-8**] to prevent rectal breakdown. Diet advanced to regular food. Reported intermittent nausea and lack of appetite which has persisted throughout post-op recovery. Foley was removed. She was able to urinate, incontinent of urine. UA and urine cultures negative. . Mobility compromised. She requires [**1-26**] people for ambulation and transfer. Requires aggressive physical Rehab, and monitoring of Nutritional, bowel, and cardiac status. She should follow-up with PCP (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2450**]), and cardiology to address cardiac events (prolonged QT interval) during this admission. [**Hospital 197**] clinic at [**Hospital1 18**] manages the patients coumadin dosing for PAF. Coumadin 2mg Po given at [**2140-4-4**]. INR should be checked on [**2140-4-5**], and daily until therapeutic. Goal INR [**1-26**]. . She will require to have the incisional staples removed in another week. This can be done per REHAB facility after authorization per Dr. [**Last Name (STitle) **] (surgeon). Medications on Admission: Allopurinol 100', lipitor 20', colchicine prn, DiltSR 240', Flonase 50", Lasix 80", Diazepam 5 prn, Gabapentin 600HS/300AM/300PM Hydralazine 50 TID, ToprolXL 100 daily, Nitroglycerin prn, prilosec 40 daily, zoloft 100', Spironolactone 25', ASA 81', Coumadin 1mgMWF 2mg other days Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO Q 12H (Every 12 Hours). 3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for breakthrough for 2 weeks. 4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for Gout flare/pain. 7. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 8. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day). 9. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 11. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 12. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 13. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 15. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 16. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever or pain for 2 weeks: Do not exceed 4000mg in 24hrs. 19. Coumadin 1 mg Tablet Sig: Titrate dose per INR Tablet PO once a day: Goal INR [**1-26**]. Usual dosing MWF-1mg,other days 2mg. 20. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 5 days. 21. Zofran 2 mg/mL Solution Sig: Two (2) Intravenous every eight (8) hours as needed for nausea for 1 weeks. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: Primary: Pre/op prolonged QT interval-managed in ICU & cardiology consulted Recurrent incisional hernia reduced intestine post-op dysphagia-evaluated per Speech & Swallow Specialist post-op blood loss anemia . Secondary: Hx of SBOx3, Hchol, HTN, labile blood pressure,[**Last Name (un) 6043**] LV dysfn, CRI, Chronic chest pain, Paroxysmal AFib, Esoph spasm, Gout, GERD, migraines, gall stones Discharge Condition: Stable Tolerating a regular diet with Ensure supplements. Tolerating oral medications, whole, if purees. Adequate pain control with oral medication. Discharge Instructions: For REHAB: Weigh patient every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: none. Contact PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2450**], with any concerns. . Please call Dr. [**Last Name (STitle) **] or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Continue to ambulate several times per day. . Incision Care: -Your staples will be removed at your follow-up appointment with Dr. [**Last Name (STitle) **]. Staples may be removed at Rehab facilit. Please contact Dr.[**Name (NI) 10946**] office to authorize removal. Steri strips will be applied. -Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. . Medications: 1. Coumadin: Continue to dose patient daily according to INR level. Goal INR [**1-26**]. Usual home dosing is 1 mg MWF, and 2mg other days of week. Patient is followed per [**Hospital 18**] [**Hospital 197**] clinic. Followup Instructions: 1. Please follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 9**] in [**12-25**] weeks for removal of staples. 2. Follow-up with PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2450**], [**Telephone/Fax (1) 250**], 1-2 weeks after discharge from REHAB. 3. Follow-up with [**Hospital 197**] Clinic([**Telephone/Fax (1) 10844**]-[**Hospital1 18**] [**Location (un) 86**]-after discharge from REHAB for continued management of COUMADIN. . Previous appointments: 1. Provider: [**Name Initial (NameIs) 703**] (H3) GENERAL 2 [**Name Initial (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2140-4-5**] 9:30 2. Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2140-4-7**] 8:00 3. Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2140-4-7**] 8:15 Completed by:[**2140-4-4**]

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icd9cm

[ [ [] ] ]

[ "45.62", "04.81", "53.51", "96.27", "99.04", "54.59" ]

icd9pcs

[ [ [] ] ]

11983, 12068

6550, 9652

335, 466

12506, 12657

2917, 6527

14864, 15782

2237, 2353

9983, 11960

12089, 12485

9678, 9960

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14050, 14841

2368, 2368

2382, 2898

281, 297

494, 1208

1230, 1878

1894, 2221

45,012

145,064

41823+58481

Discharge summary

report+addendum

Admission Date: [**2114-10-9**] Discharge Date: [**2114-10-19**] Date of Birth: [**2049-9-18**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 165**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: [**2114-10-12**]: -Urgent coronary artery bypass graft x6; left internal mammary artery to left anterior descending artery and the saphenous vein grafts to diagonal, obtuse marginal 1 and 2, and distal circumflex, and distal right coronary artery. - Endoscopic harvesting of the long saphenous vein. History of Present Illness: 65-year-old male with uncontrolled diabetes and hyperlipidemia presenting with 2-3wks of exertional chest pain. Patient describes pain as non-radiating, sub-sternal, crushing "tightess", that appears after minimal exercise and resolves 1-2min after rest. He is unable to walk more than 10 steps without eliciting this pain. Pt has been increasingly conscious of pain/tightness over the past 2-3wks and has purposefully limited his activities recently (e.g. rests frequently when walking) to avoid symptom onset. Denies any chest pain/tightness at rest. Denies associated diaphoresis, nausea, palpitations, light-headedness, or shortness of breath. All other ROS negative In the ED, initial vitals were 98 65 195/140 18 98% ra. EKG showed NSR, PR prolongation 240, LAD, possible Q-waves in III/AVF, poor R wave progression, no ST-T wave changes, unchanged from 1 year prior other than PR prolongation. Two sets of Troponin-T returned at 0.02. CXR was unremarkable. He was sent for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4001**] protocol stress test. After minimal exercise (8 min), there was an inappropriate bp response (hypotensive) and ST elevations in V1-3 (<1.5mm - convex in V1, concave in V2-3), and the test was stopped as the patient developed typical anginal symptoms. The patient ws seen by cardiology. Given symptoms consistent with typical angina, he was admitted for cardiac catheterization. Vitals prior to transfer to the cath lab were 66 119/78 19 99%RA. In the cath lab he was found to have triple vessel disease (preliminary report: LAD: 90% occlusion, mid LCx: 80% occlusion, OM1 90% occlusion, RCA 80% occlusion). Given 4-vessel disease, PCI was not performed due to need for evaluation by cardiac surgery. Patient is being admitted to [**Hospital1 1516**] pending cardiac surgery workup (Dr. [**Last Name (STitle) **]. On arrival to the floor, the patient is in no acute distress. He confirms the history as above, and denies any chest pain, dyspnea, palpitations, lightheadedness at present. Review of symptoms was otherwise negative. REVIEW OF SYSTEMS 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, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia 2. CARDIAC HISTORY: none 3. OTHER PAST MEDICAL HISTORY: -Diabetes Mellitus (per pt poorly controlled with blood sugars regularly >200) -Hiperlipidemia -Perirectal Abscess -Erectile Dysfunction PAST SURGICAL HISTORY: -ORIF left distal radius fx -cholecystectomy -tonsillectomy Social History: Works in corporate media as video producer. Lives with wife. [**Name (NI) **] four adult children. Denies smoking, EtOH. Family History: n/a Physical Exam: Admission: Pulse:76 Resp:16 O2 sat:99/RA B/P Right:152/88 Left:144/94 Height:6'2" Weight:217 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x] Extremities: Warm [x], well-perfused [x] Edema: none Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right:1+ Left:1+ DP Right:1+ Left:1+ PT [**Name (NI) 167**]:1+ Left:1+ Radial Right:2+ Left:2+ Carotid Bruit Right:- Left:- Discharge: VS T 99.7 HR 77 BP 112/65 RR 18 O2sat 94%-2LNP Wt 99.6kg Gen: NAD Neuro: A&O x3, MAE-full strength. continues to have right side visual deficit that has improved slightly over last several days. continues to have difficulty [**Location (un) 1131**] printed data. CV: RRR, no murmur. Sternum stable, incision CDI Resp:CTA-bilat Abdm: soft, NT/ND/+BS Ext: warm well perfused. no pedal edema Pertinent Results: Discharge labs: [**2114-10-18**] 05:05AM BLOOD WBC-9.5 RBC-3.20* Hgb-9.9* Hct-30.2* MCV-95 MCH-31.0 MCHC-32.8 RDW-12.9 Plt Ct-297 [**2114-10-18**] 05:05AM BLOOD Plt Ct-297 [**2114-10-18**] 05:05AM BLOOD Glucose-227* UreaN-18 Creat-1.3* Na-140 K-3.4 Cl-104 HCO3-29 AnGap-10 [**2114-10-18**] 05:05AM BLOOD ALT-32 AST-47* LD(LDH)-304* AlkPhos-157* Amylase-80 TotBili-0.7 [**2114-10-17**] 03:46AM BLOOD ALT-33 AST-60* LD(LDH)-310* AlkPhos-170* Amylase-82 TotBili-0.9 [**2114-10-18**] 05:05AM BLOOD Albumin-3.1* Mg-2.1 [**2114-10-9**] EKG Sinus rhythm. The P-R interval is prolonged. There is a late transition that is probably normal. There are tiny R waves in the inferior leads consistent with possible myocardial infarction. Non-specific ST-T wave changes. Compared to the previous tracing of [**2113-9-10**] QRS voltages are less. Intervals Axes Rate PR QRS QT/QTc P QRS T 62 [**Telephone/Fax (3) 90830**]/401 22 -22 3 [**2114-10-10**] Exercise Tolerance Test RESTING DATA EKG: SINUS BRADY, LAA, AV DELAY, PRWP HEART RATE: 58 BLOOD PRESSURE: 130/80 PROTOCOL [**Doctor Last Name **] - TREADMILL STAGE TIME SPEED ELEVATION HEART BLOOD RPP (MIN) (MPH) (%) RATE PRESSURE 1 0-3 1.0 5 79 134/72 [**Numeric Identifier 79288**] 2 [**4-10**] 1.6 6 88 134/72 [**Numeric Identifier 90831**] 3 [**7-13**] 2.2 7 96 128/72 [**Numeric Identifier 90832**] TOTAL EXERCISE TIME: 8 % MAX HRT RATE ACHIEVED: 62 SYMPTOMS: ANGINA PEAK INTENSITY: [**2112-3-9**] TIME HR BP RPP ONSET: PEAK EX/IPE 90 134/70 [**Numeric Identifier 90833**] RESOLUTION: 2.75 REC 63 144/72 9072 INTERPRETATION: This 65 year old NIDDM man with h/o HLD was referred to the lab for evaluation of exertional chest pain. Patient exercised for 8 minutes of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4001**] protocol (~ 4.3 METS), representing a poor exercise tolerance for his age. Test was stopped due to ST elevation in association with an abnormal BP response and chest discomfort. During exercise, the patient noted central chest soreness that has been constantly present and sore with palpation. At peak exercise, the patient noted [**2112-3-9**] substernal chest tightness, unchanging with deep inspiration and resolving by minute 2.75 of recovery. 1-1.[**Street Address(2) 90834**] elevation was noted in leads V1-3 and 0.5 mm of upsloping ST segment depression in leads I and II, returning to baseline by minute 4 of recovery. The rhythm was sinus with rare, isolated apbs, one vpb and ventricular couplet during exercise/early recovery. Flat blood pressure response with a slight drop noted at peak exercise. Increase in heart rate to achieved workload with exercise. IMPRESSION: ST elevation in the setting of probable anginal type symptoms and abnormal BP response to exercise. [**2114-10-10**] Cardiac Catheterization 1. Selective coronary angiography of this codominant system demonstrated three vessel coronary artery disease. The LMCA had a distal 30% stenosis. The LAD had a proximal 90% stenosis and a mid 70% stenosis. The LCx had a mid 80% stenosis and a distal 60% stenosis. There was a large OM1 with a 90% stenosis. 2. Limited resting hemodynamics revealed mild systemic arterial hypertension with a central aortic pressure of 149/84 mmHg. 3. Recommend CABG. Patient admitted for CABG evaluation and to have his diabetes and medical therapy optimized perioperatively. Patient will need echo to assess LVEF. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Mild systemic arterial hypertension. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**2114-10-12**] Conclusions PRE-BYPASS: The left atrium is mildly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. There are focal calcifications in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. POST-BYPASS: Intact thoracic aorta. Preserved biventricualr systolic functin. LVEF 55%. No new valvular findings. Interpretation assigned to [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting physician [**2114-10-11**] Carotid USS IMPRESSION: Unremarkable carotid Doppler examination. No evidence of significant plaque or carotid artery stenosis. Flow in the vertebral arteries is prograde. Radiology Report CHEST (PORTABLE AP) Study Date of [**2114-10-15**] 7:09 AM Final Report: As compared to the previous radiograph, there is no relevant change. Low lung volumes, sternal wires in situ. Right internal jugular vein catheter in unchanged position. Unchanged moderate cardiomegaly with bilateral areas of atelectasis, left more than right. The left costophrenic sinus, suggesting a small left pleural effusion. Unchanged colonic dilatation. Minimal fluid overload. DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**] Brief Hospital Course: Mr [**Known lastname **] is a 65 year old male with h/o of poorly controlled diabetes, hyperlipidemia who presented with 2-3 weeks of chest pain on exertion with positive stress test admitted for cardiac catheterization and found to have 3VD then referred for CABG. [**Last Name (un) **] diabetes center was consulted for assistance with blood glucose control. Brought to the operating room with Dr. [**First Name (STitle) **] on [**10-12**] for coronary bypass grafting. Please see operative report for details, in summary he had: Urgent coronary artery bypass graft x6 with left internal mammary artery to left anterior descending artery and the saphenous vein grafts to diagonal, obtuse marginal 1 and 2, and distal circumflex, and distal right coronary artery. Endoscopic harvesting of the long saphenous vein. His bypass time was 146 minutes and crossclamp time was 123 minutes. He tolerated the operation well following which he was transferred to the cardiac surgery ICU in stable condition. Post operatively he woke, weaned from the ventilator and was extubated without difficulty, however he developed vision loss during this time and neglected to tell anyone until POD1. He had a head CT, neurology and ophthalmology were consulted. The head CT revealed: hypoattenuation in the left parieto-occipital lobe. There is no hemorrhage. There is no shift of normally midline structures. Ventricles and sulci are otherwise unremarkable. His vision loss was:right homonymous hemianopia He remained in the ICU because of hypoxia requiring high flow O2 therapy. Over the next several days his visual deficit improved slightly, he remained hemodynamically stable and was diuresed with resultant weaning from O2 therapy. He did however develop an ileus which required reinsertion of nasogastric tube and stopping oral intake for 24 hours. It resolved and diet was gradually resumed. All tubes, lines and drains were removed per cardiac suregry protocol w/o complication. On POD5 he was transferred to the floor for continued care and recovery. The remainder of his hospital course was uneventful. On POD 7 he was discharged to [**Hospital1 **], [**Location 1268**]. He is to follow up with Dr [**First Name (STitle) **] in one month. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientAtrius. 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea, wheeze 2. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] 3. glimepiride *NF* 4 mg Oral with breakfast 4. Simvastatin 40 mg PO HS 5. MetFORMIN (Glucophage) 1000 mg PO BID 6. Aspirin 81 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] 3. Docusate Sodium 100 mg PO BID 4. Metoprolol Tartrate 25 mg PO BID Hold for HR<60,SBP<90 5. Milk of Magnesia 30 mL PO DAILY:PRN constipation 6. Omeprazole 20 mg PO DAILY Duration: 1 Months 7. Senna 2 TAB PO BID 8. Simvastatin 40 mg PO HS 9. MetFORMIN (Glucophage) 500 mg PO BID 10. Acetaminophen 650 mg PO/PR Q4H:PRN temperature >38.0 11. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 12. Furosemide 20 mg PO DAILY Duration: 5 Days 13. Glargine 14 Units Bedtime Humalog 3 Units Breakfast Humalog 3 Units Lunch Humalog 3 Units Dinner Insulin SC Sliding Scale using HUM Insulin 14. Potassium Chloride 20 mEq PO DAILY Duration: 5 Days Hold for K >4.5 Discharge Disposition: Extended Care Facility: [**Hospital1 **] Nursing & Therapy Center - [**Location 1268**] ([**Location (un) 86**] Center for Rehabilitation and Sub-Acute Care) Discharge Diagnosis: [**2114-10-12**]: -Urgent coronary artery bypass graft x6; left internal mammary artery to left anterior descending artery and the saphenous vein grafts to diagonal, obtuse marginal 1 and 2, and distal circumflex, and distal right coronary artery. - Endoscopic harvesting of the long saphenous vein. -intra/post operative CVA with neurological findings of right homonymous hemianopia (without macular sparing) and alexia without agraphia; these findings localize to the left visual cortex with involvement of the posterior corpus callosum, both in the left PCA territory, thus causing the disconnection syndrome of alexia without agraphia. Also c/o lower extremitiy neuropathy felt to be d/t EVH harvest -post operative illeus, now resolved PMH: Diabetes Mellitus (poorly controlled with blood sugars regularly >200) Hyperlipidemia Perirectal Abscess Erectile Dysfunction Positive PPD Past Surgical History: ORIF left distal radius fx Tonsillectomy Discharge Condition: Alert and oriented x3 nonfocal Ambulating, deconditioned Incisional pain managed with Tylenol Incisions: Sternal - healing well, no erythema or drainage Leg bilat EVH sites- healing well, no erythema or drainage. Edema- trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **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) **] [**Name (STitle) **], [**Last Name (NamePattern1) **] [**Hospital Unit Name **], Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2114-11-6**] 1:45 Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2114-11-29**] at 8:50am Please call to schedule appointments with your Primary Care Dr.[**Last Name (STitle) 90835**],[**First Name3 (LF) **] P. [**Telephone/Fax (1) 17794**] in [**5-10**] 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** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2114-10-19**] Name: [**Known lastname **],[**Known firstname 11032**] Unit No: [**Numeric Identifier 14339**] Admission Date: [**2114-10-9**] Discharge Date: [**2114-10-19**] Date of Birth: [**2049-9-18**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 265**] Addendum: Diabetes regimen was ammended, see below: Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] 3. Docusate Sodium 100 mg PO BID 4. Metoprolol Tartrate 25 mg PO BID Hold for HR<60,SBP<90 5. Milk of Magnesia 30 mL PO DAILY:PRN constipation 6. Omeprazole 20 mg PO DAILY Duration: 1 Months 7. Senna 2 TAB PO BID 8. Simvastatin 40 mg PO HS 9. Acetaminophen 650 mg PO/PR Q4H:PRN temperature >38.0 10. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 11. Furosemide 20 mg PO DAILY Duration: 5 Days 12. Potassium Chloride 20 mEq PO DAILY Duration: 5 Days Hold for K >4.5 13. Glargine 18 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 14. glimepiride *NF* 4 mg ORAL WITH BREAKFAST 15. MetFORMIN (Glucophage) 1000 mg PO BID Discharge Disposition: Extended Care Facility: [**Hospital1 **] Nursing & Therapy Center - [**Location 205**] ([**Location (un) 42**] Center for Rehabilitation and Sub-Acute Care) [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**] Completed by:[**2114-10-19**]

[ "413.9", "560.1", "414.01", "E878.8", "997.02", "250.02", "434.91", "368.46", "997.49", "272.4", "401.9", "V58.67" ]

icd9cm

[ [ [] ] ]

[ "88.56", "39.61", "36.15", "36.14" ]

icd9pcs

[ [ [] ] ]

17925, 18205

10310, 12546

321, 623

14863, 15091

4900, 4900

15930, 17171

3817, 3822

17194, 17902

13890, 14776

12572, 12931

8336, 10287

15115, 15907

4916, 8319

14799, 14842

3837, 4881

3404, 3409

271, 283

651, 3292

3440, 3578

3336, 3384

3679, 3801

45,767

157,789

40354

Discharge summary

report

Admission Date: [**2110-7-5**] Discharge Date: [**2110-8-9**] Date of Birth: [**2049-6-26**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 99**] Chief Complaint: Decreased sensation and weakness in lower extremities, stool incontinence, and urinary retention for initial admission, hypoxia for his ICU transfer Major Surgical or Invasive Procedure: Elective intubation for CT and MRI scans Elective intubation for push enteroscopy S/p laminectomy x2 and hemilaminectomy x2 push enteroscopy EGD Capsule endoscopy TLC placement in RIJ History of Present Illness: Mr [**Known lastname 24347**] is a 61 y/o male with prior history of multiple myeloma s/p chemo and XRT to pelvis, who presented to ED on [**7-4**] with decreased sensation and weakness in his lower extremities, stool incontinence, and urinary retention. MRI showed compressive metastatic lesions at the T3/T5 levels. He underwent T2/T4 hemilaminectomies and T3/T5 laminectomies on [**7-5**]. His post-operative course has been complicated by upper extremity DVT, for which he was started on heparin gtt. He was also found to have lung nodules on chest imaging, for which he underwent CT-guided biopsy on [**7-11**], pathology pending. . Today, the patient was initially normoxic on the floor, but had progressively worsening hypoxia throughout the day. O2 sats were 95% on room air at 0800, and on evening vital sign checks, he was found to be satting in the 80s on room air. He was initially placed on high flow nasal cannula without significant response, and subsequently required 100% non-rebreather mask to maintain sats in the low 90s. He was written for fluconazole, acyclovir, SS bactrim, and 40 mg IV lasix. Prior to transfer to the ICU, he was satting 93% on the NRB. He reported worsening shortness of breath, and frustration at the prospect of transfer to the ICU. He felt that he had not been eating and receiving pain medications on time, and that is why his oxygen level was low. . On arrival to the ICU, he reports stable labored breathing, and is requesting to remove his non-rebreather mask. He denies chest pain, palpitations, nausea, vomiting, or abdominal pain. He does state that his abdomen is more distended than usual but he is not constipated. He has no strength or sensation in his legs, and cannot move them. . Review of systems: As per HPI. Also endorses chronic back pain that is at its baseline. Otherwise denies fever, chills, night sweats, cough, chest pressure, dysuria, urinary frequency or urgency. . Oncologic history (per BMT notes): Patient reports being diagnosed with multiple myeloma after he presented to an outside hospital [**2109-3-11**] with bilateral lower extremity pain, weakness and fatigue, renal dysfunction and confusion. Intial bone marrow biopsy demonstrated MM with 100% invovlement, and IgA 2,655. The patient was started on XRT to bonysites of disease in the pelvis and chemotherapy(velcade/revlimid/dex per outside notes). Since that time patient has tolerated therapy well and reports a significant improvement in symptoms. Patient has had a significant decrease in paraprotein, normalization of plasma cells in marrow and improvement in disease on imaging. During this hospitalization, in addition to the above spinal imaging, he also received a CT of his chest, which revealed multiple pulmonary nodules, concerning for metastatic disease Past Medical History: - Multiple hospitalizations in Spring [**2110**] -hospitalized from [**Date range (1) 88502**] at [**Last Name (un) 1724**] with shingles requiring high dose acyclovir and analgesia, as well as PNA with resultant bandemia and hypotension requiring ICU admission, treated with 5 days vanco and azithromycin, and seven days pip/tazo -hospitalized at [**Last Name (un) 1724**] [**Date range (1) 88503**], with E coli, PCP and [**Date range (1) 1074**] pneumonia; was initially treated with Bactrim, but experienced thrombocytopenia and was switched to atovaquone - DVTs status post IVC filter placement - HTN - HL - Disc herniation with sciatica - CAD, s/p stent x2 - Hypothyroidism - Prior R rotator cuff repair - R knee arthroscopic surgery - Appendectomy age 17 Social History: +1-1.5 PPD since age 15. No current ETOH, no illicits. Previosuly worked in automotive parts. Family History: Mother died of lung cancer. No other malignancies Physical Exam: Admission Exam: 7/ ICU-->BMT Transfer Exam: Vitals T 97.5 HR 73 BP 108/64 RR 20 O2 96 % RA General: Alert, oriented, no acute distress, sitting upright working on computer HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Diffuse rhonchi, R>L, no wheeze CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: thin lower extremities with muscle atrophy. 2+ pulses, no edema Neuro: AAOx3, Speech fluent, thought process clear. Moving upper extremities freely, but with limited grip strength in left hand. Sensation intact throughout upper extremities. Lower extremities with flaccid paralysis. +sensation intact over distal legs. . [**8-2**] ICU Admission Exam: General: sedated, falling asleep during interview but arousable HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: Upper extremities markedly edematous and firm, LUE with gauze dressing on, wasting of lower extremities . [**8-7**] Updated ICU Exam: General: Intubated (not sedated), ill-appearing and grossly edematous, lying in bed in no acute distress, eyes partially open, does not more fully open eyes or track to voice or sternal rub. HEENT: ETT and NGT in place. Neck: Single left-sided supraclavicular node, firm and mobile CV: Tachycardic, regular rhythm. Nl S1/S2. No murmurs appreciated. Lungs: Coarse bilaterally, anteriorly. Abd: BS+. Soft. NT/ND. Red blood oozing from urethra around foley. Ext: 2+ LE pitting edema b/l. Weeping & ecchymoses of the UE bilaterally, extensively bandaged. Neuro: Does not follow commands nor respond to voice or touch. . DISCHARGE EXAM: Expired Pertinent Results: [**2110-7-14**] 01:06AM BLOOD WBC-19.7* RBC-2.65* Hgb-8.1* Hct-25.0* MCV-94 MCH-30.6 MCHC-32.4 RDW-19.8* Plt Ct-299 [**2110-7-14**] 01:06AM BLOOD PT-14.2* PTT-91.1* INR(PT)-1.2* [**2110-7-14**] 01:06AM BLOOD Plt Ct-299 [**2110-7-14**] 07:48AM BLOOD PTT-98.4* [**2110-7-15**] 03:06AM BLOOD PT-14.3* PTT-113.6* INR(PT)-1.2* [**2110-7-15**] 03:06AM BLOOD Plt Ct-286 [**2110-7-15**] 11:24AM BLOOD PTT-114.9* [**2110-7-14**] 01:06AM BLOOD Glucose-146* UreaN-28* Creat-0.5 Na-139 K-4.0 Cl-101 HCO3-25 AnGap-17 [**2110-7-15**] 03:06AM BLOOD Glucose-157* UreaN-31* Creat-0.6 Na-138 K-4.3 Cl-99 HCO3-24 AnGap-19 [**2110-7-15**] 04:36PM BLOOD Glucose-118* UreaN-34* Creat-0.6 Na-138 K-4.4 Cl-100 HCO3-29 AnGap-13 [**2110-7-14**] 01:06AM BLOOD ALT-39 AST-31 LD(LDH)-563* AlkPhos-130 TotBili-0.3 [**2110-7-14**] 06:53PM BLOOD Type-ART Temp-35.7 pO2-56* pCO2-28* pH-7.52* calTCO2-24 Base XS-0 Intubat-NOT INTUBA ___ MICROBIOLOGY: [**2110-8-6**] 7:43 am SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2110-8-6**]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): BUDDING YEAST. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND SINGLY. RESPIRATORY CULTURE (Preliminary): MODERATE GROWTH Commensal Respiratory Flora. GRAM NEGATIVE ROD(S). SPARSE GROWTH. FUNGAL CULTURE (Preliminary): ACID FAST SMEAR (Final [**2110-8-7**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. [**2110-8-1**] 11:48 am BLOOD CULTURE Source: Line-Picc. Blood Culture, Routine (Final [**2110-8-7**]): NO GROWTH. [**2110-7-31**] 9:08 am SPUTUM Source: Induced. GRAM STAIN (Final [**2110-7-31**]): [**11-4**] PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. 2+ (1-5 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Final [**2110-8-2**]): MODERATE GROWTH Commensal Respiratory Flora. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2110-8-1**]): NEGATIVE for Pneumocystis jirovecii (carinii).. [**2110-7-18**] 5:44 pm Rapid Respiratory Viral Screen & Culture BRONCHIAL LAVAGE. Respiratory Viral Culture (Final [**2110-7-23**]): No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Respiratory Viral Antigen Screen (Final [**2110-7-21**]): Less than 60 columnar epithelial cells;. Specimen inadequate for detecting respiratory viral infection by DFA testing. Interpret all negative results from this specimen with caution. VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary): No Cytomegalovirus ([**Month/Day/Year 1074**]) isolated. [**2110-7-18**] 5:44 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE. GRAM STAIN (Final [**2110-7-18**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2110-7-21**]): 10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2110-7-19**]): NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Final [**2110-8-1**]): YEAST. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. ACID FAST SMEAR (Final [**2110-7-21**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): Reported to and read back by DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8402**] AND [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16137**] @ 1440, [**2110-8-1**]. AFB GROWN IN CULTURE; ADDITIONAL INFORMATION TO FOLLOW. SENT TO STATE LAB FOR FURTHER IDENTIFICATION [**2110-8-3**]. [**2110-7-15**] 3:06 am Blood (EBV) Source: Line-PICC. **FINAL REPORT [**2110-7-17**]** [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2110-7-17**]): POSITIVE BY EIA. [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2110-7-17**]): POSITIVE BY EIA. [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2110-7-17**]): NEGATIVE <1:10 BY IFA. INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION. [**2110-7-15**] 3:06 am Immunology ([**Month/Day/Year 1074**]) Source: Line-PICC. **FINAL REPORT [**2110-7-17**]** [**Month/Day/Year 1074**] Viral Load (Final [**2110-7-17**]): [**Month/Day/Year 1074**] DNA not detected. Performed by PCR. Detection Range: 600 - 100,000 copies/ml. ------ ------ IMAGING: [**8-7**] Renal Doppler FINDINGS: The exam is somewhat limited due to patient's intubated status and inability to breath-hold. The right main renal vein is patent. The right main renal artery shows a normal arterial waveform with a peak velocity of 35 cm/sec. The right upper, mid, and lower pole arterial waveforms are normal appearing with brisk upstrokes; although resistive index could not definitely detected with the upper pole, resistive indices for the mid and lower poles were 0.78 and 0.80 respectively. The left main renal vein is patent. The left main renal artery shows a normal-appearing waveform with a peak velocity of 63 cm/sec. Resistive indices for the upper, mid, and lower poles were 0.75, 0.79, and 0.78 respectively. IMPRESSION: Patent renal arterial and venous vasculature as described above with normal resistive indices. RIB UNILAT, W/ AP CHEST LEFT [**8-4**] There are patchy opacities throughout both lungs. Please see report of [**2110-8-3**] chest x-ray for a more complete discussion of this abnormality. The cardiomediastinal silhouette is widened and a right-sided PICC line tip appears to overlie the SVC/RA junction. No left-sided rib fracture is detected. No focal lytic or sclerotic rib lesion is identified. ECHO [**8-1**] The left atrium and right atrium are normal in cavity size. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>65%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be quanitfied. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. No definite valvular dysfunction identified. Compared with the prior study (images reviewed) of [**2110-3-14**], biventricular cavity sizes are somewhat smaller and left ventricular systolic function is more dynamic. The heart rate is also much higher and image quality is suboptimal on the current study. LENI [**7-10**]: CONCLUSION: Intraluminal thrombus is noted in one of the brachial veins, the one lying more anteriorly. PICC line present in the basilic vein. LENI [**7-24**] 1. No flow within the distal left subclavian vein with presence of thrombus. Proximal subclavian vein shows minimal flow. 2. Left internal jugular, axillary, brachial, basilic, and cephalic veins appear patent. LENI [**7-25**] IMPRESSION: No evidence of DVT within the right upper extremity veins. Redemonstration of previously seen thrombus in the left subclavian vein. CT Torso [**7-7**] IMPRESSION: 1. Multiple lung nodules. Differential diagnosis is broad and includes infection, vasculitis, and lung involvement of myeloma. 2. Extensive lymphadenopathy . 3. Epidural mass better seen in prior MR [**First Name8 (NamePattern2) 767**] [**7-5**]. 4. Right adrenal lesion, not characterized as adenoma. CT Torso [**7-17**] IMPRESSION: 1. Multiple bilateral pulmonary lesions are slightly decreased in size but show new evidence of cavitation, concerning for septic emboli or infection with an organism such as Nocardia or pseudomonas. Additional new ground-glass opacities predominantly in the upper lobes, right greater than left, are also concerning for infection, although asymmetric pulmonary edema could also have this appearance. 2. New tree-in-[**Male First Name (un) 239**] opacities in the right lower lobe are concerning for aspiration pneumonitis/pneumonia. 3. Diffuse lymphadenopathy and soft tissue nodules within the mediastinum, parasternal region, posterior cervical region, retroperitoneum, pelvis, and gluteal region, as described above. These lesions are consistent with extraosseous involvement of multiple myeloma, an uncommon manifestation of the disease described in an article from AJR dated from [**2103**] (183:929-932). 4. Diffuse metastatic disease involving the axial skeleton, as described on MR [**First Name8 (NamePattern2) 767**] [**2110-7-5**]. A mid thoracic paraspinal/epidural mass causes compression of the spinal cord, most significant at T5, not appreciably changed compared to the prior study. 5. Infrarenal abdominal aortic aneurysm measuring up to 5.9 cm. CT Torso [**7-27**] IMPRESSION: 1. Progression of right basilar tree-in-[**Male First Name (un) 239**] opacities with new areas of consolidation at both bases. Progression of ground-glass opacities in the left and right upper lobes. These findings are concerning for progressive infectious process. Several pulmonary lesions again seen with evidence of cavitation concerning for septic emboli or infection with Nocardia or Pseudomonas. 2. Diffuse lymphadenopathy and soft tissue nodules within the mediastinum, parasternal region, posterior cervical soft tissue nodules. These lesions are consistent with extraosseous involvement of multiple myeloma. 3. Mid thoracic paraspinal mass again seen, better evaluated on MRI. Spine MRI - multiple studies, see OMR Brief Hospital Course: Prior to patient's ICU courses, the patient underwent laminectomy x2 and hemilaminectomy x2 and he was subsequently transferred to the BMT unit for further management of his multiple myeloma. . 61 y/o M with past multiple myeloma treated with chemo and XRT, multiple hospital admissions for pneumonia in recent months, now admitted on [**7-5**] for lower extremity paralysis related to spinal cord involvement, c/b upper extremity DVT, and newly found lung nodules concerning for malignancy, now s/p biopsy. Initially on Ortho Spine [**Hospital 81944**] transferred to BMT floor following post-operative stabilization, then transferred to the ICU for hypoxia and bloody stools. . First ICU Course: Hypoxia improved within hours, with the patient weaning from a non-rebreather to room air in less than 12 hours. He had an acute drop in his hematocrit with dysphagia and guaiac positive stool. He received RBC transfusions and his heparin was stopped, with subsequent improvement in his hct. GI was consulted and performed upper endoscopy and capsule endoscopy, neither of which revealed active bleed. He was scheduled to start radiation therapy but was unable to lie flat due to back pain. He was electively intubated, to be able to tolerate imaging studies and bronchoscopy/BAL. He developed asymmetric left hand weakness, was seen by neurology, and underwent MRI of brachial plexus and cervical spine, showing posterior fluid collection between C5-T2. He had a CT chest on [**7-17**], which showed diffuse peribronchovacular GGO's, signs of aspiration, and increased bilateral lymphadenopathy. Concurrent abdominal imaging also revealed a 5.8cm infrarenal AAA. He was followed by the pain service for his significant LBP, and he was started on bortezomib chemotherapy. Transferred back to the BMT service for management. . . Second ICU Course . Readmitted to ICU on [**7-24**] for persistent hypoxia and ongoing GI bleed. . # Hypoxemia: Pt has had multiple recent admissions with various pulmonary infections, but on admission was not demonstrating septic physiology or signs of severe systemic infection. He triggered on the floor for hypoxia, was diuresed and transferred to the ICU. Diuresis improved his Sp02 to 94% on RA, resolved respiratory distress, & produced good UOP. Multiple chest imaging studies were obtained, as follows: CXR showed new lower lobe opacity with concern for new bacterial lobar pneumonia vs aspiration pneumonia/pneumonitis. CT chest showed nodules concerning for malignancy, but this likely an indolent process which would not account for abrupt worsening of oxygenation over 12 hour course. He underwent a lung nodule biopsy which showed focal organizing pneumonitis, chronic inflammation, and non-necrotizing granulomas. Additional CT finding of ground-glass opacities c/f PNA improved on more recent CT. Pt is at risk for PE with known DVTs, hematologic malignancy, & recent interruption in systemic anticoagulation for lung biopsy; heparin was started but stopped when the pt developed dropping Hct with guaiac positive stools suspicious for GI bleed (see below). Pt remained hemodynamically stable throughout his ICU course. Bronchioalveolar lavage and sputum cultures were negative including AFB, [**Month/Year (2) 1074**], and PCP, [**Name10 (NameIs) 151**] the exception of one BAL culture which grew yeast after 5 days. Beta-glucan, galactomannan and PCP PCR labs were pending at time of transfer. He was treated empirically with an 8 day course of vancomycin and zosyn, 5 days azithromycin, 6 days fluconazole (ongoing), 6 days acyclovir (ongoing), and bactrim prophylaxis was started. . #GI bleed Pt suffered a 6-point Hct drop during first ICU admission -- suspected source was upper GI bleed given coincident melanotic stools. Other possibilities considered and ruled out included: retroperitoneal bleed (negative CT Abdomen), bleeding into or rupture of pre-existing 5.8cm AAA (asymptomatic, vital signs stable), or bleed into recent spinal surgical site (surgical site appeared non-concerning). Pt underwent capsule endoscopy, which showed multiple non-bleeding angioectasias throughout the small bowel but no evidence of active bleeding. Plan from GI was to prep patient for a colonoscopy in the near future if the capsule study is negative, but this did not happen as patient's Hct stabilized at baseline 27 and melanotic stools resolved. Vital signs remained stable. . # Spinal cord compression/paralysis: S/p laminectomy x2 and hemilaminectomy x2, without subsequent improvement in extremity strength/sensation. We continued him on his corticosteroids and frequently repositioned to avoid skin breakdown. Orthospine service monitored the patient in the ICU; staples were removed and post-surgical site appeared clean. Pain service was involved in pain management; initially controlled on IV methadone, pt was transitioned to tylenol, lidocaine patch, and dilaudid PCA. Radiation oncology evaulated the patient for XRT to palliate pain and prevent loss of or even improve some neurological function of the LUE. Patient underwent mapping and completed a course of XRT. At time of transfer he was on a dexamethaxone taper with dilaudid PCA for pain management. . # DVTs: Pt has lower extremity DVTs diagnosed at [**Last Name (un) 1724**] last month plus upper extremity DVT in the LUE involving the subclavian, earlier on this admission. After his lung biopsy on [**7-11**], heparin gtt was restarted. Anticoagulation was stopped in the context of Hct drop/suspected GI bleed. Patient refused pneumoboots. Deferred decision on chronic anticoagulation until GI w/u complete, including possible evaluation for intracranial metastases. . # Multiple myeloma: Per onc notes, pt had excellent response to prior treaments, as of [**2110-3-11**]. No close oncology follow up between that time and this presentation. CBC/diff not concerning for acute myeloma, and SPEP showing hypogammaglobulinemia except normal IgA level. Has elevated free kappa light chains in serum, consistent with prior IgA kappa MM. He received velkade per hematology consult. Given concern for metastases to spinal cord and pulmonary nodules, pt was prepped twice for radiation therapy; the first time he was unable to tolerate lying flat due to respiratory distress. He was ultimately able to receive the full course of 5 radiation treatments to C5-C7, last dose received [**2110-7-31**]. Patient was actively followed by BMT through his course in the [**Hospital Unit Name 153**]. . # Leukocytosis: Patient developed elevated WBC to 33.8 in the ICU. Considered infectious process vs post-operative vs leukemoid reaction from glucocorticoids. WBC trending down, 23.3 at time of transfer, s/p several days of broad-spectrum antibiotics including antivirals and antifungals. Pt afebrile but pt on standing tylenol. Steroid reponse most likely but persistent bands on diff (3% today) suggests possible ongoing infectious process. . # CAD: Developed CP in the [**Hospital Unit Name 153**]. ECG without ischemic changes. He was previously ruled out by biomarkers earlier in admission. On telemetry, no events. . # Hypertension: Stable BP in ICU, mildly hypotensive while sleeping on floor, but improves when awakened. Not listed as taking beta blocker as outpatient despite CAD. Continued amlodipine and furosemide in ICU. . # Hyperlipidemia: Continued home statin. . # Hypothyroidism: Continued home synthroid. _____ Third ICU Course ([**8-2**] - [**8-9**]): . 61 y/o M with PMH as above, transferred back to [**Hospital Unit Name 153**] from BMT service for recurrent GI bleed. . # Goals of care: At a meeting between the patient's primary oncologist and the patient's HCP, the oncologist informed the HCP that there were no other treatment options available for the patient's underlying multiple myeloma. At this discussion, the decision was made to transition the patient to DNR/DNI status with no further escalation in care. The patient expired on [**2110-8-9**]. . # GI bleed: Transferred from BMT unit for melanotic stool and tachycardia with a Hct 21, requiring 3U PRBC on the day of transfer to maintain Hct >25. was held. Previous capsule study did show non-bleeding AVMs in small bowel. Pt required intubation for push enteroscopy which did not identify any bleeding source. Plan was for follow-up balloon enteroscopy to evaluate the small bowel, but no further GI procedures were performed because patient was persistently ventilator-dependent post-procedure with mental status changes (see below). Through the ICU course, melena continued & hematocrits were checked every 8 hours. The patient was transfused as necessary to meet transfusion goals: Hct >25 and platelets > 50. In the ICU (as of [**2110-8-7**]) he had received a total of 10 U PRBCs, 6 platelet transfusions, and 2 cryoprecipitate transfusions. . # Hypoxemia: After transfer back to the ICU he was found to have a significant A-a gradient on ABG. No evidence of right heart strain on EKG. At high risk for PE given immobility, known DVTs in multiple extremities, and active malignancy. Acute onset of hypoxia was suggestive of vascular event. Unfortunately, ability to treat suspected PE by anticoagulation was limited by ongoing GI bleed. . Other possible explanations for initial hypoxemia included infectious process, pulmonary edema, or transfusion-related pulmonary process given the numerous blood product transfusions he required for his ongoing GI bleed. Initial CXR showed no infiltrate and pt was afebrile. No improvement with diuresis. However, CT chest showed progression of right basilar tree-in-[**Male First Name (un) 239**] opacities with new areas of consolidation at both bases, progression of ground-glass opacities in the left and right upper lobes, and several progressively cavitating parenchymal lesions concerning for septic emboli, Nocardia, Pseudomonas or Tuberculosis. . Extensive infectious workup was performed in consultation with Infectious Disease consult service. Empiric antibiotic therapy with Vancomycin /Zosyn /Acyclovir was continued. Vanc/Zosyn were stopped given serial negative sputum and blood cultures were negative but restarted when pt spiked fevers to 102-103; sputum cultures sent at that time grew GPC and GNR. He was also continued on Voriconazole for yeast+ sputum cultures; this was transiently changed to micofungin but changed back to voriconazole when patient's respiratory status further deteriorated after the GI procedure. In addition, a BAL culture sent on [**2110-7-18**] eventually grew AFB positive; cultures were sent to the state lab for speciation. Pt was placed on TB precautions and started on empiric therapy for TB/[**Doctor First Name **] (isoniazid, rifampin, ethanbutol, moxifloxacin, azithromycin). These were all stopped when serial sputum smears were AFB-negative. Studies were also negative for the PCP, [**Name Initial (NameIs) 1074**] (and other viral studies); given acyclovir-induced crystal nephropathy was within the differential when the patient became anuric (see below), acyclovir was also stopped when tests returned negative. He received supplemental oxygen and nebulizers with O2 saturation >90% until elective intubation for a GI procedure (see below). . #Elective intubation: Patient underwent elective intubation for GI push enteroscopy. Following the procedure he had persistent respiratory acidosis and was not able to be extubated. Maintained primarily on pressure support ventilation; took in large tidal volumes with some improvement in his acidosis. He had recurrent fever to 102-103, non-responsive to tylenol. Vancomycin/Zosyn/Voriconazole was continued as above. The patient did not require sedation on the ventilator. He expired on the ventilator. . #Acure Renal Failure: Patient became acutely anuric with an elevated serum creatinine. Urine lytes suggested a pre-renal state. Renal was consulted. Sediment showed muddy-brown casts c/w ATN. Other possible diagnoses, per Renal, are various types of "obstructive uropathy" including myeloma cast nephropathy and acute acyclovir crystallopathy. Renal U/S showed no hydronephrosis. Per renal recs, repleted the patient intravascularly with 25% albumin solution and monitored the patient's CVP. He also received significant albumin load via multiple blood product transfusions during this time. Serial ABGs while ventilated showed mixed respiratory/metabolic acidosis. Her remained anuric. . #Mental Status Changes. Following elective intubation, patient initially required a fentanyl drip for sedation. However, his mental status gradually declined such that he did not require sedation on the vent, and on examination was unresponsive and unable to follow commands. At the time he remained intubated on mechanical ventilation, continued to be anuric and anasarcic, and continued to spike tylenol-nonresponsive fevers to 102 on vancomycin/ zosyn/ micofungin and empiric antibiotics for AFB. Melanotic stools and dropping Hct continued to require blood and platelet transfusion. All pain and sedating medications were held. All meds were checked for renal dosing and non-essential medications were stopped, including empiric TB antibiotics (AFB negative smears x3). No improvement in mental, respiratory, or renal status. [**Name (NI) 1094**] HCP changed his code status from Full to DNR/DNI with instructions not to escalate care. . # Multiple myeloma: Previously started bortezomib therapy and had completed XRT. BMT actively followed the patient while in the [**Hospital Unit Name 153**]. Follow-up IgA was elevated, suggesting relapse of MM. UPEP was sent, showed trace monoclonal free Bence-[**Doctor Last Name **] Kappa detected and additional monoclonal IgA Kappa Bence-[**Doctor Last Name **] now representing 4% of urinary protein. In addition, a firm, mobile, palpable left supraclavicular nodule was identified on exam, concerning for plasmacytoma. Underwent U/S guided excisional biopsy. Lymph node microbiology was gram stain-negative, AFB-negative. Hematopathology examination showed a mass of plasma cells with necrosis.. . # DVT: Unable to treat multiple known thromboses given active GI bleed requiring RBC transfusions. Of note, the patient does have an IVC filter in place. . # Spinal cord mets s/p decompressive laminectomies: Path consistent with plasma cell metastases. Left with flaccid paralysis on bilateral lower extremities, although has some residual sensation. Continued management with pain control and dexamthasone; all pain medications were stopped when patient's mental status changed as above. . # Chronic back pain: Patient's prior pain regimen of acetaminophen, gabapentin, dilaudid PCA, tizanidine, and lidoderm were continued upon transfer to the ICU. When the patient was intubated, his oral pain regimen and PCA were held, and pain control was continued with Fentanyl PCA. All pain meds including gabapentin and fentanyl were stopped when his mental status changed (as above). . # CAD: Patient c/o left-sided CP not associated with SOB and without radiation. No ischemic changes were seen on ECG. Patient was monitored on tele with no events noted. Patient underwent left-sided rib films as patient's pain was reproducible with palpation. Rib series showed no fractures, focal or sclerotic lesions. . # Nutrition/Hypoglycemia. Pt developed hypoglycemia to 40s, which started while NPO prior to GI procedure. Unclear etiology, asymptomatic. Received D50 as needed for hypoglycemia. Tubefeeds were started after patient was intubated on mechanical ventilation. # Hypertension: Home amlodipine was discontinued in the setting of GI bleed. Patient's BPs were stable with systolic pressures in the 110s-120s. . # Hypothyroidism: Continued home levothyroxine. Medications on Admission: Medications (home): ALLOPURINOL 300 mg PO daily AMLODIPINE 5 mg PO daily DEXAMETHASONE Dosage uncertain FENTANYL - 100 mcg/hour Patch/72 hr FUROSEMIDE 40 mg PO daily LENALIDOMIDE [REVLIMID] last dose was [**2110-3-13**] LEVOTHYROXINE 200 mcg PO daily LORAZEPAM 1 mg PO Q8 hrs PRN OMEPRAZOLE 40 mg Capsule, Delayed Release(E.C.) PO daily OXYCODONE 5-10 mg PO Q4-6H PRN PAIN PROCHLORPERAZINE MALEATE 10 mg PO Q6-8Hrs PRN nausea SIMVASTATIN 20 mg PO QHS ASPIRIN 81 mg PO daily CALCIUM CARBONATE-VITAMIN D3 [OS-CAL 500 + D] - Dosage uncertain MULTIVITAMIN Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired

[ "305.1", "414.01", "285.1", "279.00", "244.9", "441.4", "789.39", "707.20", "707.23", "401.9", "518.81", "707.22", "799.02", "203.00", "584.9", "486", "724.5", "787.20", "251.2", "578.1", "724.01", "707.03", "518.89", "507.0", "453.82", "336.3", "338.3", "344.60" ]

icd9cm

[ [ [] ] ]

[ "45.13", "99.25", "96.71", "96.72", "38.97", "77.49", "96.04", "03.09", "33.24", "33.26", "92.29", "38.93" ]

icd9pcs

[ [ [] ] ]

33225, 33234

16855, 32590

449, 634

33285, 33294

6510, 7744

33350, 33360

4390, 4442

33193, 33202

33255, 33264

32616, 33170

33318, 33327

4457, 6466

10195, 16832

6482, 6491

7912, 10156

7785, 7879

2423, 3474

261, 411

662, 2403

3496, 4262

4278, 4374

18,199

193,811

43308

Discharge summary

report

Admission Date: [**2194-3-15**] Discharge Date: [**2194-3-18**] Date of Birth: [**2119-10-31**] Sex: M Service: [**Location (un) **] Dictating for: [**Name6 (MD) **] [**Name8 (MD) 93272**], M.D. CHIEF COMPLAINT: Shortness of breath and stridor. HISTORY OF PRESENT ILLNESS: This is a 74-year-old white male with hypertension, history of congestive heart failure, multiple malignancies with metastases, who presented on [**2194-3-15**] with shortness of breath, chest pain, lower extremity edema, and purulent discharge from infected site from thyroidectomy on [**2194-1-29**]. The patient was on three days of dicloxacillin for the wound infection prior to presentation. The patient had a total thyroidectomy on [**2194-1-29**] for advanced papillary thyroid cancer with invasion of the esophagus and the right laryngeal nerve. The esophagus was entered and repaired, and the right laryngeal nerve was sacrificed during the operation. Postoperatively, the patient received radioactive iodine for adjuvant chemotherapy. Eight days ago he developed swelling and erythema to the surgical wound site in his neck and upper chest. He was started on dicloxacillin by Dr. [**Last Name (STitle) 574**]. Three days after initiation of treatment, he had purulent discharge from the site and developed progressively worsening stridor, dyspnea, and orthopnea (unable to sleep supine), one episode of chest pain (nonradiating, lasting seconds), and lower extremity edema. He had fever. He denies chills, nausea, vomiting, abdominal pain, diarrhea, rashes, constipation, lightheadedness, diaphoresis, and palpitations. Myocardial infarction was ruled out per serial creatine kinase and troponin I (troponin I level was 0.3). CT of the neck showed severe focal narrowing of larynx and trachea. He was admitted to Intensive Care Unit on [**2194-3-15**] and underwent bronchoscopy with dilation, followed by open tracheostomy. Currently, had tracheostomy tube with oxygen mask. He may have had a previous chest x-ray showing mild congestive heart failure and calcified granuloma in the left middle lung. Treated in the Medical Intensive Care Unit with cefazolin for operative infection. PAST MEDICAL HISTORY: 1. Thyroid cancer, status post total thyroidectomy on [**2194-1-29**] (Dr. [**Last Name (STitle) **]. 2. Renal cancer with lung metastases. 3. Hypertension. 4. Hyperlipidemia. 5. Abdominal aortic aneurysm. 6. Peripheral vascular disease, status post femoral-popliteal over 10 years ago. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Synthroid, Plavix, Cardizem, Capozide, iodine, aspirin, Pravachol, dicloxacillin. SOCIAL HISTORY: Sixty years of smoking one pack per day. Social alcohol drinker. He lives with his wife. [**Name (NI) **] is a primary care doctor. Speaks Russian only. PHYSICAL EXAMINATION ON PRESENTATION: On physical examination, vital signs revealed temperature of 98.3, pulse of 67, blood pressure of 150/90, respiratory rate of 20, saturation of 97% on 10 liters. On physical examination, the patient appeared in no acute distress, alert and oriented. Could not speak, but appeared comfortable. Tracheostomy tube was in place. There was an oxygen mask near the tube. The patient is Russian-speaking. Head and neck examination showed mild conjunctival injection (right more than left), and xanthelasma. Head examination also showed supraorbital swelling. Pupils were equal and reactive to light. Extraocular movements were intact. The oropharynx was moist and clear. On neck examination, the neck was tender near the wound, tracheostomy tube was in place. There was no purulent drainage. The patient had active secretions from the tracheostomy tube. On heart examination, first heart sound and second heart sound were audible, a regular rate and rhythm. No murmurs, rubs or gallops. No jugular venous distention. No carotid bruits. On lung examination, there was good air movement bilaterally, coarse breath sounds with diffuse bilateral crackles, rhonchi, bilateral wheezes, loud air sounds from the tracheostomy tube in the upper lobes. On abdominal examination, bowel sounds were present. The abdomen was soft and nontender, slightly distended. Liver was 5 cm below the costal margin. No masses palpated. On examination of extremities, he had fine pulses in the feet, normal pulses in the hands. No clubbing, cyanosis or edema. On skin examination, he had multiple seborrheic keratosis and skin tags and was hirsute. On neurologic examination, cerebellar examination was within normal limits. Cerebral examination was within normal limits. Cranial nerves were intact and within normal limits. Preserved touch sensation. Muscular strength was 4+, brisk deep tendon reflexes. Intact motor function in all extremities, and in the head and neck. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories revealed a white blood cell count of 11.2, platelets of 765, hematocrit of 40.3. Coagulation studies were within normal limits. Chem-7 was notable for an increased creatinine of 1.6 (this is his baseline). Blood sugar was 114. Calcium level was 8.3. Magnesium and phosphate levels were normal. Serial cardiac enzymes including troponin I were within normal limits. Swab of pretracheal fluid showed 4+ Gram stain (over 10/1000 times field), positive polys. Wound culture was pending, and blood cultures were pending. RADIOLOGY/IMAGING: A chest x-ray on [**3-14**] showed a possible left lower lobe pneumonia with a possible left pleural effusion. CT on [**3-15**] showed focal tracheal narrowing, soft tissue density and piriform sinuses (right more than left), and a patent airway. A chest x-ray on [**3-16**] confirmed tracheal tube placement and showed that there was no pneumothorax. The patient had an I-131 scan on [**3-4**] which showed no evidence of distant metastatic disease from thyroid cancer. ASSESSMENT AND PLAN: A 74-year-old white male with hypertension, history of congestive heart failure, multiple malignancies with metastases (status post total thyroidectomy on [**2194-1-29**]), an 8-day infection of thyroidectomy wound (treated three days with dicloxacillin) who presented on [**2194-3-15**] with worsening stridor, dyspnea, orthopnea, lower extremity edema, chest pain, and purulent wound discharge. The patient ruled out for myocardial infarction per serial enzymes (troponin I level was 0.3). A CT of the neck showed focally narrowed larynx and trachea, and the patient had open tracheostomy performed by Dr. [**First Name (STitle) **] on [**2194-3-15**] with placement of tracheal tube. Postoperative treatment for infection was with cefazolin in the Intensive Care Unit. He was transferred to CC7 on [**2194-3-16**] in stable condition, unable to speak. The patient has no right laryngeal nerve from surgery, and a porotic left laryngeal nerve. He was afebrile during his stay on CC7. HOSPITAL COURSE: 1. STATUS POST TRACHEOSTOMY: The procedure was performed by Dr. [**First Name (STitle) **]; tracheostomy was in place producing active secretions of clear appearance. Per Dr.[**Name (NI) 18353**] recommendations, the patient was suctioned every two hours until secretions decreased, and special care was taken of tracheal tube. The patient was comfortable and had no respiratory complaints. Breath sounds were loud and coarse with diffuse crackles, bilateral wheezes, and bilateral rhonchi. [**Name (NI) **]/Nose/Throat performed changes of iodoform packing daily and took care of the tracheostomy ties. The patient was scoped on [**2194-3-18**] by Dr. [**First Name (STitle) **], and his initial tracheostomy tube was switched to a fenestrated tube with a cap. The patient was subsequently able to speak. Per Dr. [**First Name (STitle) **], the wound had healed nicely. For his lungs, the patient received Atrovent nebulizers and was followed by Respiratory and Physical Therapy. 2. CARDIOVASCULAR: The patient has a history of hypertension, hyperlipidemia, and congestive heart failure. His exercise test with MIBI in [**2193-10-26**] showed an ejection fraction of 58%, and no perfusion abnormalities, with 81% maximal calculated heart rate achieved on exercise. The patient ruled out for myocardial infarction as a cause of his chest pain on this visit. His serial enzymes were within normal limits (troponin level was 0.3). The patient also has a history of peripheral vascular disease, status post tib-fib. The patient received subcutaneous heparin for his deep venous thrombosis prophylaxis. He was also restarted on lipid-lowering [**Doctor Last Name 360**] (atorvastatin). The patient had several episodes of hypertension while in the hospital for which he was started on Cardizem, hydrochlorothiazide, and captopril. 3. ENDOCRINE: The patient is status post total thyroidectomy. He is followed by Dr. [**Last Name (STitle) 574**]. In the hospital, the patient was restarted on Levoxyl 100 mcg. Dr. [**Last Name (STitle) 574**] was contact[**Name (NI) **] regarding the patient's admission for recommendations for thyroid hormone dose. 4. ONCOLOGY: 5. RENAL: 6. FLUIDS/ELECTROLYTES/NUTRITION: The [**Hospital 228**] hospital course was stable. He remained afebrile. His tracheal tube secretions had decreased and were suctioned twice per day by nurses. Changes of iodoform packing and management of the tracheal tube was performed by the [**Hospital **]/Nose/Throat team (Dr. [**First Name (STitle) **] and resident). He was scoped by [**First Name (STitle) **]/Nose/Throat on [**3-18**] to evaluate the vocal cords; upon which his tube was changed to another fenestrated tube with a cap. On the day of discharge, the patient was feeling better than the day before. He had no new complaints. His vital signs were stable. Temperature was 98.3, pulse of 71, blood pressure of 134/84, respiratory rate of 20, oxygen saturation of 94% on room air. His intake and output were appropriate. He was eating a full diet and had a bowel movement. On physical examination, the patient's respiratory status improved; although, he still had some rhonchi in his lungs bilaterally and coarse breath sounds. On neck examination, on the day of discharge, he had some serosanguineous exudate from the wound site, but no erythema or swelling. For management of his wound infection, he was switched from cefazolin in the Emergency Room to cephalexin on [**2194-3-17**]. His white blood cell count on the day of discharge was 11.3. As mentioned above, he was also on diltiazem, hydrochlorothiazide, and captopril for management of his hypertension. DISCHARGE DISPOSITION: The patient was discharged on [**2194-3-18**] to live with his son; who is a primary care physician affiliated with [**Hospital1 188**], and the patient was told to arrange an appointment with Dr. [**First Name (STitle) **] within one week. MEDICATIONS ON DISCHARGE: The patient's discharge medications included) cephalexin 500 mg p.o. q.6h. for eight more days (to complete a 14-day course of antibiotics), diltiazem, hydrochlorothiazide, captopril, ranitidine, and Prilosec. He also received a prescription for ipratropium inhalers. DISCHARGE INSTRUCTIONS: The patient was instructed to contact the hospital if he had any further respiratory distress, any worsening of symptoms, or no improvement. He was also instructed to contact the [**Name (NI) **]/Nose/Throat team for management of any complications with the tracheostomy tube. [**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**] Dictated By:[**Last Name (NamePattern1) 93273**] MEDQUIST36 D: [**2194-3-20**] 14:48 T: [**2194-3-20**] 18:05 JOB#: [**Job Number 34502**]

[ "428.0", "E878.8", "998.59", "519.1", "199.1", "518.81", "V10.87", "478.33" ]

icd9cm

[ [ [] ] ]

[ "31.1", "31.49" ]

icd9pcs

[ [ [] ] ]

10667, 10909

10936, 11206

2586, 2669

6961, 10643

11231, 11756

232, 266

295, 2205

2227, 2559

2686, 6943

15,398

174,816

21986

Discharge summary

report

Admission Date: [**2117-10-6**] Discharge Date: [**2117-10-20**] Date of Birth: [**2049-8-24**] Sex: F Service: CSU HISTORY OF PRESENT ILLNESS: This is a 60-year-old patient who is known to Dr. [**Last Name (STitle) **] with a history of coronary artery disease and aortic stenosis. She was seen originally on [**2117-9-29**] from the history and physical. She was doing well for several years. She had a prior coronary artery bypass grafting and aortic valve replacement in [**2110**]. Approximately one month ago she had an episode of chest pain which resolved and then another episode of chest pain one week later and dyspnea on exertion. An echocardiogram done on [**2117-9-13**] showed concentric LVH with an ejection fraction of 50-55 percent, mild aortic insufficiency, severe AS with a peak gradient of 113, and mean gradient of 72, moderate MR, mild TR, and mild pulmonary hypertension. TE on [**2117-9-21**] showed LVH with EF of 50-55 percent AS, mitral annular calcification with mitral valve thickening, and moderate MR. Cardiac catheterization performed prior to this admission on [**2117-9-29**] showed severe native three vessel disease with a patent LIMA to the LAD, circumflex 90 percent with a PTI stent, saphenous vein graft to the OM had an 80 percent lesion, RCA 70 percent lesion with significant damping, mild aortic insufficiency, mild aortic arch dilatation. The patient reported angina, dyspnea on exertion, but denied nausea, vomiting, palpitations, diaphoresis. She reports a presyncopal event times one yesterday. No peripheral edema. PAST MEDICAL HISTORY: 1. AVR CABG in [**2110**] with [**Last Name (un) 3843**]-[**Doctor Last Name **] tissue valve and LIMA to LAD, SVG to OM. 2. Rheumatic fever. 3. Spinal meningitis four to seven years ago. 4. Gastrointestinal bleed in [**6-27**]. 5. Polyps. 6. Congestive heart failure. 7. AS. 8. Noninsulin-dependent diabetes mellitus. 9. Hypertension. 10. Hypercholesterolemia. PAST SURGICAL HISTORY: 1. AVR CABG. 2. Hysterectomy. 3. Appendectomy. 4. Back surgery. ALLERGIES: She is allergic to Crestor which gave her splenomegaly and elevated LFTs. Surgery was cancelled on [**2117-9-29**] for a platelet drop to a low of 60,000. Hematology workup was in progress when the patient was discharged with plans to follow-up with Hematology, Dr. [**Last Name (STitle) **], as an outpatient and return for CABG AVR when hematology issues and platelet issues were controlled. The patient was complaining of shortness of breath at home, orthopnea, and unable to have a conversation secondary to shortness of breath. She called her PCP who recommended that she go to the Emergency Department. The patient presented to an outside hospital Emergency Department and was treated for CHF with much improvement. The platelets at the outside hospital were 110 and transferred in for treatment and consideration for CABG AVR again on [**2117-10-7**]. PHYSICAL EXAMINATION: On examination, the patient's blood pressure was 124/63, heart rate in sinus tachycardia at 94, respiratory rate 25, saturating 97 percent. The patient was sitting at the edge of the bed in no apparent distress. She was short of breath with talking and at the time she was laying flat for a chest x-ray with significantly increased shortness of breath and heart rate. She was alert and oriented, appropriate with a nonfocal neurologic examination. She had rales at the bilateral bases. The heart revealed a regular rate and rhythm, S1, S2, grade III-IV/VI systolic ejection murmur that radiated to her carotids. Her abdomen was soft, round, nontender, nondistended with positive bowel sounds. The extremities were warm and well perfuse with no varicosities and trace peripheral edema. She had 2 plus bilateral radial pulses, 1 plus bilateral DP and PT pulses. LABORATORY DATA: The preoperative laboratories revealed a white count of 5.7, hematocrit 30.3, platelet count 83,000. Sodium 142, K 4.0, chloride 105, bicarbonate 28, BUN 32, creatinine 1.1 with a blood sugar of 166, PT 13.9, PTT 28.4, INR 1.2. ALT 22, AST 29, LDH 354, alkaline phosphatase 94, total bilirubin 0.8. Chest x-ray showed bilateral effusions and CHF. Bone marrow biopsy showed a question of early myelodysplasia syndrome. Please refer to the official report. Hematology was consulted again and felt that the platelet count was probably closer to normal range then was registering and the patient was probably sequestering platelets in the spleen with splenomegaly. This was discussed with Dr. [**Last Name (STitle) **] for a question of whether or not the patient could continue and go to the Operating Room. MEDICATIONS AT HOME: 1. Lopressor 50 mg p.o. twice daily. 2. Norvasc 7.5 mg p.o. daily. 3. Glyburide 5 mg p.o. twice daily. 4. Metformin 1,000 mg p.o. twice daily. 5. Lisinopril 20 mg p.o. twice daily. 6. Lasix 20 mg daily. 7. Aspirin 81 mg daily. 8. Paxil 5 mg daily. HOSPITAL COURSE: The patient was admitted to the CCU and was followed daily by Cardiology and was evaluated by the Cardiac Surgery team as we awaited her hematology workup to be completed and her platelet count to rise. The patient had an episode of epistaxis on the 15th and was seen by Dr. _________________ of Hematology. Platelet counts remained low at 75,000. Surgery was delayed as Hematology continued to work on this issue for Dr. [**Last Name (STitle) **]. The patient received a transfusion of platelets preoperatively on the 15th. The patient was also seen by Cardiology daily and received a second unit of platelets on the 16th for her significant thrombocytopenia which was 113 on the 16th. On the 17th, the platelet count rose to 139 with a white count of 5.2 and hematocrit of 29.7, creatinine was stable at 1.1 and INR of 1.2. On the 17th, the patient was transferred out of the CCU to [**Hospital Ward Name 121**] III, the step-down floor, as her preoperative workup continued. On [**2117-10-11**], the patient underwent redo CABG with a vein graft to the RCA and aortic valve replacement with a 19 mm mosaic porcine tissue valve. The patient was transferred to the Cardiothoracic Intensive Care Unit in stable condition on a milrinone drip at 0.3 micrograms per kilogram per minute, Amiodarone drip at 2.4 mg per minute, epinephrine 0.04 micrograms per kilogram per minute, Levophed drip at 0.06 micrograms per kilogram per minute, Neo- Synephrine drip at 0.3 micrograms per kilogram per minute, and a titrated propofol drip. Of note, the patient did have an asystolic cardiac rest at 12:15 a.m. on the morning prior to surgery. She had some low blood pressures. Lasix was held. She became unresponsive with bradycardia to asystole noted on the telemetry strip. CPR was briefly initiated with bagging but she became responsive within several seconds and was sleepy but alert. The patient had good pulses which returned spontaneously with blood pressure in the 120s/60s which had dropped to 80/60. She had sinus tachycardia on EKG and stable diffuse ST changes that were unchanged since her recent EKGs. She was transferred back to the CCU. This was all in the early morning hours prior to surgery. On postoperative day number one, the patient had some metabolic acidosis and received 3 amps of bicarbonate which helped resolve this problem, lactate up to 11.6 and back down to 6.0. Epinephrine was decreased. Milrinone was increased. The patient received intravenous fluids and 20 of Lasix and remained on Amiodarone, epinephrine, insulin, Levophed, milrinone and propofol drips. Postoperatively, the platelet count was 253,000 with an INR of 1.5. The white count was 21 and a hematocrit of 30. The K was 4.8, creatinine stable at 1.0. The patient began Plavix, continued Lasix diuresis with the plan to wean epinephrine and keep the patient intubated. On postoperative day number two, the patient received 1 unit of packed red blood cells for a hematocrit of 26, platelet counts dropped again to 79,000. A HIT screen was sent. The patient was in sinus rhythm, hemodynamically stable. The patient was alert and oriented. The patient had decreased breath sounds at the bases. The examination was unremarkable. The chest tubes were discontinued. Plavix was held. Lasix was increased to 80 twice daily. Milrinone was decreased down to 0.2. Amiodarone was switched over from intravenous to oral. The patient remained in the Intensive Care Unit on face mask after being extubated, saturating 100 percent on 4 liters nasal cannula. The patient was also seen daily by the Hematology/Oncology team. On postoperative day number three, aspirin was decreased to 81, Zantac was changed to Protonix, Amiodarone had been switched to oral, milrinone continued to be decreased, Captopril was added in for blood pressure control. The patient was in sinus rhythm in the 60s with a blood pressure of 112/38 and the last chest tube was discontinued. The patient was encouraged to be out of bed and ambulate after she had been transferred from the Intensive Care Unit to the floor. On postoperative day number four, the patient had been transferred out to the floor, was hemodynamically stable with a platelet count that dropped again to 59,000 and a creatinine was stable at 1.1. The patient did not appear to be bleeding, was started on Lopressor beta blockade. The patient was ambulating in the [**Doctor Last Name **]. The platelets were transfused so that the pacing wires could be pulled. The Foley was discontinued and aggressive diuresis was continued. The patient was screened for rehabilitation, was restarted on oral diabetes medicines as well as restarting the Plavix. The patient was seen and evaluated by Case Management as part of the screening process. On postoperative day number five, the patient's platelets had been transfused the evening prior. The pacing wires were discontinued. The patient had an unremarkable examination. The incisions were clean, dry, and intact. The Foley was discontinued. The patient continued to ambulate as the screening for rehabilitation continued. On postoperative day number six, the blood sugar rose to 344. The patient continued on beta blockade with a heart rate of 80, in sinus rhythm with a blood pressure of 106/46 as well as intravenous Lasix. The patient had decreased breath sounds bilaterally with occasional expiratory wheezes. The patient had 1 plus peripheral edema. The incisions were clean, dry, and intact. The sternum was stable. Metformin was added back in. Lasix was switched over from intravenous to twice daily. The patient continued to ambulate. On postoperative day number seven, the patient had a small amount of sternal drainage the afternoon prior but the incision was clean and dry on the morning of postoperative day number seven. There was no erythema. There was still some increased peripheral edema and elevated glucose. Lasix was increased. Lopressor was increased. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult for diabetes management was called. The patient was seen by the [**Last Name (un) **] fellow and evaluation and recommendations were reviewed. On postoperative day number eight, the patient still had significant peripheral edema, approximately 2 plus bilaterally. The creatinine was stable at 1.1. The hematocrit was 31.3. The patient was saturating 96 percent on room air, continued with metformin and Glyburide. The patient had some metabolic alkalosis from probable fluid overload. Diamox was added and electrolytes were rechecked with plans to hopefully discharge the patient in the morning. The patient was seen again by the [**Last Name (un) **] fellow to evaluate her diabetes management and recommended having the patient following up as an outpatient with Dr. [**Last Name (STitle) **], beeper number [**Serial Number 57556**]. Dr. [**Last Name (STitle) **] was the attending. On postoperative day number nine, the patient was stable overnight with a hematocrit of 30.4 and creatinine 1.2. The examination was nonfocal neurologically. The patient had 2 plus peripheral edema. The incisions were clean, dry, and intact. The patient was doing very well, much improved. Glyburide was increased to 10 mg p.o. twice daily. The patient was encouraged to ambulate and plans to discharge the patient home with VNA services which was accomplished on [**2117-10-20**]. DISCHARGE DIAGNOSIS: 1. Status post redo coronary artery bypass graft times one and aortic valve replacement. 2. Status post aortic valve replacement and coronary artery bypass graft in [**2110**]. 3. Rheumatic fever. 4. Spinal meningitis. 5. Gastrointestinal bleed. 6. Polyps. 7. Congestive heart failure. 8. Aortic stenosis. 9. Mild insulin-dependent diabetes mellitus. 10. Hypertension. 11. Hypercholesterolemia. DISCHARGE MEDICATIONS: 1. Potassium chloride 20 mEq p.o. twice daily times ten days. 2. Colace 100 mg p.o. twice daily. 3. Enteric coated aspirin 81 mg p.o. once daily. 4. Percocet 5/325 one to two tablets p.o. as needed every four hours for pain. 5. Plavix 75 mg p.o. once daily. 6. Metformin 1,000 mg p.o. twice daily. 7. Paroxetine hydrochloride 5 mg p.o. once daily. 8. Lasix 40 mg p.o. three times daily times ten days and then decrease the dose to Lasix 20 mg p.o. daily. 9. Metoprolol tartrate 25 mg p.o. twice daily. 10. Glyburide 10 mg p.o. twice daily. DISCHARGE INSTRUCTIONS: The patient is to make a follow-up appointment with Dr. [**Last Name (STitle) 17567**], the primary care physician, [**Name10 (NameIs) **] one to two weeks and make an appointment to see Dr. [**Last Name (STitle) **] in the office in four weeks for a postoperative surgical visit. DISPOSITION: The patient was discharged to home with VNA services on [**2117-10-20**]. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2117-11-19**] 14:52:30 T: [**2117-11-19**] 16:53:09 Job#: [**Job Number 57557**]

[ "413.9", "401.9", "V45.82", "996.71", "238.7", "250.00", "414.01", "428.0", "427.5", "414.02", "287.5", "272.0" ]

icd9cm

[ [ [] ] ]

[ "99.04", "35.21", "99.05", "39.61", "36.11" ]

icd9pcs

[ [ [] ] ]

12872, 13425

12436, 12849

4969, 12415

13450, 14059

4701, 4951

2015, 2959

2982, 4680

166, 1598

1620, 1992

53,802

178,204

33783

Discharge summary

report

Admission Date: [**2156-9-28**] Discharge Date: [**2156-10-8**] Date of Birth: [**2117-4-1**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1936**] Chief Complaint: Bright Red Blood Per Rectum Major Surgical or Invasive Procedure: Flex Sigmoidoscopy Upper endoscopy History of Present Illness: This is a 39 year old male with a history of UC s/p subtotal colectomy with ileo-anal pull-through, who presents with BRBPR x10 episodes starting this am. Notes stool is purple and bright red. This has been associated with fatigue, lightheadedness, orthostasis, tinnitus, and dyspnea/palpitations on exertion. He also confirms mild crampy lower abdominal discomfort, but denies nausea, emesis, epigastric pain, or melena. The patient had a prior episode of BRBPR in [**3-18**], and flex sig showed mild pouchitis and chronic inactive colitis, which was treated with ciprofloxacin and canasa suppositories. An EGD also in [**3-18**] was notable for Schatzki ring, eosinophilic esophagitis, and a small duodenal erosion. He had similar self-limited episodes of rectal bleeding in [**5-9**], and [**7-18**], for which he took canasa. He notes that his current presentation is more severe than prior episodes. . On arrival to the ED, vital signs were: 98.8 115 108/70 16 99%. He remained tachycardic to the 120s and his hematocrit was found to be 32, down from 42 last month. He had a frankly bloody BM in the ED. 18g and 16g peripheral IVs were placed and he was given 2 units pRBCs and 1L IV fluids. His BP remained stable. GI was consulted and plan for a flex sig in the am. Prior to transfer, vitals were: 98.5 98 113/65 16 98RA. . In the ICU, he is currently feeling better after fluid/blood tranfusion. Review of systems is negative for f/c/n, undercooked or unusual foods, recent dehydration, or travel. He is unaware of sick contacts, but works in an elementary school. Past Medical History: Ulcerative colitis, diagnosed late [**2126**]. - S/p subtotal colectomy [**2143**] for toxic megacolon (some retained rectal mucosa). - S/p ileoanal pull-through with J-pouch [**2144**]. - Pouchitis [**3-18**] flex sig and [**9-17**] Eosinophilic esophagitis Schatzki ring s/p dilation [**3-18**] Depression and anxiety Multiple epiphyseal dysplasia s/p L knee arthroscopy Allergic rhinitis Septoplasty at age 19 Social History: Lives with his wife, no kids. Works as an elementary school teacher. He does not smoke or use drugs. He has ~3 drinks of alcohol per week. Family History: Paternal grandfather with [**Name2 (NI) 499**] CA in his 30s. No other GI diseases. Physical Exam: VS: HR 110s BP 120s/70s GENERAL: Pleasant, well appearing male in NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. MM dry. OP clear. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. . . On discharge Vitals: 96.6 110/81 100-107 18 94%RA Pain: denies today Access: RUE midline Gen: nad HEENT: anicteric, mmm CV: regular, no m Resp: CTAB, no crackles or wheezing Abd; soft, nondistended today, +BS, improved Ext; no edema Neuro: A&OX3, grossly nonfocal Skin: LUE with palpable cord antecubital, improved erythema psych: appropriate . Pertinent Results: *had normal WBC around [**5-19**], then developed acute leukopenia since [**0-**] (wbc 2.5-3 with up to 19% bands), has resolved since [**10-4**], with wbc 6s on discharge . HCT 31-->35-36 for 3days before discharge (baseline hct 40, down to 29, s/p 3U prbc last [**9-28**], then stable at HCT 30s, now increasing to 35) chem panel: BUN/creat 9/0.9 Mag 2.1 LFTs [**10-3**] wnl coags wnl . Stool Cx [**9-28**]: negative UA [**10-2**] negative blood cx X2 [**10-2**] NTD C-diff [**10-3**] negative . . Imaging/results: CT scan [**10-4**] (reviewed with GI and Surgery): 1. Partial small- bowel obstruction with two transition points in the left lower quadrant, the appearance is most conistent with two adhesions as the transition points are farther apart. Internal hernia remains in the differential diagnosis with volvulus being least likely. There are no signs of ischemia. 2. Cholelithiasis without evidence of cholecystitis. 3. Trace left pleural effusion and associated bibasilar atelectasis. . [**10-1**] SBFT: IMPRESSION: Findings may represent ileus or early partial small bowel obstruction. Recommend follwup KUB to document movement of contrast through the bowel . KUB #1 and #2 from [**10-1**] and [**10-2**] am--personally reviewed imaging and discussed findings with radiologist: proximally dilated bowel loops, likely jejunal, +air fluid levels, no transition point, contrast throughout bowel, concern for partial SBO vs ileus . KUB #3 [**10-2**]: The current study was obtained in the supine and upright AP projection. The bowel loops, in particular of jejunum, continue to be dilated up to 5.3 cm in the left lower quadrant. Contrast is seen through the rectum. The findings are nonspecific and differentiation between partial obstruction versus ileus cannot be determined based on the radiograph of the abdomen . KUB #4 [**10-3**]-reviewed personally and with radiology: dilated bowel and contrast but improved since last study. no free air. . KUB #5 [**10-4**]: Persistent intestinal distention. No significant contrast migration since one day prior . . Flex Sig [**9-28**]; Stool in the pouch. Very shallow ulcerations and erythema in the pouch compatible with pouchitis. Both limbs of anastomosis was examined. No blood or activate bleeding was noted. Otherwise normal sigmoidoscopy to splenic flexure . EGD [**9-28**]: Multiple mucosal rings in the whole Esophagus compatible with eosinophilic esophagitis Small hiatal hernia Otherwise normal EGD to third part of the duodenum . Bleeding scan [**9-28**]: IMPRESSION: Normal study without evidence of gastrointestinal system bleed. Brief Hospital Course: 39year old male with h/o UC s/p colectomy, eosophillic esophagitis, schatzki's ring s/p dilation [**3-18**], anxiety, h/o GIB of unclear etiology was admitted again with bloody stools and acute blood loss anemia. He was initially admitted to ICU. Recieved total of 3U blood with nadir HCT 29 (baseline 40). He underwent upper and lower endoscopy [**9-28**] w/o a source. Given dropping HCT, he also underwent bleeding scan [**9-28**] which did not reveal as source either. He was stabilized by HD#3 w/o further bleeding and stable HCT. Was seen by GI who reccommended he have oupt capsule study to further eval. Given his h/o Schatzki's ring, they wanted an UGI/SBFT to make sure capsule would pass. He had previously been tolerating PO okay. However, the SBFT on [**10-1**] suggested there was delayed transit of the barium either due to ileus or SBO (air fluid levels w/o clear transition point). Pt also felt distended and was passing very little. He did not have any nausea/vomiting so NGT was defered. He also developed acute leukopenia and bandemia on [**10-1**] (wbc 10->2.5 with 19% bands) which was very concerning. Serial KUBs showed the ileus vs pSBO but no free air to suggest obstruction. CT scan was held off because radiology felt it would have too much artifact due to dense barium used for SBFT. He was monitored with serial KUBs, exams, npo/IVFs, and Surgery consult. He was started on empiric cipro/flagyl on [**10-2**] given persistant leukopenia-neutropenia/bandemia and low grade fevers. His CXR, UA, c-diff was negative. He completed a 7day course with now normalized wbc count and no fevers. On [**10-4**], the barium had diluted enough so that we were able to get CT a/p to further eval whether this was SBO vs ileus. He did show 2 transition points in LLQ which Dr. [**First Name (STitle) 2819**] (surgery) and Dr. [**Last Name (STitle) 3315**] (GI) were made aware off. However, by this time, pt was clincially doing better, passing more barium, less distended etc. Given a sugery for LOA would be high risk, we opted to continue medical management. Since he was stable, he was started on clears on [**10-6**] which he tolerated. He was advanced to low residue diet on [**10-7**] and he tolerated this as well. He is asked to continue low residue diet until his BMs are more formed as previous. By time of discharge, his HCT was already rising and was 35. He still needs a capsule study at some point after a couple weeks and GI fellow, Dr [**Last Name (STitle) 1256**] will schedule this. His HR remained 100s but this is due to anxiety per patient. As for the pouchitis seen on lower endoscopy and findings of eosinophiilc esophagitis seen on EGD, he needs to f/u with dr. [**Last Name (STitle) 6880**] for further management. . . See progress note below from day of discharge for detailed plan according to problem list: . 39year old male with h/o UC s/p colectomy, eosophillic esophagitis, schatzki's ring s/p dilation [**3-18**], anxiety, h/o GIB of unclear etiology admitted [**9-28**] with brbpr X10, acute blood loss anemia s/p blood transfusion, unclear etiology of bleed. Hospital course now complicated by abdominal distention, partial SBO, and leukopenia/low fevers, all of which are improving . Abdominal distention, partial SBO: No nausea/vomiting, clinically is doing better. Occuring since about [**9-30**]. -CT scan with possible adhesions as cause. Would be high risk surgery -improved with conservative management. has tolerated low residue diet. -continue cipro/flagyl, change to PO, day [**6-15**], bandemia/fevers resolved -replete lytes aggressively -no narcotics . Leukopenia: unclear etiology. Developed abruptly on [**10-1**] with significant bandemia which was very concerning. no pulm symptoms, UA negative. Has superficial phlebitis from IVs but no evidence of cellulitis and would not expect such bandemia. Other concern is focal perforation or abcess in abdomen, esp given ileus/pSBO. pt also at risk for c-diff but this was negative.Wouldnt expect myelosuppression from meds to cause bandemia. No longer leukopenic/bandemic improved with Abx. -cont empiric cipro/flagyl to cover GI pathogens, day [**6-15**]. -NTD blood cx and CIS . Acute GI bleeding/blood loss anemia: s/p 3U total (last [**9-28**]), HCT 30 since [**10-1**]. no further bloody BMs. EGD/Flex sig/bleeding scan unrevealing for source. Plan was for SBFT to ensure no obstruction, then outpt capsule, but SBFT showed above. -stable for GI bleeding standpoint. still plan for capsule in a few weeks -PPI PO qd -follow HCT, has been rising so good BM response . Pouchitis: defer further mesalamine enema to Dr. [**Last Name (STitle) 6880**]. hold imodium on discharge. . Eosinophilic esophagitis: unclear how symptomatic pt is. not on any treatment currenlty. seen on [**3-18**] and [**9-17**]. Note, eosinophilia is related to this. pt was supposed to start PPI, which was started here. . Depression/anxiety: resume elavil 200mg qhs . Superficial thrombophlebitis: LUE>RUE. no cellulitis. -warm packs. no NSAIDs given GIB . Sinus tachy: continue hydration. also anxiety component. follow, stable around 100. Medications on Admission: Amitriptyline 200mg qhs Loperamide 2mg daily Omeprazole 20mg daily (hasn't yet started) MVI daily Naproxen 1 tab daily Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. Amitriptyline 50 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime). 3. Multi-Day Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: Gastrointestinal Bleed of unclear source acute blood loss anemia s/p 3U prbc partial small bowel obstruction [**1-12**] adhesions . Secondary: Anxiety Ulcerative Colitis s/p colectomy with pouchitis Eosinophilic esophagitis Discharge Condition: GOOD Discharge Instructions: You were admitted to the Intensive Care Unit at [**Hospital1 771**] because you were having bright red blood per rectum, and there was concern that the bleeding could increase and become dangerous. Your bleeding stopped. However, we did not find the source of bleeding despite upper and lower endoscopy or bleeding scan. You have not had any further bleeding for 10days. You need to have capsule study done as outpt and Dr. [**Last Name (STitle) 1256**] will schedule this. Please return to the hospital if you develop recurrent bleeding, lightheadedness, dizziness, or any concerning symptoms. . Also while you were here, you developed a small bowel obstruction around [**10-1**]. This was managed conservatively with bowel rest, fluids, serial xrays and exams. Luckily you improved with this and did not require surgery. Please follow low residue diet until you start to have formed bowel movements. I would not take loperamide until you follow up with Dr. [**Last Name (STitle) 6880**]. Finally your upper endoscopy showed eosinophillic esophagitis and your lower scope showed pouchitis. please discuss further management with Dr. [**Last Name (STitle) 6880**]. You are started on omeprazole while here. try to avoid naproxen and take tylenol for pain. Followup Instructions: [**Last Name (LF) **],[**First Name3 (LF) **] S. [**Telephone/Fax (1) 78127**], please make an appointment in 2weeks to review your hospital stay Please f/u wtih Dr. [**Last Name (STitle) 6880**] in 2weeks. You will be contact[**Name (NI) **] regarding your capsule study

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icd9cm

[ [ [] ] ]

[ "45.24", "45.13" ]

icd9pcs

[ [ [] ] ]

11768, 11774

6197, 9035

342, 378

12050, 12056

3571, 6174

13361, 13635

2591, 2676

11500, 11745

11795, 12029

11357, 11477

12080, 13338

2691, 3552

275, 304

406, 1982

9049, 11331

2004, 2419

2435, 2575

24,841

104,290

2843

Discharge summary

report

Admission Date: Discharge Date: [**2127-5-6**] Date of Birth: [**2080-1-31**] Sex: M Service: TRANSPLANT SERVICE HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old white male with a history of hepatitis B and hepatitis C, Child C class on the liver transplant list who presented to the Emergency Room on [**2127-4-10**], with lethargy, weakness, and a hematocrit of 19, abdominal pain, status post hemodialysis. In the Emergency Room, the patient received 3 U packed red blood cells and 4 U FFP. Hematocrit raised from 19 to 22, and the patient was given approximately 8 L intravenous fluids, and Dopamine drip for a brief period of hypotension. hepatitis C, Child C class cirrhosis, and the patient was a liver transplant candidate. HOSPITAL COURSE: The patient was admitted to the Surgical Intensive Care Unit. The patient was started on tube feeds on hospital day #2, and tube feeds were increased to goal nutritional status. The patient was initially intubated because of his worsening respiratory conditions and was placed on Lasix for diuresis and hemodialysis. The patient was hepatitis C cirrhosis and was found to have intraperitoneal bleeding and positive paracentesis sample for coagulase negative Staphylococcus aureus. Infectious Disease was consulted on [**4-16**], and with their recommendation, resampling of the ascitic fluids were carried out, and the patient was started on Vancomycin; however, the patient's condition still remained critical. In the Intensive Care Unit, he was still intubated with multiple blood transfusions for platelet coagulation factors. FFP and packed red blood cells were given in order to stop the hemorrhage and correct his coagulopathy. The patient developed ARDS on hospital day #3. Several attempts to tap the ascites were carried out, and each time several liters of fluid was removed. Per Nephrology recommendation, the patient was started on CVVH on [**2127-4-22**], for rising BUN and creatinine because the patient was not able to tolerate the hemodialysis due to hypotension. On [**4-24**], the patient was started on TPN due to his worsening nutritional status. On [**4-27**], a large volume paracentesis was again carried out. Approximately 6.5 L of fluid was drained from his ascites. The patient's condition continued to deteriorate in the Intensive Care Unit. On hospital day #22, it was decided that the patient was no longer eligible for liver transplant due to his worsening medical condition, and the patient was taken off the transplant list, and the options were discussed with the family members. With the patient requiring blood products almost daily due to his coagulopathy and liver failure, on [**2127-5-6**], it was discussed with the patient's family, and the patient was made DNR and CMO. After withdraw of the care per family, the patient expired at 1852 on [**2127-5-6**]. Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 13853**] was notified, and the options were discussed with the patient's family regarding postmortem examination. The patient's sister refused. The patient expired due to end-stage liver disease, cirrhosis, and cardiopulmonary arrest, and multiple organ failures. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366 Dictated By:[**First Name3 (LF) 13854**] MEDQUIST36 D: [**2127-5-6**] 19:45 T: [**2127-5-6**] 19:51 JOB#: [**Job Number 13855**]

[ "286.9", "571.5", "789.5", "276.6", "572.2", "263.9", "785.59", "584.5", "518.5" ]

icd9cm

[ [ [] ] ]

[ "39.95", "96.72", "96.04", "54.91", "38.91", "99.15", "38.93" ]

icd9pcs

[ [ [] ] ]

793, 3495

172, 775

73,243

179,937

42494

Discharge summary

report

Admission Date: [**2176-12-12**] Discharge Date: [**2176-12-20**] Date of Birth: [**2139-2-10**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 371**] Chief Complaint: s/p MVC Major Surgical or Invasive Procedure: [**2176-12-13**] 1. Open reduction internal fixation left transverse acetabular fracture with intracolumnar screws. 2. Open reduction internal fixation pelvic ring fracture with assessment of stability with fluoroscopy and manually-applied stress, and fixation of the left sacroiliac fracture with sacroiliac screw. 3. Closed treatment calcaneus fracture without manipulation. 4. Examination under anesthesia for stability of right knee with manually-applied stress on fluoroscopy and closed treatment of right fibular fracture. [**2176-12-13**] IVC filter insertion via the right femoral route [**2176-12-18**] 1. Open reduction and internal fixation of right Le [**Location 56204**] fracture and left Le [**Location 59383**] fracture with and zygomaticomaxillary fracture. 2. Maxillomandibular fixation. History of Present Illness: 37 yo M unrestrained driver, s/p high-speed head-on MVC with positive head strike and loss of consciousess. The patient was the driver of a small truck where the engine and the patient got dislodged posteriorly in the vehicle. There was a 15 minute extrication of the driver, who was amnestic of the events of the accident. He was taken to [**Hospital6 3105**] where he was found to have multiple facial fractures. He was transferred to [**Hospital1 18**] at this time. He was hemodynamically stable throughout. Past Medical History: Hypertension Social History: 2 PPD smoker. Drinks 12 pack qnight. Physical Exam: Physical exam on admission: HR: 82 BP: 137/75 Resp: 11 O(2)Sat: 97 Normal Constitutional: Awake, responsive to questioning. HEENT: Pupils equal, round and reactive to light. Pupils [**2-28**]. Laceration of lower lip straight through to base of chin. Left orbital hematoma. Right superior eyelid laceration. C-spine immobilized in c-collar. Chest: Airway intact. Good breath sounds bilaterally. No chest crepitus. Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds. 2+ distal pulses, palpable radial pulses. Abdominal: Soft, Nondistended. Left lower quadrant tenderness to palpation Pelvic: Pelvis tenderness to palpation. Rectal: Good rectal tone, no gross blood. Extr/Back: Left ankle tenderness to palpation. No deformities of upper extremities or right lower extremity. No step offs of CTLS spine. Skin: Multiple lacerations and abrasion Neuro: Speech fluent. Strength and sensation equal bilateral upper and lower extremities. Psych: Normal mood, Normal mentation Physical Exam on Discharge: T 96.6 HR 97 BP 146/82 R 20 Sa02 93% FSBG 118 General: No acute distress, AOx3 Neuro: CN II-XII intact HEENT: steri strips in place over orbits and nasal bridge, sutured laceration on jaw MSK: Resolving L lateral thigh hematoma Cardiac: RRR nl S1S2 Lungs: clear to auscultation bilaterally, no respiratory distress Abd: normal bowel sounds, soft, nontender, nondistended, no rebound/guarding, suprapubic incision clean/dry/intact, no erythema or induration Wound: L flank incision clean/dry/intact, no erythema or induration Pertinent Results: [**2176-12-19**] 04:00AM BLOOD WBC-9.6 RBC-3.17* Hgb-8.4* Hct-24.3* MCV-76* MCH-26.3* MCHC-34.4 RDW-13.1 Plt Ct-385 [**2176-12-18**] 05:03AM BLOOD WBC-9.6 RBC-3.42* Hgb-9.1* Hct-26.1* MCV-76* MCH-26.5* MCHC-34.7 RDW-13.1 Plt Ct-373 [**2176-12-17**] 05:12AM BLOOD WBC-7.2 RBC-3.38* Hgb-8.9* Hct-25.9* MCV-77* MCH-26.3* MCHC-34.4 RDW-12.9 Plt Ct-298 [**2176-12-19**] 04:00AM BLOOD Plt Ct-385 [**2176-12-19**] 04:00AM BLOOD PT-12.7* PTT-29.6 INR(PT)-1.2* [**2176-12-18**] 05:03AM BLOOD Plt Ct-373 [**2176-12-18**] 05:03AM BLOOD PT-11.5 PTT-30.0 INR(PT)-1.1 [**2176-12-12**] 09:07PM BLOOD Fibrino-205 [**2176-12-19**] 04:00AM BLOOD Glucose-130* UreaN-14 Creat-0.7 Na-138 K-4.5 Cl-100 HCO3-30 AnGap-13 [**2176-12-18**] 05:03AM BLOOD Glucose-109* UreaN-17 Creat-0.7 Na-137 K-3.8 Cl-100 HCO3-28 AnGap-13 [**2176-12-17**] 05:12AM BLOOD Glucose-107* UreaN-14 Creat-0.7 Na-141 K-3.8 Cl-102 HCO3-30 AnGap-13 [**2176-12-12**] 09:07PM BLOOD Lipase-31 [**2176-12-19**] 04:00AM BLOOD Calcium-8.4 Phos-5.0* Mg-2.1 [**2176-12-18**] 05:03AM BLOOD Calcium-8.7 Phos-4.3 Mg-2.0 [**2176-12-18**] 11:01PM BLOOD Type-ART Rates-14/ Tidal V-600 FiO2-40 pO2-148* pCO2-47* pH-7.42 calTCO2-32* Base XS-5 Intubat-INTUBATED Vent-CONTROLLED [**2176-12-18**] 04:56PM BLOOD Type-ART pO2-228* pCO2-38 pH-7.46* calTCO2-28 Base XS-3 Intubat-INTUBATED Vent-CONTROLLED [**2176-12-18**] 04:56PM BLOOD Glucose-117* Lactate-0.8 K-3.7 Cl-102 [**2176-12-14**] 02:09AM BLOOD Glucose-115* [**2176-12-18**] 04:56PM BLOOD freeCa-1.02* [**2176-12-14**] 02:09AM BLOOD freeCa-1.09* Brief Hospital Course: Pt admitted to TSICU on [**12-13**]. He went to the OR for repair of his pelvic fracture, R sacral ORIF, EUA of R knee, and IVC filter. He was transiently placed on pressors. He had CSF rhinorrhea noted during intubation, which was likely a CSF leak from cribriform/ethmoid fractures that were seen on repeat head CT. He was extubated on [**12-14**] and started on nectar thick liquids. He was advanced to a mechanical clear diet on [**12-15**] and started on SQH. He was transferred to the floor on [**12-15**]. His PCA was D/C'd on [**12-16**] and he was started on PO pain medications. On [**12-18**] he had an ORIF of bilateral lefort fractures and maxillomandibular fixation with zygomatic fx. He was intubated and observed in the PACU overnight. Extubated on the morning of [**12-19**] and transferred back out to the floor where he remained in stable condition until discharge. He will be discharged home with his mouth wired shut x 4 weeks. Medications on Admission: None Discharge Medications: 1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. acetaminophen 650 mg/20.3 mL Solution Sig: 20.3 ml PO Q6H (every 6 hours). Disp:*400 ml* Refills:*1* 5. oxycodone 5 mg/5 mL Solution Sig: [**5-12**] mL PO Q3H (every 3 hours) as needed for pain. Disp:*500 mL* Refills:*0* 6. cefadroxil 500 mg/5 mL Suspension for Reconstitution Sig: Five (5) ml PO twice a day for 7 days. Disp:*75 ml* Refills:*0* 7. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1) application Ophthalmic QID (4 times a day) for 2 weeks: Please apply to lower eyelid. Disp:*1 tube* Refills:*0* 8. docusate sodium 50 mg/5 mL Liquid Sig: Five (5) ml PO BID (2 times a day) as needed for constipation for 1 weeks. Disp:*70 ml* Refills:*0* 9. senna 8.8 mg/5 mL Syrup Sig: Five (5) ml PO BID (2 times a day) as needed for constipation for 1 weeks. Disp:*70 ml* Refills:*0* 10. dexamethasone sodium phosphate 4 mg/mL Solution Sig: One (1) injection Injection Q8H (every 8 hours) for 2 doses. Disp:*2 injection* Refills:*0* 11. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane QID (4 times a day). Disp:*1 bottle* Refills:*2* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: s/p MVC polytrauma: Injuries: - multiple facial fx and complex facial lacs - anterior med bilat maxillary sinuses - floor left frontal - medial lat and inferior bilat orbits - air in orbit - nasal bone, septum fx - ramus fx - bilat medial and lat pterigoids - L zigomatic arch - R sacral ala fx - pubic diastesis - perirectal hematoma - R prox fibula fx - R tib plateu fx vs. variant anatomy - comminuted left acetabular fx - L calcaneus fx - thickened falx concerning for SDH Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital after sustaining a motor vehicle collision. You have multiple injuries from the accident including multiple facial fractures, pelvic fractures, right leg fractures and a fracture in the bone of your left heel. You were taken to the operating room and had your leg and pelvic fractures fixed. You also had an IVC filter placed given your high risk to develop blood clots because of your injuries. You also had your facial fractures repaired by the plastic surgeons in the operating room. You are recovering well. You were evaluated by the physical and occupational therapists who have taught you how to get out of bed to a chair safely. They have cleared you as safe to go home with visiting therapists. You are being given a prescription for narcotic pain medication to control your pain. Take the pain medicine as prescribed, do not take it more frequently than prescribed and do not take more than prescribed at one time. You can continue to take tylenol to alleviate your pain along with the narcotics but do not exceed more than 4 gm of tylenol in 24 hours. Narcotic medications can cause sedation so do not drink alcohol or drive/operate heavy machinery while taking narcotics. Narcotics can also cause constipation so be sure to take in plenty of fluids and fiber in your diet and take an over the counter stool softener such as colace or milk of magnesia if needed to prevent constipation. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Followup Instructions: Department: SURGICAL SPECIALTIES When: WEDNESDAY [**2176-12-25**] at 11:15 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], MD [**Telephone/Fax (1) 31444**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: TUESDAY [**2176-12-31**] at 12:00 PM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: TUESDAY [**2176-12-31**] at 12:20 PM With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] When: THURSDAY [**2177-1-9**] at 1:30 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 Department: Cognitive Neurology With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] When: We are working on a follow up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the Neurology department within a month to follow up on your head injury. You will be called at home with the appointment. If you have not heard within 2 days post discharge or have questions, please call [**Telephone/Fax (1) 1690**]. Phone: [**Telephone/Fax (1) 1690**] Ophthalmology: Please call the ophthalmology clinic as soon as possible to schedule a follow-up appointment. The phone number is [**Telephone/Fax (1) 253**] Completed by:[**2176-12-20**]

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icd9cm

[ [ [] ] ]

[ "76.72", "76.79", "76.92", "21.71", "79.07", "03.53", "79.19", "38.7", "93.55", "79.06" ]

icd9pcs

[ [ [] ] ]

7235, 7310

4935, 5885

312, 1158

7832, 7832

3380, 4912

10460, 12371

5940, 7212

7331, 7811

5911, 5917

8008, 10437

1807, 1821

2834, 3361

265, 274

1186, 1700

1836, 2806

7847, 7984

1722, 1736

1752, 1792

69,487

125,941

35433

Discharge summary

report

Admission Date: [**2125-3-15**] Discharge Date: [**2125-3-27**] Date of Birth: [**2046-3-12**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1253**] Chief Complaint: Right Subdural Hematoma Major Surgical or Invasive Procedure: [**3-16**]: Right craniotomy for Subdural hematoma [**3-23**]: PICC placement History of Present Illness: 79 yo male w/ PMHx [**Month/Year (2) 65**] for HTN, hypercholesterolemia, and CABG x4 10 years ago who present after outpt CT showed R SDH. The patient fell off a bike on [**11-4**] and struck the side of his head. He states that he was seen at an OSH at the time and had imaging, the results are unclear. [**Name2 (NI) **] has not noticed and residual problems since that time. Two days ago, he was walking across the street and could not stop himself so he had to make himself fall onto some grass. He landed on his R shoulder. He was seen at an outside hospital and sent home. He then saw his PCP who ordered [**Name Initial (PRE) **] CT head for [**3-15**] that showed subacute on chronic R SDH with partial effacement of R lateral ventricle and moderate midline shift. He was then transferred to [**Hospital1 18**] for further management. Past Medical History: HTN, hyperchol, CABG x4 - 10 years ago Social History: Lives alone. Trained horses. No tobacco. No ETOH. Only living relative is sister [**Name (NI) **] [**Name (NI) 10113**], who is not close to him as they have not communicated much since her marriage. Family History: Non-contributory. Physical Exam: On Admission: Vitals: T 97.0; BP 138/62; P 61; RR 18; O2 sat 100% RA General: lying in bed NAD Pulmonary: CTA b/l Cardiac: regular rate and rhythm, with no m/r/g Abdomen: soft, nontender, non distended, normal bowel sounds Extremities: no c/c/e. Neurological Exam: Mental status: A & O x3. Fluent speech with no paraphasic or phonemic errors. Adequate comprehension. Follows simple and multi-step commands. Cranial Nerves: I: Not tested II: PERRL, 4-->2mm with light. III, IV, VI: EOMI. saccadic pursuits. V, VII: facial sensation intact, facial strength VIII: hearing intact b/l to finger rubbing. IX, X: Palatal elevation symmetrical. XII: Tongue midline without fasciculations. Motor: Normal bulk. Normal tone. Mild L drift. Full strength on R with mild L hemiparesis. Sensation: intact light touch. Toes downgoing bilaterally. Coordination: FNF intact. Pertinent Results: Labs on Admission: [**2125-3-15**] 06:10PM BLOOD WBC-5.6 RBC-3.94* Hgb-12.4* Hct-35.5* MCV-90 MCH-31.5 MCHC-34.9 RDW-13.3 Plt Ct-296 [**2125-3-15**] 06:10PM BLOOD Neuts-51.9 Lymphs-33.3 Monos-6.6 Eos-7.3* Baso-0.9 [**2125-3-15**] 06:10PM BLOOD PT-14.4* PTT-29.6 INR(PT)-1.3* [**2125-3-15**] 06:10PM BLOOD Glucose-86 UreaN-19 Creat-1.1 Na-140 K-4.4 Cl-104 HCO3-25 AnGap-15 [**2125-3-16**] 03:03AM BLOOD Mg-2.2 Imaging: Head CT [**3-16**]: NON-CONTRAST HEAD CT: There is a right frontoparietal subdural collection, measuring approximately 22 mm from the inner table. This has heterogeneous attenuation suggesting acute-on-chronic hemorrhage. The hyperattenuating regions have a linear, septated appearance. There is associated mass effect, with effacement of the adjacent right cerebral sulci, as well as approximately 8-9 mm shift leftward of normally midline structures. However, there is no dilatation of the contralateral lateral ventricle. There is no evidence for transtentorial herniation. There is no evidence for intraparenchymal, or intraventricular blood. The [**Doctor Last Name 352**]-white differentiation appears preserved, with no significant edema and no evidence for acute large vascular territorial infarction. Osseous structures are unremarkable with no suspicious lytic or sclerotic lesions. The visualized paranasal sinuses are normally pneumatized and likely clear, although motion artifact limits evaluation of the ethmoid air cells. IMPRESSION: Moderate heterogeneous right subdural collection, suggesting acute-on-chronic hemorrhage with associated effacement of the adjacent sulci and approximately 8-9 mm leftward shift of normally midline structures. Head CT [**3-17**](post-op): NONCONTRAST HEAD CT: A right frontal craniotomy is again seen. Compared to one day prior, there has been decrease in the amount of pneumocephalus bilaterally. The right frontal/parietal/temporal subdural collection has decreased in size. There are hyperdense blood products in the dependent portion of the collection. Since the collection has changed in size and configuration, it is not clear whether any new hyperdense blood products are present. There is persistent leftward shift of midline structures by approximately 5 mm, unchanged. There is persistent partial effacement of the right lateral ventricle. There remains fluid and mucosal thickening in the frontal, ethmoid and sphenoid sinuses, which may be related to the nasogastric tube. IMPRESSION: The right subdural collection has decreased in size, but associated leftward shift of midline structures is not significantly changed. Cardiac Echo [**3-16**]: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. CXR [**3-17**]: FINDINGS: The Dobbhoff tube has been repositioned, and the tip now resides within the stomach. There is again mild fluid overload versus edema. There is mild atelectasis at the left lung base. The appearance of the chest is not significantly changed since prior study. Bilateral healed rib fractures again noted. Brief Hospital Course: A/P: 79 yo M with CAD s/p CABG in [**2114**], HTN, hyperlipidemia, admitted after fall with acute on chronic right subdural hematoma, s/p craniotomy with dysphagia, confusion and new onset atrial flutter. . Fall s/p SDH: Patient was found to have subacute on chronic subdural hematoma with midline shift on admission s/p fall in [**Month (only) **] and repeat fall 2 days prior to admission; etiology of falls is unclear. Craniotomy with evacuation of clot was performed on [**3-16**] by Dr. [**Last Name (STitle) **]. Patient's postoperative course was significant for delirium/confusion and dysphagia which required a post-pyloric Dobhoff to be placed. His neurological status remained stable after surgery with resolution of his left-sided hemiparesis upon evaluation when transferred to the medicine service. He was placed on dilantin for anti-seizure prophlyaxis at 100mg PO TID. His goal levels are [**10-16**]. On discharge his level was 6.5 but after correction for hypoalbuminemia it was 9. Tomorrow he should be at a steady state and he should have his levels checked on [**2125-3-28**] and his phenytoin adjusted appropriately for goal levels between [**10-16**]. We restrated ASA 81mg daily. He will need neurosurgery follow up around [**2125-4-16**] with head CT prior. This appointment needs to be scheduled after discharge; the nurse practioner for Dr. [**Last Name (STitle) **] has his information and said she will contact the rehabilitation center. . Delirium/Confusion: Patient was significantly confused/delirious after surgery; this was likely multifactorial including surgical insult, LLL pneumonia, hypernatremia. As he was treated for his LLL pneumonia and his electrolytes corrected, he gradually improved back to baseline. He received haldol for agitation, but had not used any for many days prior to discharge. . Atrial flutter: Patient developed Aflutter with RVR on [**2125-3-20**] with HR into 150s. He was transferred to the medical service for management and was rate controlled on metoprolol with good effect. Chemical cardioversion with amiodarone was considered by cardiology but not performed due to poor risk/benefit ratio plus thyroid dysfunction secondary to illness. Patient continued on metoprolol with good control of both HR (70-80s) and BP (110-130s) throughout his hospital course. [**Month (only) 116**] be able to down titrate metoprolol as improves clinically. He is not on coumadin given his subdural hematoma. He has been restarted on low dose aspirin. . Dysphagia: Patient was evaluated several times by speech and swallowing service after surgery. He was initally found to be unsafe for POs with a risk for aspiration; a Dobhoff was put in for tube feeds and medications until [**3-23**] when patient pulled tube out. He was reevaluated by speech and swallowing on [**3-26**]. He passed for soft solids and thin liquids with whole pills. He also had evidence of thrush and has been on nystatin swish and swallow for 7 days to end on [**2125-4-1**]. . Pneumonia: Patient was dyspneic with oxygen requirement upon transfer to medicine service and found to have LLL consolidation with pleural effusion on CXR. He was treated with 8 days of Zosyn/Vanco for presumed health care associated pneumonia vs aspiration pneumonia, and rapidly improved with elimination of his oxygen requirement and resolution of his dyspnea. A PICC was placed [**2125-3-23**]. He should continue his antibiotics through [**2125-3-28**]. . Acute renal failure: On last day of hospitalization, creatinine rose from 1 to 1.4. This is likely secondary to dehydration and pre-renal azotemia given he was NPO for S&S evaluation. His lisinopril has been discontinued until his creatinine normalizes. He should be given 1L of [**12-29**] normal saline very slowly today (75ml/hr). He should be allowed to drink fluids liberally. His electrolytes should be rechecked on [**2125-3-28**] including creatinine. If back to baseline (around 0.8 or 1), please restart lisinopril 5mg daily PO. CAD s/p CABG: Unclear anatomy. All per report but no records here. No ischemic events throughout his hospital course, but developed atrial flutter as described above. He remained asymptomatic without chest pain or diaphoresis throughout his hospital course. His home aspirin was held for surgery and restarted on POD 7. He was continued on his simvastatin, ACE-I and metoprolol. Lipid profile on [**2125-3-20**] was good. (As above, ACEI was held at discharge given acute renal failure.) . Hypertension: Patient was borderline hypertensive on home regimen to 140s. After initiation of metoprolol for rate control of atrial flutter, his SBPs improved to the 110-120s consistently. Lisinopril 5mg PO is being held for acute renal failure. . Lipids: Patient was on simvastatin on admission; this was continued throughout his hospital course. A lipid panel obtained on [**2125-3-20**] demonstrated a good profile. . Hypernatremia: Patient developed hypernatremia to 148-149 on [**3-20**]. This resolved with free water boluses through his NGT. . PPX: pneumoboots for DVT ppx given SDH. Bowel regimen. . Code: Full Medications on Admission: Medications (home): ASA 81 mg daily Lisinopril 5 mg daily Simvastatin 20 mg daily MVI daily Fish oil Medications (transfer): Insulin SC (per Insulin Flowsheet) Lisinopril 5 mg PO DAILY Acetaminophen 325-650 mg PO Q6H:PRN Metoprolol Tartrate 5 mg IV ONCE Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN Multivitamins 1 TAB PO DAILY Bisacodyl 10 mg PO/PR DAILY:PRN Ondansetron 4 mg IV Q8H:PRN Cepacol (Menthol) 1 LOZ PO PRN Phenytoin (Suspension) 100 mg PO Q8H Docusate Sodium 100 mg PO BID Haloperidol 0.5 mg PO TID:PRN Haloperidol 1 mg IV Q4H:PRN Ranitidine 150 mg PO BID Heparin 5000 UNIT SC BID Simvastatin 20 mg PO DAILY HydrALAzine 10 mg IV Q6H:PRN Use to keep SBP <140 mmHg Discharge Medications: 1. Therapeutic Multivitamin Liquid [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 2. Acetaminophen 325 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO Q6H (every 6 hours) as needed. 3. Docusate Sodium 100 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO BID (2 times a day) as needed for constipation: hold for loose stools. 4. Simvastatin 10 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO DAILY (Daily). 5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Month/Year (2) **]: One (1) nebulizer Inhalation Q4H (every 4 hours) as needed for Wheezing. 6. Humalog sliding scale Please check QID, AC:HS according to your sliding scale protocol 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 8. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable PO DAILY (Daily). 9. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO QID (4 times a day) for 7 days. 10. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Last Name (STitle) **]: One (1) gram Intravenous Q 12H (Every 12 Hours): through [**2125-3-28**]. 11. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback [**Month/Day/Year **]: One (1) injection Intravenous Q8H (every 8 hours): through [**2125-3-28**]. 12. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 13. Metoprolol Tartrate 25 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times a day): titrate based on HR, goal 60-80 bpm. 14. Phenytoin 50 mg Tablet, Chewable [**Month/Day/Year **]: Two (2) Tablet, Chewable PO TID (3 times a day): adjust based on levels, goal level [**10-16**]. 15. Outpatient Lab Work On [**2125-3-28**] Please check electrolytes including BUN and creatinine and check phenytoin level. Goal phenytoin level is [**10-16**]. Discharge Disposition: Extended Care Facility: Life Care Center at [**Location (un) 2199**] Discharge Diagnosis: Primary diagnosis: 1. Right subacute on chronic Subdural Hematoma 2. Atrial flutter 3. Healthcare associated pneumonia 4. Mild malnutrion 5. Acute renal failure Secondary diagnosis: 1. Hypernatremia 2. Dysphagia 3. Coronary Artery Disease 4. Hypertension Discharge Condition: Neurologically Stable, Afebrile, no oxygen requirement with O2 Sat >95% on room air, ambulating with assistance. Discharge Instructions: You had a subdural hematoma (bleeding in the brain) which was cleaned out by surgery. You have also been diagnosed with a heart rhythm called atrial flutter. Please continue your metoprolol to control your heart rate. You also have a pneumonia which was being treated with antibiotics (vancomycin and zosyn) to end on [**2125-3-28**]. You have thrush which is being treated by nystatin S&S to end on [**2125-4-1**]. Your kidney function is measured by a lab called creatinine which was elevated on the day of discharge. This is likely from dehydration. You should drink liberally. You should receive 1 liter of [**12-29**] normal saline at 75ml/hr today [**2125-3-27**]. You should have your creatinine checked on [**2125-3-28**]. In the meantime, your lisinopril has been held. This can be restarted when your labs return to normal (basline Creatinine is 0.8-1 for you). You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine as prophylaxis given your head bleed. Your phenytoin level was mildly low today (6.5 but corrected to 9 when considering the low albumin). The goal range is [**10-16**]. You only just started taking the oral medication yesterday. You should continue phenytoin 100mg PO TID and have your levels checked tomorrow morning. Please adjust levels for goal range 10-20. If questions, please have the results faxed to [**Telephone/Fax (1) 87**]. You will need to make a follow up appointment with the neurosurgery office with Dr. [**Last Name (STitle) **] as described below. His Nurse practioner has your information and should contact the rehab facility. General Instructions Check your incision daily for signs of infection. Exercise should be limited to walking; no lifting, straining, or excessive bending. You may shower using a shower cap to cover your head. Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. We have restarted your baby aspirin Clearance to drive and return to work will be addressed at your post-operative office visit. Make sure to continue to use your incentive spirometer while at home. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING New onset of tremors or seizures. Any confusion or change in mental status Any numbness, tingling, weakness in your extremities. Pain or headache that is continually increasing, or not relieved by pain medication. Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office around [**2125-4-16**] (from your date of surgery) for follow up appointment with your neurosurgeon, Dr. [**Last Name (STitle) **]. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. His Nurse practioner has your information and should contact the rehab facility. If she does not contact you, please call the number above to schedule this. ??????You will need a CT scan of the brain without contrast before this appointment. Please inform the nurses of this when booking your follow up appointment. Please follow up with your primary care physician as soon as possible Completed by:[**2125-3-28**]

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icd9cm

[ [ [] ] ]

[ "97.49", "01.24", "01.31", "96.6", "38.93" ]

icd9pcs

[ [ [] ] ]

14009, 14080

6152, 11277

339, 419

14380, 14495

2523, 2528

17326, 18075

1600, 1619

12002, 13986

14101, 14101

11303, 11979

14519, 17303

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447, 1301

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2542, 2975

1917, 2048

1323, 1363

1379, 1584

67,917

111,391

55688

Discharge summary

addendum

Name: [**Known lastname 3784**],[**Known firstname 448**] Unit No: [**Numeric Identifier 3785**] Admission Date: [**2192-5-3**] Discharge Date: [**2192-5-12**] Date of Birth: [**2132-8-7**] Sex: M Service: ORTHOPAEDICS Allergies: Iodine; Iodine Containing / Latex Gloves Attending:[**Doctor Last Name 147**] Addendum: Please not that the patient's previous discharge summary was signed as final in error prematurely. This addendum serves as the complete and accurate discharge summary for patient [**Known firstname **] [**Known lastname **] ([**Numeric Identifier 3785**]) who expired on [**2192-5-12**]. Chief Complaint: Back pain Major Surgical or Invasive Procedure: [**2192-5-3**]: Anterior L1-S1 interbody fusion [**2192-5-4**]: Posterior instrumented fusion T10-S1, L2 pedicle subtraction ostoetomy History of Present Illness: 59M with persistent back pain and bilateral anteiror thigh pain and discomfort. He underwent a lumbar laminectomy approximately 10 years ago and has noted progressive deformity as well as anterior thigh pain. No distal weakness. Denies numbness or tingling. The patient was made aware of the risks and benefits of surgical intervention given the extent of his deformity and elected to proceed with surgical intervention. Past Medical History: NIDDM HTN GERD s/p ACDF s/p prior lumbar laminectomy Social History: Non-contributory Family History: Non-Contributory Physical Exam: The patient expired on [**2192-5-12**]. He had an open abdomen after emergent exploratory laparotomy on [**5-11**]. The posterior spine wound on [**5-11**] had some moderate serosanguinous drainage without significant surulence or erythema. Pertinent Results: [**2192-5-11**] 11:30AM BLOOD WBC-20.8* RBC-2.87* Hgb-8.2* Hct-24.4* MCV-85 MCH-28.7 MCHC-33.7 RDW-16.0* Plt Ct-310 [**2192-5-11**] 06:55AM BLOOD WBC-20.0* RBC-3.39* Hgb-9.3* Hct-28.9* MCV-85 MCH-27.3 MCHC-32.0 RDW-15.3 Plt Ct-326 [**2192-5-10**] 06:45AM BLOOD WBC-22.4* RBC-3.45* Hgb-9.6* Hct-28.9* MCV-84 MCH-27.9 MCHC-33.3 RDW-15.6* Plt Ct-322 [**2192-5-9**] 07:05AM BLOOD WBC-18.1* RBC-3.54* Hgb-9.8* Hct-29.7* MCV-84 MCH-27.6 MCHC-32.9 RDW-15.4 Plt Ct-280 [**2192-5-8**] 06:35AM BLOOD WBC-13.8* RBC-3.86* Hgb-10.8* Hct-32.1* MCV-83 MCH-28.1 MCHC-33.7 RDW-14.8 Plt Ct-255 [**2192-5-7**] 09:00AM BLOOD WBC-12.8* RBC-3.84* Hgb-11.0* Hct-31.7* MCV-82 MCH-28.7 MCHC-34.9 RDW-14.8 Plt Ct-224 [**2192-5-6**] 05:40AM BLOOD WBC-10.9 RBC-3.15* Hgb-8.9* Hct-26.4* MCV-84 MCH-28.3 MCHC-33.8 RDW-14.7 Plt Ct-189 [**2192-5-5**] 09:20AM BLOOD WBC-10.7 RBC-3.34* Hgb-9.6* Hct-27.8* MCV-83 MCH-28.6 MCHC-34.3 RDW-14.8 Plt Ct-163 [**2192-5-4**] 11:07PM BLOOD Hct-29.0* [**2192-5-4**] 05:17PM BLOOD WBC-11.4* RBC-3.61* Hgb-10.4* Hct-29.9* MCV-83 MCH-28.8 MCHC-34.7 RDW-14.5 Plt Ct-160 [**2192-5-4**] 09:00AM BLOOD WBC-10.7 RBC-3.35* Hgb-9.5* Hct-27.5* MCV-82 MCH-28.2 MCHC-34.5 RDW-14.3 Plt Ct-203 [**2192-5-3**] 02:00PM BLOOD WBC-11.4*# RBC-3.72* Hgb-10.5* Hct-30.6* MCV-82 MCH-28.3 MCHC-34.4 RDW-13.8 Plt Ct-209 [**2192-5-11**] 06:55AM BLOOD Neuts-93* Bands-1 Lymphs-4* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2192-5-11**] 11:30AM BLOOD PT-20.0* PTT-29.5 INR(PT)-1.9* [**2192-5-5**] 09:20AM BLOOD PT-15.0* PTT-26.2 INR(PT)-1.3* [**2192-5-11**] 11:30AM BLOOD Glucose-103 UreaN-39* Creat-1.9* Na-148* K-3.7 Cl-118* HCO3-19* AnGap-15 [**2192-5-11**] 06:55AM BLOOD Glucose-97 UreaN-39* Creat-1.7* Na-148* K-3.6 Cl-116* HCO3-19* AnGap-17 [**2192-5-10**] 06:45AM BLOOD Glucose-144* UreaN-28* Creat-1.0 Na-149* K-3.3 Cl-117* HCO3-23 AnGap-12 [**2192-5-9**] 07:05AM BLOOD Glucose-156* UreaN-28* Creat-1.0 Na-147* K-3.8 Cl-116* HCO3-23 AnGap-12 [**2192-5-8**] 06:35AM BLOOD Glucose-163* UreaN-24* Creat-0.9 Na-143 K-3.6 Cl-111* HCO3-22 AnGap-14 [**2192-5-7**] 09:00AM BLOOD Glucose-112* UreaN-24* Creat-0.9 Na-142 K-3.9 Cl-110* HCO3-21* AnGap-15 [**2192-5-5**] 09:20AM BLOOD Glucose-222* UreaN-24* Creat-1.1 Na-141 K-4.2 Cl-113* HCO3-19* AnGap-13 [**2192-5-4**] 05:17PM BLOOD Glucose-220* UreaN-23* Creat-1.3* Na-140 K-4.3 Cl-115* HCO3-16* AnGap-13 [**2192-5-3**] 02:00PM BLOOD Glucose-195* UreaN-27* Creat-1.1 Na-143 K-3.9 Cl-112* HCO3-23 AnGap-12 [**2192-5-11**] 11:30AM BLOOD Calcium-7.5* Phos-3.6 Mg-1.6 [**2192-5-11**] 03:12PM BLOOD Type-ART pO2-158* pCO2-42 pH-7.26* calTCO2-20* Base XS--7 [**2192-5-11**] 11:38AM BLOOD Type-ART pO2-109* pCO2-41 pH-7.31* calTCO2-22 Base XS--5 [**2192-5-11**] 09:30AM BLOOD Type-ART pO2-70* pCO2-30* pH-7.44 calTCO2-21 Base XS--1 Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 8**] Spine Surgery Service on [**2192-5-3**] and taken to the Operating Room for the above procedures performed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 85**] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please refer to the dictated operative note for further details. The surgery was without complication and the patient was transferred to the PACU in a stable condition. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were continued for 24hrs postop per standard protocol. Initial postop pain was controlled with a PCA. His hematocrit was monitored daily and he received transfusions of PRBCs as needed. His diet was advanced slowly and he began to develop symptoms of an ileus. KUB showed dilated loops of bowel and the patient still had persistent nausea and abdominal pain. An NGT was placed on [**5-7**] with bilious output. He was kept NPO while the NGT was in place and was trialed on POs once passing flatus and had a bowel movement. Physical therapy was consulted for mobilization OOB to ambulate. He was out of bed with PT in a TLSO brace. On [**2192-5-10**], the NGT was removed when he passed a clamp trial with low residuals and he was started on a slow PO trial. He tolerated POs throughout the day and then had an episode of emesis overnight and was made NPO again. He spiked a temp of 102.7 on the evening of [**5-10**] and a fever workup was initiated. Blood cultures returned as positive with gram negative rods on the morning of [**5-11**] in addition to some tachypnea and increased abdominal pain. A medicine consult was obtained and he began to have increased work of breathing, tachypnea, hypotension, and increased abdominal pain and distension. He began to decompensate rapidly and was started on Vanco/Zosyn/Cipro. He was transferred emergently to the SICU and an NGT and central line were placed. He was rescusitated with pressors and fluid but remained hypotensive. General surgery was consulted and decided to take the patient emergently to the OR for an exploratory laparotomy by Dr. [**Last Name (STitle) **]. In the OR, he was found to have diffuse small and large bowel ischemia. It was determined by multiple vascular and general surgeons intra-operatively that there was no obvious salvagable bowel or any indication for resection. He remained intubated and was transferred back to the ICU where a family meeting was held including all involved surgeons, social work, and the ICU team. The patient's family elected to make him DNR/DNI. He was then extubated and made CMO and expired on [**2192-5-12**]. Medications on Admission: Glipizide ER 10mg [**Hospital1 **] Doxazosin 8mg QD Quinipril 10mg QD Avandia 8mg QD Protonix 40mg TID Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Rigid kyphoscoliosis Septic shock due to diffuse ischemic bowel Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 148**] MD [**MD Number(2) 149**] Completed by:[**2192-5-12**]

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icd9cm

[ [ [] ] ]

[ "81.62", "84.52", "96.71", "84.51", "54.64", "54.12", "81.63", "38.93", "80.99", "81.05", "81.06", "38.91", "80.51" ]

icd9pcs

[ [ [] ] ]

7425, 7434

4522, 7244

728, 865

7541, 7550

1741, 4499

7602, 7762

1447, 1465

7397, 7402

7455, 7520

7270, 7374

7574, 7579

1480, 1722

679, 690

893, 1320

1342, 1396

1412, 1431

1,354

135,614

48140

Discharge summary

report

Admission Date: [**2111-12-18**] Discharge Date: [**2111-12-26**] Date of Birth: [**2055-3-4**] Sex: M Service: MEDICINE Allergies: Percocet / Percodan Attending:[**First Name3 (LF) 425**] Chief Complaint: SOB, s/p PVI Major Surgical or Invasive Procedure: attempted pulmonary vein isolation endarterectomy of the LCF with bovine patch History of Present Illness: 56 y/o man with PMHx significant for a-fib on dabigatran (s/p multiple cardioversions, most recently [**2111-11-20**]), CAD s/p multiple PCI (BMS to LAD, multiple BMS to RCA in [**2100**]; [**2101**] ISRS of RCA and proximal RCA stent; [**2104**] DES x2 to proximal and distal RCA), idiopathic dilated cardiomyopathy (EF 20% s/p [**Company **] ICD), PAD, HTN, HLD, OSA presenting after a pulmonary vein isolation today. . The pt was recently hospitalized at the [**Hospital1 18**] ([**Date range (1) 19710**]) for shortness of breath, likley secondary to atrial fibrillation. The pt underwent a TEE to rule out thrombi in the heart [**Doctor Last Name 1754**] and underwent successful cardioversion on [**2111-11-20**]. He stated his SOB was improved s/p cardioversion and he was discharged in stable condition in sinus rhythm and without complaints. . Pt was recently seen by Dr. [**Last Name (STitle) **] on [**2111-12-7**]. Pt was feeling unwell, and electrocardiogram showed underlying atrial fibrillation in a fully ventricularly paced rhythm at 60 beats/minute; the right ventricle is paced from the outflow tract. ICD interrogation showed a low OptiVol fluid index. Has been back in atrial fibrillation since [**2111-11-25**]. Over the past 12 months, this has been his sixth episode of atrial fibrillation starting [**Month (only) 956**], [**2111**]. . The patient was scheduled for a pulmonary vein isolation on the day of admission. During the procedure, R groin was appropriately accessed in the vein, L groin was arterially accessed. Procedure was terminated and patient was taken away to the OR for urgent arterial closure. No PVI was performed. He underwent endarterectomy of the LCF with bovine patch with a drain left in place. Sheath removed by EP fellow. . In the CCU, patient arrived intubated on propofol, dopamine 6 mcg/kg/min and neo 0.3 mcg/kg/min from the OR. He appeared comfortable with some intermittent episodes of agitation. Family reports that he has been having increased leg swelling and dyspnea in the few days preceeding admission. . ROS was unable to be obtained because he was intubated and sedated. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: BMS to LAD, multiple BMS to RCA in [**2100**]; [**2101**] ISRS of RCA and proximal RCA stent; [**2104**] DES x2 to proximal and distal RCA -PACING/ICD: [**Company 1543**] ICD (EF 15%) 3. OTHER PAST MEDICAL HISTORY: 1. Symptomatic atrial fibrillation 2. CAD s/p multiple PCIs 3. Dilated cardiomyopathy s/p ICD (EF 15%) 4. Hypertension 5. Hyperlipidemia 6. Melanoma ([**Doctor Last Name **] level IV) s/p resection Social History: Lives with wife and son On disability, sits on the boards of several companies Smoked 1.5 ppd for 20 years, quit 5 years ago No EtOH Distant hx of recreational cocaine use Likes golf Family History: Mom: Died at 88, cause unknown Dad: Died at 77, CHF Sibs: 2 brothers, 1 with dilated CMP No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM GENERAL: NAD. Appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM. NECK: Supple with JVP of 14cm above the RA CARDIAC: irregularly irregular, normal S1, S2. 2/6 systolic murmur in the LLSB. PMI located in 5th intercostal space LUNGS: Intubated, some crackles at the lung bases, faint diffuse ronchi in the anterior lung fields ABDOMEN: Soft, NT, obese. No rigidity, rebound or guarding. EXTREMITIES: 1+ pitting edema of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] to the mid-shin. PULSES: Right: Carotid 2+ DP/PT easily dopplerable Left: Carotid 2+ DP/PT quietly dopplerable . DISCHARGE EXAM unchanged except RRR Pertinent Results: ADMISSION LABS [**2111-12-18**] 06:40PM BLOOD WBC-13.3* RBC-3.55* Hgb-12.0* Hct-35.2* MCV-99* MCH-33.8* MCHC-34.1 RDW-16.9* Plt Ct-225 [**2111-12-18**] 06:40PM BLOOD PT-13.2* PTT-37.9* INR(PT)-1.2* [**2111-12-18**] 06:40PM BLOOD Glucose-142* UreaN-74* Creat-1.7* Na-130* K-3.4 Cl-91* HCO3-29 AnGap-13 [**2111-12-20**] 06:24AM BLOOD ALT-54* AST-89* AlkPhos-57 TotBili-0.7 [**2111-12-18**] 06:40PM BLOOD Calcium-9.0 Phos-3.6 Mg-2.4 [**2111-12-19**] 04:32AM BLOOD TSH-3.4 [**2111-12-18**] 07:57AM BLOOD Type-ART pO2-97 pCO2-32* pH-7.52* calTCO2-27 Base XS-3 Intubat-NOT INTUBA [**2111-12-18**] 07:57AM BLOOD Glucose-115* Lactate-1.2 Na-125* K-3.2* Cl-89* PERTINENT LABS AND STUDIES CXR [**12-19**] 1. Left transvenous pacer unchanged. A right internal jugular central line with its tip in the mid SVC unchanged. A nasogastric tube is seen coursing below the diaphragm and an endotracheal tube has its tip approximately 5 cm above the carina. 2. Stable cardiac enlargement with interval improvement in aeration in the lungs consistent with resolving pulmonary edema. There is persistent retrocardiac opacity and likely layering effusion which may reflect compressive atelectasis although pneumonia cannot be entirely excluded. No pneumothorax. [**12-20**] Nonspecific bowel gas pattern with several mildly dilated loops of small bowel in the left upper quadrant. The imaging appearance would favor postoperative ileus, but early small bowel obstruction cannot be excluded. Prominent amount of gas within a moderately distended stomach. Followup imaging should be considered. No evidence of free air. [**12-22**] ECHO Mild spontaneous echo contrast is seen in the body of the left atrium. No thrombus/mass is seen in the body of the left atrium. Moderate spontaneous echo contrast is present in the left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). No thrombus is seen in the left atrial appendage. No spontaneous echo contrast or thrombus is seen in the body of the right atrium or the right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. LV systolic function appears depressed. Right ventricular chamber size is normal with borderline normal free wall function. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Moderate spontaneous echo contrast in the left atrial appendage without organized thrombus. Diffuse and complex aortic atherosclerosis without mobile components. [**12-23**] CT HEAD WITHOUT CONTRAST Subtle changes in the posterior left parietal lobe in the left MCA territory concerning for early acute infarction. Urgent neurology consult is recommended. If MRI is contraindicated and additional imaging is required, CT perfusion scan may be utilized CT HEAD/NECK WITH CONTRAST [**12-23**] 1. No acute intracranial abnormality. 2. Calcified plaques causing severe stenosis at the origin of the right internal carotid artery. 3. Calcified and soft plaques at the left common carotid bifurcation and proximal left internal carotid artery causing mild narrowing. 4. There is no evidence of high-grade stenosis or occlusion in arteries of head. DISCHARGE LABS: [**2111-12-26**] 07:00AM BLOOD WBC-13.9* RBC-3.12* Hgb-10.5* Hct-32.3* MCV-104* MCH-33.7* MCHC-32.6 RDW-18.2* Plt Ct-290 [**2111-12-26**] 07:00AM BLOOD Glucose-127* UreaN-68* Creat-1.6* Na-134 K-4.4 Cl-94* HCO3-29 AnGap-15 [**2111-12-26**] 07:00AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.6 Brief Hospital Course: 56M with PMHx significant for atrial fibrillation on dabigatran and previously on Amiodarone (s/p multiple cardioversions, most recently [**2111-11-20**]), CAD s/p multiple PCI (BMS to LAD, multiple BMS to RCA in [**2100**]; [**2101**] ISRS of RCA and proximal RCA stent; [**2104**] DES x2 to proximal and distal RCA), dilated cardiomyopathy (EF 20% s/p [**Company **] ICD), PAD, HTN, HLD, OSA presenting to the CCU after arterial puncture s/p surgical repair c/b hypotension. ACUTE CARE #Left femoral artery repair - Pt initially presented to [**Hospital1 18**] for a PVI for refractory Afib. The beginning of the procedure was complicated by inadvertent arterial puncture x3 in the left groin. Pressure was applied and vascular surgery was consulted. He was taken for surgical repair of the left common femoral, superficial femoral, and profunda femoris arteries with bovine patch amgioplasty. A JP drain was initially placed and was subsequently removed after drainage had slowed. There was evidence of a seroma after the drain was removed which was managed conservatively. #Hypotension - Upon presentation to the CCU, he was hypotensive and briefly required dopamine and phenylepherine to maintain his MAP >60. The hypotension was thought to be related to the sedation used during his procedure and subsequent surgery, he did not appear hypovolemic and there was no evidence of cardiogenic shock. #Rhythm/atrial fibrillation (CHADS2=2) - Pt has refractory AF with multiple prior cardioversions and trial of many antiarrhythmics, including amiodarone. He was supposed to have a PVI which was aborted because of the arterial puncture mentioned above. During this admission, he remained in artial fibrillation with intermittent V-pacing on telemetry while he was in the CCU. In an attempt to chemically convert him to NSR, he was started on doeftilide after a TEE was negative for thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] RA. At discharge, his rhythm was NSR after well-tolerated DCCV. He was anticoagulated with dabigatran after the femoral artery repair operation. His rate remained well controlled during this admission. #Pump/coronaries - He has a history of CAD with multiple prior stents. He had a cath in [**10/2110**] which showed non-obstructive coronary disease and did not report any chest pain during this admission. His ASA and Plavix were initially held after the arterial puncture with repair, but were restarted after discussion with vascular surgery. #Mental status changes - On hospital day 5, after transfer from the CCU to the floor, he was noted to appear more confused and was using words inappropriately. There were no focal neurologic defecits noted, however there was ongoing concern that his mental status was declining and a non-contrast head CT was obtained. There was initial concern for a stroke in the left MCA distribution and a code stroke was called, NIHSS was 0. A CT perfusion was obtained which showed no evidence of ischemia. The initial thought was that he may have global hypoperfusion from severe carotid stenosis with mild hypotension. This concern was also dismissed and the prevailing theory was that his mental status changes were a result of delirium from a combination of oxazepam and ambien. #Dilated cardiomyopathy (EF=15-20%) - He initially appeared volume overloaded on exam and his family gave a history of worsening dyspnea and LE edema prior to presentation (patient was intubated and initially unable to provide history). There was no clear precipitating cause, although reverting back to afib after his last cardioversion likely contributed. He was treated with a lasix drip at admission and diuresed well. After the lasix drip was stopped, we slowly added back his home dose of oral lasix as his blood pressure tolerated. We initially held his ramipril and Coreg because of the hypotension, these were also slowly added back as his BP allowed. At discharge, his weight is 92.6kg and his volume status is slightly hypervolemic. CHRONIC CARE #Hypertension - He was hypotensive upon arrival to the CCU and, as above, his Coreg, ramipril and eleprenone were initially held. These were slowly restarted and at discharge he will continue on his home regimen except a decreased dose of carvedilol. #Hypothyroidism - Continued on levothyroxine 50mcg daily. #Hyperlipidemia - Continued atorvastatin and Zetia #COPD - Noted on CT scan prior to admission, not reporting any wheezing at admission. He does not take any medications at home TRANSITIONS IN CARE: #Code status this admission - FULL CODE # Contact: [**Name (NI) **] [**Name (NI) **] (wife, [**Name (NI) 382**] - [**Telephone/Fax (1) 101485**] #Transitional issues: -Will need follow-up of pulmonary nodules in 1 year -Dofetilide management -Sleep study and fitting of face mask #Pending Studies: Carotid ultrasounds Medications on Admission: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. lipitor 60 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. metolazone 5 mg Tablet Sig: One (1) Tablet PO Every Other Day. 8. oxazepam 15 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime) as needed for anxiety. 9. eplerenone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO PRN (as needed) as needed for dizziness. 11. ramipril 5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 12. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO [**Hospital1 **] (2 times a day). 14. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 15. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 16. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). HELD PRIOR TO PULMONARY VEIN ISOLATION 17. furosemide 80 mg Tablet Sig: 2-3 Tablets PO DAILY (Daily): Takes 2 tabs on the days you are taking metolazone and 3 tabs on days you are not taking metolazone 160AM/80PM and 40AM/80PM 18. tadalafil 5 mg Tablet Sig: One (1) Tablet PO once a day as needed. 19. zolpidem 10 mg Tablet Sig: 0.5-1 Tablet PO at bedtime as needed for insomnia. 20. omega-3 fatty acids 1,000 mg Capsule Sig: One (1) Capsule PO once a day. 21. [**Doctor First Name **] seed oil-omega 3-6-9 1,000(630-210- 72) mg Capsule Oral . Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. atorvastatin 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. oxazepam 15 mg Capsule Sig: [**1-18**] Capsules PO at bedtime as needed for anxiety. 8. meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) as needed for vertiginous symptoms. 9. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 12. tadalafil 5 mg Tablet Sig: One (1) Tablet PO once a day as needed. 13. omega-3 fatty acids 1,000 mg Capsule Sig: One (1) Capsule PO once a day. 14. [**Doctor First Name **] seed oil-omega 3-6-9 1,000(630-210- 72) mg Capsule Sig: One (1) Capsule PO once a day. 15. dofetilide 250 mcg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Disp:*60 Capsule(s)* Refills:*0* 16. ramipril 2.5 mg Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*0* 17. metolazone 5 mg Tablet Sig: One (1) Tablet PO every other day. 18. eplerenone 25 mg Tablet Sig: One (1) Tablet PO once a day. 19. zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for insomnia. 20. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 5 days. Disp:*20 Tablet(s)* Refills:*0* 21. furosemide 40 mg Tablet Sig: 2-3 Tablets PO twice a day: Take 3 pills in the morning and 2 pills in the evening. Disp:*150 Tablet(s)* Refills:*0* 22. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day. Disp:*30 Tablet, ER Particles/Crystals(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Atrial fibrillation Secondary: coronary artery disease, dilated cardiomyopathy, hypertension, hyperlipidemia, Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure caring of you at [**Hospital1 18**]. You were admitted for a pulmonary vein isolation to treat your atrial fibrillation. The procedure was aborted because the femoral artery was accessed. You were then started on dofetilide. You underwent direct cardioversion, which was well tolerated and you were returned to [**Location 213**] sinus rhythm. Weigh yourself every morning, call Dr. [**Last Name (STitle) 1911**] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. Please note the following changes to your medications: - START dofetilide - START Cefpedoxime for 5 more days - START Potassium - CHANGE carvedilol to 3.125mg twice a day - CHANGE Lasix 120mg each morning; 80mg each evening - CHANGE ramipril to 2.5mg daily - STOP amiodarone - CONTINUE the remainder of your medications as directed Please be sure to follow up with your physicians. Followup Instructions: CV: [**Doctor Last Name 1911**]: Please call Dr.[**Name (NI) 101486**] office to schedule an appt on [**Name (NI) 766**] [**12-28**]. . Department: VASCULAR SURGERY When: THURSDAY [**2111-12-31**] at 4:15 PM With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1490**], MD [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

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icd9cm

[ [ [] ] ]

[ "88.72", "00.17", "99.62", "00.42", "38.18" ]

icd9pcs

[ [ [] ] ]

16638, 16644

7914, 12636

293, 373

16807, 16807

4223, 7591

17896, 18366

3319, 3523

14612, 16615

16665, 16786

12835, 14589

16958, 17515

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3538, 4204

2638, 2872

12657, 12809

17544, 17873

241, 255

401, 2544

16822, 16934

2903, 3102

2566, 2618

3118, 3303

58,454

183,212

35550

Discharge summary

report

Admission Date: [**2180-3-6**] Discharge Date: [**2180-3-9**] Date of Birth: [**2153-1-18**] Sex: M Service: CARDIOTHORACIC Allergies: Hydromorphone Attending:[**First Name3 (LF) 5790**] Chief Complaint: Laryngeal trauma Major Surgical or Invasive Procedure: [**2180-3-6**] Flexible bronchoscopy. History of Present Illness: 27 y M s/p traumatic injury to left anterior neck at approximately 9:30 on [**9-5**] when the patient was struck by a hockey puck. He immediately felt short of breath and experienced several episodes of hemoptysis. He was taken to [**Hospital3 4107**] where a CT scan was performed which demonstrated diffuse subcutaneous air in the neck and chest, as well as pneumomediastinum and small apical bilater pneumothoraces. The pt was then transfered to [**Hospital1 18**] for definitive care. He currently complains of neck pain, chest discomfort with deep inspiration, odynophagia, inability to swallow saliva, and hoarseness of voice. He does not have fever/chills, nausea, or any focal neurologic symptoms. Past Medical History: Left medial meniscal tear, s/p repair Social History: Single lives with family. Tobacco [**12-10**] pack-day. ETOH socal Family History: non-contributory Physical Exam: VS: T: 97.4 HR: 60 SR BP: 108/62 Sats: 96% RA General: 27 year-old no apparent distress HEENT: Speech fluent. Voice Hoarse but functional Neck: supple no lymphadenopathy Card: RRR Resp: breath sounds clear GI:benign Ext: warm no edema Neuro: non-focal Pertinent Results: [**2180-3-8**] WBC-9.7 RBC-4.50* Hgb-13.4* Hct-39.2* Plt Ct-210 [**2180-3-7**] WBC-10.9 RBC-4.64 Hgb-14.2 Hct-40.3 Plt Ct-213 [**2180-3-6**] WBC-16.2* RBC-4.74 Hgb-14.9 Hct-41.3 Plt Ct-202 [**2180-3-7**] Glucose-135* UreaN-13 Creat-0.9 Na-137 K-4.1 Cl-102 HCO3-29 [**2180-3-6**] Glucose-100 UreaN-17 Creat-1.1 Na-140 K-4.2 Cl-106 HCO3-27 [**2180-3-6**] Glucose-92 UreaN-20 Creat-1.2 Na-139 K-4.3 Cl-105 HCO3-24 [**2180-3-6**] CK(CPK)-410* CK-MB-4 cTropnT-<0.01 [**2180-3-7**] Calcium-8.9 Phos-4.6* Mg-2.6 [**2180-3-6**]: CT neck Question fracture of the left aspect of the anterior thyroid cartilage with associated extensive emphysema along the fascial planes. [**2180-3-9**] No evidence for trauma in the cervical esophagus. Air in the soft tissue, better evaluated on prior neck CT. Brief Hospital Course: Mr. [**Name13 (STitle) 12101**] was admitted on [**2180-3-6**] for SOB and neck hematoma. He had a Neck CT which showed diffuse subcutaneous air in the neck and chest and a pneumomediastinum with small bilateral apical pneumothoraces. Thoracic surgery was consulted. A bronchoscopy was done which showed swelling in the posterior aspect of the epiglottis. ENT was consulted for endoscopic exam which showed a hematoma involving the left false cords extending inferiorly involving the epiglottis. They recommended NPO x 72 hours. He was admitted to the SICU for airway monitoring. An Endoscopic exam was done daily. He was on IV fluids. He was seen by voice service. On [**2180-3-9**] an esophagus study revealed no leak. He was seen by Speech and Swallow who cleared him a regular diet which he tolerated. He was discharged to home and will follow up as an outpatient with ENT. Medications on Admission: none Discharge Medications: none Discharge Disposition: Home Discharge Diagnosis: Laryngeal trauma Discharge Condition: stable Discharge Instructions: Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if experience: -Fever > 101 or chills -Difficulty or painful swallowing -Soft solid foods (nothing with edges i.e pizza, crackers) for a couple of days Followup Instructions: Follow-up with Dr. [**Last Name (STitle) 3878**] in 2 weeks call for an appointment [**Telephone/Fax (1) 2349**] Completed by:[**2180-3-10**]

[ "920", "860.0", "E916", "958.7", "925.2", "E917.0" ]

icd9cm

[ [ [] ] ]

[ "33.22", "31.42" ]

icd9pcs

[ [ [] ] ]

3330, 3336

2361, 3246

296, 336

3397, 3406

1545, 2338

3671, 3815

1234, 1252

3301, 3307

3357, 3376

3272, 3278

3430, 3648

1267, 1526

239, 258

364, 1072

1094, 1134

1150, 1218

52,593

148,720

48652

Discharge summary

report

Admission Date: [**2151-7-5**] Discharge Date: [**2151-7-18**] Date of Birth: [**2085-6-12**] Sex: M Service: MEDICINE Allergies: Iodine / Peanut Attending:[**First Name3 (LF) 10293**] Chief Complaint: Abdominal wound infection Acute on chronic renal failure Volume overload Major Surgical or Invasive Procedure: 7/23/089: IR placed PICC line [**2151-7-11**]: Paracentesis [**2151-7-14**]: paracentesis [**2151-7-16**]: Paracentesis [**2151-7-16**]: IR guided HD line placement History of Present Illness: 65M s/p segment 3 resection for HCC [**6-11**] c/b oliguria, ATN, respiratory failure, with readmission for fatty necrosis with wound infection of abdominal wound ----> wound opened, he had wet to dry dressings for a day then the vac was placed. Now readmitted from rehab with hyponatrmia, rising creatinine, hyperkalemia, increased edema, SOB, and cellulitis. Subjectively no he says that the only thing bothering him the the wound, he has no other pain and his shortness of breath is no worse than it had been. Past Medical History: HCV cirrhosis Hepatocellular CA s/p segement III resection peripheral neuropathy obesity osteoarthritis COPD Social History: Habits: former smokere (tobacco free b/w 1 month and 12 years) Currently residing at rehab Family History: N/C Physical Exam: 98.5 109 149/73 20 85% 5L FS 114 AAOX3 NAD Sinus tachycardia, no murmurs Lungs are clear in upper lung fields with decreased bs at bases with mild coarseness at bases abdomen is soft, tender at wound site, otherwise non-tender, soft, obese Wound has no obvious purluent drainage, fibrinous exudate, good granulation tissue that has some mild bleeding. The wound is about 30 cm and extendes superiorly under the skin. Fascia feels intact 3+ pitting LE edema, hands without edema RLE anteror cellulitis below the knee feet warm Pertinent Results: On Admission: [**2151-7-5**] WBC-10.2 RBC-3.14* Hgb-9.8* Hct-30.5* MCV-97 MCH-31.2 MCHC-32.1 RDW-13.4 Plt Ct-165 PT-20.4* PTT-34.1 INR(PT)-1.9* Glucose-100 UreaN-55* Creat-4.1*# Na-131* K-5.3* Cl-93* HCO3-29 AnGap-14 ALT-35 AST-51* AlkPhos-66 TotBili-2.0* Lipase-10 Albumin-2.6* Calcium-8.3* Phos-4.9*# Mg-2.0 Triglyc-61 CULTURES: [**2151-7-16**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE-PRELIMINARY; BLOOD/AFB CULTURE-negative (PRELIM) [**2151-7-16**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2151-7-16**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2151-7-15**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2151-7-15**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2151-7-14**] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL; ANAEROBIC CULTURE-PRELIMINARY INPATIENT (negative) [**2151-7-11**] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL; ANAEROBIC CULTURE-FINAL INPATIENT (negative) [**2151-7-10**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT (negative) [**2151-7-10**] URINE URINE CULTURE-FINAL INPATIENT (negative) [**2151-7-10**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT (negative) [**2151-7-9**] URINE URINE CULTURE-FINAL INPATIENT (negative) [**2151-7-6**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL; LEGIONELLA CULTURE-FINAL INPATIENT (contaminant) [**2151-7-6**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT (negative) [**2151-7-5**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT (negative) [**2151-7-5**] URINE URINE CULTURE-FINAL INPATIENT (negative) Brief Hospital Course: 66 y/o male s/p segment III resection with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2151-6-11**] who was discharged to rehab facility and now returns with abdominal incision wound infection. His other concerns are fluid overload and acute on chronic renal failure. He was initially admitted to [**Hospital Ward Name 121**] 10 but was transferred to the SICU for worsening respiratory status, however he did not require intubation. Legionella culture was negative. Bubble study was negative for intracardiac shunt A wound VAC was placed to the abdominal incision after completely opening the incision and Vancomycin was started x 3 days. Blood cultures were negative. Right leg cellulitis was noted on admission and this improved with the Vancomycin. LENIs were obtained and negative for DVT. He was seen in consult by Nephrology and Hepatology. Per both their recommendations Midodrine and octreotide were added as was Rifaxamin. With mild volume expansion, the ARF appeared to be resolving and all diuretics continued to be held. On [**7-11**] he underwent paracentesis for increasing abdominal pain. Ultrasound did indicate the presence of ascites. 1.7 liters of fluid was removed and the WBC was 955 with 79% polys. No organisms were seen on gram stain and the fluid culture was reported as no growth. He was started on Zosyn (6 days total) and the Vancomycin was added back in and dosed per trough levels. Nutrition consult was obtained and TPN was initiated via newly placed PICC line. He was transfused 2 units RBCs on HD 7 for Hct 28.2 which dropped 4% from previous day in setting of paracentesis. Hct remained stable thereafter. On [**7-14**] a repeat paracentesis was performed and the WBC was now elevated to 3925 with 70% polys. As this occured while on Zosyn, the antibiotic was changed to Meropenem, this was per ID recommendation who was also consulted. Renal consult service was recommending the initiation of hemodialysis as his creatinine which initially decreased to 3.3 by HD 5 was increasing daily in the ensuing days. The patient was transferred to the medical service on [**2151-7-15**] with the hepatobiliary (West 1 team) following abdominal wound and VAC changes. On [**2151-7-16**], the patient was in respiratory distress with tachypnea and sat-ing at 95% on 5 liters of oxygen. This was secondary to fluid overload secondary to liver and renal failure. Paracentesis with ultrasound was attempted at the bedside, but very little fluid could be removed. Fluid was sent for fungal cultures. To date, all blood, peritoneal, and urine cultures have been negative. Hemodialysis line was placed by IR in anticipation of hemodialysis for fluid overload. Hemodialysis did not provide any relief of respiratory symptoms and the patient remained in a great deal of pain with respiratory distress. Goals of care were discussed with the patient, his family, and the PCP (Dr. [**First Name (STitle) 572**], as well as the attending of record, Dr. [**Last Name (STitle) 7033**]. The patient was made DNR/DNI on [**2151-7-16**]. Clinical status continued to deteriorate on [**2151-7-17**]. On [**2151-7-18**], the family decided on comfort measures only and all medications/treatments were discontinued. Mr. [**Known lastname 42058**] [**Last Name (Titles) **] at 15:42 on [**2151-7-18**]. Medications on Admission: Ascorbic acid 500" Keflex 500"" Heparin SQ ''' Dilaudid PRN Vac change Advair diskus 1" Thiamine 100' MVI Zinc 220' Atrovent PRN senna Serax 15 PRN HS Ambien 5' Dilaudid PRN Discharge Medications: None, pt deceased Discharge Disposition: [**Date Range **] Discharge Diagnosis: 1. Respiratory Failure 2. Acute Renal Failure 3. Hepatocellular Carcinoma 4. Cirrhosis 5. Spontaneous Bacterial Peritonitis 6. Cellulitis Discharge Condition: [**Date Range **]. Discharge Instructions: Patient has [**Date Range **]. Please see discharge summary. Followup Instructions: None Completed by:[**2151-7-20**]

[ "278.00", "356.9", "682.6", "584.9", "995.92", "496", "567.23", "715.90", "998.59", "571.5", "V10.07", "038.9", "585.9", "070.54" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.93", "38.95", "99.15", "54.91" ]

icd9pcs

[ [ [] ] ]

7109, 7128

3497, 6841

349, 515

7310, 7331

1885, 1885

7440, 7476

1316, 1321

7067, 7086

7149, 7289

6867, 7044

7355, 7417

1336, 1866

237, 311

543, 1059

1899, 3474

1081, 1191

1207, 1300

6,213

162,758

16104+56731

Discharge summary

report+addendum

Admission Date: [**2139-5-7**] Discharge Date: [**2139-5-15**] Date of Birth: [**2122-7-8**] Sex: M Service: TRAUMA [**Last Name (un) **] HISTORY OF PRESENT ILLNESS: The patient is a 16 year old male who was the restrained driver in a high speed motor vehicle collision, car versus tree with death of the passenger at the scene. At the scene patient's GCS was 5 and he was combative. He was intubated at the scene. There was witnessed aspiration at the scene and gastric contents were suctioned from the ET tube. No hypotension throughout the rescue at the scene and no hypertension during transfer. Patient did have O2 desaturation to 86% after the aspiration which improved with suctioning. Patient was transferred to [**Hospital1 69**] for management. PAST MEDICAL HISTORY: None. MEDICATIONS: None. ALLERGIES: None. SOCIAL HISTORY: The patient is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1573**] in high school. Patient lives with his mother and father. [**Name (NI) **] has a past history of marijuana use. No known regular use of drugs or alcohol. PHYSICAL EXAMINATION: On arrival temperature was 89.5, was rechecked and was 95.3. Heart rate was 99, blood pressure 160/palp, saturation 97% with an ET tube in place and bag ventilation. In general, patient was sedated, intubated, was paralyzed with a GCS of 3. Pupils were 3 mm and fixed bilaterally. Neck was in a C-collar. There was right periorbital swelling and hematoma. There was a laceration above the right eye. The midface was stable. There was no obvious mandibular fracture. TMs were clear bilaterally. There was no battle sign. No evidence of CSF leak. Cardiac exam S1, S2 within normal limits, regular rhythm. Chest exam had breath sounds present bilaterally. There was no crepitus, no subcu air. Positive seat belt sign over the torso. Abdomen was soft with positive seat belt sign across the lower abdomen as well as diagonal from the right lower quadrant heading toward the left shoulder. Pelvis was stable. Peritoneum was atraumatic. Rectal exam revealed normal tone. There was no gross blood. On examination of the back there was no step-off. Examination of the extremities revealed bilateral knee abrasions. There was right hand lacerations and abrasions. There was no obvious deformity or dislocation of any limb. Peripheral pulses were 2+ distally in all four extremities. LABORATORY DATA: White blood cell count 16.1, hematocrit 42.1, platelets 193. Sodium 141, potassium 3.3, chloride 105, glucose 155. Lactate 2.4. PT 14.1, PTT 32.7, INR 1.3. Urinalysis was remarkable for large blood, greater than 50 red cells per high powered field, otherwise negative. ABG was 7.33, 48, 170, 26, -1. DPL fluid analysis revealed 3 white cells, [**2082**] red cells. Chloride 104, BUN 11, creatinine 0.5. Amylase 77, calcium 8.2, phosphate 4.1, magnesium 1.4. Serum tox screen was negative. Urine tox screen was positive for benzodiazepines. DPL fluid amylase was less than 3. Total bilirubin on DPL fluid was 0.0. Chest x-ray was remarkable for right lower and middle lobe pulmonary contusions versus aspiration. The mediastinum appeared initially to be within normal limits. There did not appear to be any evidence of pneumothorax or hemothorax and no rib fractures on initial x-ray. Pelvic x-ray revealed no fractures. CT of the head revealed two small punctate regions of intraparenchymal hemorrhage, one at the left basal ganglia and one at the right frontal lobe. There was also a right zygomatic arch fracture as well as a right lateral maxillary sinus wall fracture. CT of the C-spine was remarkable for no fracture with right lung apical contusion. HOSPITAL COURSE: The initial trauma workup was performed including CT scanning as well as DPL with results of the fluid as above. A neurosurgery consult was called for the question of whether a ventriculostomy drain should be placed and ICP monitored. This was done by neurosurgery with the plan to repeat the head CT. Initially patient became hemodynamically labile with evidence of hyperdynamic state with associated hypotension. Levophed was given for pressor support to keep cerebral perfusion pressure greater than 70. Regarding the pulmonary contusions, the patient was on a fairly high FIO2 percent, requiring 88% to 90% with PEEP of 10. An orogastric tube was placed. After obtaining the head CT, patient was transferred immediately to the trauma intensive care unit for close monitoring. After transfer to the ICU, DPL was repeated and was again negative. Throughout hospital day one patient remained intubated and was monitored carefully. Antibiotics consisted of penicillin and clindamycin. Repeat chest x-ray performed two hours after arrival was significant for opacities of the right middle and right lower lobes suggestive of hemothorax with no pneumothorax seen. A right sided chest tube was placed for the hemothorax. After stabilization in the unit, the patient was then transferred back for CT of the chest, abdomen and pelvis. On CT of the chest there was a significant pneumomediastinum observed with no definite evidence of tracheal or bronchial laceration. Bilateral pulmonary contusions were observed. There was no evidence of aortic injury. There was no evidence of bladder rupture with no evidence of extravasation of contrast. Bone windows demonstrated no evidence of fracture. Because of the pneumomediastinum and the question of blunt cardiac injury, a cardiology consult was obtained to obtain bedside echocardiography. This was performed and revealed little to no presence of effusion. There was tachycardia present on examination. The image quality was limited secondary to the bedside instrument. EF was greater than 55%. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 18153**], M.D. [**MD Number(1) 18154**] Dictated By:[**Last Name (NamePattern1) 44283**] MEDQUIST36 D: [**2139-5-15**] 14:56 T: [**2139-5-15**] 17:12 JOB#: [**Job Number 46050**] Name: [**Known lastname 856**], [**Known firstname **] Unit No: [**Numeric Identifier 8470**] Admission Date: [**2139-5-7**] Discharge Date: [**2139-5-15**] Date of Birth: [**2122-7-8**] Sex: M Service: TRAUMA [**Last Name (un) **] ADDENDUM: This is a continuation of the discharge summary due to interruption of the summary by the dictation system. On [**Hospital 8471**] hospital day two, after the esophagoscopy was performed, which again revealed no obvious evidence of esophageal injury, an esophageal barium study was performed. This was negative for any evidence of extra-luminal contrast or esophageal rupture. Total parenteral nutrition was started for nutritional support. On SICU second day, the patient was continued intubated and was found to be coagulopathic with an INR of 1.8, which was treated with fresh frozen plasma. Levophed was continued to maintain cerebral perfusion pressure but was being titrated downwards. The P to F ratio was 300; no evidence of acute lung injury and the patient was found to be ventilating easier than previously. On second day on the floor, the patient was noted to be improving. The antibiotic regimen now consisted of Pen-G, Zosyn and Fluconazole. The patient remained intubated and sedated. TLS spine was cleared and cervical spine MRI was performed which was negative for ligamentous injury. The ventriculostomy drain was raised to 20 centimeters of water and was kept open. On the day five, the patient continued to improve; he was awake and continued to be intubated. Total parenteral nutrition was continued. A four-vessel angiogram was performed to evaluate for injury; no vascular injury was noted. The patient was successfully extubated on SICU day five. On SICU day six, the patient was found to be doing well. He was alert and minimally conversant. He was oxygenating well with stable hematocrit. The ventriculostomy drain was discontinued on this day. A trial of p.o. clears was started and the patient tolerated this well. The patient was subsequently transferred to the floor. On hospital day seven because of comments heard by the patient regarding feelings that perhaps he should not have lived through the accident and apparently some degree of difficulty understanding that his passenger had suffered a fatal injury, there was a question of whether the patient was expressing suicidal ideation and a psychiatry consultation was obtained. The psychiatric consultant felt that there was no acute suicidal or homicidal ideation present, and their impression was the patient would likely need therapy following discharge during his recovery, to deal with this traumatic experience. The patient was found to be agitated in the evening of hospital day six and was medicated with Haldol with good effect. On hospital day seven, the patient was tolerating clears and his diet was advanced. The patient was found to continue to improve and was less agitated on that evening. On hospital day eight, the patient was tolerating p.o. and intravenous fluids were Hep-locked. The Physical Therapy consultation was obtained. The patient was ambulated. The Foley catheter was discontinued. Dilantin was discontinued on the previous day. On hospital day nine, an Occupational Therapy consultation was obtained whose impression was that there were significant deficits in orientation, judgement, attention, and visual/spatial relationships, with decreased ability to sequence, to problem solve, and also to perform visual and cognitively inter-related tasks. Their impression was that the patient should be referred to rehabilitation for neuro-behavioral rehabilitation. DISCHARGE STATUS: Discharged to extended care facility. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSES: 1. Status post motor vehicle collision. 2. Punctate intracranial hemorrhages. 3. Right lateral maxillary sinus fracture. 4. Right zygomatic arch fracture. 5. Pneumomediastinum. 6. Bilateral pulmonary contusions. 7. Status post esophagoscopy. 8. Status post right frontal ventricular drain placement. 9. Diffuse external injury. 10 Traumatic brain injury. DISCHARGE MEDICATIONS: 1. Percocet 5/325, one to two tablets p.o. q. four to six hours p.r.n. 2. Colace 100 mg p.o. twice a day. DISCHARGE INSTRUCTIONS: 1. The patient was instructed to follow-up with Dr. [**Last Name (STitle) **] Trauma Clinic in two weeks for follow-up and suture removal with the number provided [**Telephone/Fax (1) 8472**]. 2. The patient was also instructed to follow-up with Neurosurgery, Dr. [**First Name (STitle) 24**], in one month, number [**Telephone/Fax (1) 8473**]. 3. The patient was also scheduled for Neuro-Psychiatric Testing on [**2139-6-23**], at 1 p.m. at the [**Hospital1 960**] East, Rab 205. The number is [**Telephone/Fax (1) 8474**]. [**First Name11 (Name Pattern1) 184**] [**Last Name (NamePattern4) 2931**], M.D. [**MD Number(1) 2932**] Dictated By:[**Last Name (NamePattern1) 8475**] MEDQUIST36 D: [**2139-5-15**] 14:56 T: [**2139-5-15**] 17:09 JOB#: [**Job Number 8476**]

[ "801.30", "860.2", "873.0", "E849.5", "861.01", "861.21", "E816.0", "802.4", "958.7" ]

icd9cm

[ [ [] ] ]

[ "96.6", "01.18", "44.13", "34.04", "88.41", "54.25", "38.93", "96.72", "38.91", "02.2" ]

icd9pcs

[ [ [] ] ]

9897, 10263

10286, 10395

3741, 9841

10419, 11227

1132, 3723

188, 783

806, 853

870, 1109

9867, 9876

3,252

153,174

10240

Discharge summary

report

Admission Date: [**2159-2-7**] Discharge Date: [**2159-2-9**] Date of Birth: [**2091-8-5**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 425**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: s/p intubation on [**2-6**] and extubation on [**2-7**] s/p cardiac catheterization on [**2-7**] History of Present Illness: 67 year old female with CAD s/p CABG (SVG-PDA, SVG-OM, LIMA-LAD), HTN, AFib who presents with chest pain, shortness of breath, intubated at scene for decreased O2 sats 60's, she was given lasix, ASA, Nitro. The daughters state that their mother has become a little more short of breath over the past couple of days. The night of admission, she had gone to dinner and ate Chinese food, then became suddenly short of breath. In the ED she was hypertensive, she was given 5mg Versed with intubation with bp decrease to 60's/40's, started on Dopamine temporarily until blood pressure increased. She was taken to cath lab for diffuse ST-T changes on EKG and ? ST elevation III. Past Medical History: CAD s/p CABG [**5-16**] past Inferior MI DMII HTN PAF Social History: Lives with husband, daughter, son-in-law and 2 grandchildren. Husband with Alzheimer's very recently placed in respite facility for short time, daughter with MS. [**Name13 (STitle) **] history of tobacco. Family History: Non-contributory Physical Exam: 99.4 HR 91 BP 181/50 RR 16 93%/Vent (600x14/100%/8) Gen: Intubated, sedated HEENT: MMM, intubated CV: Normal S1, S2, RRR, no murmurs. Pulm: coarse BS b/l-Anterior fields Abd: (+) BS< soft, obese, nontender Ext: WWP, 1+ DP b/l, no edema. Right groin w/ sheath. Rectal: guaiac negative in ED Pertinent Results: Admission labs: [**2159-2-6**] 10:50PM WBC-13.5* RBC-4.39 Hgb-12.5 Hct-40 MCV-87 MCH-28.3 MCHC-32.6 RDW-13.7 Plt Ct-369 Neuts-40* Bands-1 Lymphs-52* Monos-5 Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0 PT-12.2 PTT-21.3* INR(PT)-1.0 Fibrino-358 Glucose-439* UreaN-21* Creat-1.1 Na-137 K-3.8 Cl-99 HCO3-19* AnGap-23* Calcium-8.5 Phos-5.3* Mg-1.7 Digoxin-0.2* Theophy-<0.8* Phenoba-<1.2* Phenyto-<0.6* Lithium-<0.2 Valproa-<3.0* BLOOD ASA-NEG Ethanol-NEG Carbamz-<1.0* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Lactate-6.2* . [**2159-2-7**] 01:26AM BLOOD Type-ART Rates-14/ Tidal V-600 FiO2-100 pO2-279* pCO2-45 pH-7.36 calHCO3-26 Base XS-0 AADO2-399 REQ O2-69 -ASSIST/CON Intubat-INTUBATED [**2159-2-7**] 01:26AM BLOOD Glucose-367* Lactate-2.9* Na-137 K-3.9 [**2159-2-7**] 06:22PM BLOOD Lactate-1.9 [**2159-2-7**] 04:40AM BLOOD ALT-41* AST-145* . [**2159-2-6**] 10:50PM CK(CPK)-209* CK-MB-12* MB Indx-5.7 cTropnT-0.05* [**2159-2-7**] 04:40AM CK(CPK)-523* CK-MB-64* MB Indx-12.2* cTropnT-2.53* [**2159-2-7**] 11:28AM CK(CPK)-438* CK-MB-48* MB Indx-11.0* cTropnT-3.73* . [**2159-2-7**]: Cardiac catheterization: C.O 3.94 C.I. 2.30 RA 14 RV 42/15 PA 42/24 PCWP 21 1. Three vessel coronary artery disease. 2. Biventricular diastolic dysfunction with elevated filling pressures and slightly low cardiac index 3. Patent bypass grafts. 4. Overall clinical presentation consistent with flash pulmonary edema COMMENTS: 1. Selective coronary angiography in this right dominant patient revealed severe native CAD with proximally occluded RCA and LMCA. 2. Selective angiography of grafts revealed a widely patent SVG-OM that filled a large OM. The SVG to PDA was widely patent. The LIMA to LAD was widely patent. 3. Resting hemodynamics revealed elevation of right and left sided filling pressures with RA of 14mmHG and PCWP of 21mmHG. The cardiac index was low at 2.3. There was mild pulmonary hypertension. There was no gradient across the aortic valve. 4. Ventriculography was limited as the pigtail migrated back to ascending aorta one second after injection began. However there appeared to be anterolateral and inferior hypokinesis with EF of about 35%. . [**2159-2-7**] Echocardiogram: 1.The left atrium is normal in size. 2.There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50-55%). While the study is technically difficult and the views limited, it appears that there is mild inferior wall hypokinesis. The inferolateral wall is not seen well enough to comment on its function. 3.Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The ascending aorta is mildly dilated. 5.The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. 6.The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. 7.There is no pericardial effusion. . [**2158-2-6**]:CHEST, AP PORTABLE: The tip of the endotracheal tube lies in the right main stem bronchus and should be withdrawn for more optimal positioning. There is a nasogastric tube coursing into the stomach, whose inferior position is not fully evaluated here. The heart size is normal. The mediastinal and hilar contours are unremarkable. There are no pleural effusions or pneumothorax. There is diffuse bilateral air space disease with a somewhat patchy distribution, which could be seen in a variety of conditions, including congestive heart failure, pneumonia, and ARDS. Of note, there are no pleural effusions, cardiomegaly, or hilar opacities to suggest cardiac failure, however. IMPRESSION: Diffuse airspace disease. Right mainstem bronchus intubation. . [**2159-2-7**]: PORTABLE AP CHEST. Compared to the prior radiograph obtained yesterday,there is marked improvement in the interstitial and alveolar pulmonary edema. There are no pleural effusions or pneumothorax. The heart size is normal. The mediastinal and hilar contours are normal. ET tube and NG tube are in good position. IMPRESSION: Marked improvement in the pulmonary edema. Brief Hospital Course: 67 year old female with CAD s/p CABG [**5-16**] ((SVG-PDA, SVG-OM, LIMA-LAD), HTN, AFib, DM presents with acute dyspnea, intubated, now s/p cardiac cath, likely acute pulmonary edema from diastolic and systolic congestive heart failure given CABG vein grafts widely patent. No interventions on cardiac catheterization and patient tolerated procedure without complications, PCWP was 21. Patient was diuresed with lasix and extubated hours after the catheterization. . 1. CV: Ischemia, taken to cath, with vein grafts widely patent, no evidence of acute coronary syndrome. Continue ASA, statin, beta blocker. Pump: Echo performed, EF 50-55%, Diastolic and systolic dysfunction seen on Left ventriculogram on cath (Echo results above). Likely pulmonary edema in setting of dietary indiscretion. Diuresed with lasix, pulmonary edema much improved by exam and cvhest x-ray. Restarted ACEI for afterload reduction. Changed to po lasix dose. This may need to be increased as outpatient. Patient instructed to check daily weights and call physician if weight increases > 2 lbs. Rhythm: normal sinus rhythm, monitored on Telemetry . 2. DM: insulin gtt on day of admission given blood sugars 300's, monitored finger sticks. No ketones in urine, so unlikely DKA. Transitioned to RISS the next day. Restarted oral hypoglycemics prior to discharge and sugars well-controlled and not requiring insulin. . 3. Resp: s/p extubation on [**2-5**], breathing comfortably off oxygen. . 4. FEN: low sodium, diabetic diet. Patient had nutrition consult for low salt diet education. . 5. Dispo: Patient to be discharged to home without services after being cleared by physical therapy. She has an appointment scheduled with her cardiologist, Dr. [**Last Name (STitle) 32963**] on [**2159-2-21**]. Medications on Admission: ASA 325 HCTZ 1 tab qday Glucophage 500 [**Hospital1 **] Lipitor 20 glyburide 5 qday atenolol 25 qday Lisinopril ? qday Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: pulmonary edema congestive heart failure, diastolic and systolic Discharge Condition: stable Discharge Instructions: Please call your doctor or return to the hospital if you experience chest pain, shortness of breath, increased leg swelling. Please weight yourself daily and call your doctor for weight gain greater than 2 lbs. Followup Instructions: You have a follow-up appointment scheduled with your cardiologist, Dr. [**Last Name (STitle) 32963**] on [**2159-2-21**] at 11:30 a.m. Please call [**Telephone/Fax (1) 34119**] to reschedule if you are unable to keep this appointment. Completed by:[**2159-2-9**]

[ "414.00", "V45.81", "428.40", "250.00", "427.31" ]

icd9cm

[ [ [] ] ]

[ "96.71", "88.53", "96.04", "88.56", "37.23" ]

icd9pcs

[ [ [] ] ]

8702, 8708

6068, 7877

331, 430

8817, 8826

1800, 1800

9086, 9351

1452, 1470

8046, 8679

8729, 8796

7903, 8023

8850, 9063

1485, 1781

272, 293

458, 1136

1816, 6045

1158, 1213

1229, 1436

31,029

158,673

52702

Discharge summary

report

Admission Date: [**2106-8-13**] Discharge Date: [**2106-8-18**] Date of Birth: [**2039-2-13**] Sex: F Service: MEDICINE Allergies: Morphine / Dilaudid (PF) Attending:[**First Name3 (LF) 7744**] Chief Complaint: lethargy Major Surgical or Invasive Procedure: Reason for MICU transfer: hyponatremia, hypotension, respiratory distress History of Present Illness: . History of Present Illness: Ms. [**Known lastname 108723**] is a 67 year old female with multiple medical problems, including diabetes mellitus, alcohol-related-cirrhosis, coronary artery disease with a bare metal stent, and chronic diastolic heart failure, who is admitted to the ICU from the ED for management of hyponatremia, hypotension, and hypoxia. . She was diagnosed with a left lower lobe pneumonia on [**2106-8-5**] and was on day eight of ten of a levofloxacin course. She was referred to the ED by her PCP due to increasing fatigue and an inability to care for herself at home. . Upon arrival to the ED, her vital signs were T 98.2, HR 84, BP 93/62, RR 20, saturating 90% RA. She complained of bilateral lower extremity pain that had been going on for weeks. Her exam was notable for crackles in the left lower field and erythema in the right lower extremity. Her labs were notable for a sodium of 121, Chloride 86, Cr 2.6, BUN 37, proBNP of 1329 (elevated from 687 in [**2106-1-9**]), hematocrit of 31.5 (down from 34.3 in [**2106-7-9**]), and white cells of 10.1k with 78% neutrophils. A UA showed few bacteria, positive leuks, 7 wbc, and negative nitrite. A repeat UA two hours later was completely neative. The urine sodium was less than 10. A chest x-ray showed a resolving left lower lobe opacity. Lower extremity dopplers were negative for dvt in the right lower extremity. A CTA was contraindicated in the setting of renal failure, and a V-Q scan was ordered. Suspicion was high for a pulmonary embolism given the patients prior history of pulmonary embolism; however, heparin was not initiated because she had guaiac positive stool. She was given one liter of normal saline, afterwhich her systolic blood pressure improved from the low 90s to the low 100s. . Her vital signs upon transfer were bp 105/62, hr 62, sat 99 4L, rr unknown, and was reported to be afebrile. She had one 18 guage peripheral iv. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1. Coronary artery disease s/p RCA w/bare metal stent on [**2102-2-2**] (single vessel disease) 2. Diastolic CHF (Recent ECHO [**2105-10-15**], EF~55%) 3. Crohn's Disease: h/o pancolitis w/o small bowel involvement; colonoscopy [**10-14**] showed no active disease, was on 5-[**Month/Year (2) **] 4. Chronic Renal Failure (Cr~1.4 at baseline) 5. DM Type II on insulin 6. Hypertension 7. h/o idiopathic dilated CMP, now resolved 8. Peptic ulcer disease 9. Alcoholic cirrhosis 10. GERD 11. Rheumatoid arthritis 12. Pulmonary embolus in [**2098**] 13. Total right knee replacement with subsequent chronic pain 14. [**Doctor Last Name **] mal seizure in childhood 15. Cervical disc disease 16. L5/S1 radiculopathy with anterolisthesis of L4 on L5 on X-Ray with EMG consistent with mild radiculopathy 17. History of GI bleed of unclear etiology ([**2-/2103**]), questionable hemorrhoids 18. h/o MRSA right knee wound infection s/p knee replacement 19. Anemia 20. H/o CDiff colitis ([**5-/2102**]) 21. Osteopenia 22. Chronic pancreatitis 23. Cervical spndylysis 24. Candidal esophagitis X3 Social History: Patient lives with a disabled son in [**Name (NI) 669**]. One other son currently incarcerated. Last son recently back from rehab. She was married but divorced a long time ago. 4 pack year smoking history, quit 15 years ago. Drank ~1 pint alcohol/day x 10 years, quit 15 years ago. Denies illicit drug use. Ambulates with a walker at baseline. Family History: "Mom died of [**Name (NI) 499**] cancer. Father with DM requiring bilateral below the knee amputation. One sister has had cervical cancer(cured) and rheumatoid arthritis. Son with stroke 2 years ago. Extensive family history of hypertenison." Physical Exam: On Admission: Physical Exam: Vitals: T: 97.5 BP: 99/49 P: 81 R: 21 O2: 95% 2L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . On discharge: VS: 98.6 (98.8), 128/78 (120s-150s/70s-90s), 82 (70s-80s), 20, 95% RA GEN: awake, alert, oriented x3, obese woman, NAD, able to state days of week and months of year forwards but not backawards, able to give directions to her home (was not able to 2 days ago) HEENT: sclera anicteric, MMM Neck: supple CV: RRR, no m/r/g Lungs: CTAB, no wheezes, crackles, or rhonchi, slightly diminished breath sounds at left base Abd: soft, non-tender, non-distended Ext: warm, no edema, DPs palpable bilaterally Pertinent Results: ADMISSION LABS: [**2106-8-13**] 11:52PM WBC-8.3 RBC-3.36* HGB-10.5* HCT-30.9* MCV-92 MCH-31.3 MCHC-34.2 RDW-14.3 [**2106-8-13**] 11:52PM GLUCOSE-114* UREA N-36* CREAT-2.3* SODIUM-123* POTASSIUM-3.7 CHLORIDE-91* TOTAL CO2-20* ANION GAP-16 [**2106-8-13**] 11:52PM CALCIUM-8.2* PHOSPHATE-3.9 MAGNESIUM-1.3* [**2106-8-13**] 11:52PM PT-14.1* PTT-29.5 INR(PT)-1.2* [**2106-8-13**] 11:52PM PLT COUNT-213 [**2106-8-13**] 08:36PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006 [**2106-8-13**] 08:36PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2106-8-13**] 06:30PM URINE HOURS-RANDOM SODIUM-<10 POTASSIUM-22 CHLORIDE-<10 TOTAL CO2-LESS THAN [**2106-8-13**] 06:30PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.011 [**2106-8-13**] 06:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2106-8-13**] 06:30PM URINE RBC-<1 WBC-7* BACTERIA-FEW YEAST-NONE EPI-13 TRANS EPI-2 [**2106-8-13**] 06:30PM URINE HYALINE-9* [**2106-8-13**] 05:58PM LACTATE-0.8 [**2106-8-13**] 04:50PM GLUCOSE-135* UREA N-37* CREAT-2.6* SODIUM-121* POTASSIUM-4.0 CHLORIDE-86* TOTAL CO2-22 ANION GAP-17 [**2106-8-13**] 04:50PM estGFR-Using this [**2106-8-13**] 04:50PM proBNP-1329* [**2106-8-13**] 04:50PM WBC-10.1 RBC-3.46* HGB-10.8* HCT-31.5* MCV-91 MCH-31.3 MCHC-34.3 RDW-14.4 [**2106-8-13**] 04:50PM NEUTS-78.0* LYMPHS-14.5* MONOS-5.2 EOS-2.0 BASOS-0.4 [**2106-8-13**] 04:50PM PLT COUNT-245 [**2106-8-13**] 04:50PM PT-14.3* PTT-29.8 INR(PT)-1.2* DISCHARGE LABS: [**2106-8-18**] 05:17AM BLOOD WBC-8.8 RBC-3.63* Hgb-11.1* Hct-32.3* MCV-89 MCH-30.5 MCHC-34.3 RDW-14.6 Plt Ct-266 [**2106-8-18**] 05:17AM BLOOD Glucose-105* UreaN-13 Creat-1.2* Na-141 K-4.1 Cl-106 HCO3-23 AnGap-16 [**2106-8-18**] 05:17AM BLOOD Calcium-9.5 Phos-3.4 Mg-2.1 . IMAGING: CXR ([**8-5**]): Left lower lobe pneumonia. . CXR ([**8-13**]): Improved left lower lobe opacification, with interval development of bibasilar atelectasis in the setting of low lung volumes. . RLE U/S ([**8-13**]): No evidence of right lower extremity deep venous thrombus. . LIVER/GALLBLADDER U/S ([**8-14**]): 1. Patent hepatic vasculature. 2. Increased echogenicity and coarseness of the liver likely relates to underlying cirrhosis. 3. Prominent but unchanged main pancreatic duct. 4. Mild gallbladder wall thickening, likely related to the underlying liver disease. . CT Head ([**8-15**]): No evidence of an acute intracranial process. . TTE ([**8-16**]): Mild focal LV systolic dysfunction. EF 45% (decreased from prior Echo) . ECG ([**8-16**]): Normal axis and rate, Q waves in III and avF suggesting area of old ischemia, unchanged from prior EKGs . MICRO: Urine Legionella: negative Urine Cx ([**8-14**]): KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- =>512 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R Sputum Cx: MODERATE GROWTH Commensal Respiratory Flora. GRAM NEGATIVE ROD(S). RARE GROWTH. . DFA: Negative . Stool Cx ([**8-18**]): NO SALMONELLA OR SHIGELLA FOUND. NO CAMPYLOBACTER FOUND. NO VIBRIO FOUND. NO YERSINIA FOUND. NO E.COLI 0157:H7 FOUND. . C diff: negative Brief Hospital Course: Ms. [**Known lastname 108723**] is a 67 year old female with multiple medical problems, including diabetes mellitus, alcohol-related-cirrhosis, coronary artery disease with a bare metal stent, and chronic diastolic heart failure, who was admitted to the ICU from the ED for management of hyponatremia, hypotension, and hypoxia in the setting of UTI. . # AMS: Pt was lethargic at presentation which was thought to be due to hyponatremia, hypoxia, or infection. Pt became febrile to 100.6F. Pt was given fluids and started on vancomycin and zosyn, then vanc and meropenem for treatment of presumed HAP. Her tox screen was negative expect for benzos which she was given in the ED. She also had a CT-scan of her head which did not show any acute process. Urine cx was grossly positive for Klebsiella, so infection was most likely important contributor to pt's AMS. Pt showed attention deficits on the floor, though remained largely oriented and alert, patient was discharged home with close follow-up. . #Hypoxia: Initial O2sat in the ER was 90% on RA and she had an ABG that showed PO2 of 63 with A-a gradient. Her CXR showed atelectasis, but no consolidation. Pt was mildly febrile but without an elevated white count and only mild cough. Based on a CXR from [**8-5**], pt had been treated for LLL pna as an outpt with levoquin though her cough and malaise persisted. Her oxygen saturation quickly improved to the mid 90s% on RA once in the ICU. Differential diagnosis of pt's hypoxia included atelectasis, infection, hypoventilation due to AMS, acute exacerbation of pt's diastolic CHF, or viral illness. Pt was started on vanc and zosyn while sputum cxs were sent. Viral DFA was negative. Pt was switched to vanc and meropenem when her hx of ESBL was noted. On transfer to the floor, suspicion for HAP was low so vanc was d/c'ed. Pt continued to sat well on the floor. . # UTI: Pt's urine cultures were positive for Klebsiella sensitive to cephalosporins so patient was switched from meropenem to cefpodoxime for a 10 day course to be completed on [**2106-8-23**]. . #Hyponatremia: Likely to be hypovolemia hyponatremia due to decreased PO intake as pt corrected appropriately with IV fluid. Sodium remained within the normal range for the remainder of her hospitalization. . #Hypotension: She initially had a systolic blood pressures in the low 100s, but she has been in this range before. She had poor PO intake, and her hypotension may have reflected hypovolemia as it improved with fluid hydration. There was low concern for sepsis as she was only mildly febrile and she was not tachycardic. . #Diarrhea: On day 2 of admission, pt had several loose bowel movements with no frank blood and guaiac negative. They were liquidy and orangey in appearance. Pt states it did not feel like her Crohn's, her last flare was three years ago. Pt's H/H remained stable throughout her course. C.diff and stool cultures were negative. . #Acute on Chronic Renal Failure: Likely pre-renal given pt's low FeNa and the quick improvement of her creatinine with fluids. . CHRONIC ISSUES #Diasolic HF: Stable. Pt's torsemide was initially held in the setting of robust autodiuresis but then re-started prior to discharge. TTE showed hypokinesis of the anterior wall and EF of 45%, slightly depressed from one year ago. ECG was normal. Pt did not complain of any chest pain, worsening PND, or exertional symptoms so concern for new or recent ACS was low. Pt was instructed to follow-up with her outpt cardiologist for further recommendations on optimizing her heart failure regimen. . #CAD: Pt's carvedilol was initially held in the setting of her initial hypotension but as her blood pressures improved this was re-started. Pt was continued on her aspirin and simvastatin. ECG on [**8-16**] showed no changes from previous. . #Diabetes Mellitus type II: Stable. Pt was maintained on a regular insulin sliding scale while in the hospital. . TRANSITIONAL ISSUES . - Follow-up newly depressed EF with outpt cardiology. Determine whether her outpatient CAD/CHF regimen should be altered. Medications on Admission: -carvedilol 25mg po bid -ciprofloxacin 250mg [**Hospital1 **] -codeine/guaifenesin 100/10mg q6hrs prn -cyclobenzaprine 5mg [**Hospital1 **] prn pain/spasms -diazepam 10mg qhs prn pain -fluticasone/salmeterol 250/50mcg 1 puff, [**Hospital1 **] -gabapentin 600mg [**Hospital1 **] -hydrocortisone cream [**Hospital1 **] -lantus 40 units sq qhs -ipratropium/albuterol 18/103mcg 1-2 puffs q6 hrs prn -levofloxacin 250mg po daily, day [**8-18**] was on [**2106-8-13**] -lidocaine patch 5% q12hrs to affected area -zenpep(lipase-protease-amylase) 20k/68k/109k units, 4 capsules po tid with meals -mesalamine (asacol) 400mg e.c. 4 tabs, tid -nitroglycerine .4mg SL prn -omeprazole 20mg [**Hospital1 **] -oxycodone ER 20mg tid -oxycodone/acetaminophen 5/325mg 1 tab tid prn -simvastatin 20mg daily -torsemide 80mg daily -aspirin 325mg daily -docusate -ergocalciferol 800 units daily -ferrous sulfate 325mg daily -glucosamine/chondroitin 250/200mg cap tid -lac-hydrin cream -omega three fatty acids 1000mg [**Hospital1 **] Discharge Medications: 1. codeine-guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 2. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-10**] Puffs Inhalation Q6H (every 6 hours) as needed for wheezing. 3. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 4. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule, Delayed Release(E.C.) Sig: Four (4) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four (4) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 9. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 11. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for pain. 12. torsemide 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 13. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO twice a day: Please start taking this medicine on [**8-24**]. 14. cyclobenzaprine 5 mg Tablet Sig: One (1) Tablet PO BID PRN as needed for pain. 15. diazepam 10 mg Tablet Sig: One (1) Tablet PO QHS PRN as needed for pain. 16. Lantus 100 unit/mL Solution Sig: Forty (40) units Subcutaneous at bedtime. 17. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual PRN as needed for chest pain. 18. OxyContin 20 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO three times a day. 19. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 20. ergocalciferol (vitamin D2) 400 unit Tablet Sig: Two (2) Tablet PO once a day. 21. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. 22. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 5 days: Please stop taking this medicine on [**8-23**]. Disp:*20 Tablet(s)* Refills:*0* 23. hydrocortisone Topical 24. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 25. omega-3 fatty acids 1,000 mg Capsule Sig: One (1) Capsule PO twice a day. 26. glucosamine-chondroitin 250-200 mg Capsule Sig: One (1) Capsule PO three times a day. 27. Lac-Hydrin Topical Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: (Primary) Urinary tract infection (Secondary) Diabetes Diastolic Congestive heart failure Hypertension Coronary artery disease Cirrhosis Crohn's Disease Rheumatoid Arthritis Discharge Condition: Mental Status: Alert and oriented but intermittently confused/inattentive Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [**Known lastname 108723**], You were admitted to [**Hospital1 18**] because you were feeling poorly, were sleepy and confused, and because you were not breathing as well as you normally do. We found a bacteria in your urine that might have been explaining your symptoms and so we treated you with an antibiotic. . Also, please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. . The following medications were changed during this admission: 1. Please START taking cefpodoxime. You will stop taking this medicine on [**8-23**]. This is an antibiotic for your urinary tract infection. 2. Please STOP taking Advair until you talk to your PCP about whether this is needed. . Please take all your other medications as prescribed. Followup Instructions: Department: RHEUMATOLOGY When: MONDAY [**2106-8-23**] at 1 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 14465**], MD [**Telephone/Fax (1) 2226**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: [**Hospital **] HEALTH CENTER When: THURSDAY [**2106-8-26**] at 12:00 PM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 5808**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: DIV. OF GASTROENTEROLOGY When: MONDAY [**2106-9-20**] at 11:00 AM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 2163**], 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

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Discharge summary

report+addendum

Admission Date: [**2174-2-16**] Discharge Date: [**2174-2-18**] Date of Birth: [**2114-8-9**] Sex: F Service: NEUROSURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 78**] Chief Complaint: Elective admission for recoiling of L MCA and Supraclinoid aneurysm Major Surgical or Invasive Procedure: [**2174-2-16**]: Cerebral angiogram with stent assisted coiling of the L MCA and Supraclinoid aneurysm History of Present Illness: 59F hx of multiple aneurysms with previous clippings and endovascular treatment. Elective admission for recoiling. Past Medical History: HTN High cholesterol h/o aneurysm clipping; first in '[**47**] (initially comatose and does not remember the onset) and then in '[**51**], when she had a sudden, severe headache and lost consciousness. The first aneurysm was left-sided and the second on the "right" Social History: currently not working. 30pk-yr smoking, current. Drinks 2-3 per night. Family History: no h/o aneurysms. Father had stroke at 42, mother unknown. Physical Exam: On admission: Awake, alert, PERRL, EOM intact, MAE [**5-7**], follow commands Upon discharge: nonfocal groin intact, no hematoma or staining Pertinent Results: *************ANGIO REPORT PENDING************ CT HEAD W/O CONTRAST [**2174-2-17**] Final Report FINDINGS: Examination is limited by extensive streak artifact from aneurysm coiling and clips. Old areas of tissue loss in the region of surgery are again seen. Within these limitations, no acute hemorrhage or significant mass effect Is identified. The ventricles are unchanged in size and configuration. The patient is status post multiple bilateral craniotomies. No concerning osseous lesion is identified. The visualized paranasal sinuses and mastoid air cells are clear. The frontal sinuses are not pneumatized. IMPRESSION: Limited examination due to extensive streak artifact from aneurysm coils and clips. However, within these limitations, no acute intracranial process identified. Note that early infarction could be particularly difficult to detect with these artifacts. Consider MR if that is a clinical concern. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: 59F who underwent recoiling of the L MCA and Supraclinoid aneurysm. A stent was placed in the L MCA adjacent to the previous stent. Post-operatively, the patient was admitted to the Neuro ICU. Her right femoral sheath was kept in place and discontinued later in the day. Pressure was held for 30 minutes, no bleeding or hematoma was noted post-pull. Post op day number one her exam was stable. She had subtle rue weakness overnight and a CT CTA was performed. There were no infarcts noted on CT. Her rue weakness was noted on the following morning exam and was ? related to pain / a-line. It was decided to keep her in the hospital for another 24 hours. On 217, patient's exam was stable, but reported a slight headache that was relieved with tylenol. She was eating appropriately and ambulating independently and was discharged home. Medications on Admission: Norvasc 10mg daily, Lisinopril 10mg daily, Toprol XL 25mg Qhs, Zocor 20mg Qhs, Plavix 75mg daily, Fioricet PRN, Prilosec Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**1-3**] Tablets PO Q4H (every 4 hours) as needed for Headache. Disp:*60 Tablet(s)* Refills:*0* 4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*1* 5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO HS (at bedtime). 8. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. Chantix 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Recanalization of L MCA and Supraclinoid aneurysm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Angiogram with Embolization and/or Stent placement Medications: ?????? Take Aspirin 325mg (enteric coated) once daily. ?????? Take Plavix (Clopidogrel) 75mg once daily for one month. ?????? 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. ?????? We recommend that you quit smoking. Please speak to your PCP regarding options. 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 white, 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: Please follow-up with Dr [**First Name (STitle) **] in 4 weeks with no imaging. You will also need to follow-up in 6 months with a MRI/MRA ([**Doctor Last Name **] protocol). Please call [**Telephone/Fax (1) 4296**] to make this appointment. Completed by:[**2174-2-18**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 7120**] Admission Date: [**2174-2-16**] Discharge Date: [**2174-2-18**] Date of Birth: [**2114-8-9**] Sex: F Service: NEUROSURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 40**] Addendum: plavix 75mg QD was prescribed for 1 month only 30 pills no refills Discharge Disposition: Home [**Name6 (MD) **] [**Last Name (NamePattern4) 43**] MD [**MD Number(2) 44**] Completed by:[**2174-2-18**]

[ "305.1", "437.3", "338.18", "272.0", "401.9" ]

icd9cm

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Discharge summary

report

Admission Date: [**2163-11-14**] Discharge Date: [**2163-12-1**] Date of Birth: [**2144-12-25**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1674**] Chief Complaint: fever fatigue Major Surgical or Invasive Procedure: Kidney biopsy History of Present Illness: 18 year old woman without significant PMH who initially presented with a 2 week history of HA, back pain, fevers, and general malaise, as well as intermittant cough. She was evaluated at OSH [**11-5**], [**Hospital1 18**] ED [**11-10**]; thought to have viral syndrome. CT at that time showed b/l hilar LAD and enlarged spleen. LP negative. She represented on [**11-14**] with a fever of 103 at which time she was admitted for further workup. . Pulmonary was consulted regarding hilar adenopathy, recommended supportive care and f/u CT in [**1-22**] months, felt dx likely [**1-21**] mono, though cannot exclude sarcoid. ID was consulted; patient found to have EBV IgM+ mononucleosis, treated with supportive care. Her CMV IgM and IgG was also positive. On [**11-20**], the patient's albumin was noted to be low; prot/creat ratio was found to be 33.9. Renal was consulted for new nephrotic syndrome (thought to be possibly [**1-21**] acute EBV). Renal biopsy performed on [**11-22**] (5 passes), consistant with minimal change disease; steroids were initiated. She developed ARF with increase in Cr from 0.9 on [**11-20**] to 2.5 on [**11-23**]. Hospital course also complicated by transaminitis and elevated bilirubin (resolving), as well as poor PO intake throughout her hospital course due to persistant abdominal / RUQ pain, thus has been receiving IVF (however, also has total body fluid overload/anasarca [**1-21**] nephrotic syndrome). . On the evening of transfer to the [**Hospital Unit Name 153**] the patient developed acute onset SOB and hypoxia. Vitals: afebrile, BP:140s/90s, HR: 130-140s, RR: 30, O2 sat: 94% 4L NC (new O2 requirement). ABG: 7.29/29/80. CXR: Volume overload. Given Lasix 80 mg with minimal response, then given Lasix 160 mg. Nitro paste applied. Non contrast CT abd done, which showed large intrascapsular renal hematoma, large b/l pleural effusions, stable splenomegaly, ?PNA. Transferred to [**Hospital Unit Name 153**] for further evaluation/treatment. ROS: +SOB, Chest pain (pleuritic, b/l), LUQ pain, back pain. Past Medical History: Asthma: (Mild intermittent, exercise induced) Social History: No tobacco, etoh, drugs. No recent travel or sick contacts. Lives with family, student. Not sexually active x 4 years. Physical Exam: Gen: Tachypnic, in mild respiratory distress, crying. VS: 99.2, BP:136/92, HR: 135, RR: 30, O2 sat: 94% 4L NC HEENT: MMM, OP clear Neck: +ant cervical LAD PULM: absent BS at bases, +diffuse crackles CV: tachy, RRR, [**12-25**] SM at RUSB ABD: distended, +mild LUQ tenderness, no rebound/guarding, +splenomegaly EXT: [**12-21**]+ b/l LE edema Pertinent Results: Admit labs: [**2163-11-13**] 11:32PM WBC-8.4# RBC-4.10* HGB-11.6* HCT-33.2* MCV-81* MCH-28.2 MCHC-34.8 RDW-13.4 [**2163-11-13**] 11:32PM NEUTS-52 BANDS-6* LYMPHS-27 MONOS-2 EOS-1 BASOS-0 ATYPS-12* METAS-0 MYELOS-0 [**2163-11-13**] 11:32PM GLUCOSE-107* UREA N-8 CREAT-1.0 SODIUM-135 POTASSIUM-4.0 CHLORIDE-99 TOTAL CO2-23 ANION GAP-17 [**2163-11-14**] 07:50AM ALT(SGPT)-64* AST(SGOT)-82* LD(LDH)-544* ALK PHOS-71 AMYLASE-38 TOT BILI-0.5 Vial Syndrome work up: EBV, CMV IgM and IgG positive Monospot positive HIV ab and viral load negative RPR negative Toxo IGM and IGG negative Nephrotic Syndrome work up [**2163-11-14**] 07:50AM TSH-1.9 [**2163-11-14**] 07:50AM HBsAg-NEGATIVE HBs Ab-POSITIVE HBc Ab-NEGATIVE HAV Ab-NEGATIVE [**2163-11-14**] 07:50AM [**Doctor First Name **]-NEGATIVE [**2163-11-14**] 07:50AM HCV Ab-NEGATIVE [**2163-11-22**] 07:55AM BLOOD RheuFac-11 [**2163-11-20**] 02:07PM BLOOD [**Doctor First Name **]-NEGATIVE [**2163-11-14**] 07:50AM BLOOD [**Doctor First Name **]-NEGATIVE [**2163-11-20**] 07:20AM BLOOD SPEP-NO SPECIFIC abnormalities [**2163-11-17**] 07:45AM BLOOD HIV Ab-NEGATIVE [**2163-11-20**] 07:20AM BLOOD C3-112 C4-27 [**2163-11-27**] 07:08AM BLOOD VITAMIN D 25 HYDROXY-PND12/05/07 01:10PM BLOOD EBV Culture data: Blood cultures 11/26, [**11-18**], [**11-20**] all no growth [**11-23**]: [**1-23**] S. viridans positive Radiology: Please refer to OMR, multitude of studies Brief Hospital Course: Ms. [**Known lastname 13741**] is an 18 year old woman admitted [**11-14**] with fevers, left lower abdominal pain. She had been having ongoing fevers, non-specific fatigue and myalgias for about the past 1-2 weeks and has been to [**Hospital **] hospital and [**Hospital3 **] with these complaints and they were attributed to viral syndrome. On admission to [**Hospital1 18**], she was febrile with ongoing left lower quadrant and left sided back pain. On work up, her monospot, CMV and EBV IGM and IGG serologies all returned positive and was diagnosed with mononucleosis-unclear if CMV or EBV or both. She was treated conservativly with ivf's, nsaids, tylenol but continued to feel extreme fatigue, abdominal pain, back pain and have ongoing fevers. Ob/gyn consulted and did not feel any gynecologic pathology. She was monitored closely and by [**11-19**] her transaminitis was improving and her fevers were well controlled with tylenol/nsaids. Multiple blood cultures without growth. However, albumin noted to be dropping precipitously from mid 3 range to mid 1 range. Protein/creatinine ratio checked and found to be 33. Patient began to develop anasarca and abdominal pain more diffuse, particularly left upper quadrant. Left lower back pain ongoing throughout this time. CT abdomen scan checked on [**11-20**] to look for splenic injury and demonstrated moderate splenomegaly, anasarca. Renal consulted on [**11-20**] for possible biopsy. Given age, concern for Minimal change disease and need for steroids. Patient became progressively more edematous and with this third spacing patient with acute renal failure by [**11-21**]. Patient had renal biopsy on [**11-22**] and steroids initiated. Pain ongoing [**Date range (1) 52675**] attributed to splenomegaly and bowel wall, total body edema. Pain signifiant enough to require dilaudid PCA over this time. On [**11-23**] renal biopsy reviewed and consistent with MCD vs. FSGS. Given clinical picture, more consistent with MCD. ID following initially [**Date range (1) 75674**] and then with development of nephrotic syndrome, re-consulted [**11-20**] with ? of need for anti-virals. Extensive literature search conducted and risks and benefits of steroids and anti-virals weighed. Renal failure progressive from [**Date range (1) 75675**], creatinine to mid 2's, attempted fluids but unable to stave off worsening renal function and patient more edematous. On [**11-23**] while teams reviewing biopsy, patient developed respiratory distress secondary to worsening pleural effusions. Diuresis with iv lasix initiated, cxr with large pleural effusions, fluid overload, CT scan abdomen performed(stable splenomegaly and perinephric hematoma at biopsy site). GIven nephrotic syndrome, concern for VTE but unable to perform CTA secondary to acute renal failure. Empiric heparin considered after CT scan showed no splenic bleeding but concern given hematoma. V/Q scan unreliable in setting of large pleural effusions. Ultimately not started and patient transferred to [**Hospital Ward Name 332**] ICU for closer monitoring. Patient had negative LENI's, negative perfusion scan and responded with brisk diuresis to high dose lasix and therefore never started on heparin gtt. Patient in the [**Hospital Unit Name 153**] from [**11-23**] evening until [**11-26**] evening. Diuresed about 4 liters over this time with iv lasix. Additionally, infectious disease ultimately decided to initiated ganciclivir after extensive consideration of risk and benefits. Concern for worsening CMV in setting of steroids for minimal change most prominent concern and therefore initiated. Creatinine continued to trend up until a peak of 3.4 on [**11-26**]. Steroids continued over this time. . By [**11-27**] patient auto-diuresing briskly, consistent with post ATN diuresis. Last lasix dose on [**11-26**] AM. Patient feeling much improved with decrease in abdominal pain on [**11-27**] into [**11-28**] and creatinine trending down into 2's by [**11-28**]. Ganciclovir continued as per infectious disease. Unfortunately, despite this clinical improvement, blood cultures drawn on [**11-23**] during respiratory distress had returned positive [**11-24**]. Initially GPC reported and felt to be contaminant given clinical improvement. GIven cefipime and vancomycin [**11-23**] throught [**11-25**]. Ultimately strep viridans 2/4 bottles (same set). Antibiotics discontinued [**11-26**] on recommendation of ID, felt to be contaminant. On [**11-27**] with transfer back to hospitalist service who was aware of previous unexplained back pain complaints, decision made to pursue work up of possible strep viridans occult source. Consideration given that strep viridans could have been cause of presenting symptoms, or could have explained back pain (?sacroileitis/epidural abcess etc.), or could possibly have been secondary to gut translocation in setting of bowel wall edema from nephrotic syndrome. Surveillance blood cultures drawn [**11-27**], [**11-28**] and tylenol discontinued to monitor fever curve. MRI L-spine and pelvis obtained on [**11-27**] and demonstrated some hypointense areas on the spine. By that point back pain had resolved, afebile, and surveillance cultures were normal. Infectious disease attending reviewed case and felt that infection/abscess was unlikely and recommended no further workup, no wbc scan done. Discharged home to continue valgancylovir for CMV. Nephrotic syndrome ultimately felt to be complication of mononucleosis. [**Doctor First Name **], ANCA negative, spep/upep with no monoclonal abnormalities, hepatitis serologies consistent with hep b immunization otherwise negative, HIV ab and viral load negative. No history of diabetes mellitus or other systemic disease to explain nephrotic syndrome. REnal failure, nephrotic syndrome also lead to metabolic acidosis and hyponatremia which were managed with bicarbonate and diuresis. Minimal change disease treated with prednisone, plan for follow up with renal. [**Month (only) 116**] need to start ACE inhibitor as outpatient. For perinephric hematoma, serial hematocrits followed, urology consulted and recommend close monitoring. Hematocrit largely stable (did have drop over hospitalization likely multifactorial). For splenomegaly, LAD, on CT will need repeat CT 6wks to ensure resolution. Medications on Admission: None, intermittent tylenol, nsaids Discharge Disposition: Home Discharge Diagnosis: minimal change disease renal failure CMV infection Discharge Condition: stable Discharge Instructions: Please call your doctor with any headache, shortness of breath, fever or other concerning symptoms. Followup Instructions: Please go to the infectious disease clinic laboratory to have your blood drawn any time on [**12-11**] at [**Last Name (NamePattern1) 439**] (a hospital building) Please go to [**Last Name (NamePattern1) 439**] infectious disease clinic to see Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2163-12-16**] 10:30 Please follow up with the kidney specialist (Dr. [**Last Name (STitle) 7143**] and Dr. [**Last Name (STitle) **] on [**12-6**] at 4pm in [**Hospital Ward Name 23**] Building ([**Location (un) **]) [**Location (un) 436**]. Please make an appointment with your new primary care doctor within the next 6 weeks. This doctor will need to help schedule a repeat Ct scan to make sure your spleen and lymph nodes have returned to [**Location 213**] size. This doctor will also help to schedule a bone scan to make sure that your bones are not getting fragile (this can be a side effect of steroids). [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**] Completed by:[**2163-12-21**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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Discharge summary

report+addendum

Admission Date: [**2171-11-14**] Discharge Date: [**2171-11-20**] Date of Birth: [**2085-10-4**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2569**] Chief Complaint: Visual changes and CT findings Major Surgical or Invasive Procedure: None History of Present Illness: 86 yo RHM who presented initially to [**Hospital1 2436**] this morning on [**2171-11-14**] after he awoke and had visual changes and a headache. He states that when he awoke he looked at his alarm clock and felt that he could not read the numbers. He usually has dry eyes in the morning and thought it may have been related to this, but then he used some drops and still could not see them. He said he saw the images, but could not interpret them. He also described that he was having a headache mostly on the right side of his head. This he described as a tightness over the temporal aspect of his head. He became worried at this time and called 911. He was transported to [**Hospital3 **] and a noncontrast CT revealed a right parieto-occipital hemorrhage and he was sent to [**Hospital1 18**] for definitive care. On neuro ROS, the pt denies blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: COPD (no smoking histroy) HTN - well controlled on antihypertensives HLD Social History: Retired from wholesale distribution of candy and cigarettes. Family History: Mother - CHF Father - MI 2 sons who are healthy Physical Exam: Admission physical examination: Vitals: 97.6 140/76 66 16 97% 3L General: Awake, cooperative, NAD. HEENT: NC/AT Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: decreased I:E ratio, no crackles Cardiac: soft heart sounds, no murmurs Abdomen: soft, nontender, nondistended Extremities: no edema, pulses palpated Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt. was able to register 3 objects and recall [**1-18**] at 5 minutes. The pt. had good knowledge of current events. There was no evidence of apraxia or neglect. Had some difficulty with [**Location (un) 1131**] - likely related to visual field deficits. Able to write a senstence. With clock construction he was unable to place the figures correctly around the clock. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. Significant left visual field deficit not seeing finger until at the nasal bridge. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Delayed saccades to the left. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. Increasing tremor w/ outstretched hands. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: good initiation, unsteady initially, slightly wide base with short steps. . . Discharge examination: Left homonymous hemianopia, left sensory and possible visual inattention. Otherwise neurologically intact with good strength all 4 limbs and present reflexes. Pertinent Results: Laboratory investigations: Admission labs: [**2171-11-14**] 12:20PM BLOOD WBC-8.2 RBC-4.42* Hgb-13.2* Hct-38.3* MCV-87 MCH-30.0 MCHC-34.6 RDW-13.1 Plt Ct-187 [**2171-11-14**] 12:20PM BLOOD Neuts-87.3* Lymphs-7.6* Monos-2.5 Eos-2.2 Baso-0.3 [**2171-11-14**] 12:20PM BLOOD PT-11.5 PTT-33.6 INR(PT)-1.1 [**2171-11-14**] 12:20PM BLOOD Glucose-121* UreaN-17 Creat-0.7 Na-139 K-3.9 Cl-105 HCO3-26 AnGap-12 [**2171-11-15**] 03:03AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.9 Cholest-106 . Other pertinent labs: [**2171-11-15**] 03:03AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.9 Cholest-106 [**2171-11-15**] 03:03AM BLOOD Triglyc-58 HDL-39 CHOL/HD-2.7 LDLcalc-55 [**2171-11-15**] 03:03AM BLOOD %HbA1c-5.7 eAG-117 [**2171-11-15**] 03:03AM BLOOD TSH-1.1 [**2171-11-14**] 12:20PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2171-11-14**] 03:15PM BLOOD Ethanol-NEG [**2171-11-14**] 12:36PM BLOOD Lactate-0.8 . Discharge labs: [**2171-11-20**] 04:15AM BLOOD WBC-5.9# RBC-3.93* Hgb-12.5* Hct-34.7* MCV-88 MCH-31.8 MCHC-36.0* RDW-13.5 Plt Ct-165 [**2171-11-20**] 04:15AM BLOOD Glucose-99 UreaN-26* Creat-1.0 Na-136 K-4.1 Cl-99 HCO3-30 AnGap-11 [**2171-11-20**] 04:15AM BLOOD Calcium-8.3* Phos-3.0 Mg-2.0 . . Urine: [**2171-11-14**] 05:12PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011 [**2171-11-14**] 05:12PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG [**2171-11-18**] 06:50AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020 [**2171-11-18**] 06:50AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR [**2171-11-18**] 06:50AM URINE RBC-7* WBC-10* Bacteri-NONE Yeast-NONE Epi-0 [**2171-11-18**] 06:50AM URINE Mucous-FEW [**2171-11-14**] 05:12PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG . . Microbiology: [**2171-11-14**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2171-11-14**] 5:13 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2171-11-16**]** MRSA SCREEN (Final [**2171-11-16**]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. [**2171-11-18**] 6:50 am URINE Site: CATHETER Source: Catheter. **FINAL REPORT [**2171-11-19**]** URINE CULTURE (Final [**2171-11-19**]): GRAM POSITIVE BACTERIA. ~3000/ML. SUGGESTING STAPHYLOCOCCI. . . Radiology: MR HEAD W & W/O CONTRAST Study Date of [**2171-11-14**] 7:53 PM FINDINGS: There is an extensive right parieto-occipitotemporal hematoma, measuring 26 x 93 mm in its largest axial diameter. The hematoma displays fluid-fluid level, is hypointense on T1 and heterogeneously hyperintense on T2, suggesting hyperacute state with the signal predominantly related to oxyhemoglobin. A rim of high signal on diffusion imaging along the medial aspect of the medial aspect of the hematoma may be related to blood products or indicate underlying infarction. Thus, this might be a hemorrhagic infarction. There is significant perilesional edema and mass effect on the right atrium with CSF trapping in the right temporal [**Doctor Last Name 534**]. Faint linear enhancement within and along the margins of the hemorrhage is likely vascular in nature; there is no evidence of underlying mass. Also, there is no evidence of chronic microhemorrhages on gradient echo sequence that would suggest an etiology of amyloid angiopathy. The basal cisterns are patent. Flow voids of the major intracranial vessels are preserved. Mild mucosal thickening is seen involving the bilateral anterior ethmoid air cells. The mastoid air cells are clear. IMPRESSION: Extensive right parieto-occipitotemporal hematoma in hyperacute state with mass effect on the right atrium and CSF trapping in the right temporal [**Doctor Last Name 534**]. There is no evidence of underlying mass. No microhemorrhages or other regions bleeding are detected. While a rim of high signal on diffusion imaging along the medial border of the hematoma might be solely related to blood products, it may also indicate associated or underyling infarct and follow-up MR should be obtained for further characterization. . CTA HEAD W&W/O C & RECONS Study Date of [**2171-11-15**] 10:03 AM FINDINGS: NON-CONTRAST HEAD CT: Redemonstrated centered within the right parieto-occipital region is an extensive area of parenchymal hemorrhage with mild extent of surrounding vasogenic edema. There is associated mass effect with compression of the right occipital [**Doctor Last Name 534**] and associated enlargement of the right temporal [**Doctor Last Name 534**]. The degree of enlargement is similar since MR and prior CT. There is no evidence of intraventricular extension of hemorrhage. There is no evidence of subarachnoid hemorrhage. No extra-axial fluid collections are identified. There is persistent mass effect with effacement of the adjacent sulci with this large area of hemorrhage and leftward shift of the midline structures by approximately 7 mm. There is no transtentorial or uncal herniation. The [**Doctor Last Name 352**]-white matter differentiation is preserved. There is no evidence of acute infarction. The visualized portions of the paranasal sinuses and mastoid air cells are well aerated. There is no acute fracture. CTA EXAMINATION: This examination is markedly limited by poor contrast opacification. The circle of [**Location (un) 431**] is patent with no evidence of stenosis, dissection, or aneurysm. No vascular malformation is identified. Atherosclerotic calcification is demonstrated in the bilateral carotid siphons. IMPRESSION: 1. Known right parieto-occipital intraparenchymal hemorrhage. 2. No evidence of underlying vascular malformation. Patent circle of [**Location (un) 431**] within the limitations of poor contrast opacification. . CT HEAD W/O CONTRAST Study Date of [**2171-11-16**] 2:25 PM FINDINGS: A right parietooccipital hemorrhage and surrounding edema are identified with mild mass effect on the right lateral ventricle. There is prominence of temporal [**Doctor Last Name 534**] which is likely secondary to entrapment from compression of the periatrial region. The remaining ventricular system is normal. There is no significant change in extent of midline shift or mass effectidentified. There is no significant compression or deformity of the brainstem identified. IMPRESSION: Right parieto-occipital hemorrhage and surrounding edema as well as the associated mass effect are not significantly changed. There is persistent dilatation of the right temporal [**Doctor Last Name 534**] from compression of the ventricle. . CHEST (PA & LAT) Study Date of [**2171-11-19**] 10:24 AM IMPRESSION: No evidence of pneumonia. Over inflation of the lungs consistent with underlying COPD. . . Cardiology: ECG Study Date of [**2171-11-14**] 12:21:14 PM Normal sinus rhythm. Intra-atrial conduction abnormality. Abnormal R wave progression which may be due to lead position or prior anteroseptal myocardial infarction. This is a borderline tracing. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 72 202 94 394/415 62 6 48 . . Speech and language therapy VIDEO OROPHARYNGEAL SWALLOW Study Date of [**2171-11-20**] 9:26 AM EVALUATION: SUMMARY: Mr. [**Known lastname **] presented with a mild- moderate oral dysphagia due to poor dentition and reduced oral control. He tolerated single sips of thin liquids and soft solids without concern, but did aspirate thin liquids silently when taking the barium tablet with water. This risk is also there with mixed consistencies, although he did not aspirate mixed textures when given today. Pt spiked a fever and had increased WBC counts with concern for PNA after initiating POs, but his CXR from yesterday was c/w COPD and not PNA. We should continue to monitor him as he is at risk for aspiration and he will benefit from SLP f/u after d/c to rehab which is scheduled for later today. FOIS rating of 6 RECOMMENDATIONS: 1. PO diet of thin liquids and moist, soft solids - avoid mixed consistencies that contain both liquids and solids 2. Small, single sips if liquid only 3. Meds whole with apple sauce (aspirated thin liquid when taking pill with water) 4. TID oral care 5. Continued SLP follow up in rehab for tolerance after d/c. Brief Hospital Course: 86 year-old right handed man who presented initially to [**Hospital3 **] for visual changes and a headache and was transferred to [**Hospital1 18**] after CT revealed a large (6.5 x 6.5 x 2 cm) R parieto-occipital intraparenchymal hemorrhage. He was an inpatient from [**2171-11-14**] and transferred to rehab on [**2171-11-19**]. # Neurology: Patient awoke with a right-sided headache and visual loss. AT OSH, head CT revealed a right parieto-occipital hemorrhage and he was sent to [**Hospital1 18**] for further management on [**2171-11-14**]. On examination, he had a left homonymous hemianopia and left sensory and possibly also visual inattention. Otherwise, examination was unremarkable. He was assessed with an MRI head which showed extensive right parieto-occipitotemporal hematoma in hyperacute state with mass effect on the right atrium and CSF trapping in the right temporal [**Doctor Last Name 534**]. It was unclear whether there may have been an underlying infarct although there was no evidence of underlying mass. Radiology therefore recommended interval MRI evaluation to better elucidate for any underlying lesion. He had a repeat CTA showed no evidence of stenosis, dissection, or aneurysm or vascular malformation in addition to atherosclerotic calcification in the bilateral carotid siphons. Repeat CT head imaging showed no change in his bleed. Stroke risk factors were addressed and HbA1c was 5.7%. Lipid panel revealed Chol 106 TGCs 58 and LDL 55. TSH was 1.1. ECG revealed sinus rhythm. The patient was initially admitted to the ICU on [**2171-11-14**] and transferred to the floor after observation on [**2171-11-15**]. He remained stable in house with persistent left homonymous hemianopia and left sensory inattention. His BP and other vitals remained in teh goal raneg <160. He had no further headache. The most likely cause of his ICH is amyloid angiopathy but as above will need an o/p MRI in [**4-24**] weeks to evaluate for an underlying lesion. Aspirin was stopped and will be reviewed when he is seen in clinic by Dr [**First Name (STitle) **]. He shuld avoid NSAIDs and can have Tylenol for pain control. He was assessed by PT/OT and deemed to require rehab. S&S assessed and although there were no immediate signs of aspiration, they recommended video swallow which showed silent aspiration only with medications and he was placed on a soft diet with thin liquids and medications crushed with applesauce. He was transferred to rehab on [**2171-11-20**]. He has neurology follow-up. . # Urology: The patient had previously been on Flomax although had not been taking this recently and on the floor was noted to have significant urinary retention >700ml and a catheter was inserted. The patient failed a voiding trial and the catheter was re-inserted on the day of discharge. We also restarted Flomax. He should have a further voiding trial at rehab. We restarted his Flomax on [**2171-11-21**]. We have contact[**Name (NI) **] his PCP who will [**Name9 (PRE) 92473**] [**Name (NI) 2287**] urology follow-up. . . # ID: The patient had low grade fevers and CXR was clear without evidence of pneumonia and UA suggested a possible UTI and he was commenced on a week course of Bactrim for this to stop [**2171-11-24**]. WCC was increasing peaking at 12.8 and following antibiotic therapy had fallen to the normal range (5.9 on discharge) with no further fevers. He had no other focus for infection. . . # Transitional issues: - Patient was discharged with a urinary catheter due to urinary retention and failing voiding trial. He should have a further trial without catheter at rehab. His PCP will organise outpatient urology follow-up - Repeat MRI-head in [**4-24**] weeks to evaluate for underlying lesion Medications on Admission: ASA 81 daily Advair Diskus 500/50 Ipratropium/Albuterol nebulizer solution Lorazepam 0.25 mg [**Hospital1 **] PRN Furosemide 20 mg daily Vitamin D Multivitamin (not verfied by outside pharmacy) Lisinopril - pharmacy said not taking these Diltiazem - pharmacy said not taking these Simvistatin - pharmacy said not taking these Flomax - pharmacy said not taking these Combivent (list from wife) fosinopril 40 daily diltiazem 240 mg daily Discharge Medications: 1. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. diltiazem HCl 30 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day) for 2 doses: To take last two doses and start ER in am. 3. ipratropium bromide 0.02 % Solution Sig: One (1) Nebule Inhalation Q6H (every 6 hours) as needed for dyspnea. 4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Nebule Inhalation Q6H (every 6 hours). 5. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) puff Inhalation [**Hospital1 **] (2 times a day). 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Dose Injection TID (3 times a day). 10. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for Constipation. 11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 12. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days: To finish [**2171-11-24**]. Disp:*qs Tablet(s)* Refills:*0* 13. lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO twice a day as needed for anxiety. 14. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 15. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO once a day. 16. multivitamin Tablet Sig: One (1) Tablet PO once a day. 17. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 18. diltiazem HCl 240 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day: To start [**2171-11-21**]. 19. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Primary diagnosis: Right parieto-occipital intraparenchymal haemorrhage . Secondary diagnosis: Urinary retention Urinary tract infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Neurologic: Left homonymous hemianopia and left sensory and ? visual inattention compatible with left neglect. Discharge Instructions: It was a pleasure taking care of you during your stay at the [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]. . You were found to have a bleed in the brain on the right side and you were initially admitted to the ICU for observation. This affected your vision on the left side and you also had problems appreciating touch on the left side of your body called neglect. As you were stable you were transferred to the main neurology floor and repeat scans revealed no change in the size of the bleed. In order to determine if there is any underlying stroke or other lesion to account for your bleed (although there was no obvious mass seen on your original MRI) you should have an outpatient MRI scan in [**4-24**] weeks before your neurology follow-up appointment. You had a video swallow test and this revealed very mild aspiration and they recommended a soft diet with normal liquids with medications to be crushed with applesauce which will be re-evaluatted at rehab. . You were found to have a urinary infection on your urine sample and have started you on a 7 day course of antibiotics for this. You also had difficulty passing urine and you went into urinary retention and for this a Foley catheter was placed. At rehab they may try and remove this again to see if you can pass urine but if this is unsuccessful you will require a likely temporary Foley catheter. We restarted your Flomax. We have contact[**Name (NI) **] your PCP who will organise urology follow-up. . You were seen by PT and deemed to require rehab. You were transferred to rehab on [**2171-11-20**]. . Medication changes: Given your bleeding, we have STOPPED your aspirin and DO NOT TAKE THIS until you are evaluated by Dr [**First Name (STitle) **] in clinic Because of the bleeding, we also recommend you avoid non-steroidal anti-inflammatories such as advil and ibuprofen. (You could use tylenol for pain.) We STARTED Bactrim 1 tablet twice daily for a total of 7 days to finish [**2171-11-24**] We STARTED atorvastatin 40mg daily for cholesterol We STARTED Flomax daily We STARTED laxatives We CHANGED fosinopril to lisinopril 20mg daily Please continue your other medications as prescribed Followup Instructions: Please see your PCP within the next 1 week. . We have also arranged the following neurology follow-up: Department: NEUROLOGY When: TUESDAY [**2172-1-14**] at 11:30 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**] Building: [**Hospital6 29**] [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Due to your urinary retention we have contact[**Name (NI) **] your PCP who will arrange urology follow-up. [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**] Name: [**Known lastname 14539**],[**Known firstname **] Unit No: [**Numeric Identifier 14540**] Admission Date: [**2171-11-14**] Discharge Date: [**2171-11-20**] Date of Birth: [**2085-10-4**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3326**] Addendum: Regarding radiology findings: Vasogenic edema associated with the hemorrhage was noted on MRI and CT scans and was not significantly changed on interval scans as described. Vasogenic edema associted with the ICH as described was clinically significant. Pertinent Results: Regarding radiology findings: Vasogenic edema associated with the hemorrhage was noted on MRI and CT scans and was not significantly changed on interval scans as described. Discharge Disposition: Extended Care Facility: [**Hospital6 3465**] - [**Location (un) 824**] [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 3327**] Completed by:[**2171-12-18**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

23661, 23872

13273, 16715

338, 345

19646, 19646

23464, 23638

22207, 23445

2068, 2117

17509, 19370

19486, 19486

17047, 17486

19939, 21590

5839, 9201

3321, 4902

2132, 2142

2164, 2517

21610, 22184

268, 300

373, 1877

19581, 19625

9211, 13250

4964, 5394

19505, 19560

5416, 5823

19661, 19915

16738, 17021

1899, 1974

1990, 2052

28,066

104,954

12031+56255

Discharge summary

report+addendum

Admission Date: [**2193-2-25**] Discharge Date: [**2193-2-28**] Date of Birth: [**2142-7-14**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 443**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: 50yo man w/ sarcoidosis & HTN who presents with SSCP since 2pm. Of note, pt was seen in [**Hospital1 18**] ED on [**2193-2-22**] w/ HTN urgency, which was noted incidentally as he was being prepped for an outpatient lung biopsy scheduled for same day, though the procedure was cancelled due to pt's HTN. The patient's dose of lisinopril was increased & he was discharged home. He reports being in his USOH until the day of presentation when, while walking up stairs, he developed [**10-25**] SSCP radiating to jaw & l arm. Associated w/ diaphoresis & light-headedness. He initially presented to [**Hospital 26580**] hospital, where his EKG was reportedly unchanged from priors--though I do not have these to confirm this finding. His TropI was 1.97. He received asa 81mg (?x2), nitro, lovenox, morphine and lopressor and was to transferred to [**Hospital1 18**] ED. Prior to transfer his pain had improved to [**1-24**]. . In [**Hospital1 18**] ED, VS 97.8, 64, 143/98, 18, 97% on RA. His pain was [**6-25**]. EKG showed LAD, LAFB, IVCD, new Q waves lateral precordial leads (V4 &5), TWI in III, flattened TW in avF and V1, V3, V4, and ?V5, also ~1mm STE in lead II. Cardiology was consulted. The patient's nitro was increased and heparin gtt was started. Pt also received IV morphine. Pain reportedly resolved, thus, pt was not started on integrillin. . He arrived on the floor and reported a pain of [**2195-2-18**]. His nitro gtt was increased and he was given morphine 4mg IV x2 w/o significant change. His EKG showed no change from than in the ED. Integrillin gtt was started for refractory pain. A plavix load was also given. Past Medical History: - Sarcoidosis--affecting abd & lungs (dx'd at [**Hospital1 112**] years ago) - HTN - CVA 2yr ago --> residual r sided weakness/ pfo v. asd/ stress in [**2189**] (may have been done at [**Hospital1 112**]) - H/o DVT - Chronic pain - l adrenal adenoma - s/p splenectomy, cholecystectomy, ? adrenalectomy - asthma Social History: From [**Location (un) 17927**]. Divorced. Lives w/ mom who is his HCP. Family History: N/C Physical Exam: VS - 97.6, 52, 133/94, 16, 96% Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP not elevated. CV: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM. Areas of induration throughout abd. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: EKG demonstrated EKG showed LAD, LAFB, IVCD, new Q waves lateral precordial leads (V4 &5), TWI in III, flattened TW in avF and V1, V3, V4, and ?V5, also ~1mm STE in lead II. Significantly changed from prior. . OTHER TESTING: AP UPRIGHT CHEST: The study is compared to a chest radiograph from [**2-22**], [**2193**]. Additional history not provided on requisition includes sarcoid. The cardiac, mediastinal, and hilar contours are unchanged given differences in technique with tortuosity of the thoracic aorta and prominence of the hila. Mild cardiomegaly is stable. The previously noted vague opacity in the left mid lung is not as well seen on the current study; however, please note that the previous study was a dedicated PA and lateral chest. No other areas concerning for consolidation are identified. The left costophrenic angle has been excluded; however, no large pleural effusions are noted. There is no pulmonary vascular congestion. . Echo: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. The right atrial pressure is indeterminate. 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%). 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 ascending aorta is moderately dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There is no aortic valve stenosis. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . OSH: tropi 1.97, CK 310 WBC 17.4, DDimer 1.4 (<1.3 nml), hct 45 Trop-T: 0.94 Comments: cTropnT: Notified [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 2357 On [**2193-2-25**] cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi . Cardiac catheterization: 20 % LAD, mild disease in the LCX and mild disease in the RCA with thrombotic occlusion of the distal wrap around PDA "dottered with balloon" with improvement in flow and partial resolution of thrombus . Cardiac Enzymes [**2193-2-25**] 09:45PM BLOOD cTropnT-0.94* [**2193-2-25**] 09:45PM BLOOD CK(CPK)-529* [**2193-2-26**] 06:30AM BLOOD CK-MB-56* MB Indx-11.5* cTropnT-1.59*[**2193-2-26**] 06:30AM BLOOD CK(CPK)-485* [**2193-2-27**] 05:44AM BLOOD CK-MB-11* MB Indx-7.1* cTropnT-1.13* [**2193-2-27**] 05:44AM BLOOD CK(CPK)-154 [**2193-2-28**] 06:30AM BLOOD CK(CPK)-83 . MISC [**2193-2-26**] 06:30AM BLOOD Triglyc-119 HDL-42 CHOL/HD-5.2 LDLcalc-152* . CBC [**2193-2-25**] 09:45PM BLOOD WBC-17.6* RBC-4.71 Hgb-14.2 Hct-42.3 MCV-90 MCH-30.1 MCHC-33.5 RDW-14.3 Plt Ct-460* [**2193-2-26**] 06:30AM BLOOD WBC-18.8* RBC-4.41* Hgb-13.4* Hct-39.7* MCV-90 MCH-30.4 MCHC-33.8 RDW-14.4 Plt Ct-397 [**2193-2-26**] 01:15PM BLOOD Hct-37.3* Plt Ct-388 [**2193-2-27**] 05:44AM BLOOD WBC-16.0* RBC-4.07* Hgb-12.8* Hct-36.9* MCV-91 MCH-31.5 MCHC-34.8 RDW-14.6 Plt Ct-345 [**2193-2-28**] 06:30AM BLOOD WBC-15.4* RBC-4.25* Hgb-13.0* Hct-39.1* MCV-92 MCH-30.5 MCHC-33.2 RDW-14.3 Plt Ct-392 . Chem 7 [**2193-2-25**] 09:45PM BLOOD Glucose-85 UreaN-12 Creat-0.9 Na-140 K-4.2 Cl-105 HCO3-25 AnGap-14 [**2193-2-26**] 06:30AM BLOOD Glucose-109* UreaN-13 Creat-0.9 Na-139 K-3.8 Cl-102 HCO3-25 AnGap-16 [**2193-2-27**] 05:44AM BLOOD Glucose-136* UreaN-8 Creat-0.8 Na-137 K-3.5 Cl-104 HCO3-28 AnGap-9 [**2193-2-28**] 06:30AM BLOOD Glucose-100 UreaN-10 Creat-1.0 Na-139 K-3.9 Cl-105 HCO3-28 AnGap-10 Brief Hospital Course: The patient was admitted with an NSTEMI for cardiac catheterization. On cardiac catheterization, an RCA thrombus with thrombotic occlusion of distal wrap around PDA was found. Angioplasty was attempted but unsuccessful. During the procedure, the patient developed CP and with small ST elevation on EKG. CP was reduced with morphine but was in some pain after catheterization with EKG rvealing some resolution of ST elevations in V3-V4. He was started on heparin, integrilin and nitro drips. He was also started on Simvastatin, Aspirin, Plavix Troprol XL and nicotine patch and tolerated all of these medications well. He was monitored in the CCU overnight. His cardiac enzymes were followed and continued to trend down. He was transfered to the floor. On the floor, he had mild [**2-24**] constant "aching" chest pain that patient reported was chronic, related to severe sarcoid and unlike his CP on admission or in the cath lab. An echo was obtained showing a normal EF and no wall motion abnormalities. A lipid panel was obtained with an elevated LDL 152. Simvastatin 40mg daily was started. He was discharged with baseline CP with cardiology and pulmonology follow up. Medications on Admission: oxycontin 80mg q12hr lisinopril 20mg daily (?) xanax 2mg [**Hospital1 **] prevacid 30mg qd prozac 20mg qd norvasc 10mg Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Xanax 2 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 3. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 4. Prozac 20 mg Capsule Sig: One (1) Capsule PO once a day. 5. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day. 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. Disp:*30 Tablet(s)* Refills:*2* 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. OxyContin 80 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO twice a day. 9. Toprol XL 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:*2* 10. Nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*30 Patch 24 hr(s)* Refills:*2* 11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Non-ST Segment Elevation Myocardial Infarction. Discharge Condition: improved Discharge Instructions: You were admitted for chest pain. You had a heart attack because of a blockage in one of your coronary arteries. A stent was not placed due to the inability to pass through the clot. Instead, you were given medications to stabalize the clot and prevent further clot formation. . If you have chest pain, significant worsening of shortness of breath or extreme sweating (diaphoresis), you should call your doctor and come to the emergency room. . The following changes were made to your medications. You should take all other medications as previously prescribed. 1. Start taking Aspirin daily 2. Take Plavix every day for one month 3. Start taking Toprol Xl daily. 4. Nicotine patch. Followup Instructions: Please call [**Telephone/Fax (1) 1989**] to arrange a follow up appointment with Dr. [**Last Name (STitle) 171**] (cardiology) in the next 1-2 weeks. . You should also follow up with your primary care provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1057**] on 10:45 on Februaruy 29, [**2193**]. Please call [**Telephone/Fax (1) 37774**] if you need to reschedule this appointment. . You should also make an appointment to see your pulmonologist in the next 2-3 weeks. Name: [**Known lastname **],[**Known firstname 133**] Unit No: [**Numeric Identifier 6567**] Admission Date: [**2193-2-25**] Discharge Date: [**2193-2-28**] Date of Birth: [**2142-7-14**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3780**] Addendum: The patient arrived DNR/DNI but willing to reverse code status for cardiac catheterization. After catheterization, his code status was revisted, and the patient chose to continue as full code. Discharge Disposition: Home [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3782**] MD [**MD Number(2) 3783**] Completed by:[**2193-3-2**]

[ "272.4", "438.89", "517.8", "401.9", "410.71", "135", "728.89" ]

icd9cm

[ [ [] ] ]

[ "88.55", "88.52", "00.66", "37.22", "99.20", "00.40" ]

icd9pcs

[ [ [] ] ]

11443, 11605

7005, 8181

325, 351

9609, 9620

3235, 6982

10351, 11420

2451, 2456

8350, 9488

9538, 9588

8207, 8327

9644, 10328

2471, 3216

275, 287

379, 2012

2034, 2346

2362, 2435

47,101

145,305

35695

Discharge summary

report

Admission Date: [**2198-4-13**] Discharge Date: [**2198-5-2**] Date of Birth: [**2153-9-15**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 695**] Chief Complaint: Tylenol overdose Major Surgical or Invasive Procedure: Intubation, extubation, cenral line placement [**2198-4-27**]: Ex-lap LOA History of Present Illness: 44 yo M with PMH of fibular fx in [**12-9**], s/p plated placement, who developed increasing pain in his left leg s/p a wash-out in [**3-/2198**] for potential infection and began taking increasing doses of Tylenol for his pain. In the last 3 weeks, pt states he's been taking [**11-20**] Extra Strength Tylenol each day. He also drinks 1-2 beers per night, but denies a history of abuse or any social / legal problems from his alcohol intake. 3 days prior to admission, he developed severe abdomiinal pain, worse in the RUQ with associated N, intermittent V and anorexia. Has had decreased BMs in this setttind and has lost about 10lbs. Last Tylenol 2 days PTA. The day of admission, he was referred to the ED by his friends after they said his 'skin was yellow'. Upon presentation to OSH ED, VS notable for SBP 120s and tachycardia > 100. Tylenol level 37.7, INR > 9, TBili > 9. He was treated with 1L NS, Benedryl, Reglan, Zofran and po NAC. He then vomited the NAC one hour later and it was 'red-brown' but apparently gastro-occult negative. He also became 'shakey' at one point and was noted to have a FS glucose of 30. [**Hospital1 18**] was contact[**Name (NI) **] for transfer given potential need for Liver Transplant evaluation. Past Medical History: Multiple fractures s/p L fibular fracture [**12-9**] with plate placement, s/p washout in early [**2198**] Social History: Lives alone. Works in bakery overnight. Smokes 1ppd x 24 years (less in last week due to feeling unwell). Drinks 1-2 beers /night. Remote history of marijuana. No IVDU. Multiple tattoos. Per further discussion with his mother, patient was drinking significantly more with 6-10 beers daily, hard alcohol and was also using marijuana. Family History: Maternal grandmother with heart disease. No history of liver or autoimmune problems. Physical Exam: ADMISSION PHYSICAL EXAM 96.8, 90/39, 125, 19, 95/RA Gen: Mildly anxious, no acute distress HEENT: PERRL, MM dry, scleral icterus CV: Tachycardia > 100bpm, regular, no M/G/R PULM: CTAB withotu w/r/r Abd: Mildly distended, diffusely TTP but most prominently in RUQ with only light touch, liver palpated to 7cm below costal margin Ext: LLE with well healed scar, mild edema, no exudate; RLE without erythema, edema; DP pulses [**3-7**] distally b/l Neuro: A&O x 3, no asterixis Pertinent Results: ADMISSION LABS [**2198-4-13**] 11:34PM WBC-7.4 RBC-3.14* HGB-9.6* HCT-29.1* MCV-93 MCH-30.5 MCHC-32.9 RDW-24.3* [**2198-4-13**] 11:34PM GLUCOSE-86 UREA N-20 CREAT-2.6* SODIUM-136 POTASSIUM-3.4 CHLORIDE-94* TOTAL CO2-20* ANION GAP-25* [**2198-4-13**] 11:34PM CALCIUM-7.1* PHOSPHATE-3.8 MAGNESIUM-1.7 IRON-50 [**2198-4-13**] 11:34PM PT-53.0* PTT-51.1* INR(PT)-6.0* [**2198-4-13**] 11:34PM ALT(SGPT)-1365* AST(SGOT)-4792* LD(LDH)-2532* CK(CPK)-124 ALK PHOS-174* TOT BILI-8.2* [**2198-4-13**] 11:34PM calTIBC-270 FERRITIN-1199* TRF-208 [**2198-4-13**] 11:34PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc Ab-NEGATIVE HAV Ab- POSITIVE IgM HAV-NEGATIVE [**2198-4-13**] 11:34PM Smooth-NEGATIVE [**2198-4-13**] 11:34PM [**Doctor First Name **]-NEGATIVE [**2198-4-13**] 11:34PM IgG-1086 [**2198-4-13**] 11:34PM ASA-NEG ETHANOL-NEG ACETMNPHN-20.3 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2198-4-13**] 11:34PM HCV Ab-NEGATIVE [**2198-4-13**] 11:55PM HIV Ab-NEGATIVE Brief Hospital Course: 44 yo M with h/o fibular fracture, admitted with hepatic / renal failure in the setting of excessive acetaminophen use. # Hepatic Failure: Likely secondary to Tylenol overdose, but other considerations include viral infection (h/o tattoos), ischemia, auto-immune or other toxin exposure. INR > 9, TBili > 9 on presentation. Liver Transplant team was notified and came in to see patient the night of admission. Initial approach was close monitoring of his LFTs and coags. NAC was reloaded upon arrival as it was unclear if the patient had tolerated any oral dosing prior to admission. Tylenol level was still elevated at 20.3. NAC was continued until [**4-22**], held for one day, then restarted [**4-24**] for concern for rising INR. Infectious, iron overload and autoimmune work-up were negative as above for other sources of liver failure. Initial RUQ ultrasound imaging revealed possibly coarsened liver echotexture, although this assessment is difficult given presence of bowel gas, no focal liver lesion, appropriate vascular waveforms and a thickened gallbladder wall which may be secondary to hepatitis or chronic liver disease. Transplant surgery and Hepatology followed patient throughout his stay. Thorough evaluation revealed that he was not a liver transplant candidate at this time given his excessive alcohol use prior to admission. On [**4-24**] repeat right upper quadrant ultrasound revealed no flow through his portal vein. Liver was contact[**Name (NI) **] and recommended monitoring with repeat CT scan in [**3-6**] days. # Polymicrobial bacteremia: with coag-neg Staph, Strep anginosus, Veillonella, Bacteroides, Citrobacter in blood. Pan-scan [**4-16**] without obvious source but with colitis. Was initially on Vancomycin and Zosyn, which was then transitioned to Vancomycin, Meropenum and Metronidazole. As his cultures and sensitivities returned, his Meropenum was changed Ceftriaxone. LP had normal glucose and protein, no WBCs. CSF with no bacterial growh. OSH Op notes unrevealing. HIDA scan unrevealing and repeat u/s without clear evidence of cholecystitis but indeterminate, surgery following but did not recommend percutaneous drain. Changed NG to an OG [**3-5**] sinus infection, and this ultimately discontinued [**4-23**]. Dental consult was obtained given his polymicrobial infection and were unable to determine if he had a dental source but recommended getting a panorex once able to participate in study. Antibiotics course was ultimately a plan for Ceftriaxone and Flagyl for total 14 days starting from [**4-14**] (first day of negative blood culture). # Altered mental status: [**4-15**] noted to have increasing agitation, anger, hostility, tachycardia, hypertension. Per mother, patient has been drinking heavily. Concern for withdrawal vs hepatic encephalopathy. Thus, he was treated with benzodiazepines for probable alcohol withdrawl. He was continued on IV thiamine. Despite this, his mental status continued to worsen until his was essentially obtunded. LP was performed but CSF studies were unremarkable. EEG revealed no seizure. Brain imaging studies were unremarkable. Keppra was initially started for concern of occult seizure but this was stopped [**4-21**]. Patient was successfully extubed [**4-21**]. He was continued on Lactulose and Rifaximin for his hepatic encephalopathy and he slowly improved. On [**4-23**] he developed hallucinations and was treated with Haldol PRN. # Renal Failure: Noted on admission and likely secondary to Tylenol overdose in combination with prerenal etiology given poor po intake and dry on physical exam. Also could have developed ATN if low BP in the last several days. He was treated with IV fluids and his renal failure resolved within the first several days of hospitalization. # Tachycardia: Significant on admission and likely secondary to poor po intake, hepatic failure and anxiety. 12 lead EKG to verified that he was in sinus tachycardia. He was fluid resuscitated with improvement of his rapid heart rate. Further evaluation revealed both alcohol withdrawl and infection as other potential contributing etiologies. # Pain control: Patient complaining of significant abdominal pain, likely secondary to hepatitis. Given hepatic / renal failure, pain medication was administered judiciously. # History of fibular fracture: Did not appear infected upon admission but was a potential source of his polymicrobial sepsis. Leg imaging with both noncontrast and contrast CT revealed no fluid collection or evidence of infection. Orthopedics was consulted but did not think surgical evalaution was warranted. # Respiratory failure: Intubated due to altered mental status and inability to protect airway. Extubated [**4-21**] with good cough and gag. Mental status continued to improve and he was able to protect his airway appropriately. # Pancytopenia: Thought to be secondary to hepatic failure and bleeding from hemorrhoids. Plan was to transfuse for HCT <27, Plt <15 or evidence of bleeding. He did not require blood cell transfusions while in the ICU. # Buttocks rash: Noted on [**4-23**]. Appears fungal and patient with increased stool output with lactulose for hepatic encephalopathy. Treated with Miconazole powder TID. >>>This portion of the discharge summary entails his post-operative course while on the transplant service. On [**4-25**], he began to complain of nausea and some abdominal pain; he was also noted to have bilious emesis. An NGT was placed with significant bilious output. A KUB demonstrated dilated loops of small bowel and air-fluid levels. The patient, however, failed to improve with medical management and concern for an SBO vs paralytic ileus arose. A susbequent CT scan demonstrated a possible transition point in the RLQ. He was taken to the OR urgently by Dr. [**Last Name (STitle) **]. Please see Dr. [**Last Name (STitle) **] operative note for further detail, but in brief, underwent an exploratory laparotomy, lysis of adhesions, and a liver biopsy. Post-operatively, he was transferred to the ICU for further care. Neuro: He persisted to have an altered mental status. Sedating medications and narcotics were held. CV: Stable Resp: Progressive worsening of respiratory status, requiring increasing amount of oxygen over the course of stay in ICU. GI: Never regaining bowel function. Diagnostic paracentesis was performed which was revealed a large number of WBCs. He was treated empirically with Cipro and Flagyl. On [**5-2**], given his poor clinical status and grim prognosis, a family meeting was held with the monther. After a lengthy discussion, the patient was made CMO. All medications were stopped, and the patient was started on a morphine gtt for comfort. The patient then became bradycardic and eventually asystolic. The patient showed no signs of life and was pronounced dead at 19:50. The family was then notified. Medications on Admission: KCl (he is unsure why he has low potassium) Tylenol Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Liver failure Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: None [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]

[ "E850.4", "789.59", "558.9", "965.4", "305.1", "572.2", "455.5", "995.92", "560.81", "284.1", "V64.41", "518.81", "570", "038.8", "111.9", "571.2", "291.81" ]

icd9cm

[ [ [] ] ]

[ "54.91", "96.04", "50.11", "96.6", "99.15", "54.59", "38.93", "54.11", "03.31", "96.72" ]

icd9pcs

[ [ [] ] ]

10835, 10844

3777, 6400

329, 405

10901, 10910

2768, 3754

10966, 11100

2170, 2256

10806, 10812

10865, 10880

10730, 10783

10934, 10943

2271, 2749

273, 291

433, 1674

6415, 10704

1696, 1804

1820, 2154

31,928

121,201

52464

Discharge summary

report

Admission Date: [**2125-3-21**] Discharge Date: [**2125-3-29**] Date of Birth: [**2045-6-5**] Sex: F Service: MEDICINE Allergies: Keflex / Heparin Agents Attending:[**First Name3 (LF) 949**] Chief Complaint: Upper GIB bleed, ICU transfer for hemodynamic instability. Major Surgical or Invasive Procedure: PICC line placement Hemodialysis Upper endoscopy History of Present Illness: Pt is a 79 yo female with cryptogenic cirrhosis and esophageal varices, diastolic CHF requiring multiple hospitalizations in the past for exacerbation, who had presented to the [**Hospital **] hospital on [**3-16**] (?[**3-15**]) with ARF and hypotension. [**2-20**] wks prior to admission pt was complaining of worsening fatigue and insominia, PCP was concerned for recurrent CHF exacerbation and hence increased lasix x2 over a course of 2 weeks. Given ongoing symptoms of malaise and fatigue pt presented to OSH, where she was found to be ind ARF and hypotensive. Her hospital [**Last Name (un) 10128**] was marked by ICU stay and work up for infection and cardiogenic shock, which was negative. Her renal function did not recover and patient was started on HD the day prior to transfer. On the day of transfer patient started vomiting BRB during dialysis, requiring a total of 5 RBc and 1 unit of plt, EGD revieled 3 cords, of which one was successfully banded. Pt transferred to [**Hospital1 18**] for further managment . On the floor, pt arrived sedated on propofol, and octreotide drip, with right HD cath IJ, on vent. 30 cc of BRB in oropharynx. Past Medical History: Lower GIB [**2123-12-13**] - colonoscopy with diverticulosis and angioectasias Diabetes Type 2 - on insulin (last A1C unknown) Atrial fibrillation CAD s/p stent to RCA in [**2104**] and 2 bare metal stents to the LCx on [**2123-11-23**] Acute and Chronic Diastolic CHF (EF per records preserved but no records in our system) Hypertension Pulmonary HTN Dyslipidemia Hypothyroidism (s/p thyroidectomy) Breast CA s/p b/l mastectomies and tamoxifen (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2036**]) s/p breast reconstruction COPD Thrombocytopenia Recent ICU admission [**10/2123**] at OSH with staph aureus bacteremia Infected 3rd left toe [**10/2123**] . Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 108377**] PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 4768**] [**Last Name (NamePattern1) 5456**] Social History: Social history is significant for the absence of current tobacco use; she quit smoking in [**2106**]. There is no history of alcohol abuse. Patient lives with her husband; she used to work in a candy factory. She currently uses a walker and has home PT and [**Year (4 digits) 269**]. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: ICU Admission Exam: Vitals: T: 97.4 BP: 130/60 P: 101 R: 16 O2: 100% on AC General: Intubated. Moves all extremities, responds to noxious stimuli HEENT: Sclera anicteric, MMM, oropharynx 30 cc of BRB 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, distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2125-3-21**] 12:54AM BLOOD WBC-8.8# RBC-3.87*# Hgb-11.9*# Hct-34.1* MCV-88 MCH-30.6# MCHC-34.8# RDW-16.6* Plt Ct-41* [**2125-3-21**] 09:16AM BLOOD Hct-32.2* Plt Ct-60* [**2125-3-21**] 11:42AM BLOOD Hct-32.6* [**2125-3-21**] 01:30PM BLOOD Hct-32.1* Plt Ct-57* [**2125-3-21**] 03:50PM BLOOD Hct-32.2* [**2125-3-21**] 08:00PM BLOOD Hct-31.0* Plt Ct-46* [**2125-3-22**] 12:11AM BLOOD Hct-31.1* Plt Ct-43* [**2125-3-22**] 04:05AM BLOOD WBC-6.3 RBC-3.34* Hgb-10.3* Hct-30.0* MCV-90 MCH-30.9 MCHC-34.4 RDW-17.1* Plt Ct-42* [**2125-3-22**] 11:04AM BLOOD Hct-31.2* Plt Ct-40* [**2125-3-22**] 06:35PM BLOOD Hct-34.6* [**2125-3-21**] 12:54AM BLOOD Neuts-89* Bands-5 Lymphs-1* Monos-4 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2125-3-21**] 12:54AM BLOOD PT-16.1* PTT-32.9 INR(PT)-1.4* [**2125-3-21**] 12:54AM BLOOD Fibrino-247 [**2125-3-21**] 12:54AM BLOOD Glucose-82 UreaN-75* Creat-2.3* Na-145 K-4.1 Cl-113* HCO3-26 AnGap-10 [**2125-3-21**] 12:54AM BLOOD ALT-18 AST-26 LD(LDH)-209 CK(CPK)-71 AlkPhos-114 TotBili-2.1* [**2125-3-21**] 12:54AM BLOOD CK-MB-NotDone cTropnT-0.07* [**2125-3-21**] 12:54AM BLOOD Lipase-14 [**2125-3-21**] 12:54AM BLOOD Albumin-3.2* Calcium-7.7* Phos-5.3*# Mg-1.9 [**2125-3-21**] 03:50PM BLOOD CRP-73.3* [**2125-3-21**] 03:50PM BLOOD [**Doctor First Name **]-NEGATIVE [**2125-3-21**] 03:50PM BLOOD ANCA-NEGATIVE B [**2125-3-21**] 03:50PM BLOOD Cryoglb-PND***** [**2125-3-21**] 01:41AM BLOOD Lactate-0.9 [**2125-3-21**] 01:41AM BLOOD freeCa-1.11* . ECG [**2125-3-21**] Baseline artifact. Atrial fibrillation with controlled rate is suggested. Low voltage. Compared to the previous tracing of [**2124-5-25**] the rhythm has changed and the voltage is now lower. Rate PR QRS QT/QTc P QRS T 94 0 88 338/397 0 143 149 . EGD report OSH: single colum cord one band placed, grade II varices EKG: sinus rythm, no signs of ischemia . CXR [**2125-3-22**] Widespread severe pulmonary opacification could be all edema, but the heterogeneous quality in the left lung suggests pneumonia and a 3-cm wide nodular opacity projecting superior to the left hilus could be a lung mass. Moderate right and smaller left pleural effusion have increased since [**5-29**]. Heart is normal size. Leftward shift of the lower mediastinum indicates some volume loss in the left lower lobe. ET tube and nasogastric tube are in standard placements and a right jugular line ends at the junction of the brachiocephalic veins. . Renal U/S [**2125-3-22**] 1. No hydronephrosis, nephrolithiasis, or solid renal mass. 2. Renal parenchymal changes consistent with medical renal disease. 3. Bilateral renal cysts. 4. Ascites and right pleural effusion 5. Splenomegaly. . CXR [**2125-3-22**] IMPRESSION: Increased pulmonary edema. Unchanged pulmonary opacities. CT is recommended if left suprahilar opacity persists after resolution of acute chest pathology. . CXR [**2125-3-24**] IMPRESSION: Tubes and catheters in expected position. Increased moderate right and small left pleural effusion with increase in basilar opacity, could be aspiration or pneumonia. Minimal interstitial edema. . CXR [**2125-3-26**] In comparison with the study of [**3-25**], the left subclavian catheter has been pulled back to the mid portion of the SVC. Persistent moderate, partially loculated right pleural effusion. Left retrocardiac opacification persists, most likely related to a combination of atelectasis and effusion, though superimposed pneumonia cannot be excluded. . ECHO [**2125-3-24**] IMPRESSION: Mild symmetric left ventricular hypertrophy with hyperdynamic left ventricular systolic function and elevated cardiac index. Elevated ventricular filling pressures. At least moderate pulmonary hypertension. Moderately dilated right ventricle with borderline normal function. Trivial aortic and mild mitral regurgitation. . EGD [**2125-3-24**] #Varices at the lower third of the esophagus and gastroesophageal junction #Congestion, petechiae and mosaic appearance in the whole stomach compatible with portal hypertensive gastropathy #Normal mucosa in the duodenum #Otherwise normal EGD to third part of the duodenum . Right Upper Extremity Ultrasound [**2125-3-25**] IMPRESSION: No evidence of right upper extremity DVT. Brief Hospital Course: 79 yo female with cryptogenic cirrhosis and esophageal varices, diastolic CHF requiring multiple hospitalizations in the past for exacerbation, who had presented to the [**Hospital **] hospital [**2125-3-16**] with acute renal failure, hypotension, and gastrointestinal bleeding. . # Variceal bleed: Outside hospital EGD showed one esophageal varix that was banded. The patient received five units PRBCs and one unit platelets prior to transfer from outside hospital. On admission, hematocrit was 34 and platelet count was 41. She had some bright red blood in her oropharynx on admission, but had no further episodes of hematemesis in the ICU. She received one additional unit of PRBCs the day of admission. Her esophageal varices are most likely due to portal hypertension, though the precipitant to this bleed is unknown. She has a predisposition to bleeding due to thrombocytopenia and uremic platelet dysfunction. Upon admission, she was placed on octreotide and PPI drip x 2 days, given DDAVP x1, and one unit of platelets. Per GI recs, she was then transitioned to PPI IV BID, Nadolol 20 mg daily, and Ciprofloxacin and Carafate PO for 7 day course (both Cipro and Carafate can be stopped on [**2125-3-30**]). Once patient was hemodynamically stable, GI performed repeat EGD on [**2125-3-24**], which showed 1 cord of grade II varices as well as portal hypertensive gastropathy. GI recommends repeat banding in [**2-20**] weeks. The patient continued to have small amounts of melanotic stool during admission, but her hematocrit remained stable. Patient has a follow-up appointment scheduled with Dr. [**Name (NI) **] in the liver clinic at [**Hospital1 18**]. . # Respiratory Failure: The patient was intubated prior to transfer in the setting of acute hemodynamic instability during upper GI bleed. Chest x-ray on admission showed evidence of pulmonary edema. The patient's respiratory status improved dramatically after multiple courses of hemodialysis and ultrafiltration to remove >3L fluid. She was successfully extubated on [**2125-3-24**]. At the time of transfer O2 Sat was 98% on 3L shovel mask. Chest xray showed interval improvement in pulmonary edema. At time of discharge, she is on 1-2L oxygen by nasal cannula with oxygen saturations in the mid to high 90s. . # Renal failure: The patient has a history of chronic renal insufficiency due to diabetic nephrosclerosis with a baseline Cr of 1.5. She was admitted to OSH in acute renal failure and HD was initiated there. The etiology of this ARF is unclear but likely largely due to prerenal ATN. She was found to be ASO+, and thus there could be some component of post-streptococcal glomerulonephritis. She was ANCA negative and Urine sediment was not active. Renal ultrasound showed increased echogenicity of both kidneys, but no hydronephrosis or renal masses. Patient's urine output ranged from 100-200cc/day. A new tunneled HD line was placed [**2125-3-21**]. She was continued on HD, last dialyzed on [**3-26**], and per renal, it is unknown how much renal function she will recover. In addition, patient had frank hematuria on admission, which cleared rapidly with continuous bladder irrigation on HD1. For outpatient dialysis placement, a PPD was placed and was negative. Hepatitis panel was negative. Hepatitis B Surface Antigen NEGATIVE, Hepatitis B Surface Antibody NEGATIVE, Hepatitis C Virus Antibody NEGATIVE. . # Acute on chronic diastolic heart failure: The patient has chronic diastolic CHF and was noted to be fluid overloaded with pulmonary edema on exam likely in the setting of multiple transfusions at OSH. An ECHO was obtained on [**2125-3-24**],which showed hyperdynamic systolic function w/ EF 75%, at least moderate pulmonary HTN, and dilated RV. The patient has baseline hypertension and home BP meds were held because patient was initially hypotensive. The patient required a nitroglycerin drip and emergent hemodialysis for flash pulmonary edema on one occasion in the ICU. On [**2125-3-25**] nadolol was started for esophageal varices, with good BP control. . # Thrombocytopenia: Etiology is multifactorial in this patient, including portal hypertension with splenic sequestration. OSH records indicated that patient may have history of Heparin Ab positive, but per Hematology notes, this diagnosis was unclear. Heparin antibody was rechecked and was positive. Serotonin release assay was pending at time of transfer and Argatroban was held pending this result. Of note, patient did receive lovenox at OSH, and heparin flushes x 2 days after admission here before this diagnosis was confirmed. . # Anemia: Likely both chronic component along with acute blood loss. Patient continued on Epogen 10000U TIW as well as iron supplementation, and hematocrit remained stable around 30%. . # Type 2 diabetes: She can restart home lantus 25U qPM once she has stable glucose source. . # Hypothyroidism: Patient maintained on home dose levothyroxine. . # Coronary artery disease: Patient continued on lipitor 25 mg daily. Aspirin was held in setting of GIB. The patient was started on nadolol, but home antihypertensives were not restarted. . # Confusion/dementia: Patient oriented to self and "hospital". Has some dementia, and per husband, was back to baseline on day of transfer. We limited narcotic administration and kept on soft restraints to maintain lines. . # Atrial Fibrillation: She remained in AF, with rate in the 80s. Initally her metoprolol was held for concern of GIB. Nadolol was then started in its place for varices prophylaxis. Her rate remained well controlled. Aspirin, as above, has been held, and she is not on any anti-coagualation due to concern of re-bleeding. . FULL CODE Medications on Admission: Medications: on transfer octreotide levofloxacin ppi drip RBC propofol -------------------- meds on recent hosp course fluticasone salmeterol inhaler citalopram 20 iron ppi levothyroxine 50 daily insulin SS metolazone 5 mg 30 min prior to iv lasix dopamine gtt insulin glargine 10 iu atorvastatin 10 ppi propofol levofloxacin octreotide drip albuterol ipratropium bromide lorazepam tylenol epo bowel regiment po vanc for recent c-diff course finished?! Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: per sliding scale Injection ASDIR (AS DIRECTED). 2. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-19**] Puffs Inhalation Q6H (every 6 hours) as needed. 3. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day) for 7 days: Last dose on [**3-30**]. 4. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection MWF (MO,WE,FR). 5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours). 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 7. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 12. Ciprofloxacin 200 mg IV Q24H please dose after HD on dialysis days 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 14. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 15. Donepezil 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary Diagnoses Upper gastrointestinal bleeding, likely from esophageal varices Acute on chronic renal failure, on dialysis . Secondary Diagnoses Diverticulosis Angioectasias Atrial fibrillation Diabetes type 2 on insulin Hypertension Hypothyroidism Pulmonary hypertension Chronic diastolic heart failure Dementia Discharge Condition: Vital signs stable. Hematocrit stable. Discharge Instructions: You were admitted to the hospital because there was concern of upper gastrointestinal bleeding. At the time you were transferred from the outside hospital, you also had acute kidney failure and were placed on dialysis. We performed endoscopy to look at the esophagus and stomach for bleeding. There were varices (dilated veins) visualized in the esophagus, but no signs of active bleeding. The hematocrit remained stable during the entire admission. You received one unit of red blood cells when you were in the intensive care unit. We continued the dialysis while you were in the hospital. This is because the kidneys were not producing adequate amounts of urine. . We made the following changes to your medicines: 1. We stopped the Lasix. 2. We stopped the lisinopril. 3. We stopped the metoprolol. 4. We stopped the aspirin. 5. We added nadolol. 6. We added ciprofloxacin. Please continue through [**3-30**]. 7. We added sucralfate. Please continue through [**3-30**]. 8. We added bronchodilator nebs (albuterol and ipratropium). 9. We added pantoprazole. . Please note your follow-up appointments below. . Please call your doctor or return to the emergency room if you develop lightheadedness, dizziness, change in mental status, or any signs of bleeding. Please note that you will continue to receive dialysis after you leave the hospital. This may be stopped sometime in the future if your kidney function returns. Followup Instructions: [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2125-4-9**] 11:30 [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2125-5-3**] 11:40 Completed by:[**2125-3-29**]

[ "244.9", "V10.3", "428.33", "572.3", "518.81", "290.3", "585.9", "416.8", "456.20", "285.1", "427.31", "584.5", "V45.82", "428.0", "250.40", "562.10", "496", "287.5", "571.5", "403.90", "V58.67" ]

icd9cm

[ [ [] ] ]

[ "45.13", "38.95", "39.95", "38.93", "96.71" ]

icd9pcs

[ [ [] ] ]

15240, 15306

7717, 13407

341, 392

15666, 15707

3500, 7694

17176, 17460

2823, 2905

13911, 15217

15327, 15645

13433, 13888

15731, 17153

2920, 3481

243, 303

420, 1575

1597, 2505

2521, 2807

29,389

191,060

26311

Discharge summary

report

Admission Date: [**2147-7-22**] Discharge Date: [**2147-7-25**] Date of Birth: [**2090-6-13**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3556**] Chief Complaint: Mental status changes and weakness. Major Surgical or Invasive Procedure: None. History of Present Illness: Patient is a 57 year old woman with metastatic small cell lung carcinoma to the brain and spine diagnosed in [**2146-2-6**] who presents with progessive mental status changes and weakness over the past several days. On the day of admission, patient's husband brought her to MRI and then immediately to ED for evaluation. Over the past several days, he endorsed that the patient had been more lethargic and had increased difficulty ambulating with her walker. Before the onset of symptoms, she had been able to walk all around the [**Location (un) 448**] of their house, but was now limited to two steps. She had increased shortness of breath and bilateral lower extremity swelling over the last three days, but denied any recent cough, fever, emesis. She suffers continual pain in her back and a band-like pain across the lower aspect of her ribs/upper abdomen. For this, she has required increased doses of sustained oxycodone. She did endorse mild nausea on the morning of admission and her appetite had decreased recently. On review, she denied any stool or bladder incontinence or falls. In the ED, she was afebrile at 95.0, HR 131, BP 101/53, RR 20, and oxygen saturation was 96% on room air. She received one liter of normal saline and was started on vancomycin and cefepime. She also received 10mg of PO oxycodone. Past Medical History: -Small cell lung cancer: diagnosed [**2146-2-6**]. XRT and chemotherapy. Oncologist is Dr. [**Last Name (STitle) 65126**] at [**Hospital1 1474**] Oncologists. Serial CT of torso and chemotherapy regimens could not be obtained. -History of DVT's and PE while on warfarin in [**2146-2-6**] Social History: Lives with husband and two daughters. Previously smoked one pack per day for 20 years until quit in [**2146-2-6**]. Occasional alcohol use. Family History: Aunt with pancreatic cancer. Physical Exam: (on admission) T:96.9 BP:130/94 HR:116 RR:14 O2saturation:98% on 2L nasal canula Gen: Pleasant, cachectic looking woman in slight distress. Laying in bed. Appears older than stated age. HEENT: Slight conjunctival pallor. No icterus. Dry mucous membranes. NECK: Supple. No cervical or supraclavicular lymphadenopathy. No JVD. Left-sided port in place. CV: Tachycardic, but regular rhythm. Normal S1 and S2. No murmurs, rubs or [**Last Name (un) 549**] appreciated. LUNGS: Clear to auscultation bilaterally. Decreased breath sounds in lower lung fields, bilaterally. No wheezes, crackles, or rhonci appreciated. ABD: Hypoactive bowel sounds in all four quadrants. Soft. Nontender and nondistended. No guarding or rebound. Foley catheter in place. EXT: Distal lower extremities cool with 2+ pitting edema. 1+ dorsalis pedis pulses. 2+ radial pulses, bilaterally. NEURO: Alert and oriented to person, place, date. Affect appropriate. Did not assess gait. Pertinent Results: STUDIES: -MRI Head with and without contrast ([**2147-7-22**]): Since the previous MRI of [**2147-5-18**], there has been considerable decrease in size and resolution of several of the previously noted lesions. No new enhancing lesions to indicate new metastatic foci are noted. There has been decrease in edema seen on FLAIR and T2-weighted images since the previous study. No mass effect or hydrocephalus seen. . -Chest Xray ([**2147-7-22**]): 1. No acute cardiopulmonary process. 2. Unchanged small left pleural effusion or scarring. Mild left basilar atelectasis. . -CT chest/abd/pelvis ([**2147-7-22**]): 1. This study cannot rule out pulmonary embolism given lack of IV contrast. 2. Density within the right anterior upper lobe which follows a peribronchovascular pattern which is worrisome for metastatic spread of disease. 3. Small left pleural effusion. 4. Unchanged appearance of infrarenal IVC filter. 5. Diffuse permeative metastatic disease to the osseous structures. . -EKG ([**2147-7-22**]): Sinus tachycardia at 123. Normal intervals. Mild ST wave flattening. . . MICRO: -Blood culture ([**2147-7-22**]): Negative to date. . -Urine culture ([**2147-7-22**]): Negative to date. . . LABS: [**2147-7-25**] 05:25AM BLOOD WBC-13.4* RBC-3.63* Hgb-10.1* Hct-30.7* MCV-85 MCH-27.8 MCHC-32.8 RDW-20.4* Plt Ct-173 [**2147-7-22**] 01:30PM BLOOD WBC-12.9* RBC-3.88* Hgb-10.7* Hct-32.0* MCV-82 MCH-27.5 MCHC-33.3 RDW-19.9* Plt Ct-215 [**2147-7-23**] 05:02AM BLOOD Neuts-95.6* Bands-0 Lymphs-2.0* Monos-1.9* Eos-0.3 Baso-0.1 [**2147-7-22**] 01:30PM BLOOD Neuts-91* Bands-0 Lymphs-0 Monos-5 Eos-0 Baso-0 Atyps-0 Metas-4* Myelos-0 NRBC-1* [**2147-7-24**] 05:16AM BLOOD Plt Ct-154 [**2147-7-24**] 05:16AM BLOOD PT-16.7* PTT-23.2 INR(PT)-1.5* [**2147-7-22**] 12:50PM BLOOD PT-14.9* PTT-17.7* INR(PT)-1.3* [**2147-7-25**] 05:25AM BLOOD Glucose-107* UreaN-74* Creat-2.6* Na-133 K-4.9 Cl-100 HCO3-15* AnGap-23* [**2147-7-23**] 05:02AM BLOOD Glucose-100 UreaN-50* Creat-1.8* Na-128* K-4.4 Cl-95* HCO3-20* AnGap-17 [**2147-7-22**] 12:50PM BLOOD Glucose-134* UreaN-47* Creat-1.8*# Na-130* K-4.8 Cl-92* HCO3-19* AnGap-24 [**2147-7-24**] 05:16AM BLOOD ALT-274* AST-207* LD(LDH)-1247* AlkPhos-498* TotBili-1.3 [**2147-7-22**] 08:02PM BLOOD ALT-383* AST-662* LD(LDH)-1408* CK(CPK)-139 AlkPhos-483* Amylase-33 TotBili-1.6* [**2147-7-22**] 08:02PM BLOOD CK-MB-3 cTropnT-<0.01 [**2147-7-22**] 12:50PM BLOOD cTropnT-<0.01 [**2147-7-25**] 05:25AM BLOOD Calcium-8.7 Phos-3.8 Mg-2.6 [**2147-7-22**] 08:02PM BLOOD Albumin-3.0* Calcium-8.9 Phos-3.4 Mg-2.4 [**2147-7-22**] 10:04PM BLOOD Cortsol-84.3* [**2147-7-22**] 09:43PM BLOOD Cortsol-82.1* [**2147-7-22**] 08:02PM BLOOD Cortsol-61.8* [**2147-7-24**] 05:42AM BLOOD Lactate-1.4 [**2147-7-22**] 08:26PM BLOOD Lactate-1.7 [**2147-7-22**] 12:55PM BLOOD Lactate-4.1* K-4.5 Brief Hospital Course: Hospital Course/Assessment/Plan: 57 year old woman with metastatic small cell lung cancer to brain and spine who presents with several days of worsening mental status and weakness. Expired at 7:45PM on evening of [**2147-7-25**]. [**Name (NI) **] husband was present. . . 1) Pain: Most likely related to metastatic spread from small cell lung cancer. Palliative care team had extensive family meeting. Before patient expired, determined that patient would be transferred home with hospice and plan to continue fentanyl and lidocaine patch, concentrated morphine, ativan, lorazepam, and oral steroids. . 2) Acute renal failure: Baseline creatinine 0.5, but on admission elevated to 1.8 and increased to 2.6 during admission. FeNa 0.1%, but urine output did not respond to fluid challenges. In setting of anasarca and liver dysfunction, most likely decreased renal perfusion. . 3) Elevated White count: White count 14.9 and lactate 4.1 on admission. Indicative of infection, with concern on CT chest for left lower lobe pneumonia. Urine and blood cultures negative during admission. Declined placement of central venous line. -Started on vancomycin and cefepime in ED, but discontinued broad spectrum antibiotics as afebrile. Switched to seven day course of levofloxacin. White count remained slightly elevated, but results difficult to interpret given oral steroids for pain relief. . 4) Shortness of breath: Patient with history of PE and DVTs while on coumadin. IVC filter in place, so unlikely to be pulmonary embolus, although tachycardic with [**Known lastname **] oxygen saturations. No IVC thrombus detected on CT abdomen and pelvis. IVC filter placed on [**5-19**], as coumadin was stopped as concern for intracranial bleed in setting of metastases. -Cardiac enzymes negative. No evidence of pericardial effusion on chest CT. . 5) Weakness: Increased weakness on days prior to admission. Most likely due to decreased PO intake. Hydrated with IV fluids and given thiamine. Calcium and cortisol levels normal. . 6) Oncology: -Followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 65126**] at [**Hospital1 1474**] Oncology group ([**Telephone/Fax (1) **]). Oncology team at [**Hospital1 18**] aware of patient and consulted on patient in [**2146-5-7**]. At that time, believed patient's mean survival 7-12 months from time of diagnosis in [**2146-2-6**]. -Received palliative XRT to spine, with course completed on [**5-18**]. Palliative XRT to whole brain completed on [**5-25**]. No evidence of new metastatic foci in brain. . 7) FEN: Continued on regular diet. Repleted electrolytes, as needed. Placed on multivitamin and thiamine. . 8) Prophylaxis: Continued bowel regimen. Placed on H2 blocker, but patient deferred SC heparin. . 9) Access: Left port. . 10) CODE: DNR/DNI. Expired at 7:45PM on [**2147-7-25**]. Medications on Admission: -Acetaminophen 650 mg QID -Oxycodone 40-80 mg Sustained Release PO Q12HR -Oxycodone 10-15 mg PO Q4HR PRN -Docusate Sodium 100 mg [**Hospital1 **] -Senna 8.6 mg [**Hospital1 **] -Dulcolax 10 mg PRN -Lactulose PRN -Aluminum-Magnesium Hydroxide 225-200 QID PRN -Lorazepam 1 mg qHS PRN -Metoclopramide 10 mg PO QIDACHS PRN -Furosemide (recently started with unknown dosage) Discharge Medications: Not applicable. Discharge Disposition: Home With Service Facility: Hospice of Greater [**Location (un) 86**]/AKA [**Hospital1 11485**] Discharge Diagnosis: -Metasatic small cell lung cancer -Acute renal failure -Respiratory failure Discharge Condition: Expired. Discharge Instructions: Patient expired on evening of [**2147-7-25**] at 7:45PM. Followup Instructions: Not applicable. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9409, 9507

6082, 8949

351, 359

9627, 9638

3240, 6059

9743, 9891

2210, 2241

9369, 9386

9528, 9606

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276, 313

387, 1721

1743, 2035

2051, 2194

60,790

165,667

14232

Discharge summary

report

Admission Date: [**2103-1-22**] Discharge Date: [**2103-1-26**] Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Known firstname 922**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2103-1-22**] Aortic valve replacement with a 27-mm [**Company 1543**] Mosaic Ultra aortic valve bioprosthesis History of Present Illness: 88 year old male with known aortic stenosis complaining of increased dyspnea on exertion. He states he is requiring oxygen at night due to shortness of breath.Further cardiac workup revealed no coronary disease, severe Aortic Stenosis. Cardiac surgery was donsulted for surgical correction. Past Medical History: CHF CAD s/p MI [**2077**], 96, s/p PTCA without stenting afib AS TIA HTN HL h/o bradycardia on BB ? Stage III CKD ? Asbestosis Past Surgical History: s/p hemicolectomy [**2102-9-14**] s/p right knee replacement Social History: SHx - resides in [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 731**] Rest Home in [**Location (un) 1157**] [**Telephone/Fax (1) 42303**]. He is widowed x1 yr. Has 3 grown children to assist with discharge needs. Daughter [**First Name4 (NamePattern1) 2411**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 42304**] Family History: Mother and father with "heart problems" Physical Exam: Pulse:82 Resp:13 O2 sat: 97/RA B/P Right:154/80 Left:160/72 Height:5'7" Weight:182 lbs General: Skin: Dry [x] [**Telephone/Fax (1) 5235**] [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x]; Heart: RRR [x] Irregular [] Murmur: 4/6 systolic ejection murmur with radiation to both carotids Abdomen: Soft, obese [x] non-distended [x] non-tender [x] bowel sounds +; well healed midline laparotomy scar Extremities: Warm [x], well-perfused [x] no Edema Varicosities: None; Neuro: Grossly [**Telephone/Fax (1) 5235**] Pulses: Femoral Right: 1+ access site is w/o hematoma; Left: 1+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit Right/left: transmitted heart murmur Pertinent Results: [**2103-1-25**] 05:35AM BLOOD WBC-11.8* RBC-3.08* Hgb-9.8* Hct-28.2* MCV-91 MCH-31.7 MCHC-34.7 RDW-14.7 Plt Ct-179 [**2103-1-24**] 04:40AM BLOOD WBC-13.3* RBC-3.21* Hgb-10.2* Hct-29.6* MCV-92 MCH-31.9 MCHC-34.5 RDW-14.9 Plt Ct-179 [**2103-1-25**] 05:35AM BLOOD Glucose-91 UreaN-18 Creat-1.1 Na-135 K-3.2* Cl-100 HCO3-29 AnGap-9 [**2103-1-24**] 04:40AM BLOOD Glucose-125* UreaN-18 Creat-1.2 Na-135 K-3.9 Cl-102 HCO3-27 AnGap-10 [**2103-1-22**] intraop TEE Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is normal (LVEF>55%). with borderline normal free wall function. There are simple atheroma in the descending thoracic [**Month/Day/Year 5236**]. An epi-aortic study revealed simple atheroma which did alter the cannulation site. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: The patient is AV-Paced, on no inotropes. Good biventricular systolic fxn. There is a prosthetic aortic valve with no AI and no paravalvular leak. Trace- 1+ MR. [**First Name (Titles) **] [**Last Name (Titles) 5235**]. [**2103-1-26**] 06:08AM BLOOD WBC-9.4 RBC-3.00* Hgb-9.6* Hct-27.8* MCV-93 MCH-32.1* MCHC-34.7 RDW-14.2 Plt Ct-237 [**2103-1-26**] 06:08AM BLOOD WBC-9.4 RBC-3.00* Hgb-9.6* Hct-27.8* MCV-93 MCH-32.1* MCHC-34.7 RDW-14.2 Plt Ct-237 Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [**2103-1-22**] where he underwent aortic valve replacement with a 27-mm [**Company 1543**] Mosaic Ultra aortic valve bioprosthesis. Please see operative report for further details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically [**Company 5235**] and hemodynamically stable on no inotropic or vasopressor support. Beta blocker/Aspirin/diuresis was initiated and the patient was gently diuresed toward the preoperative weight. He continued to progress and was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication per protocol. During his hospital course he did have an episode of slow A flutter with a history of paroxysmal atrial fibrillation and was restarted on Coumadin at his home dose. He was in sinus rhythm at the time of discharge. Mr[**Known lastname **] was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD #4 the patient was ambulating freely, hi incision was healing well and pain was controlled with oral analgesics. He was discharged to [**Hospital6 25759**] and Rehab in [**Location (un) **], MA in good condition with appropriate follow up instructions advised. Medications on Admission: FUROSEMIDE - (Prescribed by Other Provider) - 40 mg [**Location (un) 8426**] - 1 [**Location (un) 8426**](s) by mouth DAILY (Daily) HYDRALAZINE - (Prescribed by Other Provider) - 50 mg [**Location (un) 8426**] - 1 [**Location (un) 8426**](s) by mouth four times a day Hold for SBP less than 100/ heart rate less than 50 METOPROLOL TARTRATE - (Prescribed by Other Provider) - 25 mg [**Location (un) 8426**] - 0.5 (One half) [**Location (un) 8426**](s) by mouth twice a day NITROGLYCERIN - (Prescribed by Other Provider) - 0.2 mg/hour Patch 24 hr - Apply 1 patch topically daily OXYBUTYNIN CHLORIDE - (Prescribed by Other Provider) - 5 mg [**Location (un) 8426**] - 1 [**Location (un) 8426**](s) by mouth twice a day OXYCODONE - (Prescribed by Other Provider) - 5 mg Capsule - 1 to 2 [**Location (un) 8426**] by mouth every 4 hours as needed for as needed for pain RANITIDINE HCL - (Prescribed by Other Provider) - 150 mg [**Location (un) 8426**] - 1 [**Location (un) 8426**](s) by mouth twice a day TRAZODONE - (Prescribed by Other Provider) - 50 mg [**Location (un) 8426**] - 0.5 (One half) [**Location (un) 8426**](s) by mouth HS (at bedtime) as needed for insomnia VERAPAMIL - (Prescribed by Other Provider) - 120 mg [**Location (un) 8426**] Sustained Release - 1 [**Location (un) 8426**](s) by mouth every twenty-four(24) hours WARFARIN - (Prescribed by Other Provider) - 2 mg [**Location (un) 8426**] - 3 [**Location (un) 8426**](s) by mouth once a day on Sat, & Sun Medications - OTC ACETAMINOPHEN - (Prescribed by Other Provider) - 325 mg [**Location (un) 8426**] - 2 [**Location (un) 8426**](s) by mouth three times a day ASPIRIN - (Prescribed by Other Provider) - 81 mg [**Location (un) 8426**], Chewable - 1 [**Location (un) 8426**](s) by mouth DAILY (Daily) SENNOSIDES-DOCUSATE SODIUM [SENNA-S] - (Prescribed by Other Provider) - 8.6 mg-50 mg [**Location (un) 8426**] - 1 [**Location (un) 8426**](s) by mouth twice a day as needed Discharge Medications: 1. tramadol 50 mg [**Location (un) 8426**] Sig: One (1) [**Location (un) 8426**] PO Q4H (every 4 hours) as needed for pain. [**Location (un) 8426**](s) 2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 3. aspirin 81 mg [**Location (un) 8426**], Delayed Release (E.C.) Sig: One (1) [**Location (un) 8426**], Delayed Release (E.C.) PO DAILY (Daily). 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. furosemide 20 mg [**Location (un) 8426**] Sig: One (1) [**Location (un) 8426**] PO Q12H (every 12 hours). 6. potassium chloride 20 mEq [**Location (un) 8426**], ER Particles/Crystals Sig: One (1) [**Location (un) 8426**], ER Particles/Crystals PO Q12H (every 12 hours). 7. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 8. hydralazine 25 mg [**Location (un) 8426**] Sig: Two (2) [**Location (un) 8426**] PO Q6H (every 6 hours). 9. ranitidine HCl 150 mg [**Location (un) 8426**] Sig: One (1) [**Location (un) 8426**] PO DAILY (Daily). 10. warfarin 1 mg [**Location (un) 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] Once Daily at 4 PM: For Afib INR goal=>2. 11. warfarin 2.5 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO once for 1 doses. 12. acetaminophen 325 mg [**Last Name (Titles) 8426**] Sig: Two (2) [**Last Name (Titles) 8426**] PO Q4H (every 4 hours) as needed for fever, pain. 13. glyburide 2.5 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO BID (2 times a day). 14. metoprolol tartrate 50 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO BID (2 times a day). 15. amlodipine 5 mg [**Last Name (Titles) 8426**] Sig: Two (2) [**Last Name (Titles) 8426**] PO DAILY (Daily). 16. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ACHS: PER RISS. 17. oxybutynin chloride 5 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Location (un) 25576**] Discharge Diagnosis: Aortic Stenosis Secondary: Coronary artery disease s/p MIx3 [**2085**] PTCA Diastolic dysfunction LVEF 60% colon cancer Aortic stenosis Hypertension Hyperlipidemia Diabetes type 2 Paroxysmal atrial fibrillation (tachy brady) Chronic renal insufficiency TIA x3 [**2087**] Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait with walker assistance Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage 1+ Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [**Last Name (STitle) 914**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2103-2-6**] 1:45 Cardiologist: Dr [**Last Name (STitle) 11493**] on [**2103-1-31**] AT 1:45PM Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) **] in [**3-13**] weeks [**Telephone/Fax (1) 42305**] **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 PAF Goal INR 2.0-3.0 First draw [**2103-1-27**] Rehab to dose Coumadin for INR goal [**1-11**] - long term follow up to be arranged upon discharge from rehab Completed by:[**2103-1-26**]

[ "585.3", "V12.54", "428.32", "V10.05", "428.0", "424.1", "403.90", "427.31", "414.01", "427.32", "272.4", "V45.82", "250.00" ]

icd9cm

[ [ [] ] ]

[ "35.21", "39.61" ]

icd9pcs

[ [ [] ] ]

9416, 9468

3779, 5304

276, 391

9783, 9974

2212, 3756

10814, 11588

1322, 1363

7309, 9393

9489, 9762

5330, 7286

9998, 10791

884, 947

1378, 2193

216, 238

419, 711

733, 861

963, 1306

29,164

145,993

44993

Discharge summary

report

Admission Date: [**2153-2-6**] Discharge Date: [**2153-3-2**] Date of Birth: [**2072-1-21**] Sex: F Service: SURGERY Allergies: Codeine Attending:[**First Name3 (LF) 1390**] Chief Complaint: Weakness, fall Major Surgical or Invasive Procedure: [**2153-2-9**]: ex-lap with small bowel resection and primary anastamosis [**2153-2-18**]: re-do ex-lap, small bowel resection and primary anastamosis History of Present Illness: Ms. [**Known lastname **] is an 81F with a history of schizoaffective disorder and multiple comorbidities who was admitted to the medical service s/p fall in the setting of hypotension and abdominal pain. Prior to presentation, patient stated that she was having rectal pain, increasing abdominal girth, and intermittent abdominal pain. She also reports episodes of bilious vomiting over the last year with dark stools. She has had weight loss of unknown quantity which she attributes to poor appetite. On admission, patient was not found to have any injuries but did have a CT scan showing a new rectal mass, pancreatic tail mass that is increased in size, and multiple pulmonary nodules. Her CT also showed mild small bowel thickening with possible thickening consistent with gastroenteritis or ischemia. Patient's abdominal pain had largely resolved at that point, so she was kept NPO, hydrated with IV fluids, and serially examined. Lactate trended down from 2 to 1.2. Patient was seen by gastroenterology for visceral masses and an NGT was placed. Tube put out 850 cc of feculent appearing material over 24 hours. On the day the surgical consult was placed, she began to complain of worsening right sided abdominal pain. She has had low grade tachycardia with moderate urine output (275 for 18 hours today). Her acute kidney injury has worsened. Surgery was consulted after repeat CT showed worsened small bowel thickening and interloop fluid. She currently complains of significant nausea and abdominal pain. Past Medical History: Diabetes, Schizoaffective disorder, COPD, HTN, CAD, Hypercholesterolemia, GERD, h/o head injury @ age 11 Past Surgical History: Perforated duodenal ulcer in [**2148**] s/p cholecystectomy, anterior parietal cell vagotomy, and [**Location (un) **] patch closure by Dr. [**Last Name (STitle) **]. Social History: She denies alcohol and tobacco use. Never married. Patient has a sister with whom she has not spoken for several years. Family History: Sister has history of breast cancer Physical Exam: ADMISSION EXAM VS - Temp 97.9 F, BP 103/31 , HR 100 , R 18, O2-sat 93% RA GENERAL - ill appearing female in NAD, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - distended, TTP across lower abdomen, no rebound or guarding, hypoactive BS EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**5-19**] throughout, sensation grossly intact throughout Rectal-painful soft area of rectal fullness near the gluteal cleft, soft, no gross blood. Pertinent Results: ADMISSION LABS [**2153-2-6**] 02:10PM BLOOD WBC-12.5*# RBC-3.27* Hgb-9.8* Hct-30.3* MCV-93 MCH-30.0 MCHC-32.4 RDW-13.6 Plt Ct-207 [**2153-2-6**] 02:10PM BLOOD Neuts-71* Bands-6* Lymphs-17* Monos-5 Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 [**2153-2-6**] 02:10PM BLOOD PT-12.7* PTT-23.6* INR(PT)-1.2* [**2153-2-6**] 02:10PM BLOOD Glucose-177* UreaN-49* Creat-1.6* Na-136 K-4.9 Cl-100 HCO3-27 AnGap-14 [**2153-2-6**] 02:10PM BLOOD ALT-20 AST-22 AlkPhos-74 TotBili-0.2 [**2153-2-6**] 02:10PM BLOOD Lipase-17 [**2153-2-6**] 02:10PM BLOOD cTropnT-<0.01 . URINE STUDIES [**2153-2-6**] 02:30PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014 [**2153-2-6**] 02:30PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2153-2-6**] 02:30PM URINE RBC-0 WBC-<1 Bacteri-NONE Yeast-NONE Epi-0 . MICROBIOLOGY URINE CULTURE (Final [**2153-2-7**]): NO GROWTH. BLOOD CULTURES [**2153-2-6**] Pending x 2 . STUDIES EKG Baseline artifact. Probable sinus tachycardia with a single ventricular premature beat. ST-T wave abnormalities. Since the previous tracing of 11 [**9-25**] the rate is faster. Ventricular premature beat is new. ST-T wave abnormalities are new. Clinical correlation is suggested. . FINDINGS: The heart is normal in size. The aortic arch is partly calcified. The lungs appear clear. There are no pleural effusions or pneumothorax. Cholecystectomy clips project over the right upper quadrant. . CT ABDOMEN PELVIS [**2153-2-6**] IMPRESSION: No evidence of acute disease. . 1. Borderline dilated loops of fluid-filled small bowel with trace inter-loop fluid in the mesenteric root, which is non-specific. A few loops of small bowel in the pelvis have bowel wall thickening. While this can be seen in gastroenteritis, the history of hypotension raises the possibility of a low-flow bowel ischemia. No pneumatosis or free intraperitoneal air. There are extensive atherosclerotic calcifications in the aorta and its branches without obvious arterial thrombus. No bowel obstruction. 2. No evidence of colitis. Normal appendix. 3. Eccentric wall thickening in the right posterior rectum. Correlate with rectal exam. Consider colonoscopy if clinically warranted. 4. Pancreatic tail cystic lesion is unchanged from [**Month (only) **] [**2152**], but has increased in size from [**2148**], again raising the possibility of neoplasm. 5. 4mm right lower lobe nodule unchanged from [**2152-11-23**]. The other pulmonary nodules seen on the prior CT are not included on this study and follow is recommended per the [**2152-11-23**] report. . CT ABDOMEN PELVIS [**2153-2-9**] 1. Dilated loops of small bowel measuring up to 3.8 cm, relatively transitioning to normal caliber in the ileum. Worsening concentric wall thickening in the distal ileum and ascending colon, highly concerning for bowel ischemia, likely resulting in a non-mechanical SBO. 2. Eccentric wall thickening in the right posterior rectum and pancreatic tail cystic lesion, are similar to the prior study and need further evaluation. CT Head [**2153-2-16**]: No acute intracranial process. If clinical concern for intracranial mass or stroke is high, MRI is more sensitive. EEG [**2153-2-15**]: Abnormal EEG due to slowing and disorganization of the background, bursts of generalized slowing, and occasional left frontocentral sharp waves. The first two abnormalities signify a widespread encephalopathy. Medications, metabolic disturbances, and infections are among the most common causes. The bifrontal sharp waves indicate an area of cortical hypersynchrony. There were no repetitive discharges to suggest ongoing seizures. CXR [**2153-3-1**] As compared to the previous radiograph, the left pigtail catheter has been removed. There is no evidence of recurrent pleural effusion. Remnant basal atelectasis at the left lung base. No evidence of pneumothorax. Unchanged moderate cardiomegaly, improvement in lung transparency of the right lung, presumably reflecting improved ventilation. Unchanged course of the nasogastric tube and of the right PICC line. Brief Hospital Course: ** PRIOR TO SURGICAL INTERVENTION ** Ms. [**Known lastname **] was admitted from the ED to the medical service for management of her abdominal pain and hypotension. Her hospital course from [**2153-2-6**] to [**2153-2-9**] is described below by problem: # ABDOMINAL PAIN- On admission patient was noted to have diffuse lower abdominal pain with associated abdominal distension. Initial CT demonstrated some small bowel thickening which was non specific and consistent with gastroenteritis versus ischemia from a low flow state from her recent hypotension. Dilated loops of bowel were present but there was no clear transition point which was suggestive of ileus. There were no signs of colitis. The patient was kept NPO and started on IVF for hydration in addition to a bowel regimen. She was noted to be passing gas and had one large bowel movement which was guaiac positive. GI was consulted and recommended NG decompression in addition to initiation of cipro and flagyl. Pain initially improved with NG decompression but subsequently worsened prompting repeat CT which showed worsened small bowel thickening and interloop fluid. Surgery was consulted given concern for obstruction and mesenteric ischemia. . # HYPOTENSION- Patient was initially hypotensive in the emergency department with SBP in the 70s. Blood pressure improved with administration of IVF and remained stable on admission to the floor. Her anti-hypertensives including lisinopril and diltiazem were initially held. She was however continued on her home metoprolol. As below diltaizem was restarted on HD 1 for heart rate control. . # RECTAL MASS- CT was concerning for rectal wall thickening. This had been present in [**2152-11-14**] but not in [**2148**]. Rectal exam was notable for a soft mildly tender mass. GI was consulted as above and recommend flexible sigmoidoscopy for biopsy once the patient was clinically improved. . # PANCREATIC MASS- Patient noted to have a cystic lesion in the pancreatic tail unchanged from a CT done in [**11-26**] but new increasing in size from [**2148**]. This was not further evaluation on this hospitalization given the patients acute illness. She will need a MRCP for further evaluation . # ATRIAL FIBRILLATION- Patient has a known history of post operative atrial fibrillation. On HD 1 she was noted to have a fib with RVR with rates transiently to the 150s. Blood remained stable and the patient was asymptomatic. On admission she was continued on her home metoprolol but diltiazem was held given hypotension. This medication was restarted on HD at a decreased dose with improvement in rate control. . # ACUTE on CHRONIC RENAL FAILURE- Patients creatinine was elevated from her baseline of 1.4 to 1.6 on admission. This was felt to likely be pre-renal in etiology as creatinine improved to baseline with administration of IVF. On HD 3 creatinine trended upward to 2.0 and urine output decreased suggesting poor renal perfusion. . STABLE ISSUES # COPD- Patient was continued on her home regimen # ANEMIA- Patients HCT was at baseline throughout admission. # CAD- Patient was continued on her home beta blocker and aspirin # GERD- Patient was continued on omeprazole # DM- Patients home glyburide was held and she was maintained on a ISS #Schizoaffective disorder- Patient was continued on seroquel ** AFTER SURGICAL ASSESSMENT ** Surgical consultation was requested on [**2153-2-9**] and exam was consistent with peritonitis. She was taken to the OR emergently for exploratory laparotomy where a closed loop obstruction was discovered with ischemic small bowel. After resection and primary anastomosis, she was brought to the ICU intubated and on pressors. Her postop course was complicated by a wound infection and anastomotic leak requiring return to the OR for additional resection and repeat anastomosis. Her course is described below by system: Neuro: With weaning of sedation, patient became agitated with possible myoclonic jerks of her lower extremities. Neurology was consulted and Head CT showed no abnormalities. EEG showed diffuse slowing and no evidence of ongoing seizures. After extubation, she was conversant with no major neurologic deficit. CV: Her pressors were weaned off following aggressive fluid resusitation. Echo performed on POD 3 showed good systolic function and adequate volumes. She was also in afib with RVR. Control was attempted with diltiazem drip, however she became hypotensive. Patient was loaded with digoxin and given intermittent metoprolol with good rate control. Once hemodynamically stable, she was diuresed with lasix to good effect, however a rising Creatinine limited the ability to push her diuresis. Given her inability to take PO digoxin, her A-fib was managed with IV metoprolol. As she remained in A-fib, a heparin drip was initiated with transitioning to coumadin beginning [**2-28**]. Resp: Patient was difficult to wean from the vent due to underlying COPD and fluid overload. Her nebulizers were continued and she was weaned to extubation on [**2153-2-19**] (POD [**10-15**]). She displayed bilateral pleural effusions which were resistant to medical diuresis, so bilateral chest tubes were placed which each drained several liters of transudate prior to being removed HD 22 and 24. A post pull chest x-ray on [**3-1**] revealed no reaccumulation of pleural effusions and remnant basal atelectasis on the left. She was restarted on home inhalers while. GI: Patient's wound developed erythema on POD#3 for which patient was started on cefazolin. The following day her wound was opened and culture grew MRSA so vanco was added to the regimen. Erythema resolved and a wound vac was placed on [**2153-2-16**]. By POD 9 from her first ex-lap, she developed increasing abdominal pain and fever and was found to have an anastomic leak in the small bowel. She returned to the operating [**2153-2-18**] for another ex-lap with small bowel resection and primary anastamosis. Given the re-operation and re-anastomosis, her progress to PO intake was slow. A CT abdomen [**2-26**] confirmed no anastomotic leak. Her tube feeds were advanced to goal. Initially, high residuals were noted with tube feeds, and they were held and slowly restarted. GU/FEN: After surgery, patient's Cr normalized with excellent urine output. She was intermittently oliguric (never less than 10-15 cc/hr) though typically had good urine output. She did respond to lasix, however, a gradually rising Cr (1.3 on POD #2) limited our ability to diurese her. She was given acetazolamide for several days, then returned to lasix as needed. She was given TPN for supplemental nutrition while awaiting return of bowel function. She should have TPN continued until able to tolerate tube feeds. Heme: Patient was transfused 1U of blood on POD#0. Her Hct was stable and she was given heparin sc for DVT prophylaxis, then heparin drip while transitioning to coumadin. ID: Prior to her anastamotic leak, she was on vancomycin for her wound infection. Following discovery of the leak and subsequent OR, her coverage was broadened to Vanc/Cipro/Flagyl. The vancomycin was DC'd [**2-22**] following treatment of her MRSA wound infection. The cipro and flagyl were continued for a total 14 day course after her reoperation. Social: Patient has had a healthcare proxy (her sister) who no longer functions as one, therefore steps were taken to establish Guardianship for medical decision making. Medications on Admission: 1. vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 3. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. glipizide 5 mg Tablet Sig: 1.5 Tablets PO once a day. 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) puff Inhalation [**Hospital1 **] (2 times a day). 11. Seroquel 200 mg Tablet Sig: One (1) Tablet PO three times a day. 12. Seroquel 50 mg Tablet Sig: One (1) Tablet PO at bedtime: with 200 mg tablet to make 250 mg qhs. 13. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. dextromethorphan-guaifenesin 10-100 mg/5 mL Liquid Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. 15. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for headache. Disp:*8 Capsule(s)* Refills:*0* 17. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation four times a day as needed for shortness of breath or wheezing. Disp:*2 inhalers* Refills:*0* 18. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO twice a day. 19. Senna Lax 8.6 mg Tablet Sig: One (1) Tablet PO once a day. 20. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Medications: 1. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 2. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [**1-15**] Inhalation Q4H (every 4 hours) as needed for wheezing. 4. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for pruritis. 5. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-15**] Sprays Nasal QID (4 times a day) as needed for dry nares. 6. ipratropium bromide 0.02 % Solution Sig: [**1-15**] Inhalation Q4H (every 4 hours) as needed for wheezing. 7. insulin regular human Injection 8. quetiapine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 10. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 11. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 12. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 13. Ondansetron 4 mg IV Q8H:PRN nausea 14. Acetaminophen IV 1000 mg IV Q8H:PRN pain, fever, HA 15. HYDROmorphone (Dilaudid) 0.25-2 mg IV Q3H:PRN pain 16. ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: One (1) Intravenous Q12H (every 12 hours) for 3 days. 17. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Duration: 3 Days 18. Metoprolol Tartrate 5 mg IV Q4H hold for SBP<110, HR<60 19. Pantoprazole 40 mg IV Q24H 20. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral Solution Sig: One (1) Intravenous ASDIR (AS DIRECTED): continue until INR therapeutic. 21. potassium chloride 20 mEq/50 mL Piggyback Sig: One (1) Intravenous PRN (as needed). 22. magnesium sulfate 4 % Solution Sig: One (1) Injection PRN (as needed). 23. calcium gluconate in D5W 2 gram/100 mL Solution Sig: One (1) Intravenous ASDIR (AS DIRECTED). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: Small bowel obstruction Secondary: Anastamotic leak Hypotension Atrial fibrillation MRSA wound infection Acute pulmonary edema Acute kidney injury Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital after suffering a fall in the setting of low blood pressure and abdominal pain. You sustained no injuries from your fall but a new mass in your rectum as well as increase in the size of the known mass in your pancreas was seen on CT scan. It is recommended that you have a sigmoidoscopy to biopsy the rectal mass as well as a study called an MRCP to further evaluate the mass seen on your pancreas. You were also found to have a small bowel obstruction which required surgery to fix. However, you had complications from your first operation and second operation was required to fix this. You are now being discharged to an extended care facility to continue your recovery Followup Instructions: [**Hospital 2536**] Clinic in 2 weeks. Please call [**Telephone/Fax (1) 600**] to schedule.

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Discharge summary

report

Admission Date: [**2138-3-28**] Discharge Date: [**2138-4-6**] Date of Birth: [**2060-5-11**] Sex: F Service: MEDICINE Allergies: Losartan / Lisinopril / Penicillins Attending:[**First Name3 (LF) 783**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Bronchoscopy with biopsy History of Present Illness: 77 yo female with a history of COPD and CHF who presents with sob. Pt states that she has had sob for many months, and was in fact hospitalized for this about one month ago. After discharge she felt better for a while but over the past few weeks has had worsening sob. She came to ED this morning because she felt acute worsening while trying to sleep. Denies CP, palpitations. No LE edema or PND, however she does find it more difficult to breath with lying down and has been sleeping in a chair. Additionally she has had a cough and nasal congestion but denies post nasal drip, fever, or rhinnorhea. She also denies GERD. She had any episode of myocarditis with associated heart failure in early [**2137**] but per a recent cardiac MR [**First Name (Titles) **] [**Last Name (Titles) **] is normal. In reviewing the prior discharge summary, she also presented with sob after c/o several days of nasal congestion, increasing dyspnea. During this prior hospitalization she had a CTA which showed extensive emphesematous changes. At that hospitalization it was felt that she had a COPD flare triggered by viral URI. During her hospitalization she had an allergic reaction to [**Last Name (un) **], was discharged off all afterload reducing agents. Only medicine change since discharge was discontinuing her HCTZ yesterday on advisement of her cardiologist b/c she appeared dehydrated. Of note pt had a cardiac cath in [**5-21**] with no flow limiting lesions. As past of work up for dyspnea she was seen in pulmonary clinic this past week. Pulmonologist felt that dypnea was in part due to COPD but that her COPD could not account for all of her DOE. Cardiac MR on [**2138-3-25**] with LVEF 62%, but effective forward EF 54%, no evidence of scarring or infarction, RVEF nl at 60%; mild MR. Past Medical History: COPD CHF osteoarthritis hyperlipidemia HTN migraine headaches possible chronic eosinophilic pneumonia (dxed during this admission) Social History: Pt. has a previous 40 pack-year history of smoking (stopped 25 yrs ago). She does not drink alcohol and denies other drug use. She lives with her husband and has three grown children. Family History: [**Name (NI) 1094**] mother's side notable for "extensive" heart disease (several of her family members died from this); pt's father died of "cancer of the spleen." No history of diabetes or stroke. Physical Exam: VS: T 97 BP 126/70 P 80 R 14 94% on RA Appearance: NAD HEENT: NC/AT. PERRL, EOMI. MMM, no sinus tenderness Neck: supple, no LAD. Chest: decreased air movement, exp wheezes on left > right, no rales or rhonchi; coughs after taking deep breath CV: Nl rate. Nl S1/S2, no murmurs. Abdomen: Soft, nontender, nondistended, +BS, no HSM. Ext: WWP, no edema; DP and radial pulses palpable bilaterally. Neuro: CN II-XII grossly intact. 2+ biceps and Achilles' reflexes. 5/5 strength proximal/distal flexion and extension at upper and lower extremities. No finger-to-nose dysmetria and no asterixis. Pertinent Results: EKG: 1.[**Street Address(2) 1755**] dep in v5-v6 (old EKG w/ 1 mm depressions) . CXR: no pneumonia, no pulmonary edema . Transbronchial biopsy: a). Bronchial mucosa with chronic inflammation and increased number of eosinophils. No alveolar tissue present. b). No granulomas or vasculitis seen c). No malignancy identified. . PFTs [**2138-3-4**]: Mild obstructive ventilatory defect. The reduced diffusing capacity suggests an emphysematous process. There are no prior studies for comparison: FEV1 and vital capacity to be 1.07 and 2.20 (65% and 90% predicted). FEV1 to vital capacity ratio is 49% (72% predicted). TLC and RV are normal at 98% and 106% of predicted, and DLCO is mildly reduced at 63% predicted with DL divided by alveolar volume equal to 78% predicted. These PFT's compare well to those from [**Hospital1 9487**] from [**2137-8-16**] when FEV1 and vital capacity were 1.98 and 1.92 respectively, increasing to 1.03 and 2.12 after Albuterol, though she had to take an Advair previously. During that set of pulmonary function tests she walked for 3 minutes without significant desaturation or complaints of shortness of breath, though HR increased to 120. . CT chest [**3-24**]: 1. New areas of atelectasis or consolidation in the left lower lobe, lingula and right middle lobe, probably related to the increased bronchial wall thickening in the right middle lobe suggesting active airways inflammatory disease. Infection in the areas of consolidation, particularly in the left lower and right middle lobes cannot be excluded, and neither can noninfectious causes of pneumonia due to parasitic infestation or idiopathic causes such as chronic eosinophilic pneumonia. 2. Severe emphysema. 3. Coronary atherosclerosis. No cardiomegaly or pericardial effusion. 4. Mild interval mediastinal lymph node enlargement, probably reactive. . CT chest [**2-21**]: No PE on CTA. There are extensive emphysematous changes in the lungs, particularly in the upper lung zones. There are tiny, 3-millimeter peripheral lung nodules unchanged from the prior study as well as some nonpathologically enlarged mediastinal lymph nodes and some calcified granulomas. Previous CT scans also showed no evidence of interstitial disease, CHF or pleural disease. . TTE [**1-20**]: EF cannot accurately be assessed. Moderate global left ventricular hypokinesis, trace AR, 1+MR, mild PASP, compared to prior study of [**2137-7-5**], left ventricular systolic function has improved and the severity of mitral regurgitation has increased. . Cardiac MRI [**3-24**]: 1. Mildly dilated left ventricular cavity size with normal regional left ventricular systolic function. The LVEF was normal at 62%. The effective forward LVEF was mildly depressed at 54%. No MR evidence of prior myocardial scarring/infarction. 2. Normal right ventricular cavity size and function. The RVEF was normal at 60%. 3. Mild miltral regurgitation. 4. The diameters of the ascending aorta and aortic arch were normal. The diameter of the descending aorta was mildly increased. The main pulmonary artery diameter was normal. 5. Mild biatrial enlargement . [**2138-3-28**] 08:43PM URINE HOURS-RANDOM CREAT-41 [**2138-3-28**] 08:43PM URINE OSMOLAL-227 [**2138-3-28**] 08:43PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007 [**2138-3-28**] 08:43PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2138-3-28**] 08:43PM URINE EOS-NEGATIVE [**2138-3-28**] 01:50PM CK(CPK)-48 [**2138-3-28**] 01:50PM cTropnT-<0.01 [**2138-3-28**] 01:50PM CK-MB-NotDone [**2138-3-28**] 01:50PM ANCA-NEGATIVE B [**2138-3-28**] 01:50PM [**Doctor First Name **]-NEGATIVE [**2138-3-28**] 08:42AM TYPE-ART PO2-131* PCO2-41 PH-7.48* TOTAL CO2-31* BASE XS-7 [**2138-3-28**] 06:08AM GLUCOSE-112* UREA N-17 CREAT-0.8 SODIUM-136 POTASSIUM-3.4 CHLORIDE-97 TOTAL CO2-29 ANION GAP-13 [**2138-3-28**] 06:08AM LD(LDH)-195 [**2138-3-28**] 06:08AM CK(CPK)-54 [**2138-3-28**] 06:08AM cTropnT-<0.01 proBNP-1829* [**2138-3-28**] 06:08AM CK-MB-NotDone [**2138-3-28**] 06:08AM WBC-7.3 RBC-4.10* HGB-12.8 HCT-36.6 MCV-89 MCH-31.3 MCHC-35.1* RDW-13.9 [**2138-3-28**] 06:08AM NEUTS-49.0* BANDS-0 LYMPHS-19.6 MONOS-4.6 EOS-25.4* BASOS-1.3 [**2138-3-28**] 06:08AM PLT COUNT-251 [**2138-3-28**] 06:08AM PT-11.7 PTT-22.2 INR(PT)-1.0 [**2138-3-27**] 12:14PM UREA N-15 CREAT-0.8 SODIUM-138 POTASSIUM-3.2* CHLORIDE-95* TOTAL CO2-29 ANION GAP-17 [**2138-3-27**] 12:14PM ALT(SGPT)-12 AST(SGOT)-19 [**2138-3-27**] 12:14PM TSH-1.6 [**2138-3-27**] 12:14PM FREE T4-1.3 [**2138-3-27**] 12:14PM [**Doctor First Name **]-NEGATIVE [**2138-3-27**] 12:14PM WBC-8.0 RBC-3.89* HGB-12.4 HCT-35.3* MCV-91 MCH-32.0 MCHC-35.3* RDW-14.2 [**2138-3-27**] 12:14PM PLT COUNT-257 Brief Hospital Course: 77 F with PMH COPD, CHF, much improved EF per cardiac MR, presents with SOB and elevated eosinophils. . # Likely chronic eosinophilic pneumonia: Pt had worsening 5 pillow PND, orthopnea, and dyspnea on exertion over the last few weeks, and before admission was sleeping in a chair. Pt was moderately SOB at rest. Pulmonology's assessment before admission had been that COPD was unlikely to fully account for pt's dyspnea on exertion. Patient's eosinophil count was found to be greatly elevated, with suspected etiology of chronic eosinophilic pna or ABPA. Labs were ordered for aspergillus RAS, aspergillus antibody (serum precipitant), galactomannin, total IgE, [**Doctor First Name **]. Pt maintained >90% O2 sat on RA on albuterol/atrovent and advair during admission. Advair was changed to 500. Pt was ruled out for MI. . Pt underwent bronch with biopsy x3, with resultant bleeding during the last biopsy. Bronch was terminated before BAL washings could be obtained, and pt was transferred to the MICU. In the MICU, pt had stable vital signs and Hct results throughout, and pt was transferred back to the floor. . Of note, pt's cardiac status has changed from Echo [**1-20**] which showed moderate global LV hypokinesis, to cardiac MRI [**3-24**], in which pt's EF was 62%. Therefore, pt was assessed as not being in CHF during admission. Also of note, before admission, pt was noted to have angioedema in response to losartan and a severe cough in response to lisinopril, but the pt had been taking irbesartan as an outpatient without side effects. . Due to elevated eosinophils on biopsy and presumptive diagnosis of chronic eosinophilic pneumonia, pt was started on prednisone 40 QD, with dramatic improvement in SOB within 1-2 days. Pt's eosinophil count decreased to normal limits within 1-2 days, and pt was ambulating and subjectively felt significantly less SOB and much less fatigued. Pt was discharged on prednisone x 14 days, with pulmonary and cardiology followup. . # Chronic sinusitis: CT head from [**Hospital1 392**] showed chronic sinusitis. Pt was maintained on Flonase and nasal saline spray prn. . # Headache: Pt's headache was likely associated with sinusitis. Pt's headache was well controlled on tylenol, flonase, fioricet, and percocet prn. Pt was advised to minimize fioricet use for possible dependence and rebound headaches. . # COPD: Pt was maintained on Advair and duonebs. CXR showed no pneumonia or pulmonary edema. . # No longer in CHF: Pt had a previous diagnosis of CHF, but was assessed to no longer be in CHF per cardiac MRI results. Pt's ASA was stopped, but was continued on metoprolol. Pt has had angioedema in response to losartan, and severe cough in response to lisinopril, but pt had been taking irbesartan as an outpatient before being placed on losartan as an inpatient on a previous admission. . # HTN: HTN was well controlled on metoprolol. . # Hyperlipidemia: Pt was continued on Atorvastatin per home regimen. . PPX: Heparin sc, no PPI Code: Full Medications on Admission: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY 5. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device 6. Toprol XL 25 mg Tablet 7. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation every 6-8 hours as needed. 8. Please do not take Avipro or Lisinopril. 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day for 3 doses. 10. Benadryl 25 mg Tablet Sig: One (1) Tablet PO twice a day for Discharge Medications: 1. 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* 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for 5 days. Disp:*20 Tablet(s)* Refills:*0* 5. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. Disp:*250 ML(s)* Refills:*0* 6. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-17**] Sprays Nasal TID (3 times a day) as needed. Disp:*1 month supply* Refills:*0* 7. Albuterol Sulfate 0.083 % Solution Sig: One (1) inhaler Inhalation every 4-6 hours. Disp:*1 inhaler* Refills:*2* 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhaler Inhalation every six (6) hours. Disp:*1 inhaler* Refills:*2* 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*30 Tablet(s)* Refills:*1* 10. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 14 days. Disp:*28 Tablet(s)* Refills:*0* 11. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). Disp:*90 Tablet(s)* Refills:*2* 12. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13. Alendronate 35 mg Tablet Sig: One (1) Tablet PO once a week. Disp:*4 Tablet(s)* Refills:*0* 14. Os-Cal 500+D 500-400 mg-unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. Disp:*60 Tablet, Chewable(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Likely chronic eosinophilic pneumonia Secondary diagnosis: COPD, HTN, osteoarthritis, migraines Discharge Condition: Good, VS stable, shortness of breath much improved, ambulating. Discharge Instructions: Please return to the emergency room if you experience shortness of breath, chest pain, abdominal pain, or other concerning symptoms. Followup Instructions: Please follow up with your primary care physician [**Name Initial (PRE) 176**] 1 week, Dr. [**Last Name (STitle) 9488**] [**Name (STitle) **], [**Telephone/Fax (1) 9489**]. Please follow up with pulmonology, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**], in 2 weeks. Call [**Telephone/Fax (1) 612**]. 1.Provider: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 540**] MD Phone:[**Telephone/Fax (1) 541**] Date/Time:[**2138-4-21**] 1:00 2. Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2138-8-1**] 9:40 3. Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2138-8-1**] 10:00 [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**] Completed by:[**2138-4-12**]

[ "428.0", "458.29", "E879.8", "998.11", "401.9", "496", "473.9", "272.0", "E849.7", "518.3", "346.90", "414.01" ]

icd9cm

[ [ [] ] ]

[ "33.27", "96.04" ]

icd9pcs

[ [ [] ] ]

13618, 13624

8196, 11212

314, 341

13783, 13849

3385, 8173

14030, 14984

2542, 2744

11816, 13595

13645, 13645

11238, 11793

13873, 14007

2759, 3366

255, 276

369, 2168

13723, 13762

13664, 13702

2190, 2322

2338, 2526

77,537

185,546

44617

Discharge summary

report

Admission Date: [**2145-4-8**] Discharge Date: [**2145-4-10**] Date of Birth: [**2093-10-18**] Sex: M Service: MEDICINE Allergies: Betadine Attending:[**First Name3 (LF) 5129**] Chief Complaint: Left flank pain Major Surgical or Invasive Procedure: None History of Present Illness: 51M anuric ESRD due to Lithium nephrotox on HD x7 yr with LEU AV fistula on ASA325 (last dose Wed AM) transferred from OSH following CT scan showing Left perinephric hematoma. Onset L flank pain Tues 1AM. Underwent full [**First Name3 (LF) 2286**] Wed without hemodynamic issues. Denies dizziness, fever, chills, N/V. H/O chronic back pain. Recently taken off all anti-hypertensives. AV fistula manipulated by surgeon last week. Last BM Tuesday. Initial Hct at OSH 30, repeat 26 --> 1u PRBC in transit, initially 26.6 with blood hanging. Premedicated for repeat CT Abd/pelvis. NO signs of bleeding. Serial HCT stable. Past Medical History: PUD s/p EGD and medical management (PPI) in [**2142**], bipolar, idiopathic enlarged spleen, ESRD on MWF [**Year (4 digits) 2286**] in [**Location (un) 47**], chronic back pain, HTN, anxiety, s/p splenectomy in [**2141**] Social History: Lives with his mother, denies EtOH, tobacco or illicit drugs. Family History: Non-contributory Physical Exam: (On transfer to medicine [**2145-4-9**]) Vitals: T: 100.7 BP: 117/74 P: 76 RR: 21 O2: 92% RA General: Pale, thin male, alert, oriented, no acute distress HEENT: Sclera anicteric, slight anisocoria, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic murmur loudest at RUSB Abdomen: soft, non-tender, slightly 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. LUE fistula appears patent and non-infected with bruit. Skin: macular rash on chest, appears like tinea versicolor. Pertinent Results: Admission labs: [**2145-4-8**] 12:00AM GLUCOSE-94 UREA N-38* CREAT-6.7* SODIUM-142 POTASSIUM-4.0 CHLORIDE-94* TOTAL CO2-32 ANION GAP-20 [**2145-4-8**] 12:00AM CALCIUM-10.0 PHOSPHATE-4.7* MAGNESIUM-2.0 [**2145-4-8**] 12:01AM K+-4.3 [**2145-4-8**] 12:01AM HGB-9.0* calcHCT-27 [**2145-4-8**] 12:00AM WBC-20.2* RBC-2.92* HGB-8.7* HCT-26.6* MCV-91 MCH-29.9 MCHC-32.9 RDW-13.7 [**2145-4-8**] 12:00AM NEUTS-76.0* LYMPHS-13.4* MONOS-9.6 EOS-0.5 BASOS-0.5 [**2145-4-8**] 12:00AM PLT COUNT-326 [**2145-4-8**] 08:57AM HCT-27.1* [**2145-4-8**] 01:22PM HCT-26.7* [**2145-4-8**] 07:35PM HCT-25.7* [**2145-4-8**] CT Urogram: IMPRESSION: 1. Small kidneys with innumerable cystic lesions. Large left subcapsular and perirenal hematoma. No solid mass but in view of the hemorrhage, a dedicated MRI is recommended to rule out an underlying mass. 2. Questionable mass in the mid right hemi abdomen, may represent normal non opacified small bowel loops, but a mesenteric mass can not be excluded and can be better characterized in the MRI. [**2145-4-9**] PA&Lat CXR (prelim): no acute process. Microbiology: [**4-/2140**] Blood culture: pending [**4-8**] MRSA screen: negative [**4-8**] Blood culture: pending [**4-9**] Cdiff: negative [**4-10**] Blood culture: pending Brief Hospital Course: ASSESSMENT & PLAN: 51yo man with a history of bipolar disorder, HTN, ESRD secondary to Lithium toxicity, on HD, splenectomy, here w/ perinephric hematoma, now being transferred to medicine with leukocytosis and fever. . # Leukocytosis/fever: It is unclear what the source was of his leukocytosis and fevers, as he did not have a clear, localizing source of infection. There was a question of small-bowel mass on his CTU. His large bowel movement and impressive leukocytosis could suggest c.diff colitis. With a [**Month/Year (2) 2286**] patient we always worry about bacteremia, but he uses a fistula and his site does not appear infected. He was started empirically on vancomycin and ceftriaxone. A PA&Lat CXR showed no process, Cdiff was negative, LFTs were normal, and blood cultures had no growth. The urology team felt that this could either be a reaction to his hematoma, or an infection of the hematoma pocket. On [**2145-4-10**], the patient was insistent that he be discharged, not wanting to stay in-house for a trial off of antibiotics to monitor for further fevers. He had a low-grade temp of 100.8 the night before but looked well. We decided to keep him on vancomycin empirically for one week, dosed at [**Date Range 2286**], and switch to PO ciprofloxacin for one week, instead of ceftriaxone. The patient understood the risks of leaving the hospital early, but lives with his mother, a former nurse, and will be seen Monday by a doctor [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2286**]. He agreed to call if he felt unwell or spiked fevers. . # Perinephric hematoma: His hematocrit stabilized on arrival here after one unit of PRBCs. The hematoma was again seen on repeat CT urogram. His ASA 325mg was initially held, then restarted at 81mg [**2145-4-10**]. He will follow-up with urology. . # ESRD: Dialyzed Friday without complications. Continued Phoslo, Renagel, Sensipar and Renal caps. . # Suspected early tinea versicolor on chest: He was not given treatment in the setting of fevers and leukocytosis, but advised to discuss with his primary care doctor. [**Month/Day/Year **] on Admission: Omeprazole 20mg ASA 325mg Sevelemer 3200mg TID Renagel 2668 mg w/ each meal Renal caps 1 cap daily Zoloft 150mg daily Alprazolam 1mg TID Lamictal 100mg [**Hospital1 **] Sensipar 60mg daily Discharge [**Hospital1 **]: 1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 2. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Sensipar 60 mg Tablet Sig: One (1) Tablet PO once a day. 5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Calcium Acetate 667 mg Capsule Sig: Four (4) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. Alprazolam 0.5 mg Tablet Sig: One (1) Tablet PO three times a day. 8. Sevelamer Carbonate 800 mg Tablet Sig: Four (4) Tablet PO three times a day: Take with meals. 9. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 10. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 11. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous QHD (with [**Hospital1 2286**]) for 7 days. 12. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: L perirenal hematoma Fever End-stage renal disease on [**Hospital1 2286**] Discharge Condition: Stable Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with a bleed around your kidney that has since stabilized. You had fevers and an elevated white blood cell count, which is likely caused by either an infection or the bleed around your kidney. You should have your white blood cell count checked at [**Hospital1 2286**]. You should call one of your doctors if [**Name5 (PTitle) **] have fevers at home. Please also follow the following instructions: -Continue to take antibiotics for 7 days unless told otherwise by your [**Name5 (PTitle) 2286**] doctors. The antibiotics are to treat a possible infection. You will take Ciprofloxacin once a day, and get intravenous vancomycin at [**Name5 (PTitle) 2286**]. -Please take a low-dose 81mg Aspirin instead of a full-dose 325mg. You can use a prescription or buy it over the counter. -Do not lift anything heavier than a phone book (10 pounds) or drive until you are seen by your Urologist in follow-up -Take Tylenol for pain. Call your doctor if your pain is not controlled by Tylenol. -Resume all of your home [**Name5 (PTitle) 4982**], except hold all NSAIDs (ibuprofen containing products such as advil & motrin) until you see your urologist in follow-up. You can take low-dose Aspirin. -Call your Urologist's office Monday morning to schedule your follow-up appointment in 3 weeks AND if you have any questions. -If you have fevers > 101.5 F, vomiting, increasing pain, lightdeadedness or dizziness call your doctor or go to the nearest ER. -Your CT scan could not rule-out a possible mass in your kidney. You should get an MRI scan of your kidneys to ensure that there is not a mass. Followup Instructions: Please call Dr.[**Name (NI) 24219**] office at ([**Telephone/Fax (1) 33927**] for a follow-up appointment in 3 weeks. Please call Dr.[**Name (NI) 95507**] office at [**Telephone/Fax (1) 53306**] for a follow-up appointment within 2 weeks. Please continue your regular [**Telephone/Fax (1) 2286**] schedule on Monday, Wednesday and Friday of next week. Make sure your [**Telephone/Fax (1) 2286**] doctors know what [**Name5 (PTitle) 4982**] you are taking. Completed by:[**2145-4-11**]

[ "111.0", "296.80", "285.21", "585.6", "593.81", "780.60", "403.91" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

6818, 6824

3356, 5487

285, 292

6942, 6949

2060, 2060

8741, 9230

1279, 1297

6845, 6921

7099, 8718

1312, 2041

230, 247

320, 939

2076, 3333

5501, 6795

6964, 7075

961, 1184

1200, 1263

15,110

168,525

12511

Discharge summary

report

Admission Date: [**2182-5-14**] Discharge Date: [**2182-5-17**] Date of Birth: [**2117-8-12**] Sex: F Service: MICU EAST HISTORY OF PRESENT ILLNESS: This is a 64 year-old woman with a history of nonsmall cell lung cancer with metastases to bone, axilla, thyroid with a history of non-Hodgkin's lymphoma in [**2144**] and recent right bronchial stent with Photofrin injection in [**4-/2182**] and a right subclavian deep venous thrombosis previously on Lovenox and Coumadin who presented for a bronchoscopy and stent placement. The patient had recent admission on [**4-/2182**] when a right bronchial stent was placed. A tracheal stent was removed and replaced and the patient received Photofrin therapy. Since that time the patient has been progressively more short of breath with increased dyspnea on exertion from room to room. The patient denied palpitations. She denied fever, chills, chest pain, nausea, vomiting or diarrhea. The patient reports resolved hemoptysis and now persistent nonproductive cough. The patient also reports two weeks of occasional dull cranial occipital pain. The patient was CT angio on [**2182-5-10**], which did not reveal a pulmonary embolus, but did show tumor progression with compression of trachea and bronchi and a right subclavian deep venous thrombosis. The patient was started at that time on Lovenox and Coumadin, which was discontinued on [**5-12**] in preparation for her procedure. In addition, the patient denies numbness, weakness, and tingling. She denies any hearing changes, dysphagia, bowel and bladder incontinence or back pain. PAST MEDICAL HISTORY: 1. Non small cell lung cancer diagnosed in [**2178**], status post right lobectomy in [**2178**] with metastases in [**2182**] in right axilla, thyroid and bone. She is status post radiation therapy, status post carboplatin times six cycles, last cycle on [**1-5**]. Status post Photofrin injection and stent placement in [**4-6**]. 2. Non-Hodgkin's lymphoma in [**2144**] status post radiation therapy. 3. Status post total abdominal hysterectomy in [**2165**]. 4. Basal cell CA unknown source. 5. Ventricular irritability including premature ventricular contractions. 7. Right and left subclavian deep venous thrombosis. ALLERGIES: Codeine, which causes constipation. Zofran causes syncope. Anesthetic tape causes a rash. MEDICATIONS ON ADMISSION: Serevent one puff b.i.d., Albuterol two puffs q 4 to 6 hours prn, Lovenox and Coumadin, which were discontinued on [**5-12**]. SOCIAL HISTORY: The patient is married one son. She is a retired nurse. She denies any alcohol, tobacco or drugs. FAMILY HISTORY: Unknown as she was adopted. PHYSICAL EXAMINATION: Physical examination revealed a temperature of 97.9. Blood pressure 138/80. Heart rate 96. Respiratory rate 20. Oxygenation revealed 94% on room air. She was 130 pounds. In general, she is a lively pleasant woman, comfortable, but with audible breathing. HEENT examination normocephalic, atraumatic. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements intact. Oropharynx clear. Mucous membranes are moist. No occipital masses or tenderness. Neck revealed no JVD or lymphadenopathy, but a subclavian paratracheal mass. Lungs were coarse bilaterally with decreased breath sounds on the right with occasional rhonchi. Her heart was tachycardic, but regular. Normal S1 and S2 with a 3 out of 6 systolic ejection murmur at the left upper sternal border. Her abdomen was soft, nontender, nondistended. Bowel sounds were presents. Extremities without clubbing, cyanosis or edema. She did have right upper extremity edema with trace pitting. Her neurological examination was alert and oriented. Cranial nerves II through XII were intact. Her motor strength was 5 out of 5 and symmetrical with normal sensation, 1+ patella deep tendon reflexes bilaterally, otherwise no deep tendon reflexes. Babinski was unable to quantified and she had no spinal tenderness. LABORATORIES ON ADMISSION: White blood cell count of 7.1 with 71 segments, 17 lymphocytes, 6 monocytes and 5 eosinophils. Hematocrit 38, platelet 251. PT 16.3, INR 1.8, sodium 137, potassium 4.1, chloride 102, bicarb 23, BUN 10, creatinine .5, glucose 88, albumin 3.5, calcium 9.2, magnesium 1.9, phosphorus 3.8. CT angiogram on [**5-10**] revealed no PE, but did reveal extensive mediastinal disease with distortion and compression and invasion of the airway with interval increase since [**4-6**]. Mass source marked worsening at the carina and main stem bronchi, right subclavian and bronchocephalic vein. Small pulmonary nodules likely lymphangitic and hematogenous metastases as well as a right chest wall mass and right breast lesion with skeletal metastases. IMPRESSION: This was a 64 year-old woman with nonsmall cell lung cancer and right subclavian deep venous thrombosis here for stent placement secondary to disease progression. HOSPITAL COURSE: 1. Pulmonary, nonsmall cell lung cancer with increased mediastinal burden, increased shortness of breath and dyspnea on exertion with recent right bronchial stent placement. No evidence of PE by CT angio. The patient was brought to interventional pulmonary Operating Room on [**5-15**] where a bronchoscopy revealed significant obstruction to the trachea at main stem as well as in the left main bronchus. The patient had a stent placed in the trachea as well as in the left main bronchus and the right upper lobe revealed obstruction in the posterior apical and anterior segments. The patient was extubated and was reintubated for hypoxia and tachypnea and attempt at second extubation was done, however, the patient was unable to remain extubated and was reintubated for hypoxia and tachypnea. The patient was transferred back to the MICU at this time. A repeat flexible bronchoscopy was performed in the PACU with concerns for left upper lobe collapse with question of upper lobe obstruction from stent, but this was not clearly visualized. Therefore the patient remained intubated with etiology as probably worsening of large airway obstruction. The patient was continued on ventilatory support and was followed by arterial blood gas and ventilatory parameters. The patient was transferred to the [**Hospital Ward Name 516**] for palliative radiation therapy to her mediastinal mass for which she received on [**5-17**]. The patient, however, continued to have worsening oxygen requirements as well as had respiratory acidosis and at this time the patient and her family discussed with the attending changing her aim of care toward comfort measures only. The patient's family decided they did not want anymore aggressive interventions. The patient was started on a morphine drip. Her oxygen level was brought to room air and ventilatory support was continued. At 6:24 p.m. I was called to see the patient after telemetry noted asystole and no blood pressure. The patient's examination revealed bilateral fixed and dilated pupils, no heart or lung sounds were heard and she had no response to painful stimuli. The patient was pronounced dead at 6:24 p.m. on [**2182-5-17**]. The family was present (husband and son). The attending was notified by E-mail and phone. Autopsy was deferred by the patient's family and the cause of death was respiratory distress secondary to metastatic nonsmall cell lung cancer. 2. Deep venous thrombosis: The patient had a deep venous thrombosis on the site of the Port-A-Cath on the right. The patient's Lovenox and Coumadin were held during her hospital stay. 3. Hypotension in PACU in the setting of Propofol. The patient's A line did not always correlate with her manual cuff, but her maps remained above 65 until her aim of care changed at which time the patient became hypotensive. 4. FEN: The patient received maintenance fluids, D5 one half normal saline until she was pronounced. Communication was with her husband Mr. [**First Name (Titles) 38793**] [**Last Name (Titles) 38794**] and her son. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-761 Dictated By:[**Name8 (MD) **] MEDQUIST36 D: [**2182-5-17**] 18:35 T: [**2182-5-20**] 06:53 JOB#: [**Job Number 35533**] 1 1 1 DR

[ "V10.79", "V66.7", "518.81", "519.1", "V10.83", "198.5", "162.8", "453.8" ]

icd9cm

[ [ [] ] ]

[ "96.05", "92.24", "33.23", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

2666, 2695

2403, 2531

4994, 8288

2718, 4039

167, 1611

4054, 4976

1634, 2376

2548, 2649

28,101

117,274

30977

Discharge summary

report

Admission Date: [**2191-5-27**] Discharge Date: [**2191-6-3**] Service: MEDICINE Allergies: Levofloxacin / Bactrim Attending:[**First Name3 (LF) 613**] Chief Complaint: confusion, elevated INR, guaiac positive Major Surgical or Invasive Procedure: None History of Present Illness: 87 yo F w/ PMH significant for metastatic cervical ca w/ new RP mass, HTN, A fib and h/o DVT on coumadin, R tib-fib fx [**4-24**], short gut s/p surgery for duodenal obstruction in [**2188**], h/o SBO, dCHF, sclerosing mesenteritis, chronic diarrhea, hypothyroidism, severe MR, moderate pulmonary hypertension who presents to the ED with confusion and elevated INR. Of note, she had recent admit 3 months ago for PNA, SBO, BRBPR. . No clear precipitating factor for elevated INR. Spoke with patient's son who states her appetite is good, no recent TPN, no signs of liver disease (abd pain, jaundice), no worsening malabsorption/diarrhea decompensated heart failure, fevers. . [**Name (NI) **] son is concerned about patient being more confused than baseline and weaker. No signs of bleeding (hematemesis, BRBPR, melena, bruising, etc) currently. . Son reports alternation of sleep wake cycle, possibly making meals at incorrect times, and possible incorrect self-administration of medications. Answers questions appropriately, AO x 2 at least. Per son, has had similar mental status changes with electrolyte abnormalities. . In the ED, initial VS - 0, 97.1, 98, 106/68, 16, 100% RA. Exam notable for cachexia, Guiac + black stool (not tarry). Labs notable for INR 11.6, Hct 25.5 (stable), Ca 7.4, lactate 1.5, Cr 1.9, K 3.2, bicarb 14. Bcx pending. She was given 1 gram calcium gluconate, vitamin K 5 mg po (given 5 mg previously by PCP today as well), 40 meq po potassium chloride. . CXR showing no acute process. EKG showing AF at 92, RBBB, no ischemic changes c/w prior. CT head without ICH, mass, or mass effect. . Vitals on transfer - T 96, HR 78, BP 106/70, 24, 100 RA Access - 2 PIV Past Medical History: -Hypertension -Severe MR [**Name13 (STitle) 73213**] pulmonary HTN -Atrial fibrillation on coumadin -DVT diagnosed [**2-23**], on coumadin -Duodenal obstruction from retroperitoneal mesenteric mass (sclerosing mesenteritis without evidence of malignancy) [**5-/2188**], followed by admission for marroon stool, SBO, ex lap, lysis of adhesions [**6-22**] -ureteral ca s/p ? resection/chemo [**2171**] (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73204**]) -s/p SBO requiring ileocecectomy in [**6-21**] -metastatic cervical cancer s/p hysterectomy [**2149**] and bilateral iliac lymph node dissections followed by adjuvant radiation therapy at [**Doctor Last Name **] Kettering in [**State 531**] -hypothyroidism -hemorrhoids -R femur fracture s/p ORIF [**5-19**] -gallstones s/p ERCP [**5-19**] -chronic diarrhea x 15 years [**2-16**] radiation enteritis -vein stripping [**2148**] - R tib-fib fx [**4-24**] Social History: - Widowed - She has been living with her son in [**Name (NI) 86**]. She was living in Mephis with her daughter. [**Name (NI) **] son is a dentist at [**Name (NI) **], and he is very involved with her care - Denies history of smoking - Reports 1 bourbon/day - Denies history of illicit drug use Family History: No known history of blood disorders in the family. Several of her brothers had cancer and a sister had breast cancer. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: GEN: pleasant, comfortable, 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, nt, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters 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 RECTAL: guaiac positive black stool Pertinent Results: On admission: [**2191-5-27**] 11:10AM BLOOD WBC-8.8 RBC-2.49* Hgb-8.2* Hct-25.5* MCV-103* MCH-33.0* MCHC-32.2 RDW-18.8* Plt Ct-253 [**2191-5-27**] 09:40AM BLOOD PT-99.8* INR(PT)-11.9* [**2191-5-27**] 11:10AM BLOOD Glucose-93 UreaN-54* Creat-1.9* Na-143 K-3.2* Cl-113* HCO3-14* AnGap-19 [**2191-5-27**] 11:10AM BLOOD Calcium-7.4* Phos-3.3 Mg-1.6 [**2191-5-28**] 04:49AM BLOOD Hapto-216* [**2191-5-27**] 11:10AM BLOOD TSH-2.8 [**2191-5-27**] 11:35AM BLOOD Lactate-1.5 CT Abd/Pelvis: ABDOMEN: The hepatic veins appear distended, presumably related to underlying cardiac dysfunction. An 11 mm low attenuation lesion is noted within segment [**Doctor First Name 690**] of the liver, most likely a small cyst and unchanged since previous imaging. Periportal edema is noted, again possibly related to underlying cardiac dysfunction. There is a calcified gallstones in the gallbladder. Two focal area of calcification are present within segment VI of the liver and there is a focus calcification in the spleen. The adrenal glands and pancreas are normal. 21-mm cyst is present in the interpolar region of the left kidney, unchanged since prior imaging. Right kidney is normal. No interval change in the mesenteric mass measuring 3.2 x 1.8 cm. There are multiple surgical clips in the pelvis, presumably related to previous cervical surgery. There is moderate free fluid in the abdomen and extensive anasarca. No significant bowel distention. There is extensive arterial calcification. Bilateral pleural effusions with associated atelectasis. Cardiomegaly is noted with prominent right atrium. Multiple lytic and sclerotic bone lesions are present, unchanged since previous imaging. There are wedge compression fractures of L1, 2 and 4. Bilateral pubic rami fractures are also noted. IMPRESSION: Stable retroperitoneal calcified mass. No significant intra-abdominal hematoma or hemorrhage is identified. Extensive anasarca is noted. CXR: IMPRESSION: 1. No acute cardiopulmonary process. 2. Interval worsening of bilateral acromioclavicular joint degenerative change. CT Head: NON-CONTRAST HEAD CT: There is no hemorrhage, mass, mass effect, or acute large territorial infarction. Moderate proportional enlargement of the ventricles and sulci is unchanged from prior and consistent with age-related cortical atrophy. [**Doctor Last Name **]-white matter differentiation is maintained throughout. There is no scalp hematoma or acute skull fracture. Mild mucosal thickening of the right sphenoid and maxillary sinuses is noted. The remainder of the visualized paranasal sinuses and mastoid air cells are well aerated. A scleral band is noted on the left. IMPRESSION: No acute intracranial process. CHEST (PA & LAT) Study Date of [**2191-5-27**] 11:30 AM 1. No acute cardiopulmonary process. 2. Interval worsening of bilateral acromioclavicular joint degenerative change. ECG Study Date of [**2191-5-28**] 11:34:52 AM Probable "fine" atrial fibrillation. Right bundle-branch block. Left anterior fascicular block. Borderline low QRS voltage is non-specific. ST-T wave changes are primary and are non-specific. Since the previous tracing of same date the ventricular rate is slower. ECG Study Date of [**2191-5-28**] 4:34:38 AM Probable atrial fibrillation with rapid ventricular response. Right bundle-branch block. Left anterior fascicular block. Anterolateral lead ST-T wave changes may be primary and are non-specific. Since the previous tracing of [**2191-5-27**] the ventricular rate is faster. CT ABD & PELVIS W/O CONTRAST Study Date of [**2191-5-29**] 12:48 PM Stable retroperitoneal calcified mass. No significant intra-abdominal hematoma or hemorrhage is identified. Extensive anasarca is noted. LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of [**2191-6-2**] 8:48 AM 1. Two small hepatic cysts with no solid liver lesion identified. 2. Right pleural effusion. 3. No ascites identified. 4. Patent portal veins, demonstrating hepatopetal flow. 5. Small left renal cyst. Brief Hospital Course: 87 y/o female with metastatic cervical ca with RP mass, HTN, A fib and h/o DVT on coumadin, short gut s/p surgery for duodenal obstruction in [**2188**], h/o SBO, dCHF, sclerosing mesenteritis, severe MR, moderate pulmonary hypertension who presents to the ED with elevated INR, guaiac positive black stool, and mild confusion. . # Elevated INR/Anemia: Patient presented with a HCT 25.5(baseline Hct 25-29) and INR of 11.9 (coumadin for afib). She had guiac positive dark stool, but not tarry or melanotic. No hematemesis, melena, bruising. No clear precipitating factor for elevated INR. Per son, he is concerned about patient being more confused than baseline and with possible incorrect self-administration of medications, which may be the primary etiology of elevated INR. Patient was made NPO, 2 large bore PIV were placed, protonix 40 IV BID was started and 2 units FFP along with 5mg po vitamin k (5 already given in her PCP's office). GI was consulted and deferred scope as patient was hemodynamically stable. HCT dropped to 23 so patient transfused 1 unit PRBCs, and HCT appropriately increased to 27 however it dropped to 23 again the following day and patient again transfused with 1 unit PRBC and 2 units FFP with appropriate HCT improvement and INR down to 1.8. CT scan was done without contrast that ruled out retroperitoneal bleed. Patient remained HD stable with HCT >26 and was transferred to the floor. After being transferred to the floor, patient's INR was 2.1. Over the following three days it trended up to 2.7 on its own. As she has no clinical evidence of chronic liver disease, and her albumin is 2.6, her elevated INR was attributed to moderate malnutrition. The patient was restarted on 1mg of coumadin per day. Over this period, her HCT has continued to rise to 33.6 on day of discharge. No evidence of acute bleeding. # Atrial Fibrillation: Rate controlled with metoprolol , CHADS2 = 3. Patient is anticoaguated, INR on discharge is 2.6, on Warfarin 1mg daily - Check INR [**6-5**] and redose warfarin as needed - Continue Metoprolol . # Confusion/AMS/UTI: patient is AO x [**1-16**]. Per son, patient can sometimes be confused with electrolyte disturbances in the past. Son also reports alternation of sleep wake cycle, possibly making meals at incorrect times, and possible incorrect self-administration of medications. No evidence of hypoglycemia, sepsis, or hepatic/ischemic encephalopathy. Patient had a positive U/A that grew Klebsiella Pneumoniae and she was treated with ceftriaxone. She finished her seven day course of ceftriaxone in the hospital. Though patient remains unaware of the date and her current location, her interactivity has improved since being transferred to the floor, and she has recently started knitting. . # Acute renal failure: Resolved. baseline Cr 0.9-1.3 and presented with Cr 1.9. This improved with IVF and was likely pre-renal. Upon transfer to the medicine service, Cr was 1.1, and has not exceded 1.2 during the remainder of this admission, further supporting prerenal etiology. . # HTN: In the setting of concern for GI bleeding, and normotension patient's metoprolol, torsemide were all held and restarted on [**5-31**]. She has remained normotensive for the remainder of her hospitalization. She will continue on her outpatient regimen upon discharge. . # Chronic diarrhea: Patient continued on loperamide. tincture of opium was held in the ICU given altered mental status; patient was restarted on full outpatient diarrhea regimen (including tincture of opium and tylenol with codeine) upon transfer to the medicine floor, with rapid improvement in symptoms. Patient will be discharged on her original outpatient regimen. . Medications on Admission: -torsemide 10 mg daily -cholestyramine 4 mg tid -metoprolol 50 mg [**Hospital1 **] -folic acid 1 mg daily -vitamin D 1000 mg daily -calcium carbonate 500 mg tid -loperamide 2 mg (2 tabs) 4x daily -B12 1000 mcg daily -tylenol -ferrous sulfate 325 mg 2x/day -tincture of opium 10 mg tid -potassium chloride -coumadin 2 mg daily -codeine sulfate tid -prilosec 20 mg daily -levoxyl 50 mcg daily Discharge Medications: 1. cholestyramine-sucrose 4 gram Packet [**Hospital1 **]: One (1) Packet PO TID (3 times a day). 2. folic acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 3. loperamide 2 mg Capsule [**Hospital1 **]: Two (2) Capsule PO QID (4 times a day) as needed for diarrhea. 4. cyanocobalamin (vitamin B-12) 100 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 5. metoprolol tartrate 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 6. codeine sulfate 30 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID PRN () as needed for diarrhea. 7. torsemide 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 8. levothyroxine 50 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 9. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 10. opium tincture 10 mg/mL Tincture [**Hospital1 **]: Five (5) Drop PO TID (3 times a day) as needed for diarrhea. 11. warfarin 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO Once Daily at 4 PM. 12. Vitamin D 1,000 unit Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 13. Vitamin D 50,000 unit Capsule [**Hospital1 **]: One (1) Capsule PO once a week: On Saturdays, last dose [**2192-2-1**]. 14. ferrous sulfate 325 mg (65 mg iron) Tablet [**Month/Day/Year **]: One (1) Tablet PO twice a day. 15. pantoprazole 20 mg Tablet, Delayed Release (E.C.) [**Month/Day/Year **]: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**] Discharge Diagnosis: Primary - Urinary tract infection - Delerium - Coagulopathy attributed to moderate malnutrition - Acute Renal Failure - GI Bleed, chronic, of undetermined etiology Secondary - Atrial Fibrillation Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital because of confusion. Upon admission, your lab values suggested that you were at very high risk to develop a potentially life threatening bleed, most likely from the gastrointestinal tract. Examination of your stool demonstrated occult blood, which was further concerning that you were, or had recently bled, from your GI tract. Your blood counts showed anemia (a deficiency of red blood cells), which further supported a recent GI bleed. You received blood products. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. In regard to your medications, your Potassium supplementation has been discontinued. Followup Instructions: Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2191-6-21**] 3:00 [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2191-6-3**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

13816, 13938

8146, 11862

269, 275

14179, 14179

4142, 4142

15067, 15385

3279, 3512

12303, 13793

13959, 14158

11888, 12280

14361, 15044

3527, 4123

189, 231

303, 1994

6212, 6225

6234, 8123

4157, 6203

14194, 14337

2016, 2949

2965, 3263

109

166,018

15327

Discharge summary

report

Admission Date: [**2141-3-27**] Discharge Date: [**2141-3-28**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Oxycodone Hcl/Acetaminophen Attending:[**First Name3 (LF) 3984**] Chief Complaint: Hypertensive urgency. Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. [**Known lastname **] is a 23 year-old woman with a history of SLE and renal failure secondary to lupus nephritis, off HD for one year, who presents with elevated blood pressures. Patient was in her usual state of health when she presented to her nephrologist today. At that time appoinment, her blood pressure was noted to be 240/130. Other than mild nausea, the patient did not have specific complaints. In particular, she denied any headache, chest pains, shortness of breath, palpatations, edema or decreased urine output. She reports taking her blood pressure medications, as prescribed. Given the severity of the hypertension, the patient was referred to the ED for further evaluation. In the ED, initial blood pressure was 221/134 with a heart rate of 84. With use of 600mg labetolol, 40mg lisinopril, one inch of nitropaste, 50mg PO hydralazine, then a labetolol drip, the blood pressures improved to 160-180 systolic and 90-110s diastolic. Currently, the patient feels well other than some mild nausea. She is somewhat lightheaded. Upon arrival, labetolol gtt and nitro paste were still on with a SBP in the 140s. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN - ADAMTS 13 negative 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] PAST SURGICAL HISTORY: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. Social History: Single and lives with her mother and a brother. She graduated from high school and has not continued studies due to her systemic lupus erythematosus. The patient is on disability, and participates in focus groups. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VITALS - T 97.4, BP 148/89, HR 90, RR 25, 100% on room air. GENERAL: Well appearing thin female, in good spirits. Sitting up in bed in no distress. HEENT: Prosthesis of left eye. No icteris or palor. No carotid bruits. CARDIAC: Regular rate/rhythm. Harsh systolic murmur. Possible decrease with clenched fists. LUNG: Clear bilaterally with no rales/wheeze. ABDOMEN: Soft. Non-tender. EXT: Warm. No edema. NEURO: Alert. Oriented x3. Cranial nerves intact (except left eye extraocular muscles). Sensation intact grossly. Finger-to-nose normal. Strength 5/5 in all extremities. SKIN: No rash noted. Nail bed changes with mild pitting noted. Pertinent Results: ADMISSION LABS: =============== C3: 61 C4: 16 137 108 32 AGap=13 ------------ 4.4 20 6.2 Ca: 8.2 P: 5.2 ALT: 15 AP: 216 Tbili: 0.3 Alb: 3.8 AST: 41 TProt: 6.5 WBC: 3.4 PLT: 93 HCT: 26.5 N:53.8 L:38.2 M:4.5 E:3.0 Bas:0.4 STUDIES: ======== ECG ([**2141-3-27**]): NSR at 85. Normal axis. Normal intervals. LAA. LVH. No new ST or T-wave changes. CHEST ([**2141-3-27**]): 1. Patchy retrocardiac opacity, new, which may simply represent atelectasis. Early pneumonic infiltrate cannot be excluded. 2. No CHF. Brief Hospital Course: 23 y.o. F with lupus and renal failure [**2-11**] SLE, not on HD x 1 year, HTN, and cardiomyopathy admitted with elevated BPs. # Hypertensive Urgency: This has been an ongoing issue for this patient with prior admissions with hypertensive emergency (seizures, intraparenchymal hemorrhages). In the ER, she was on a labetalol drip and given nitropaste. On presentation to the ICU, her blood pressure was below her baseline, and the labetalol drip was stopped, and the nitropaste was removed. She was transitioned to PO meds alone. Her labetalol was increased to 900 mg TID. Nicardipine was increased to 60 mg [**Hospital1 **]. IV hydralazine was used prn. Goal SBP 160-190 with DBP<110. Her pressures remained in range during her stay, and she was discharged on her home medications with instructions to increase her labetalol to 900 TID. # ESRD: Secondary to lupus nephritis. Has been off HD for almost one year. Currently, the plan is for living related donor (mother). The work-up for this is in progress. There are no plans for dialysis while awaiting transplant. Renal consult followed patient throughout hospitalization and assisted with BP control. She was continued on Vitamin D. # Thrombocytopenia: At baseline. # SLE: Continued prednisone. On discharge, she was instructed to decrease her prednisone to 10 mg daily per renal. PCP [**Name9 (PRE) **] should be addressed as an outpatient. # FEN: Repleted lytes prn, renal diet # PPX: Heparin SQ, bowel regimen, PPI # CODE: Full # DISPO: Home with close follow up with renal. Medications on Admission: 1. Clonidine 0.3 mg/24 hour patchy weekly 2. Hydralazine 50 mg TID 3. Labetalol 600 mg TID 4. Nicardipine SR 60 mg daily 5. Lisinopril 40 mg po BID 6. Valsartan 320 mg po daily 7. Prednisone 15 mg po daily 8. Aranesp 40 mcg/0.4 mL syringe as directed every 2 weeks 9. Vitamin D2 50,000 unit capsule by mouth, one tablet per week x 5 weeks, then one tablet per month x 5 months 10. Lorazepam po q4 - q6 hours prn (rarely uses) 11. Hydrocortisone 2.5% ointment to affected areas (not currently using) 12. Tacrolimus 0.1% ointment to affected areas (not currently using) Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWEEK (). 2. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 3. Nicardipine 60 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. 4. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Valsartan 320 mg Tablet Sig: One (1) Tablet PO once a day. 6. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*2* 7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO monthly (). 9. Aranesp (Polysorbate) 40 mcg/0.4 mL Syringe Sig: One (1) injection Injection every 2 weeks: as directed by your doctor. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. Hypertensive urgency Secondary Diagnosis: 1. End Stage Renal Disease 2. Thrombocytopenia 3. Lupus Discharge Condition: Stable. Ambulating. Tolerating po's. Afebrile. Discharge Instructions: You were admitted for hypertension urgency. You were treated with IV medications and then transitioned to medications by mouth. You were seen by the kidney doctors who helped [**Name5 (PTitle) **] manage your hypertension. Your blood pressure is now under control. It is very important that you take your medications as prescribed. . The following changes have been made to your medications: 1. Please decrease your prednisone dose to 10 mg daily. 2. Please increase labetalol 900 mg three times a day. . Please keep all your medical appointments. . If you have any of the following symptoms, please contact your physician or go to the nearest ER: fever>101, chest pain, shortness of breath, acute change of vision, abdominal pain, persistent nausea and vomiting, or any other concerning symptoms. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2141-4-5**] 8:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2141-4-10**] 1:00 Provider: [**Name Initial (NameIs) 11595**] (RHEUM LMOB) [**Doctor Last Name 11596**] Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2141-4-10**] 3:30 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**] Completed by:[**2141-3-28**]

[ "287.5", "V45.69", "284.1", "582.81", "585.6", "425.4", "V45.89", "710.0", "285.9", "401.0", "V45.1" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7570, 7576

4575, 6127

323, 330

7741, 7793

4040, 4040

8642, 9244

3257, 3367

6745, 7547

7597, 7597

6153, 6722

7817, 8619

2808, 2926

3382, 4021

262, 285

358, 1489

7662, 7720

4056, 4552

7616, 7641

1511, 2785

2942, 3241

50,259

193,153

51274

Discharge summary

report

Admission Date: [**2182-12-13**] Discharge Date: [**2182-12-17**] Date of Birth: [**2108-3-21**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2182-12-13**] Aortic valve replacement (21 mm Pericardial) History of Present Illness: 74 year old female with history of hypertension, aortic valve stenosis secondary to biscuspid aortic valve who has been followed with echocardiograms over last 1-2 years. Recently she has noticed some dyspnea on exertion when going up hills. Her most recent echocardiogram showed worsening aortic stenosis. Past Medical History: Aortic Stenosis Bicuspid Aortic Valve Hypertension Asthma Retinal detachment Retinal vein occlusion Actinic Keratosis Neuropathy Sciatica Vertigo Fracture-Thoracic compression-T12 Osteoporosis Hypothyroidism, Thyroid Mass Diverticulosis Cataracts Lipoma Lumbar spinal stenosis Sacroiliac join pain Hip bursitis s/p Hysterectmoy s/p Tonsillectomy Social History: Lives with: Husband Occupation: Professor Tobacco: Denies ETOH: 1 glass wine/day Family History: Brother and GF with BAV, no premature CAD Physical Exam: General: no acute distress Skin: Warm[X] Dry [X] intact [X] HEENT: NCAT[X] PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur 4/6 SEM Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema none Varicosities: None [X] Neuro: Grossly intact Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: - Left: - Pertinent Results: [**2182-12-17**] 04:53AM BLOOD Hct-27.7* [**2182-12-16**] 04:10AM BLOOD WBC-6.6 RBC-3.16* Hgb-9.5* Hct-27.3* MCV-86 MCH-30.1 MCHC-34.8 RDW-14.3 Plt Ct-110* [**2182-12-17**] 04:53AM BLOOD Na-135 K-4.2 Cl-104 [**2182-12-16**] 04:10AM BLOOD Glucose-94 UreaN-15 Creat-0.6 Na-133 K-4.5 Cl-99 HCO3-27 AnGap-12 Intra-op TEE [**2182-12-13**] PREBYPASS 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 ascending aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Physiologic mitral regurgitation is seen (within normal limits). POSTBYPASS LV systolic function is hyperdynamic. There is a well seated, well functioning bioprosthesis in the aortic position. No aortic insufficiency is visualized. The remaining study is unchanged from prebypass. Brief Hospital Course: Admitted same day surgery and underwent aortic valve replacement, see operative report for further details. She received cefazolin for perioperative antibiotics and was taken to the intensive care unit for post operative management. In the first twenty four hours she was weaned from sedation, awoke neurologically intact, and was extubated without complications. She continued to progress and was started on betablockers. She continued to progress. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 4 the patient was ambulating, but deconditioned, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to [**Hospital3 2558**] Rehab in good condition with appropriate follow up instructions. Medications on Admission: montelukast 10 mg DAILY Fosamax 70 mg every other week. lisinopril-hydrochlorothiazide 20-25 mg once a day fluticasone-salmeterol 500-50 Disk One Puff [**Hospital1 **] levothyroxine 50 mcg DAILY simvastatin 20 mg DAILY Calcium 1,250 Tablet twice a day. multivitamin once a day. Lidoderm 5 % Patch once a day as needed for pain. albuterol sulfate Inhaler 2 Puffs every six (6) hours as needed for shortness of breath or wheezing. Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week. Disp:*5 Tablet(s)* Refills:*0* 5. Advair Diskus 500-50 mcg/dose Disk with Device Sig: One (1) Inhalation twice a day. Disp:*qs qs* Refills:*0* 6. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 8. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 2 weeks. Disp:*90 Tablet(s)* Refills:*0* 9. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q6H (every 6 hours). Disp:*qs * Refills:*2* 11. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2* 12. hydrocodone-acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: LIMIT 4GRAMS APAP PER DAY. Disp:*60 Tablet(s)* Refills:*0* 13. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 14. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Aortic Stenosis s/p AVR Hypertension Asthma Retinal detachment Retinal vein occlusion Actinic Keratosis Neuropathy Sciatica Vertigo Fracture-Thoracic compression-T12 Osteoporosis Hypothyroidism Diverticulosis Lumbar spinal stenosis Sacroiliac join pain Hip bursitis Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Edema trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [**Last Name (STitle) 914**] Tuesday, [**2183-1-7**] 1:45pm Please call to schedule appointments with your Cardiologist: Dr. [**First Name (STitle) **] in 4 weeks Primary Care Dr. [**Last Name (STitle) 38584**],[**First Name3 (LF) **] P. [**Telephone/Fax (1) 3530**] in [**4-15**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2182-12-17**]

[ "724.02", "413.9", "244.9", "493.90", "366.9", "429.3", "733.00", "427.89", "401.9", "355.9", "746.4", "424.1" ]

icd9cm

[ [ [] ] ]

[ "35.21", "39.61" ]

icd9pcs

[ [ [] ] ]

6229, 6299

3159, 4052

343, 407

6609, 6770

1871, 3136

7694, 8238

1229, 1273

4532, 6206

6320, 6588

4078, 4509

6794, 7671

1288, 1852

283, 305

435, 744

766, 1114

1130, 1213

27,674

182,563

30301

Discharge summary

report

Admission Date: [**2167-6-17**] Discharge Date: [**2167-6-30**] Date of Birth: [**2092-5-2**] Sex: F Service: ORTHOPAEDICS Allergies: Sulfa (Sulfonamides) / Penicillins Attending:[**First Name3 (LF) 11415**] Chief Complaint: Right hip hardware failure Major Surgical or Invasive Procedure: [**2167-6-18**]: Removal of hardware right hip and total right hip replacement History of Present Illness: Ms. [**Known lastname **] is a 75 year old female who suffered a right hip fracture in [**2167-1-22**]. Unfortunately she went on to fail surgical fixation and now presents for a right total hip replacement. Past Medical History: -Diabetes -Hypertension -hyperlipidemia -hiatal hernia -cholecystectomy -hysterectomy secondary to endometriosis and menorrhagia -Chronic renal insufficiency -Degenerative joint disease in knees -anemia Social History: Lives at home. Denies alcohol, denies smoking and drug use. Family History: Non-contributory. Physical Exam: Upon admission Alert and oriented Cardiac: Regular rate rhythm Chest: Lungs clear bilaterally Abdomen: Soft non-tender non-distended, obease Extremities: RLE + sensation/movment, + pulses, pain with ROM Pertinent Results: [**2167-6-30**] 07:00AM BLOOD WBC-12.1* RBC-3.03* Hgb-8.7* Hct-27.7* MCV-91 MCH-28.9 MCHC-31.6 RDW-17.3* Plt Ct-269 [**2167-6-29**] 02:46AM BLOOD WBC-13.5* RBC-2.88* Hgb-8.4* Hct-25.9* MCV-90 MCH-29.2 MCHC-32.4 RDW-17.1* Plt Ct-246 [**2167-6-28**] 03:22AM BLOOD WBC-14.1* RBC-2.89* Hgb-8.4* Hct-25.8* MCV-90 MCH-29.3 MCHC-32.7 RDW-16.9* Plt Ct-215 [**2167-6-17**] 06:15PM BLOOD WBC-7.3 RBC-3.70* Hgb-10.6* Hct-32.2* MCV-87 MCH-28.7 MCHC-33.1 RDW-17.7* Plt Ct-161 [**2167-6-23**] 04:01AM BLOOD PT-13.4* PTT-32.9 INR(PT)-1.2* [**2167-6-30**] 07:00AM BLOOD Glucose-112* UreaN-98* Creat-1.6* Na-146* K-3.9 Cl-107 HCO3-28 AnGap-15 [**2167-6-29**] 02:46AM BLOOD Glucose-181* UreaN-88* Creat-1.6* Na-147* K-4.1 Cl-109* HCO3-28 AnGap-14 [**2167-6-28**] 03:22AM BLOOD Glucose-88 UreaN-75* Creat-1.5* Na-147* K-4.0 Cl-109* HCO3-28 AnGap-14 [**2167-6-27**] 02:42AM BLOOD Glucose-133* UreaN-75* Creat-1.5* Na-145 K-3.3 Cl-106 HCO3-27 AnGap-15 [**2167-6-26**] 04:58PM BLOOD Glucose-126* UreaN-74* Creat-1.5* Na-147* K-3.6 Cl-108 HCO3-29 AnGap-14 [**2167-6-26**] 12:00AM BLOOD Glucose-80 UreaN-76* Creat-1.6* Na-149* K-4.1 Cl-111* HCO3-27 AnGap-15 [**2167-6-25**] 06:00PM BLOOD Glucose-86 UreaN-73* Creat-1.6* Na-146* K-3.9 Cl-111* HCO3-27 AnGap-12 [**2167-6-25**] 02:59AM BLOOD Glucose-74 UreaN-72* Creat-1.7* Na-146* K-4.0 Cl-111* HCO3-27 AnGap-12 [**2167-6-24**] 02:17AM BLOOD Glucose-232* UreaN-64* Creat-1.9* Na-145 K-3.5 Cl-108 HCO3-27 AnGap-14 [**2167-6-23**] 01:16PM BLOOD Glucose-153* UreaN-59* Creat-2.1* Na-142 K-4.0 Cl-105 HCO3-25 AnGap-16 [**2167-6-23**] 04:01AM BLOOD Glucose-150* UreaN-62* Creat-2.3* Na-141 K-4.3 Cl-104 HCO3-22 AnGap-19 [**2167-6-22**] 03:23PM BLOOD Glucose-163* UreaN-61* Creat-2.5* Na-136 K-4.6 Cl-102 HCO3-21* AnGap-18 [**2167-6-22**] 03:03AM BLOOD Glucose-131* UreaN-56* Creat-2.8* Na-135 K-5.5* Cl-102 HCO3-22 AnGap-17 [**2167-6-21**] 06:25PM BLOOD Glucose-120* UreaN-56* Creat-2.9* Na-134 K-6.2* Cl-102 HCO3-21* AnGap-17 [**2167-6-21**] 01:23PM BLOOD Glucose-114* UreaN-57* Creat-2.7* Na-134 K-5.8* Cl-101 HCO3-21* AnGap-18 [**2167-6-21**] 02:41AM BLOOD Glucose-172* UreaN-55* Creat-2.9* Na-133 K-5.8* Cl-101 HCO3-21* AnGap-17 [**2167-6-18**] 02:46PM BLOOD Glucose-159* UreaN-41* Creat-1.4* Na-142 K-4.9 Cl-108 HCO3-29 AnGap-10 [**2167-6-17**] 06:15PM BLOOD Glucose-85 UreaN-37* Creat-1.3* Na-143 K-5.0 Cl-107 HCO3-24 AnGap-17 [**2167-6-29**] 02:46AM BLOOD Calcium-8.3* Phos-4.6* Mg-2.6 [**2167-6-28**] 03:22AM BLOOD Calcium-8.3* Phos-3.6 Mg-2.3 [**2167-6-27**] 02:42AM BLOOD Calcium-7.9* Phos-3.7 Mg-2.2 [**2167-6-21**] 02:41AM BLOOD TSH-4.4* Brief Hospital Course: Ms. [**Known lastname **] presented to the [**Hospital1 18**] on [**2167-6-17**] via direct admission from home. She had an x-ray at home which showed right hip hardware failure. She was seen by medicine and prepped for surgery. On [**2167-6-18**] she was taken to the operating room. She tolerated the procedure well and was transferred to the recovery room. In the recovery room she was extubated, but unfortunately she needed to be reintubated due to respiratory failure. She was then transferred to the intensive care unit, intubated, for further care and monitoring. During her stay in the intensive care unit she was transfused with packed red blood cells due to post operative anemia. She was also started on a lasix drip to help with diuresis. Renal was consulted for acute on chronic renal failure. On [**2167-6-23**] she underwent a broncospy for her left lower lobe pneumonia. On [**2167-6-27**] she was extubated. She tolerated the extubation well. On [**2167-6-29**] she was transferred to the floor for further care. She was seen by physical therapy to improve her strength and mobility. The rest of her hospital stay was uneventful with her lab data and vital signs within normal limits and her pain controlled. She is being discharged today in stable condition. Medications on Admission: Iron Protonix Lasix Foltx-Pryridox Insulin Leopoxrin Lipitor Lisinopril Discharge Medications: 1. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pyridoxine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever, pain. 6. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) 30mg syringe Subcutaneous Q12H (every 12 hours) for 4 weeks: To total 4 weeks after surgery. 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed). 8. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Zolpidem 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer treatment Inhalation Q6H (every 6 hours) as needed. 13. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) nebulizer treatment Inhalation Q6H (every 6 hours) as needed. 14. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a day) as needed. 15. Bisacodyl 10 mg Suppository Sig: One (1) Rectal HS (at bedtime) as needed. 16. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 17. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Discharge Disposition: Extended Care Facility: Liberty Commons Nursing & Rehab Center - [**Location (un) 4979**] Discharge Diagnosis: Failed right hip ORIF Right total hip replacement Post operative anemia Respiratory failure Left lower lobe pneumonia Acute on Chronic Renal Insufficiency Discharge Condition: Stable Discharge Instructions: Continue to be partial weight bearing on your right leg Continue with universal hip precautions Continue your lovenox injections for a total 4 wks after surgery You may resume 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: Partial weight bearing Left lower extremity: Full weight bearing Anterior and posterior hip precautions Treatment Frequency: You may apply a dry sterile daily or as needed for comfort or drainage Followup Instructions: Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2167-7-14**] 1:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2167-7-14**] 1:20 Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 16232**] within the next 2 weeks, her phone number is [**Telephone/Fax (1) 72138**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**] Completed by:[**2167-7-2**]

[ "403.90", "585.3", "780.57", "997.5", "278.00", "518.5", "486", "996.47", "272.4", "482.41", "401.9", "788.5", "250.00" ]

icd9cm

[ [ [] ] ]

[ "96.56", "99.04", "96.72", "00.33", "38.93", "96.04", "33.22", "78.65", "81.51", "96.6" ]

icd9pcs

[ [ [] ] ]

6723, 6815

3822, 5117

326, 407

7013, 7021

1229, 3799

7743, 8357

967, 986

5240, 6700

6836, 6992

5143, 5217

7045, 7443

1001, 1210

7461, 7627

260, 288

435, 645

7648, 7720

667, 872

888, 951

27,210

153,466

27983

Discharge summary

report

Admission Date: [**2167-11-29**] Discharge Date: [**2167-11-30**] Date of Birth: [**2142-10-11**] Sex: F Service: MEDICINE Allergies: Haldol / Oxycodone / Demerol / MS Contin / Penicillins / Fentanyl / Bactrim / Tamiflu / Keflex Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Nausea, vomiting, and abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: 25 yo female with type 1 diabetes, complicated by gastroparesis, with frequent rehospitalizations for abdominal pain and nausea, who presents with nausea, vomiting, and abdominal pain. Similar to prior hospitalizations. Slight dysuria. She is on narcotic contract and has [**Last Name (NamePattern4) 18297**] assigned by state. . In the ED, initial vitals were: 98.2, 133/87, HR 120, RR 18, Sat 100% always asked for IV compazine but was not vomiting. Received total of 30 mg compazine in addition to benadryl 25 iv x1, Refused insulin initially, got security to bring her back. glucose 70s on initial chem, but stat glucose was 395. got 10units humalog but no significant change. She was started on insulin gtt. K aimed to be repleted but she declined. Received IV fluids 2L. Recieved also diazepam 10x1, ativan 2mg, haldol 10 IM and diluadid 2 mg. Vitals on transfer were HR 114, BP 134/78, RR 18, Sat 100% RA. She refused CXR. UA not suggestive of UTI. . On the floor, was sleeping comfortably. Upon awakening, stated she has pancreatitis and is in severe pain. Asked for pain medication and "something to make me sleep". Past Medical History: (per OMR, confirmed key components of medical history with patient) 1. Diabetes, type I 2. Gastroparesis with chronic g-j tube, though most recent gastric emptying study in [**4-17**] was normal 3. Chronic abdominal pain presumed to be chronic pancreatitis - narcotics contract with PCP (recieves weekly prescription on Tuesdays) - pancreatic divisim (fibrosis and calcification in the pancreas as well as 2 completely separate pancreatic ducts on ERCP) - ampullary stenosis s/p stenting 4. Depression & Borderline personality disorder - history of cutting behavior and suicide attempts 5. Asthma 6. History of urinary retention, chronic with episodes of worsening. Has seen by Dr. [**Last Name (STitle) 770**] in urology in past, not within past year. 7. PUD secondary to H. pylori 8. gastritis 9. iron deficiency anemia 10. right adnexal cyst 11. S/p Cholecystectomy Social History: Born in the [**Country 13622**] Republic. She was sent to the US at age 11-12 years due to onset of medical problems (i.e. diabetes). Most recently lives in [**Location 686**] with roommates. She has a twin sister who is married with a baby. [**Name (NI) **] smokes cigarettes intermittently. She denies ETOH, recreational drug use. She works at an electronics store in [**Location (un) 538**] as a technician. She has a very complicated psychosocial history. [**Location (un) **]: [**Name (NI) 919**] [**Last Name (NamePattern1) **], [**Name (NI) **]. (O: [**Telephone/Fax (1) 68112**]. C: [**Telephone/Fax (1) 66842**]). Family History: Grandmother, uncle and mother with DM. Uncles with chronic pancreatitis. Physical Exam: On Admission: Vitals: 114, BP 134/78, RR 18, Sat 100% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: On Admission: [**2167-11-29**] 08:20PM BLOOD WBC-14.8* RBC-4.47 Hgb-14.7 Hct-41.2 MCV-92 MCH-32.9* MCHC-35.8* RDW-12.2 Plt Ct-335 [**2167-11-29**] 08:20PM BLOOD Neuts-75.2* Lymphs-20.9 Monos-2.1 Eos-1.7 Baso-0.2 [**2167-11-30**] 03:02AM BLOOD PT-13.6* PTT-23.4 INR(PT)-1.2* [**2167-11-29**] 11:00PM BLOOD Glucose-388* UreaN-15 Creat-0.8 Na-139 K-3.0* Cl-101 HCO3-18* AnGap-23* [**2167-11-30**] 03:02AM BLOOD ALT-36 AST-15 AlkPhos-148* TotBili-0.4 [**2167-11-30**] 07:35AM BLOOD Calcium-9.2 Phos-2.9 Mg-1.4* Brief Hospital Course: Ms [**Known lastname **] is a 25 year-old female with type 1 diabetes who presented [**2167-11-29**] with DKA. Left AMA. # Diabetic Ketoacidosis: The patient has a h/o DMI and multiple admissions for DKA. On this admission, the patient arrived complaining of abdominal pain and N/V. In the ED, her initial VS were stable. She received 30 mg of compazine and benadryl 25mg IV. Initial glucose was in the 70s; however repeat was >300. AG was 23. The patient refused insulin initially but eventually accepted a drip. Received IV fluids (2L), diazepam 10mg, ativan 2mg, haldol 10mg IM and diluadid 2mg. She refused a CXR or urinalysis. Transferred to the MICU where the patient repeatedly requested IV medications for pain control. Refused further insulin and asked to leave AMA. The patient's AG had closed by this time. She stated that she would check her own glucose levels and self-administer insulin. She demonstrated that she was capable of doing this. Given 15 units of longer acting insulin and allowed to leave AMA as it was felt physical restraint would be more harmful to the patient. Medications on Admission: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for SOB/wheezing. 2. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Inhalation every four (4) hours as needed for wheezing. 4. diazepam 10 mg Tablet Sig: One (1) Tablet PO three times a day. 5. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Inhalation twice a day. 6. gabapentin 250 mg/5 mL Solution Sig: Ten (10) cc PO at bedtime. 7. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO q3h as needed for pain. 8. ibuprofen 100 mg/5 mL Suspension Sig: Thirty (30) ml PO every six (6) hours as needed for pain. 9. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Seventy (70) units Subcutaneous at bedtime. 10. insulin lispro 100 unit/mL Solution Sig: One (1) Subcutaneous three times a day: s directed SQ three times a day. As directed by [**Last Name (un) **]. 11. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: One (1) Inhalation every six (6) hours. 12. lactulose 10 gram/15 mL Solution Sig: Forty Five (45) ml ml PO three times a day as needed for constipation: three times a day as needed for constipation 1 QUART please. 13. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day: 1 tsp swish and spit prn mouth sores. 14. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 15. mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO at bedtime. 16. zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 17. nebulizers Kit Sig: One (1) Miscellaneous every [**5-13**] hours: one nebulizer machine with accessories for nebulized asthma treatments to be used by patient every 4-6 hours as needed for severe wheezing, shortness of breath 18. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 19. polyethylene glycol 3350 Powder Sig: One (1) packet Miscellaneous once a day as needed for constipation: gram/dose Powder - 1 packet(s) by mouth daily as needed for constipation not treated with senna or docusate. 20. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours. 21. trazodone 100 mg Tablet Sig: Two (2) Tablet PO at bedtime as needed for insomnia. 22. diphenhydramine HCl 12.5 mg/5 mL Liquid Sig: Forty (40) cc PO at bedtime as needed for insomnia. 23. zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. Discharge Medications: Left AMA Discharge Disposition: Home Facility: Left AMA Discharge Diagnosis: Left AMA Discharge Condition: Left AMA Discharge Instructions: Left AMA Followup Instructions: Left AMA [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2167-12-1**]

[ "311", "493.90", "536.3", "250.13", "V58.67", "577.1", "305.1", "250.63" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8020, 8046

4283, 5380

402, 408

8098, 8108

3751, 3751

8165, 8340

3119, 3194

7987, 7997

8067, 8077

5406, 7964

8132, 8142

3209, 3209

326, 364

436, 1566

3765, 4260

1588, 2458

2474, 3103

13,305

126,212

14239

Discharge summary

report

Admission Date: [**2179-7-5**] Discharge Date: [**2179-7-7**] Date of Birth: [**2123-3-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 943**] Chief Complaint: hematemesis Major Surgical or Invasive Procedure: Esophagoduodenoscopy History of Present Illness: 56M with EtOH cirrhosis s/p TIPS who was admitted for hematemesis to MICU for 24 hours and then to the floor. Pt presented with hematemesis on [**7-5**]. Pt was hemodynamically stable with hct of 36.4 from 39.5 (checked on [**6-29**]) and was admitted to MICU. Liver was notified and performed an EGD in am which showed 3 cords of grade I - II varices and esophageal erosions without evidence of bleeding . They recommended high dose PPI and carafate. Pt had no further episodes of hematemasis and was started on diet. Pt's subsequently had a decrease in hct to 29.9 at 4 pm and then 29.8 at 8 pm and 27 at 1 am on [**7-6**]. Pt also underwent liver u/s with dopplers which showed that the TIPS remained patent. . Pt currently denies dizziness, cp, sob, abd pain, nausea, vomiting. Current vs in micu before transfer were 98.6, 93 110/61 17 98% RA. Past Medical History: 1. Alcoholic cirrhosis - hx of esophageal variceal bleed and hepatic encephalopathy. He has had 2 TIPS procedures with stent placement in [**2166**] and again in [**2176**]. 2. Chronic pancreatitis complicated by a parapancreatic cyst that was infected with enteroccocus and coagulase negative. On vancomycin from [**Date range (2) 42329**] then linezolid [**Date range (1) 42330**]. 3. Type 2 DM on insulin 4. Anemia of chronic disease 5. Thrombocytopenia 6. Depression 7. Umbilical Hernia 8. History of delerium tremens Social History: He lives alone. He is currently unemployed.Has three children. He has a history of heavy alcohol use but none since [**4-14**]. Smokes 1.5 PPD. No IVDU, no other illicits. Family History: father - cirrhosis Physical Exam: PE: T 98.6 HR 93 BP 110/61 RR 17 O2 sat 98% RA Gen: awake, alert, NAD HEENT: NCAT, scleral icterus, PERRL, EOMI, OP clear, MMM CV: RRR, no m/r/g Pulm: diffuse wheezing Abd: soft, NT, ND Ext: no c/c/e no asterixis Pertinent Results: Liver US: FINDINGS: [**Doctor Last Name **]-scale and color Doppler son[**Name (NI) 493**] images were obtained, liver is markedly coarsened and echogenic, consistent with known history of cirrhosis. There is a failed TIPS stent in the right lobe of the liver without internal flow. Adjacent to it, there is an active TIPS with wall-to- wall flow and velocities in the proximal, mid and distal TIPS measured at 22, 30, and 66 cm/sec respectively, compared to 42, 74, and 90 cm/sec previously. Hepatopetal flow is noted in the main portal vein, with velocity of approximately 23 cm/sec, compared to 29 cm/sec previously. Again noted is a cholelithiasis, without evidence of acute cholecystitis. There is no perihepatic ascites. There is no intra- or extra-hepatic biliary ductal dilatation. Common duct measures 4 mm. IMPRESSION: Patent TIPS with wall-to-wall flow; internal velocities are slightly lower than on the prior study. . [**2179-7-7**] 05:55AM BLOOD WBC-8.0 RBC-2.58* Hgb-9.7* Hct-27.9* MCV-108* MCH-37.5* MCHC-34.7 RDW-14.5 Plt Ct-80* [**2179-7-6**] 01:16AM BLOOD WBC-6.9 RBC-2.48*# Hgb-9.4* Hct-27.3* MCV-110* MCH-38.0* MCHC-34.5 RDW-14.9 Plt Ct-76* [**2179-7-5**] 06:22AM BLOOD WBC-8.3 RBC-3.32* Hgb-12.2* Hct-36.4* MCV-110* MCH-36.6* MCHC-33.4 RDW-14.7 Plt Ct-109* [**2179-7-5**] 06:22AM BLOOD PT-15.5* PTT-33.8 INR(PT)-1.4* [**2179-7-7**] 05:55AM BLOOD PT-15.5* PTT-30.7 INR(PT)-1.4* [**2179-7-5**] 06:22AM BLOOD Glucose-430* UreaN-13 Creat-1.0 Na-127* K-3.7 Cl-90* HCO3-22 AnGap-19 [**2179-7-6**] 01:16AM BLOOD Glucose-346* UreaN-12 Creat-0.9 Na-129* K-3.9 Cl-97 HCO3-25 AnGap-11 [**2179-7-6**] 05:15AM BLOOD Glucose-394* UreaN-11 Creat-0.9 Na-128* K-4.1 Cl-96 HCO3-24 AnGap-12 [**2179-7-7**] 05:55AM BLOOD Glucose-237* UreaN-10 Creat-0.7 Na-130* K-3.2* Cl-96 HCO3-25 AnGap-12 [**2179-7-6**] 05:15AM BLOOD ALT-44* AST-82* LD(LDH)-275* AlkPhos-265* TotBili-6.4* [**2179-7-7**] 05:55AM BLOOD Calcium-8.5 Phos-1.8* Mg-1.7 Brief Hospital Course: A/P: 56M with EtOH cirrhosis s/p TIPS presents for hematemesis . #. Hematemesis: s/p EGD showing nonbleeding esophageal varices and esophageal erosions/esophagitis. There was no clear ulcer visualized. It was felt his bleeding were due to GE junction erosions and microtears. No overt M-W tears were visualized. His hematocrit did drop initially which may have been dilutional but there after remained stable. Patient should continue on PPI and sucrafate. He will follow up in liver clinic. . #. DM2: - patient was continued on his home dose of lantus with a sliding scale. . #. Cirrhosis: TIPS patent on ultrasound. His aldactone, lasix were restarted on [**7-6**] with stable renal function. Patient was continued on rifaxamin, lactulose. He was continued CTX for SBP ppx for 3 days but due to true variceal bleeding his antibiotics were discontinued. Patient should continue on mvi, folic acid. . #. Full code Medications on Admission: Meds: at home folic acid 1 mg per day, Furosemide 40 mg per day, glargine insulin 36 units at night SSI lactulose 30 cc three to four times per day, Protonix one tablet per day (40 mg), Lyrica 100 mg twice a day, rifaximin 200 mg two tablets three times a day, Aldactone 150 mg per day multivitamin one tablet daily. . Meds on transfer to [**Hospital1 18**]: Aluminum-magnesium hydrox-simethicone 15-30cc po qid/prn Ceftriaxone 1gm iv q24h folic acid 1mg po qday gabapentin 600mg po q8h insulin SS lactulose 30mg po tid lyrica 100mg po bid morphin sulfate 1mg iv q4h/prn pantoprazole 40mg po q24 prochlorperazine 10mg po/iv q6h/prn rifaximin 200mg po tid sucralfate 1mg po qid Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Insulin Glargine 100 unit/mL Cartridge Sig: Thirty Four (34) units Subcutaneous at bedtime. 4. Insulin Lispro 100 unit/mL Cartridge Sig: per sliding scale Subcutaneous four times a day: inject subcutaenously four times a day according to sliding scale. 5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO three to four times a day. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 7. Pregabalin 25 mg Capsule Sig: Four (4) Capsule PO BID (2 times a day). 8. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. Aldactone 50 mg Tablet Sig: Two (2) Tablet PO once a day. 10. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 11. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Hematemesis Secondary: Alcoholic cirrhosis Chronic pancreatitis Type 2 DM Anemia of chronic disease Thrombocytopenia Depression Discharge Condition: Vitals stable. Hematocrit stable. No bleeding. Discharge Instructions: You were admitted after vomiting up a small amount of blood. You had an EGD which showed that you have esophageal varices and ulceration of your esophagus, but no active bleeding. You should continue to take all medications as prescribed. If you develop further bleeding, chest pain, shortness of breath, or other concerning symptoms, you should return to the emergency room. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2179-8-4**] 10:00 Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER - NON BILLING Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2179-7-8**] 8:30 Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2179-9-15**] 8:00 Completed by:[**2179-7-9**]

[ "285.9", "287.5", "250.00", "571.2", "577.1", "578.0" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

6842, 6848

4206, 5132

323, 346

7030, 7079

2245, 4183

7505, 7999

1976, 1996

5860, 6819

6869, 7009

5158, 5837

7103, 7482

2011, 2226

272, 285

374, 1224

1246, 1770

1786, 1960

63,290

182,051

5413

Discharge summary

report

Admission Date: [**2198-6-20**] Discharge Date: [**2198-6-29**] Date of Birth: [**2138-11-8**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3021**] Chief Complaint: Acute renal failure. Major Surgical or Invasive Procedure: [**2198-6-28**] Tunnelled dialysis catheter placement. History of Present Illness: PCP: [**Name Initial (NameIs) 7274**]: [**Last Name (LF) **], [**First Name7 (NamePattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Hospital3 249**] [**Hospital1 **]/EAST Address: [**Location (un) **], E/CC-6, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 250**] Fax: [**Telephone/Fax (1) 3382**] Email: [**University/College 21961**] . Primary oncologist Name: [**Last Name (LF) **], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD Location: [**Hospital1 18**]-DIVISION OF HEMATOLOGY/ONCOLOGY Address: [**Location (un) **] E/KS-121, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3237**] Fax: [**Telephone/Fax (1) 21962**] Email: [**University/College 21963**] . Date seen [**2198-6-20**] Time [**2203**] 59 y/o M with PMHx of AFib, PE and Diffuse Large B Cell Lymphoma who was recently admitted with acute on chronic renal failure and was seen in renal clinic on [**6-19**] where he was found to have an acute rise in creatinine. Pt represented to [**Hospital 3242**] clinic and was given 2L IVF without significant improvement in creatinine. Pt did have 500cc of urine output and received a single unit of prbcs for hct of 21. Dr. [**Last Name (STitle) **] (primary nephrology) recommended admission for further work up of acute renal failure and possible renal biopsy. . In nephrology clinc yesterday urinalysis demonstrated : specific gravity of 1.020. Urine was positive for [**2-8**]+ protein (more than last time). Microscopy showed a fragment of granular cast and possibly a white cell cast . RECENT CHEMOTHERAPY ADMINISTRATION and CREATININE MONITORING He received Velcade/Doxil C1D1 on [**2198-6-1**]: velcade x 3 days and doxil x 1 day. He then received zofran 8mg IV, Decadron 20mg IV on [**2198-6-8**]. Pt then received the Velcade 2.6mg as an IVP over 3-5sec. His velcade was held on [**6-12**] secondary to TCP with PLT = 23. PLTS = 17 and received plt transfusion on [**2198-6-13**]. On [**6-15**] Cr = 1.7 and PLT = 20. He was given 1 U plts and 500 cc IVF. On [**6-18**] Cr = 3.0 and PLTs= 13. Pt received 1U PLTS and was referred to see his neprhologist on [**2198-6-19**]. . He also reports abdominal constriction and pain which resulted in difficulty eating. He felt bloated after eating and experienced early satiety. No emesis or nausea. No focal abdominal pain. His sx improved with defecation. . PAIN SCALE:0/10 ________________________________________________________________ REVIEW OF SYSTEMS: CONSTITUTIONAL: [] All Normal [ -] Fever T with chills was 97.9 and 98.1 [+ ] Chills [ ] Sweats [ ] Fatigue [ ] Malaise [ ]Anorexia [ ]Night sweats [ +] __11___ lbs. weight gain over 2 weeks per clinic sheets . HEENT: [X] All Normal [ ] Blurred vision [ ] Blindness [ ] Photophobia [ ] Decreased acuity [ ] Dry mouth [ ] Bleeding gums [ ] Oral ulcers [ ] Sore throat [ ] Epistaxis [ ] Tinnitus [ ] Decreased hearing [ ]Tinnitus [ ] Other: . RESPIRATORY: [X] All Normal [ ] SOB [ ] DOE [ ] Can't walk 2 flights [ ] Cough [ ] Wheeze [ ] Purulent sputum [ ] Hemoptysis [ ]Pleuritic pain [ ] Other: . CARDIAC: [] All Normal [ -] Angina [ -] Palpitations [ +] Edema intermittently since [**Month (only) 205**] as long as he has been getting the chemotherapy without acute worsening [ ] PND [ ] Orthopnea [ ] Chest Pain [ ] Other: . GI: [] All Normal [ ] Blood in stool [ ] Hematemesis [ ] Odynophagia [ ] Dysphagia: [ ] Solids [ ] Liquids [ ] Anorexia [-] Nausea [] Vomiting [ ] Reflux [ ] Diarrhea [+] Constipation- pebbly [] Abd pain [ ] Other: . GU: [] All Normal [ -] Dysuria [ -] Frequency [ -] Hematuria []Discharge []Menorrhagia . SKIN: [] All Normal [X] Recent rash on trunk now resolved [ ] Pruritus . MS: [] All Normal [+] knee pain x 2 weeks with swelling when he walks 0.5 miles [ ] Jt swelling [ ] Back pain [ ] Bony pain . NEURO: [] All Normal [+] Increased frequency and duration of HA but none now. On the weekend had one all day. It was not severe and he ranks it as [**3-15**] [- ] Visual changes [ ] Sensory change [ -]Confusion [ -]Numbness of extremities- chronic neuropathy from chemotherapy since [**Month (only) 205**] but nothing new [-] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo [ ] Headache . ENDOCRINE: [X] All Normal [ ] Skin changes [ ] Hair changes [ ] Temp subjectivity . HEME/LYMPH: [X] All Normal [ ] Easy bruising [ ] Easy bleeding [ ] Adenopathy . PSYCH: [] All Normal [ ] Mood change []Suicidal Ideation [+] Other: He has occasional periods of depression but with meditation he is able to cope. . [X]all other systems negative except as noted above. Past Medical History: Mr. [**Known lastname **] presented in early [**6-/2197**] with fever, weight loss, and muscle and joint aches. He was diagnosed with PMR and started on prednisone with improvement in his symptoms. During the preceding six months, he reported a history of shoulder, neck and quadriceps pain as well as fatigue, weakness and poor appetite. He reported periodic fevers, drenching night sweats and a 25-pound weight loss also over the same six months. With initiation of his prednisone at 20 mg daily, he noted marked improvement of both his musculoskeletal and constitutional symptoms. He then presented to the emergency room on [**2197-7-17**] with palpitations and dizziness and was found to be in atrial fibrillation. He had a history of PAF in the past. He was febrile to 101.6 with a heart rate of 126. CT scan of the chest, abdomen, and pelvis on [**2197-7-19**] showed multiple low-attenuation lesions within the liver, spleen, and kidneys. On [**2197-7-20**], MRI of the abdomen showed hypovascular masses in both kidneys and spleen of various sizes consistent with lymphoma. A CT-guided biopsy of the spleen on [**2197-7-21**] was nondiagnostic. Mr. [**Known lastname **] [**Last Name (Titles) 1834**] bone marrow aspirate and biopsy on [**2197-7-26**], which showed extensive necrosis with focal involvement by high-grade B-cell lymphoma, diffuse large B-cell type. FISH translocation was notable for c-Myc and Bcl-2 indicating a "double hit" lymphoma characterized by a Burkitt's-like lymphoma. He then began chemotherapy. . TREATMENT HISTORY: -- Initiated treatment with Dose-adjusted [**Hospital1 **] chemotherapy on [**2197-7-29**] with two doses of Rituxan on [**2197-8-2**] and [**2197-8-3**]. Follow up CT imaging on [**2197-8-5**] showed stable lymphomatous lesions in the kidney, spleen, and abdominal nodes. -- Rituxan 500 mg given on [**2197-8-10**] with a fever that evening and admission for neutropenia. During admission, noted for atrial fibrillation with RVR and was started on digoxin at 0.125 mg daily along with metoprolol 200 mg daily. -- Readmitted on [**2197-8-18**] for his second cycle of [**Hospital1 **] chemotherapy, which was delayed for two days due to hypotension and cough. A CT of the chest showed bilateral lower lobe opacities, right greater than left, concerning for infection and he was treated with a course of Levaquin. -- On [**2197-8-30**], received Rituxan at 375 mg/m2. -- Follow up PET scan on [**2197-9-6**] showed no evidence for lymphoma but was notable for multiple peripheral base pulmonary opacities with rims of soft tissue density and relative central lucencies most of which were new. He [**Year (4 digits) 1834**] CT of the chest for further evaluation, which showed multiple filling defects within the segmental and subsegmental branches of the right lower lobe arteries compatible with pulmonary emboli. -- Admitted on [**2197-9-7**] for initiation of anticoagulation with fondaparinux and began third cycle of treatment with [**Hospital1 **] on [**2197-9-8**](dose level 2). -- Received Rituxan 375 mg/m2 on [**2197-9-25**]. -- Admitted on [**2197-9-29**] for fourth cycle of treatment with [**Hospital1 **](dose level 3). -- Received Rituxan 375 mg/m2 on [**2197-10-17**]. -- Admitted on [**2197-10-20**] for fifth cycle of treatment with [**Hospital1 **](dose level 3 with Adriamycin at dose level 2. Received Rituxan on [**2197-11-7**]. -- FDG tumor imaging on [**2197-10-19**] showed no evidence for lymphoma with slight interval decrease in size in bilateral pulmonary infarcts. Focal uptake in the posterior left kidney appears parenchymal, but may be within the collecting system and projecting over the kidney due to misregistration. Focal FDG uptake in the left ischial tuberosity, without corresponding lytic or sclerotic lesion. Bone marrow biopsy showed no evidence for lymphoma and no cytogenetic abnormalities, particularly no c-Myc or Bcl2 translocation. Note was made of hypercellular marrow with maturing trilineage hematopoiesis. -- Admitted on [**2197-11-16**] with sudden onset of a dark cover in the lower half of the visual field in his right eye, which lasted 10-15 minutes, then self-resolved. He was evaluated by Neurology and Ophthalmology. TEE revealed thrombus at the tip of his right atrial catheter, with no PFO. Ophthalmology work up was negative and the episode was attributed to possible TIA. Discharged on [**2197-11-18**] to continue his fondaparinux. -- Admitted on [**2197-11-23**] for high dose Cytoxan for stem cell mobilization. -- Attempted stem cell collections with yield ~ 0.5 CD 34 cels after 4 collections with slow recovery of counts. Collections stopped. -- Repeat PET imaging on [**2197-12-19**] showed new focal mild FDG-avidities in the mediastinal region. Interval worsening of FDG-avidity in the soft tissue immediately medial to the left acetabulum. Persistent FDG-avidity in the left ischial tuberosity, without CT correlate. -- Repeat bone marrow biopsy on [**2197-12-20**] showed no evidence for lymphoma with some dyspoiesis noted. No cytogenetic abnormalities, specifically no evidence for MDS. -- Initiated 4 weeks of Rituxan on [**2197-12-26**]. -- Noted slight increase in LDH to ~ 260. Repeat CT of the torso on [**2198-1-3**] showed left pelvic soft tissue and expansion of the left piriformis muscle corresponding to the regions of FDG avidity for [**2197-12-19**] scan. Small internal mammary and left juxtaclavicular lymph nodes corresponding to foci of FDG avidity. Decreased size of lymphomatous renal lesions compared to [**2197-7-6**] with stable small retroperitoneal lymph nodes. Continued evolution of pulmonary infarcts. No definite bony lesions, though there is slightly lucency in the left acetabulum in a region of FDG avidity. . Other Past Medical History: s/p RLL lobectomy in [**2198-2-6**] secondary to PNA #. PAF diagnosed in [**2180**] with now chronic atrial fibrillation in the past several months. He had no history of treatment with anti-arrhythmia or anticoagulation prior to his admission in [**8-/2197**], currently receiving treatment with metoprolol and digoxin. #. Pulmonary embolism, fondaparinux on hold due to thrombocytopenia #. Polymyalgia rheumatica diagnosed in [**2197**] and managed by Dr. [**Last Name (STitle) **], although further treatment on hold while getting treatment for lymphoma and unclear if his symptoms were related to lymphoma and not PMR. #. Remote history of syphilis, gonorrhea, and genital herpes in [**2160**]. #. Tonsillectomy and adenoidectomy in the [**2137**]. #. Myopia. #. Recent probable TIA with from thrombus on right atrial catheter tip Social History: Pt is married and lives in [**Location **]. Mr. [**Known lastname **] previously worked as a software engineer, but now works without pay from home contributing to open source software projects. They have two adult children, ages 21 and 28, but have minimal contact with them. Mr. [**Known lastname **] is a nonsmoker. He drinks alcohol on occasion. He denies any history of illicit drugs. Family History: Father had an MI in his 70s and his paternal grandfather had an MI in his 40s. His mother is status post aortic valve replacement. His younger brother had probable schizophrenia and died from suicide at age 18. There is no family history of cancer. Physical Exam: ADMISSION PHYSICAL EXAM: VITAL SIGNS: 98.6, 142/70, 74, 20, 100% on RA GLUCOSE: NA PAIN SCORE 0/10 GENERAL: Very pleasant male laying in bed. He is NAD. Nourishment: At risk. Grooming: good Mentation: good, he is a very good historian Eyes:NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted Ears/Nose/Mouth/Throat: MMM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Respiratory: Lungs CTA bilaterally without R/R/W Cardiovascular: RRR, nl. S1S2, no M/R/G noted Gastrointestinal: soft, mildly distended/ND, normoactive bowel sounds, no masses or organomegaly noted. Genitourinary: deferred Skin: no rashes or lesions noted. No pressure ulcer Extremities: [**2-8**] + pitting edema present b/l Lymphatics/Heme/Immun: No cervical lymphadenopathy noted. Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. -cranial nerves: II-XII intact -motor: normal bulk, strength and tone throughout. No abnormal movements noted. Psychiatric: Very thoughtful and contemplative. Appropriate ACCESS: [x]PIV []CVL site ______ FOLEY: []present [x]none TRACH: []present [X]none PEG:[]present [x]none [ ]site C/D/I COLOSTOMY: :[]present [X]none [ ]site C/D/I Pertinent Results: ADMISSION LABS ================ [**2198-6-20**] 10:25AM BLOOD WBC-1.4* RBC-2.33* Hgb-7.0* Hct-21.4* MCV-92 MCH-30.0 MCHC-32.6 RDW-21.1* Plt Ct-21* (Neutrophil ct approx 1000) [**2198-6-20**] 10:25AM BLOOD Neuts-81.7* Lymphs-11.1* Monos-6.4 Eos-0.6 Baso-0.3 [**2198-6-20**] 02:00PM BLOOD UreaN-63* Creat-4.7* Na-140 K-5.5* Cl-110* [**2198-6-20**] 10:25AM BLOOD UreaN-65* Creat-4.7*# Na-139 K-5.5* Cl-106 HCO3-22 AnGap-17 [**2198-6-20**] 10:25AM BLOOD ALT-38 AST-32 LD(LDH)-518* AlkPhos-69 TotBili-0.3 [**2198-6-20**] 10:25AM BLOOD Albumin-3.4* Calcium-8.1* DISCHARGE LABS ================ [**2198-6-29**] 06:00AM BLOOD WBC-3.3* RBC-3.07* Hgb-9.7* Hct-27.2* MCV-89 MCH-31.8 MCHC-35.7* RDW-18.0* Plt Ct-50* [**2198-6-27**] 06:00AM BLOOD Neuts-90* Bands-1 Lymphs-7* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2198-6-25**] 06:14AM BLOOD PT-12.2 PTT-26.8 INR(PT)-1.0 [**2198-6-29**] 06:00AM BLOOD Glucose-114* UreaN-67* Creat-4.0* Na-138 K-4.3 Cl-101 HCO3-26 AnGap-15 [**2198-6-28**] 06:30AM BLOOD Calcium-7.9* Phos-4.0 Mg-1.8 [**2198-6-28**] 06:30AM BLOOD ALT-37 AST-40 LD(LDH)-460* AlkPhos-62 TotBili-0.2 [**2198-6-23**] 06:00AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE [**2198-6-23**] 06:00AM BLOOD HCV Ab-NEGATIVE . [**2198-6-29**] PPD NEGATIVE Brief Hospital Course: A 59 year old man with DLBCL, not responding to primary curative chemotherapy, on palliative chemotherapy with gemcitabine, liposomal doxorubicin (Doxil), and bortezomib (Velcade) is admitted for acute on chronic renal failure and found to have lymphomatous invasion of the kidney. He required hemodialysis and decided after a family meeting for home hospice care while continuing outpatient dialysis. A tunnelled hemodialysis catheter was then placed. Tested for the outpatient dialysis unit prereq, a PPD was negative. . # Acute on Chronic Renal Failure: Patient was admitted from renal clinic after Cr trended up sharply from 1.7 to 4.7 over five days. Creatinine did not trend down after fluid challenge, suspicion for lymphomatous infiltration of the kidney was high. He was admitted to the ICU for renal biopsy (high bleeding risk given thrombocytopenia). Renal biopsy of the left kidney confirmed lymphomatous invasion. Given progressive renal failure, acidosis, hyperkalemia and hyperphosphatemia, a HD catheter was placed and dialysis was initiated. After deciding to continue dialysis indefinitely, a tunnelled catheter was placed. PPD was negative (prereq for outpatient HD). . # Hyperkalemia: Admitted with K 5.5 related to acute renal failure, EKG did not show peaked T waves. He was treated with Kayexylate with K trending down to 5.0. As above, dialysis was initiated. . # Pancytopenia: Related to chemotherapeutic effect and bone marrow involvement by DLBCL. He was transfused to maintain HCT >21 and Platelets >10. . # Diffuse Large B cell Lymphoma: Given "double hit" highgrade lymphoma with translocation of c-myc and Bcl-2, prognosis was grim and he had been on palliative chemotherapy. After the discovery of lymphomatous involvment of the kidneys causing renal failure, he was offered experimental chemotherapy which he declined, preferring to focus on quality of life. . # Afib s/p cardioversion and HTN: Metoprolol had been held during previous admission for bradycardia to the 30s. He was maintained on telemetry and bursts to ventricular rate of 130 were noted. Metoprolol was resumed with improved rate control. Continued amiodarone. Given a recurrence of bradycardia, the metoprolol dose was minimized and furosemide, per Nephrology, was added for uncontrolled hypertension. Not anticoagulated given thrombocytopenia. . # Hx of PE: Diagnosed with PE in [**9-/2197**] and previously anticoagulated with fondaparinux, anticoagulation was stopped prior to admission for thrombocytopenia and not resumed. . # Goals of care: Given poor prognosis and progressive renal failure, he decided to focus goals of care on comfort, and declined experimental chemotherapy. He was discharged home with hospice while continuing outpatient hemodialysis. Medications on Admission: CONFIRMED WITH PATIENT ON ADMISSION ACYCLOVIR 400 mg Tablet - 1 Tablet(s) by mouth every twelve (12) hours ALLOPURINOL 100 mg by mouth DAILY (Daily) AMIODARONE 200 mg by mouth once a day FAMOTIDINE 20 mg Tablet by mouth once a day FILGRASTIM [NEUPOGEN] - 300 mcg/0.5 mL Syringe - 1 Syringe(s) once a day as directed- NOT CURRENTLY TAKING FONDAPARINUX [ARIXTRA] - (On Hold from [**2198-5-9**] to unknown per order of [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] for low platelets) - 7.5 mg/0.6 mL Syringe - 7.5 Syringe(s) once a day LORAZEPAM [ATIVAN] - 0.5 mg Tablet - 1 to 2 Tablet(s) by mouth every eight (8) hours as needed for nausea METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 50 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth once a day- TOPROL RECENTLY D/C'ED AT LAST D/C OXYCODONE - 5 mg Tablet - [**1-7**] Tablet(s) by mouth every four (4) hours as needed for pain PREDNISONE - 10 mg Tablet - 1.5 (One and a half) Tablet(s) by mouth daily for 2 days, then 1(One) Tablet daily. PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 (One) Tablet(s) by mouth every eight (8) hours prn nausea. Can causedrowsiness SULFAMETHOXAZOLE-TRIMETHOPRIM - 800 mg-160 mg Tablet - 1 Tablet(s) by mouth MWF ([**Month/Day (2) 766**]-Wednesday-Friday) Discharge Medications: 1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 2. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 4. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for nausea. 5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. 6. prochlorperazine maleate 5 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for nausea. 7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 9. 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* 10. dexamethasone 4 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 11. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*2* 12. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital **] hospice care of [**Location (un) **] Discharge Diagnosis: 1. Acute kidney failure. 2. Non-hodgkins lymphoma. 3. Pancytopenia (low blood counts). 4. Bradycardia (slow heart rate). 5. Hypertension (high blood pressure). Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for acute kidney failure. Kidney biopsy revealed this was due to lymphoma in the kidney. Because your kidneys are not functioning, you will continue to need dialysis. For this reason, a tunnelled dialysis catheter was inserted. Your next dialysis will be [**Location (un) 766**] [**2198-7-2**] at [**Location (un) **] Dialysis in [**Location (un) **]. Also during your hospitalization, you needed blood and platelet transfusions because all of your blood counts are low. This is probably due to the lymphoma and past chemotherapy. Because your white blood cell count is low, you should call a physician for any symptoms of infection, especially a fever. You should also seek urgent medical attention for any bleeding considering your platelets are low. . MEDICATION CHANGES: 1. Nephrocaps once daily. 2. Toprol XL 25mg daily for blood pressure (decreased from old prescription of 50mg due to slow heart rate). 3. Furosemide (Lasix) 40mg daily diuretic for blood pressure. 4. Dexamethasone (Decadron) 8mg daily. 5. Stop prednisone (replaced by dexamethasone). Followup Instructions: Department: WEST [**Hospital 2002**] CLINIC When: WEDNESDAY [**2198-7-11**] at 3:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], 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 . Department: PFT When: FRIDAY [**2198-7-13**] at 10:00 AM . Department: PULMONARY FUNCTION LAB When: FRIDAY [**2198-7-13**] at 10:00 AM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) [**Location (un) 3971**] Campus: EAST Best Parking: Main Garage

[ "E933.1", "E849.7", "584.9", "311", "564.00", "V12.54", "403.90", "202.88", "V12.51", "725", "284.89", "427.31", "276.7", "428.0", "787.91", "338.3", "585.9" ]

icd9cm

[ [ [] ] ]

[ "38.95", "39.95", "55.23" ]

icd9pcs

[ [ [] ] ]

20504, 20587

15159, 17933

325, 381

20790, 20790

13874, 15136

22063, 22782

12368, 12618

19313, 20481

20608, 20769

17959, 19290

20940, 21735

13534, 13855

12658, 13438

2962, 5277

21755, 22040

265, 287

409, 2943

20805, 20916

11110, 11945

11961, 12352

26,390

118,066

52230

Discharge summary

report

Admission Date: [**2176-6-5**] Discharge Date: [**2176-6-11**] Date of Birth: [**2106-2-28**] Sex: F Service: MED Allergies: Penicillins Attending:[**First Name3 (LF) 330**] Chief Complaint: respiratory failure Major Surgical or Invasive Procedure: Intubated on mechanical ventilation. s/p colectomy with hartmann's pouch at [**Hospital3 **] [**2176-5-27**] History of Present Illness: 70 y/o female transferred from [**Hospital3 4107**] on mechanical ventilation for respiratory failure. Patient presented to [**Hospital1 **] on [**2176-5-22**] with abdominal pain and underwent a sigmoid colectomy with hartmann's pouch on [**5-27**]/o4 for microperforated diverticulitis. On [**2176-5-29**], the patient suffered a NSTEMI and developed respiratory failure secondary to multilobar pneumonia and CHF overlying her severe COPD. In addition to hyercarbic and hypoxemic respiratory failure requiring intubation, the patient had fevers unresponsive to gentamycin, flagyl, vancomycin, aztreonam and linezolid. One blood culture of 4 was postive for MRSA from [**2176-5-29**] at [**Hospital3 4107**]. Subsequent blood, urine, and sputum cultures at [**Hospital3 4107**] were negative. Past Medical History: 1. Obesity 2. COPD on chronic prednisone and home oxygen 3. CAD h/o NSTEMI and h/o positive ETT 4. HTN 5. CHF EF<45% 6. h/o diverticulitis 7. Raynaud's 8. h/o nosocomial pneumonia on mechanical ventilation 9. hypothyroidism 10 hyperglycemia Social History: 100+ pack years tobacco abuse on oxygen supplementation at home and daily prednisone for severe COPD. No alcohol or IV drug abuse. The patient was widowed and lived alone. She had seven children. Family History: Non-contributory Physical Exam: [**2176-6-11**] at 0700 Tm 97.9 T95.8 HR70 BP153/56 I/O [**2180**]/2325 PS 5 FiO20.6 TV615 R13 Ve7.8 PEEP8 95%02 RSBI26.7 7.41/43/81 Gen-obese, sedated in NAD HEENT-NCAT, PERRL, MMMI, +scleral icterus NECK-thick, supple, no JVD PULM-CTAB, no crackles/rhonchi/wheezes CV-RRR, S1S2, no M/R/G, pulses 1+ throughout ABD-obese, soft, non-distended, no masses WOUND-laparotomy +steristrips without drainage top [**12-9**]. Bottom [**12-9**] of wound dehissced and packed with clean dressings without blood or pus. OSTOMY-pink stoma, +green stool/gas, peri-stomal necrotic skin EXT-warm, no c/c, 4+ pitting edema all extremities NEURO-arousable to voice, no FC, no tracking, not moving extremities Pertinent Results: [**2176-6-11**] CBC WBC-16.9* RBC-3.11* Hgb-10.4* Hct-30.6* MCV-99* MCH-33.5* MCHC-34.0 RDW-17.8* Plt Ct-110* [**2176-6-11**] PT-13.1 PTT-27.6 INR(PT)-1.1 [**2176-6-11**] SPUTUM GRAM STAIN >25 PMNs and <10 epithelial cells/100X field. 2+ GRAM NEGATIVE ROD(S). Final [**2176-6-8**] SPUTUM GRAM STAIN >25 PMNs and >10 epithelial cells/100X field. 2+ MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. Final [**2176-6-9**] RESPIRATORY CULTURE: No predominance of these respiratory pathogens: S. pneumoniae, H. influenzae, and M. catarrhalis. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. FUNGAL CULTURE (Preliminary): GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS. [**2176-6-5**] CHEST (PORTABLE AP) CHEST AP: The tip of the right IJ line is in the mid SVC. The endotracheal tip about 5 cm above the carina. The distal end of the feeding tube is not visualized and is below the diaphragm. There is mild cardiomegaly. There are bilateral alveolar opacities, right greater than left. Some prominent interstitial markings are also seen in both mid and lower zones. There are no pleural effusions. The right costophrenic angle has been cut off from this study. There is no pneumothorax. IMPRESSION: Right IJ line in appropriate position without evidence of pneumothorax. Pneumonia in the right middle and lower zones with some pulmonary edema. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 21827**] [**Name (STitle) 21828**] DR. [**First Name (STitle) 15744**] N. [**Doctor Last Name 1447**] Approved: [**Doctor First Name **] [**2176-6-6**] 11:58 AM [**2176-6-11**] CHEST (PORTABLE AP) HISTORY: 70 y/o with history of ---no sochromal-- pneumonia. Status post colectomy. This study is compared to previous study of 1 day earlier and since the previous study there has been reexpansion of previously seen atelectatic left lower lobe. There has been worsening in the degree of consolidation involving the right middle lobe and right lower lobe since the previous study. A small associated right pleural effusion is suspected. The left lung and the right upper lobe are clear. There is continued application of the right subclavian CVP line, ET tube and NG tube. IMPRESSION: Interval expansion of the left lower lobe.Worsening infiltration of the right middle lobe and right lower lobe suggestive of pneumonia. DR. [**Last Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2372**] [**2176-6-8**] LIVER OR GALLBLADDER US INDICATION: Elevated bilirubin, alkaline phosphatase, and transaminitis. Intubated on tube feeds. TECHNIQUE: Right upper quadrant ultrasound was performed. FINDINGS: The gallbladder is nondistended, with a thin wall. No stones or sludge is seen within the gallbladder. There is no intra or extrahepatic biliary duct dilatation. The common bile duct measures 4 mm in size. No hepatic lesions are seen. IMPRESSION: No evidence of cholecystitis. study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DR. [**First Name11 (Name Pattern1) 26**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: MON [**2176-6-10**] 3:06 PM CT OF THE CHEST WITH CONTRAST: IMPRESSION: 1) Diffuse severe emphysema. 2) Diffuse superimposed ground-glass and interstitial opacities. This likely related to superimposed pulmonary edema secondary to cardiac failure. 3) Several nodular opacities, most prominent at the lung bases. Confirmation of resolution of these nodular opacities after treatment is recommended to rule-out possible metastatic disease. Conversely, these nodular opacities along with patchy opacities seen in the lower lobes may relate to superimposed aspiration and/or pneumonia. CT ABDOMEN AND PELVIS: IMPRESSION: 1) Small amount of fluid adjacent to the left colon stump, likely post operative in nature. There is no collection suspicious for a mature abscess at this time. 2) Small low attenuation lesions in the liver and spleen. These are likely benign but are not fully characterized on this study. 3) Calcified irregular aorta and prominent infrarenal plaque/thrombus. 4) Findings discussed with the Surgical Service. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: SAT [**2176-6-8**] 2:28 PM Brief Hospital Course: On [**2176-6-5**], the patient was electively transferred to [**Hospital1 18**] where pneumonia and CHF were confirmed by CXR and CT scan. She was continued on vancomycin for a total of thirteen days while the other antibiotics were discontinued since her course had been completed or they were not providing useful coverage for nosocomial pneumonia. Subsequently, the patient tolerated pressure support ventilation with acceptable oxygen saturation considering her severe COPD with home oxygen requirement. However, she was never successfully able to pass spontaneous breathing trials with ability to remain alert to support her airway. Her mental status at best was arousable to voice and very seldomly able to blink her eyes upon command. She became very hypertensive and anxious or in pain when weaned off sedation with fentanyl and/or midazolam. Throughout her hospital course, the patient was gently diuresed with lasix for CHF exacerbation and hypertension. Additionally, she received metoprolol, captopril, ASA, atorvastatin, and combivent nebulizer therapy. She remained afebrile throughout her hospital stay with a leukocytosis with WBC<20 due to pneumonia vs. chronic steroid use. The patient's CXR and ECG remained unchanged througout her hospital stay on mechanical ventilation until [**2176-6-11**] when she became hypoxemic on FiO2 of 1 and PEEP of 14 on assist control with pO2 levels in the low 50's. Her CXR showed worsening right sided infiltrate and a new course of antibiotic therapy was begun. She never recovered ability to oxygenate well in spite of maximum ventilatory support. A brief bronchoscopy was performed to identify mechanical causes of hypoventilation or hypoxemia. A small amount of mucous plugging was suctioned and the hypoxemia did not resolve. Next, the patient developed an arrhythmia without recovering oxygen saturation following a recruitment maneuver that was a final opportunity for the patient to recover oxygenation. The patient's family and her proxy health care decision [**Last Name (LF) **], [**Name (NI) 449**] [**Known lastname **], decided to render the patient DNR and she died at [**2080**] from respiratory failure due to hypoxemia. The patient received an insulin drip for hyperglycemia, levothyroxine for hypothyroidism, and methylprednisone for chronic COPD. She received tube feedings through the NGT with monitoring of ostomy output. NGT secretions and ostomy excretion was consistently guiac positive but the patient had a stable hematocrit above 30. She had scleral icterus and mildly increased tBR, dBR, AST, ALT, alk phos, and amylase that was resolving after the aztreonam was completed. For prophylaxis, the patient received protonix, subcutaneous heparin, pneumoboots, sucralfate, and aspiration precautions. Medications on Admission: 1. flagyl 500mg q6hrs 2. aztreonam 2g q8hrs 3. linezolid 600mg q12hrs 4. amlodipine 5. metoprolol 6. nitropaste 7. solumedrol 8. versed 9. levothyroxine 10.nicotine patch Discharge Disposition: Home Discharge Diagnosis: Deceased. Discharge Condition: Deceased.

[ "410.72", "444.0", "496", "790.7", "998.13", "518.81", "V44.3", "482.41", "428.0" ]

icd9cm

[ [ [] ] ]

[ "99.15", "96.72", "33.23", "96.6" ]

icd9pcs

[ [ [] ] ]

10138, 10144

7130, 9917

285, 395

10197, 10209

2464, 3091

1718, 1736

10165, 10176

9943, 10115

1751, 2445

3121, 7107

226, 247

423, 1224

1246, 1488

1504, 1702

9,274

183,870

49225

Discharge summary

report

Admission Date: [**2158-2-20**] Discharge Date: [**2158-3-6**] Date of Birth: [**2096-10-21**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: fatigue, DOE Major Surgical or Invasive Procedure: redo-redosternotomy/AVR(#21 [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 923**] [**Last Name (NamePattern1) **])[**2-20**] History of Present Illness: 61 yo M with s/p AVR x 2 (last in [**2155**]) with recent echo showing increased gradient and thickened/defromed leaflets. Past Medical History: PMH: 1. Alcohol detox 2 wks ago 2. Abdominal malignancy - 2.7cm iliac LN/abdominal LAD currently being worked up by Dr. [**Last Name (STitle) **] 3. Bicuspid aorta s/p aortic valve replacement with porcine valve in [**2151**] 4.Presence of venous angioma vs AV malformation seen on prior MRAs. 5. Status post traumatic splenectomy 6. Depression 7. Essential tremor 8. Status post bilateral herniorrhaphy 9. Status post right thumb surgery [**59**]. Status post ACL repair. Social History: retired police officer occasional cigars occasional binge drinker, history of etoh abuse Family History: GM with open heart surgery (unclear indication) Physical Exam: NAD HR 70 BP 110/60 Poor dentition Lungs CTAB Heart RRR 3/6 SEM -> carotids Abdomen Soft/NT/ND Extrem warm, trace LE edema Mild L GSV varicosities Tremor Pertinent Results: [**2158-3-6**] 06:00AM BLOOD WBC-16.5* RBC-3.37* Hgb-10.8* Hct-32.6* MCV-97 MCH-32.0 MCHC-33.1 RDW-16.5* Plt Ct-680* [**2158-3-6**] 06:00AM BLOOD PT-23.9* INR(PT)-2.3* [**2158-3-5**] 07:30AM BLOOD PT-23.6* INR(PT)-2.3* [**2158-3-4**] 12:45PM BLOOD PT-25.0* INR(PT)-2.5* [**2158-3-3**] 06:20AM BLOOD PT-24.7* INR(PT)-2.4* [**2158-3-2**] 06:00AM BLOOD PT-28.4* INR(PT)-2.9* [**2158-3-6**] 06:00AM BLOOD Glucose-99 UreaN-13 Creat-0.8 Na-137 K-4.4 Cl-100 HCO3-30 AnGap-11 CHEST (PORTABLE AP) [**2158-3-5**] 1:34 PM CHEST (PORTABLE AP) Reason: ? infiltrate [**Hospital 93**] MEDICAL CONDITION: 61 year old man with CABG REASON FOR THIS EXAMINATION: ? infiltrate STUDY: AP CHEST, [**2158-3-5**]. HISTORY: 61-year-old male with CABG. Evaluate for infiltrate. FINDINGS: Comparison is made to previous study from [**2158-3-2**]. There has been no interval change. There is persistent bibasilar subsegmental atelectasis. No focal consolidation or overt pulmonary edema is seen. The right CP angle has been cutoff from the study. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 103199**] (Complete) Done [**2158-2-20**] at 10:23:53 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. Division of Cardiothoracic [**Doctor First Name **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2096-10-21**] Age (years): 61 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Aortic valve disease. H/O cardiac surgery. Left ventricular function. Mitral valve disease. Prosthetic valve function. Valvular heart disease. ICD-9 Codes: 440.0, V43.3, 396.9 Test Information Date/Time: [**2158-2-20**] at 10:23 Interpret MD: [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW04-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *4.9 cm <= 4.0 cm Left Atrium - Four Chamber Length: 4.8 cm <= 5.2 cm Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.6 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 4.8 cm Left Ventricle - Fractional Shortening: *0.14 >= 0.29 Left Ventricle - Ejection Fraction: 35% to 40% >= 55% Aorta - Annulus: 2.3 cm <= 3.0 cm Aorta - Sinus Level: 2.6 cm <= 3.6 cm Aortic Valve - Peak Velocity: *2.4 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *54 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 29 mm Hg Aortic Valve - Valve Area: *0.7 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. All four pulmonary veins not identified. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Mild symmetric LVH. Top normal/borderline dilated LV cavity size. Moderately depressed LVEF. RIGHT VENTRICLE: Mildly dilated RV cavity. Borderline normal RV systolic function. AORTA: Normal ascending aorta diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR leaflets move normally. Severe AS (AoVA <0.8cm2). Mild (1+) AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. No MS. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Conclusions PRE-BYPASS: The left atrium is mildly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is top normal/borderline dilated. Overall left ventricular systolic function is moderately depressed (LVEF= 35-40%). The right ventricular cavity is mildly dilated with borderline normal free wall function. There are simple atheroma in the descending thoracic aorta. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis leaflets appear to move normally. There is severe aortic valve stenosis (area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. POST: Prosthetic valve in aortic position. Well seated and mechanically stable. No appreciable gradient. Improved biventricular systolci function Brief Hospital Course: On [**2-20**] he underwent redo-sternotomy and AVR. He was transferred to the ICU in stable condition on epi, neo and propofol. He was extubated the morning of POD #1 secondary to agitation. He was started on coumadin for his mechanical valve. He was transferred to the floor on POD #1. His white count remained elevated and he was pancultured and started on azithromycin for ? of bronchitis/pneumonia. He became confused and on [**2-25**] a code purple was called. He was started on ativan. Neurology was called and a head CT which showed nothing acute was obtained. He was started on IV thiamine. He continued to be confused at times and on [**2-27**] overnight another code purple was called. A psychiatry consult was called, ativan was tapered and haldol was started. He began to clear, and was weaned from his haldol. He awaited placement, and was ready for discharge home on POD #14. Spoke with Dr. [**Last Name (STitle) **] office who has agreed to manage his coumadin. Medications on Admission: Inderal 10", Zantac 150", ASA 81', Lipitor 40', Lexapro 20', MVI, Folic Acid 1' Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Escitalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 2 days: Check INR [**3-8**] with results to Dr. [**Last Name (STitle) **]. Disp:*100 Tablet(s)* Refills:*0* 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. Disp:*10 Tablet(s)* Refills:*0* 12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day) for 5 days. Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: prosthetic aortic valve stenosis now s/p redo-redo AVR chronic systolic heart failure bicuspid AVR/AVR [**2151**]/redo [**2155**], depression, essential tremor, venous angio av malformation, Abdm lymphoma, avascular necrosis-hips, traumatic splenectomy, herniography, R thumb [**Doctor First Name **], ACL repair Discharge Condition: Stable. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day of five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds or driving until follow up with surgeon. Followup Instructions: Dr. [**Last Name (STitle) 103201**] 2 weeks Dr. [**Last Name (STitle) **] 4 weeks Dr. [**Last Name (STitle) **] 2 weeks Completed by:[**2158-3-6**]

[ "293.0", "414.00", "305.02", "424.1", "333.1", "490", "996.71", "428.0", "202.83", "E878.1", "V45.81", "519.3", "428.22" ]

icd9cm

[ [ [] ] ]

[ "35.22", "39.61" ]

icd9pcs

[ [ [] ] ]

9409, 9458

6807, 7786

334, 478

9815, 9825

1487, 2044

10124, 10274

1249, 1298

7916, 9386

2081, 2107

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9849, 10101

1313, 1468

282, 296

2136, 6784

506, 630

652, 1127

1143, 1233

59,930

158,810

39623

Discharge summary

report

Admission Date: [**2187-9-18**] Discharge Date: [**2187-9-23**] Date of Birth: [**2112-8-1**] Sex: M Service: CARDIOTHORACIC Allergies: Statins-Hmg-Coa Reductase Inhibitors Attending:[**First Name3 (LF) 1505**] Chief Complaint: coronary artery disease Major Surgical or Invasive Procedure: [**2187-9-18**] Coronary Artery Bypass Graftingx3(LIMA-LAD,SVG-OM,SVG-PLV) History of Present Illness: This 75 year old male has known coronary disease, having undergone stenting in the past. He was experiencing intermittent but progressive chest pain and shortness of breath for [**1-3**] months with and without activity. He had a negative stress test in [**2-7**] which showed a medium area of myocardial scar in the PDA/OM distribution and mild hypokinesis of the mid to basal inferior walls. He had a cardiac catheterization in [**Month (only) **] which revealed triple vessel CAD. He underwent evaluation for surgical revascularization and was cleared to proceed with cardiac surgery. Past Medical History: History of MI ([**2173-3-31**]) s/p angioplasty/ stents Hypertension insulin dependent diabetes mellitus Hypercholesterolemia Nephrolithiasis Neuropathy Spondylosis Spinal Stenosis Osteoarthritis benign prostatic hypertrophy Obesity Glaucoma s/p Hernia surgeries Social History: Lives with: wife Occupation: retired Tobacco: quit in [**2172**], 30 pk yr. hx. ETOH: denies Family History: Denies premature coronary artery disease Physical Exam: admission: Pulse:56 Resp:18 O2 sat: 95% RA B/P Right: 161/86 Left: Height: 5'5" Weight: 220 lbs. General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: 2+ (cath site) Left: 2+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: no Left: no Pertinent Results: [**2187-9-18**] Intraop TEE: PRE BYPASS The left atrium is normal in size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the basal inferolateral wall. This segment may be somewhat aneurysmal - it appears thinned and calcified. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There are filamentous strands on the left ventricular side of the aortic valve leaflets that likely rebresent degenerative changes. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). There is mild to moderate, somewhat eccentric tricuspid regurgitation. There is a trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results in the operating room at the time of the study. POST BYPASS Normal right ventricular systolic function. Left ventricular systolic function unchanged from pre-bypass. No significant changes in valvular function. The thoracic aorta appears intact after decannulation. [**2187-9-20**] 03:59AM BLOOD WBC-12.1* RBC-4.04* Hgb-12.1* Hct-34.3* MCV-85 MCH-29.9 MCHC-35.3* RDW-14.4 Plt Ct-131* [**2187-9-20**] 03:59AM BLOOD Glucose-148* UreaN-18 Creat-0.9 Na-134 K-4.4 Cl-98 HCO3-31 AnGap-9 [**2187-9-18**] 03:35PM BLOOD UreaN-16 Creat-0.9 Na-143 K-4.0 Cl-111* HCO3-24 AnGap-12 [**2187-9-23**] 04:05AM BLOOD WBC-10.3 RBC-4.08* Hgb-12.5* Hct-34.7* MCV-85 MCH-30.7 MCHC-36.1* RDW-14.2 Plt Ct-300# [**2187-9-21**] 11:13AM BLOOD UreaN-30* Creat-1.1 Na-134 K-4.7 Cl-96 [**2187-9-21**] 11:13AM BLOOD Mg-2.4 Brief Hospital Course: Mr. [**Known lastname **] was admitted and underwent coronary artery bypass grafting surgery by Dr. [**Last Name (STitle) **]. For surgical details, please see operative note. Following the operation, he was brought to the CVICU for invasive monitoring on NeoSynephrine and Propofol drips. Within 24 hours, he awoke neurologically intact and was extubated without incident. He maintained stable hemodynamics and transferred to the cardiac surgical floor on postoperative day one. He remained in a normal sinus rhythm. Beta blockade was resumed and diuresis towards his preoperative weight begun. Physical Therapy worked with him for mobility. Wounds were healing well and glucose was well controlled. The patient was discharged home with VNA services on POD 5. Follow-up appointments were advised. Medications on Admission: Atenolol 100mg PO daily, Percocet [**12-2**] q 4-6 hours PRN, Humalog SS, NPH insulin 74U SC q AM, 70U SC q PM, Lisinopril 40 mg PO daily, ASA 325 mg PO daily Discharge Medications: 1. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 4 weeks. Disp:*50 Tablet(s)* Refills:*0* 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 2 weeks. 5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. 9. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. 10. insulin glargine 100 unit/mL Solution Sig: One (1) Subcutaneous twice a day: 74 units qam, and 70 units qpm as you were taking pre-op. 11. insulin lispro 100 unit/mL Solution Sig: One (1) Subcutaneous four times a day: Humalog sliding scale as you were pre-op. 12. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Coronary artery disease s/p Coronary artery bypass grafts s/p coronary stents Hypertension Dyslipidemia insulin dependent diabetes mellitus nephrolithiasis benign prostatic hypertrophy spinal stenosis glaucoma obesity 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 Left - healing well, no erythema or drainage. Edema: minimal Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2187-10-11**] at 1:30pm Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2187-10-26**] at 12:10pm Please call to schedule appointments with your Primary Care Dr. [**First Name4 (NamePattern1) 1528**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 31019**]) in [**3-5**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2187-9-23**]

[ "V45.82", "V58.66", "600.00", "411.1", "V58.67", "272.0", "412", "414.01", "401.9", "250.00", "365.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6669, 6744

4336, 5137

326, 403

7006, 7237

2155, 4313

8078, 8718

1435, 1477

5347, 6646

6765, 6985

5163, 5324

7261, 8055

1492, 2136

263, 288

431, 1022

1044, 1309

1325, 1419

46,080

119,385

42877

Discharge summary

report

Admission Date: [**2119-7-14**] Discharge Date: [**2119-7-28**] Date of Birth: [**2055-9-15**] Sex: F Service: MEDICINE Allergies: doxycycline Attending:[**First Name3 (LF) 9160**] Chief Complaint: Nausea, vomiting Major Surgical or Invasive Procedure: Replacement of Tunneled Dialysis Catheter - [**7-20**] History of Present Illness: Ms. [**Known lastname 92585**] is a 63 year-old woman with history of Goodpasture's disease on immunosupression with ESRD on HD (MWF), HTN, HLD, hypothyroidism who presented to [**Hospital3 417**] hospital on [**2119-7-13**] with nausea, vomiting, and chills. Patient was in her usual state of health until Thursday morning where she developed nausea, emesis x2, and chills at home. She was taken to [**Hospital3 417**] Medical Center by ambulance. She also had abdominal pain and right sided pleuritic chest pain. On arrival to ED, she was febrile to 102.2, HR 109, RR 22. Initials labs significant of WBC of 0.1, 10% bands, plateltes of 50,000, lactate of 5.9. She had UA with 10 - 20 WBCs. Patient received gentamycin and vancomycin for possible UTI and was admitted to medicine service. During hospitalization, patient became progressively more dyspnic requiring BiPAP and then a NRB. She had a CT abdomen/pelvis, which showed RML/RLL pneumonia. She was started on vancomycin, meropenem, and continued on gentamycin. She was started on neosynephrine for hypotension. She received hydrocort for stress stress dose steroids given chronic high dose prednisone use. Today she underwent dialysis for management of volume overload and had 3L of fluid removed and her oxygen was weaned to 4L NC (satting 98%). Following dialysis she became more hypotensive requiring low dose levophed. However, pressors were completely weaned off prior to transfer. Blood cultures negative to date. Urine cultures with GNR and alpha strep. For neutropenia, patient was seen by hematology who felt neutropenia may be secondary to infection. She received GCSF 480 mcg on thursday and friday. Course also notable for thrombocytopenia with platelets of 50,000. As per patient, she had a bloody bowel movemetn at OSH and this has been going on over the past week. She has also had bruising all over her body for the past several weeks. She had a CT scan notable for thrombosis of right femoral vein. She had b/l femoral DVTs. It was planned for her to start on a heparin gtt, but given thrombocytopenia and ? GI bleeding, she did not start the heparin gtt. On arrival to the MICU, patient reports that she feels comfortable. She thinks her breathing is much better than it was prior to dialysis. She continues to have intermittent cough. No nausea, vomiting, abdominal pain. No fevers, chills. Review of systems: (+) Per HPI (-) Denies recent 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. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Past Medical History: Goodpasture's disease diagnosed [**3-/2119**] s/p plasmaphresis, on prednisone and cytoxan (nephrologist is Dr. [**Last Name (STitle) **] ESRD on HD ([**3-16**] Goodpasture's) Hypertension Hyperlipidemia Hypothyroidism Morbid Obesity GERD Social History: Smoked from age 15 - 37, no EtOH, No illicit drug use. Lives with her husband and 26 year old son. Family History: No history of renal disease, cardiac disease or autoimmune disease that she is aware of Physical Exam: Exam upon admission: Vitals: T: 98.2 BP: 99/55 P: 82 R: 18 O2: 98% on 4L General: Alert, oriented, obese, chronically ill appearing woman in no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, obese, CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Bibasilar crackles, no wheezes Abdomen: +BS, soft, non-tender, non-distended, no rebound/guarding GU: foley in place Ext: 2+ peripheral edema to knees Skin: Ecchymoses on extremities Neuro: CNII-XII intact, moving all extremities, sensation grossly intact Pertinent Results: Labs upon admission: [**2119-7-14**] 11:26PM BLOOD WBC-0.2*# RBC-2.60* Hgb-9.2* Hct-28.3* MCV-109*# MCH-35.2*# MCHC-32.3 RDW-20.5* Plt Ct-32*# [**2119-7-14**] 11:26PM BLOOD Neuts-23* Bands-17* Lymphs-23 Monos-17* Eos-7* Baso-0 Atyps-3* Metas-7* Myelos-3* NRBC-7* [**2119-7-14**] 11:26PM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-1+ Macrocy-3+ Microcy-NORMAL Polychr-NORMAL Spheroc-OCCASIONAL Ovalocy-1+ Schisto-OCCASIONAL MacroOv-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**2119-7-14**] 11:26PM BLOOD PT-12.8* PTT-40.1* INR(PT)-1.2* [**2119-7-15**] 03:33AM BLOOD Fibrino-867* [**2119-7-14**] 11:26PM BLOOD Glucose-76 UreaN-49* Creat-3.5* Na-140 K-4.9 Cl-106 HCO3-21* AnGap-18 [**2119-7-14**] 11:26PM BLOOD ALT-20 AST-24 LD(LDH)-363* AlkPhos-53 TotBili-0.5 [**2119-7-15**] 03:33AM BLOOD CK-MB-2 cTropnT-0.02* [**2119-7-14**] 11:26PM BLOOD Albumin-2.8* Calcium-7.5* Phos-5.0*# Mg-2.4 [**2119-7-15**] 03:53AM BLOOD Lactate-1.0 Labs at Discharge: [**2119-7-28**] 06:23AM BLOOD WBC-6.1 RBC-2.04* Hgb-7.2* Hct-21.8* MCV-107* MCH-35.2* MCHC-32.9 RDW-19.7* Plt Ct-69* [**2119-7-28**] 06:23AM BLOOD PT-11.7 PTT-89.8* INR(PT)-1.1 [**2119-7-28**] 06:23AM BLOOD Glucose-81 UreaN-61* Creat-3.2* Na-138 K-3.5 Cl-99 HCO3-25 AnGap-18 [**2119-7-28**] 06:23AM BLOOD Calcium-8.6 Phos-4.3 Mg-1.8 Imaging: Echo [**2119-7-15**]: The left atrium is moderately dilated. The right atrium is moderately dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: No evidence of right heart strain. Normal regional and global left ventricular systolic function. Trace aortic and mitral regurgitation. CXR [**2119-7-15**]: The right IJ central line tip in the SVC is unchanged. There is volume loss at both bases with obscuration of the right heart border likely representing right middle lobe infiltrate. There is pulmonary vascular re-distribution and perihilar haze. It is difficult to assess for small effusions given overlying soft tissues. The overall impression is that of mild CHF with a superimposed infiltrate in the right lower lobe given history of pneumonia is likely. CTA Chest [**2119-7-24**]: 1. Acute thromboembolus in the basal trunk of the left pulmonary artery, extending to several segmental branches. 2. Lack of contrast in the right atrium may simply represent mixing artifact, however echocardiography is recommended to exclude right atrial thrombus. 3. Fat-density mass in the right middle lobe at location of prior pneumonia, is likely lipoid pneumonia. Exogenous lipoid pneumonia secondary to aspiration of a lipid-[**Doctor First Name **] substance, such as mineral oil supplementation, should also be considered. EKG [**2119-7-24**]: Sinus tachycardia. Diffuse ST-T wave changes which are modest and non-specific. Low QRS voltages in the precordial leads. Compared to the previous tracing of [**2119-7-22**] there is no significant diagnostic change. Brief Hospital Course: Chronologic course: The patient is a 63 year-old woman with Goodpasture's disease (diagnosed [**3-/2119**]) s/p plasmapheresis on prednisone and cytoxan, who initially presented to OSH with nausea and vomiting, found to have bilateral DVTs, and subsequently developed progressive dyspnea and hypotension prompting transfer to [**Hospital1 18**]. She required pressors temporarily at the OSH, but pressors were stopped prior to arrival at [**Hospital1 18**]. Upon arrival she was noted to have fever in the setting of neutropenia/pancytopenia and an infiltrate on CXR. She was started on Vancomycin and Meropenem (latter switched to Cefepime) and a Heparin drip for DVT treatment. On [**2119-7-15**], she developed Atrial fibrillation with rapid ventricular response and was given IV metoprolol without response, followed by Amiodarone bolus and drip with conversion to sinus rhythm. She was started on oral Amiodarone on [**2119-7-18**]. She was seen by Hematology and was subsequently started on Filgastrim on [**2119-7-15**]. Per heme/onc, the Neupogen was stopped on [**2119-7-18**] as she was no longer neutropenic. She was continued on vancomycin + cefepime for 8 days for her pneumonia until [**2119-7-21**]. Her platelets nadired at 12,000. Her neutropenia followed a similar course. The patient experienced R sided chest pain waxed and waned over the course of her admission reaching a crescendo on Sunday [**7-24**] when she became extremely uncomfortable, with generalized malaise. EKG and troponins were negative. CXR showed no new pathology. Chest CTA revealed a L-sided pulmonary embolism and a R-sided mass (resolving PNA vs atelectasis vs tumor). She had another episode of chest pain at dialysis on [**7-26**] that responded to high dose dilaudid and again at dialysis on [**7-28**]. ACTIVE ISSUES: # ESRD on HD: Secondary to Goodpasture's. At presentation, she was being treated with cytoxan and prednisone. Cytoxan was discontinued given pancytopenia. The patient was continued prednisone 60 mg daily, but downtitrated to 50 mg on [**2119-7-27**]. She was started on azothioprine 75 mg daily in hospital on [**7-27**]. Plan is to treat with azothioprine for 3 months (managed by Dr. [**Last Name (STitle) **] to prevent renal progression and to prevent pulmonary disease. Prednisone will be tappered off over the next few months as discussed in emails between Dr. [**Last Name (STitle) 118**], Dr. [**Last Name (STitle) **], and Dr. [**Last Name (STitle) **]. Weekly labs should be collected to monitor LFTs and CBC. These lab results should be faxed to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 92586**]. HD catheter replacement was performed on [**2119-7-20**]. # Septic shock: Likely source was pulmonary in the setting of neutropenia. Given pressors briefly at OSH. Treated at [**Hospital1 18**] initially in MICU. Treated with vancomycin and cefepime for 8 days with resolution of symptoms. # Neutropenia: WBC nadir at 0.1 on [**2119-7-18**], likely secondary to Cytoxan and sepsis. Counts recovered to 6.5 on day of discharge. Cytoxan was discontinued due to pancytopenia. Now on azothiprine and will need weekly CBC to assess for bone marrow suppression. # Thrombocytopenia: Thought to be related to Cytoxan, acute illness, and possibly Vancomycin. Nadir at 12,000 on [**2119-7-18**], which trended up to 69,000 by day of discharge. No clinically significant bleeding noted while hospitalized, except for epistaxis (see below). HIT antibody was negative. Bactrim prophylaxis was held during admission and will need to be re-started once counts stable. # DVT/PE: Started on heparin drip in hospital for DVT and PE (diagnosed by CTA) with goal PTT 60-100. On [**2119-7-24**], patient was started on 2.5 mg coumadin, increased to 4.0mg on [**2119-7-27**]. Goal INR is 2.0-3.0. Once patient is greater than 2.0 for 2 days, Heparin can be stopped. Coumadin therapy should be continued for at least 6 months with the first day being [**2119-7-18**]. # Atrial fibrillation with RVR: On [**7-15**], in ICU pt had episode of A fib with RVR that responded poorly to beta-blockers/calcium channel blockers due to hypotension but later resolved with IV Amiodarone. After another episode of A fib following discontinuation of Amiodarone, she was started on oral amiodarone therapy. The plan defined by Cardiology is a tapered course of Amiodarone starting at 200 mg TID for 3 weeks, then 200 mg daily until Cardiology follow-up at 4 weeks. # Pulmonary findings on CT: On [**2119-7-24**], a CTA chest was performed to assess for PE. This scan showed a new lesion in the right middle lobe with a differential diagnosis including resolving PNA, rounded atelectasis, or new lung mass. A 6-week follow-up CT scan was arranged and outpatient pulmonary follow-up has been scheduled. Her CT findings were not believed to be consistent with pulmonary Goodpasture's. # Anemia: Persistent for entire [**Hospital1 18**] hospitalization. Likely multifactorial, no obvious active bleeds, most recent guaiac was negative. [**Month (only) 116**] be related to chronic disease. Retic on [**2119-7-19**] was 1.4, Hct was 30, which trended later down to 21.8. One unit pRBC transfusion was given at HD prior to discharge. # Chest Pain: Ranges from 0/10 to 5/10 intensity. Pleuritic in nature, not reproducible on palpation. Has been worked-up extensively without clear explanation. There is no appreciable pulmonary embolism in the right lung, troponins were negative, and there was no clinical or radiographic evidence of new pneumonia. The mostly likely cause is musculoskeletal. Interventional Radiology believed that the HD catheter was in proper position and is unlikely to explain the patient's chest pain. Responded to PRN Dilaudid 0.25-0.5mg. The pain almost always occurred at HD. # Epistaxis: On the evening of [**7-27**] the patient developed L-sided epistaxis. It was a slow bleed but continuous and lasted until the day of discharge. She improved with Afrin and manual compression. Bleeding likely from a combination of dryness and thrombocytopenia. # Positive C. diff result: On [**2119-7-27**] found to be positive for C. diff, however no treatment was initiated bacause the patient was asymptomatic. TRANSITIONAL ISSUES: - Amiodarone taper as above and follow-up with Cardiology for further management of atrial fibrillation. - Needs to continue IV Heparin bridge to Coumadin. Once INR [**3-17**] for 2 days, can stop Heparin and continue coumadin for 6 months. Outpatient coumadin management has NOT yet been arranged but will need to be done before patient leaves for home. - Will be tapered off steroids over several months by Dr. [**Last Name (STitle) **] and continued on Azathioprine 75mg for 2-3 months. - Pulmonology follow-up and repeat CT chest have been arranged for abnormal CT finding. - Will need to determine need to re-start Bactrim for PCP prophylaxis, which was stopped in setting of bone marrow suppression. Medications on Admission: Simvastatin 40 mg qHS Singulair 10 mg daily Omeprazole 20 mg daily Clonazepam 1 mg qHS PRN restless legs Furosemide 40 mg dialy Flexeril 5 mg TID PRN pain Levothyroxine 200 mcg daily prednisone 60 mg daily bactrim SS every other day Zofran 4 mg PO Q8H PRN nausea tramadol 50 mg Q6H PRN pain renal caps 1 cap daily cyclophosphamide 150mg daily Discharge Medications: 1. Levothyroxine Sodium 200 mcg PO DAILY 2. Montelukast Sodium 10 mg PO DAILY 3. Nephrocaps 1 CAP PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Amiodarone 200 mg PO TID hold for hr < 60 sbp < 95 Maintain dose for 3wks: Day 1 -- [**2119-7-23**] 6. Heparin IV per Weight-Based Dosing Guidelines 7. HYDROmorphone (Dilaudid) 0.25 mg IV Q4H:PRN Chest Pain Hold for RR < 10 8. Sodium Chloride Nasal [**2-13**] SPRY NU QID:PRN nasal irritation 9. Cyclobenzaprine 5 mg PO TID:PRN Pain 10. Ondansetron 4 mg PO Q8H:PRN Nausea 11. Simvastatin 40 mg PO QHS 12. TraMADOL (Ultram) 50 mg PO Q6H:PRN Pain 13. Azathioprine 75 mg PO DAILY Please give AFTER HD on Monday/Wednesday/Friday dialysis days 14. Clotrimazole Cream 1 Appl TP [**Hospital1 **] Please apply under L arm over area of erythema and pruritis 15. Warfarin 4 mg PO DAILY16 Hold for INR > 3.0 Goal 2.0-3.0 Please check INR daily until goal range reached. 16. Acetaminophen 650 mg PO Q6H 17. PredniSONE 50 mg PO DAILY 18. Clonazepam 2 mg PO QHS:PRN restless legs Start: Evening of [**2119-7-23**] Start on [**2119-7-23**] Discharge Disposition: Extended Care Facility: [**Location (un) 511**] Sanai [**Location (un) 686**] Discharge Diagnosis: Pneumonia Sepsis Deep Venous Thrombosis (DVT) Pulmonary Embolus (PE) Thrombocytopenia Anemia Neutropenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [**Known lastname 92585**], You were transferred to [**Hospital1 18**] for pneumonia and sepsis (infection of the blood). While in the hospital you given antibiotics for your infections. You were also started on anticoagulation for your deep venous thromboses (DVT - blood clots) in your legs. A CT-scan of your lungs showed a pulmonary embolus (PE - blood clot in lung), which also requires anticoagulation. You are being discharged to a long-term acute care facility (LTAC) for continued treatment, hemodialysis and physical therapy. You will need to follow-up with several specialty services upon discharge. You have been scheduled for follow-up appointment with pulmonary (for Goodpasture's and repeat CT scan) and renal (for Goodpasture's and diaylsis management) and you will need to contact cardiology to make an appointment for management of your amiodarone (for cardiac arrhythmia). You were started on several new medications during your hospital stay: amiodarone, azothioprine, heparin, acetaminophen, dilaudid and coumadin. Some of your medications were stopped including bactrim and cytoxan. Followup Instructions: Department: Primary Care Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17025**] Location: [**First Name9 (NamePattern2) 17001**] [**Location (un) **] INTERNAL MEDICINE Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 85794**] Phone: [**Telephone/Fax (1) 6699**] Notes: It has been requested that you follow up with a cardiologist in 4 weeks after your hospital discharge. Please discuss the need for cardiology with your Primary Care Physician and call the cardiology number listed below to schedule your appointment. Steward Cardiology Phone: [**Telephone/Fax (1) 8725**] Department: Nephrology Name: Dr. [**First Name8 (NamePattern2) 8726**] [**Name (STitle) **] When: You will be followed by your nephrologist, Dr [**Last Name (STitle) **] during your upcoming dialysis appointment. Location: [**Hospital **] MEDICAL CARE, P.C. Address: [**Street Address(2) 8727**], STE 125E, [**Hospital1 **],[**Numeric Identifier 8728**] Phone: [**Telephone/Fax (1) 8729**] Department: PULMONARY FUNCTION LAB When: WEDNESDAY [**2119-9-13**] at 2:20 PM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PFT When: WEDNESDAY [**2119-9-13**] at 2:40 PM Department: MEDICAL SPECIALTIES When: WEDNESDAY [**2119-9-13**] at 2:40 PM With: DR. [**Last Name (STitle) **]/DR. [**Last Name (STitle) 611**] [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9162**] Completed by:[**2119-7-30**]

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icd9cm

[ [ [] ] ]

[ "39.95", "38.95", "38.97" ]

icd9pcs

[ [ [] ] ]

16107, 16187

7651, 9460

290, 347

16336, 16336

4206, 4213

17650, 19415

3505, 3595

15016, 16084

16208, 16315

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5153, 7628

375, 2762

4227, 5134

16351, 16488

3133, 3373

3389, 3489

71,084

153,725

42255

Discharge summary

report

Admission Date: [**2100-12-16**] Discharge Date: [**2100-12-22**] Date of Birth: [**2055-6-1**] Sex: M Service: UROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 11304**] Chief Complaint: blurry vision, renal mass Major Surgical or Invasive Procedure: Dr.[**Name (NI) 11306**] PROCEDURES: 1. Open left radical nephrectomy with adrenalectomy. 2. Retroperitoneal lymph node dissection. 3. Resection of omental mass. 4. Resection of urachal cystic mass. Dr.[**Name (NI) 10065**] PROCEDURES: 1. Left colectomy with splenic flexure mobilization. 2. Small-bowel resection. 3. Colorectal anastomosis History of Present Illness: HPI: Mr. [**Known lastname 59304**] is a 45yo man with a PMHx significant for recently diagnosed RCC with bone mets, HTN, HL, anxiety, migraines and season allergies who presents to the ER after having had a transient episode of right lip and tongue numbness with blurred vision. He had been in his usual state of health until approximately 11:30am [**12-15**] when he was in his firehouse and had acute onset of right lip and tongue numbness and blurred vision. He describes his lip/tongue numbness as feeling as though someone had "poured novocaine on me". No tingling associated with this. It was focal, located specifically on the right lower lip and tip of the right side of his tongue. He also had acute onset of blurred vision. He reports that things seemed out of focus and that it resolved with closing each eye. No double vision. No HA, dysarthria, feeling of weakness of any limb, no lightheadedness or dizziness. In total, this episode lasted for seven seconds. He called his oncologist's office, who recommended that he come to the ED for urgent evaluation and Head CT (apparently unable to arrange as outpatient). On arrival to the floor, patient states he has no further symptoms and feels well. Review of Systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies loss of vision, photophobia. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations, lower extremity edema. Denies cough, shortness of breath, or wheezes. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, melena, hematemesis, hematochezia. Denies dysuria, stool or urine incontinence. Denies arthralgias or myalgias. Denies rashes or skin breakdown. No numbness/tingling in extremities. All other systems negative. Past Medical History: Past Medical History: 1. RCC -- recently diagnosed three weeks ago when found to have L abdominal mass. Has mets to L humerus, femur, and right ulna. Scheduled for nephrectomy and removal of tumor on [**2100-12-17**]. 2. Hypertension 3. hypercholesterolemia 4. anxiety -- has prior history of panic attacks 5. migraines -- last migraine was three weeks ago 6. seasonal allergies Past Surgical History: Status post bilateral inguinal hernia repair 15 years ago. Social History: Divorced and lives in [**Location **]. He has two daughters ages 8 and 11. Has a girlfriend, [**Name (NI) **]. [**Name2 (NI) **] works as a firefighter and EMT. He recently quit smoking three months ago. He drinks alcohol socially. Denies illicit drug use. Family History: No history of renal cell carcinoma or other cancers. His mother died last month of a cardiac arrest with no significant cardiac history at age 66. Grandmother died of a stroke and coronary artery disease in her 80s. He has a brother who is alive and well. His biological father died when he was age 12 and he does not know his medical history. Physical Exam: VS: T 97.7 HR 88 bp: 143/87 RR 18 SaO2 96 RA GEN: NAD, awake, alert HEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and without lesion NECK: Supple, no JVD CV: Reg rate, normal S1, S2. No m/r/g. CHEST: Resp unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABD: Soft, NT,slightly distended with left-sided abdominal mass > 5cm below costal margin which is hard, non-tender, no HSM, bowel sounds present MSK: normal muscle tone and bulk EXT: No c/c/e, 2+ DP/PT bilaterally SKIN: No rash, warm skin NEURO: no focal deficits except for "mild motor impersistence of tongue", see consult note for details PSYCH: cooperative Discharge Exam: wdwn male, NAD, avss abdomen soft, appropriately tender, non-distended extremities w/out edema Pertinent Results: [**2100-12-15**] 10:40PM GLUCOSE-144* UREA N-14 CREAT-1.1 SODIUM-138 POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-27 ANION GAP-15 [**2100-12-15**] 10:40PM CALCIUM-8.8 PHOSPHATE-2.2* MAGNESIUM-2.4 [**2100-12-15**] 10:40PM WBC-8.5 RBC-4.13* HGB-11.3* HCT-34.0* MCV-82 MCH-27.4 MCHC-33.3 RDW-12.9 [**2100-12-15**] 10:40PM NEUTS-76.2* LYMPHS-17.4* MONOS-4.0 EOS-2.1 BASOS-0.3 [**2100-12-15**] 10:40PM PLT COUNT-453* [**2100-12-15**] 10:40PM PT-12.4 PTT-23.6 INR(PT)-1.0 IMAGING: CT Head W/O Contrast -- 1. No acute process. 2. No evidence of masses on CT. MRI: pending [**2100-12-21**] 06:45AM BLOOD WBC-6.3 RBC-3.04* Hgb-8.1* Hct-24.8* MCV-82 MCH-26.7* MCHC-32.7 RDW-13.2 Plt Ct-399 [**2100-12-20**] 06:25AM BLOOD WBC-8.2 RBC-3.11* Hgb-8.5* Hct-25.4* MCV-82 MCH-27.2 MCHC-33.3 RDW-13.4 Plt Ct-352 [**2100-12-21**] 06:45AM BLOOD Glucose-124* UreaN-12 Creat-0.8 Na-135 K-3.8 Cl-101 HCO3-28 AnGap-10 [**2100-12-20**] 06:25AM BLOOD Glucose-123* UreaN-11 Creat-0.9 Na-135 K-4.3 Cl-102 HCO3-26 AnGap-11 [**2100-12-21**] 06:45AM BLOOD Calcium-8.2* Mg-1.9 [**2100-12-20**] 06:25AM BLOOD Calcium-7.2* Phos-2.1* Mg-2.2 Brief Hospital Course: IMPRESSION/PLAN: 45yo man with RCC with mets to left femur, right wrist and left shoulder, HL, HTN who presents today with brief episode of blurred vision and right lower lip and tip of tongue numbness. #Blurred vision and lip/tongue numbness - F/U MRI and MRA completed on [**12-16**] - Differential includes TIA vs. metastatic lesion from renal cell carcinoma vs. V3 neuropathy - Appreciate Neurology recommendations - Would not begin Aspirin 81mg PO daily since this would delay the patient's surgery #Metastatic Renal Cell carcinoma to bone - Scheduled for nephrectomy on [**12-17**] - Patient is standard risk for intermediate risk surgery - Clear diet 11/17 per surgery - Vicodin PRN pain #Hyperglycemia - monitor AM glucose, no indication for insulin at this time #Anxiety - Zoloft, Ativan PRN #Hyperlipidemia - Statin #Hypophosphatemia - Replace PO #HTN - stop lisinopril in setting of future nephrectomy #Ppx - ambulatory (no SC heparin as may interfere w surgery) #Full Code FINDINGS: [**Hospital **] Hospital Course - RADICAL NEPHRECTOMY Mr. [**Known lastname 59304**] was admitted to Urology after undergoing: 1. Open left radical nephrectomy with adrenalectomy. 2. Retroperitoneal lymph node dissection. 3. Resection of omental mass. 4. Resection of urachal cystic mass. 5. Sigmoid colectomy and small-bowel resection (Dr. [**Name (NI) 10065**] team). Intraperative findings included: Large renal mass with huge extension of mass anteriorly through colon mesentery involving colon and ileum. Omental mass. urachal mass. No concerning intraoperative events occurred; please see dictated operative note for details. The patient received perioperative antibiotic prophylaxis. The patient was transferred to the floor from the PACU in stable condition. On POD0, pain was well controlled on epidural, hydrated for urine output >30cc/hour, provided with pneumoboots and incentive spirometry for prophylaxis. His postoperative course was complicated by prolonged hospital stay and on [**12-20**] he had fever spikes so he was pan cultured. On [**12-20**] his NGT was d/c'd and he was ambulating and reporting flatus. On [**12-21**] he was advanced to clears and his foley and epidural were removed and then he was gradually restarted on his home medications. Basic metabolic panel and complete blood count were checked regularly, pain control was transitioned from epidural to oral analgesics, diet was advanced to a clears/toast and crackers diet. The remainder of the hospital course was relatively unremarkable. The patient was discharged in stable condition, eating well, ambulating independently, voiding without difficulty, and with pain control on oral analgesics. On exam, incision was clean, dry, and intact, with no evidence of hematoma collection or infection. The patient was given explicit instructions to follow-up in clinic with Dr. [**Last Name (STitle) 3748**] in 3 weeks. Medications on Admission: 1. Lisinopril 5 mg p.o. daily 2. sertraline 50 mg p.o. daily 3. simvastatin 80 mg p.o. daily 4. vicodin 5/500 prn pain Discharge Medications: 1. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever, pain. 5. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: PREOPERATIVE DIAGNOSIS: Locally advanced renal cell carcinoma invasive to surrounding organs. POSTOPERATIVE DIAGNOSIS: Locally advanced renal cell carcinoma invasive to surrounding organs. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -Please also refer to the provided written instructions on post-operative care, instructions and expectations made available from Dr. [**Last Name (STitle) 3748**]??????s office. -Resume your pre-admission/home medications except as noted. ALWAYS call to inform, review and discuss any medication changes and your post-operative course with your primary care doctor. Do not take Aspirin/aspirin containing products unless advised to do so by your doctors. -Please call and follow-up with your PCP [PAPANICOLAOU,[**Doctor Last Name 1955**] J. [**Telephone/Fax (1) 59868**]] to review your post-operative course and your medications and weather or not you should resume Lisinopril. You have NOT been restarted on your pre-admission Lisinopril 5 mg PO DAILY during this admission. -Do not lift anything heavier than a phone book (10 pounds) or drive until you are seen by your Urologist in follow-up -Call your Urologist's office today to schedule/confirm your follow-up appointment in 3 weeks AND if you have any questions. -Do not eat constipating foods for 2-4 weeks, drink plenty of fluids to keep hydrated -No vigorous physical activity or sports for 4 weeks or until otherwise advised -Tylenol should be your first line pain medication, a narcotic pain medication has been prescribed for breakthrough pain >4. Replace Tylenol with narcotic pain medication. -Max daily Tylenol (acetaminophen) dose is 4 grams from ALL sources, note that narcotic pain medication also contains Tylenol -If you have been prescribed IBUPROFEN (the ingredient of Advil, Motrin, etc.) , you may take this and Tylenol together (alternating) for additional pain control---please try TYLENOL FIRST and take the narcotic pain medication as prescribed if additional pain relief is needed. -Ibuprofen should always be taken with food. Please discontinue taking and notify your doctor should you develop blood in your stool (dark tarry stools) -You may shower normally but do NOT immerse your incisions or bathe -Do not drive or drink alcohol while taking narcotics and do not operate dangerous machinery -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool-softener, NOT a laxative -If you have fevers > 101.5 F, vomiting, or increased redness, swelling, or discharge from your incision, call your doctor or go to the nearest emergency room. Followup Instructions: -Call Dr.[**Name (NI) 11306**] office at ([**Telephone/Fax (1) 8791**] for follow-up AND if you have any urological questions. Dr. [**Last Name (STitle) 3748**]??????s Nurse Practitioner [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 22714**] may be reached at the same number. -Please call and follow-up with your PCP [PAPANICOLAOU,[**Doctor Last Name 1955**] J. [**Telephone/Fax (1) 59868**]] to review your post-operative course and your medications and weather or not you should resume Lisinopril. Your other upcoming appointments are listed here: Provider: [**First Name11 (Name Pattern1) 4224**] [**Last Name (NamePattern4) 4225**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2101-1-17**] 10:00 Completed by:[**2101-2-7**]

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icd9cm

[ [ [] ] ]

[ "54.3", "54.4", "40.3", "45.75", "55.51", "45.62", "03.90", "07.22" ]

icd9pcs

[ [ [] ] ]

9266, 9272

5572, 8489

331, 675

9508, 9508

4435, 5549

12145, 12901

3283, 3629

8659, 9243

9293, 9487

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4320, 4416

1935, 2505

266, 293

703, 1916

9523, 9635

2549, 2907

3007, 3267

30,112

159,590

28983

Discharge summary

report

Admission Date: [**2187-6-26**] Discharge Date: [**2187-7-2**] Date of Birth: [**2130-3-24**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [**2187-6-26**] - Coronary Artery Bypass Graft x 5 (LIMA to D2, SVG to LAD, SVG to D1, SVG to PDA with y-graft to PLB) History of Present Illness: 51 y/o male who was transferred from OSH in [**2187-5-24**] after sudden onset of chest pain with +Troponins. Underwent cardiac cath on [**6-5**] which revealed severe three vessel coronary artery disease. Past Medical History: Coronary Artery Disease, Paroxysmal supraventricular tachycardia, Gout, History of diverticulitis, Ileitis, Chronic anemia, Mild chronic renal insufficiency, Low grade myelodysplastic syndrome, Thyroid nodule, s/p tonsillectomy, s/p appendectomy, s/p right shoulder arthroscopy, Diabetes c/p peripheral neuropathy, Dyslipidemia, Hypertension Social History: significant for the absence of current tobacco use. He reports [**2-25**] glasses of scotch per day. Family History: There is + family hx of CAD, +MI in aunts Physical Exam: VS: 69 18 160/98 5'[**89**]" 270lbs Gen: NAD Skin: Unremarkable HEENT: EOMI PERRL NC/AT Neck: Supple, FROM, -JVD Chest: CTAB -w/r/r Heart: RRR -c/r/m/g Abd: Soft, NT/ND, +BS, obese Ext: Warm, well-perfused, 1+ edema NEuro: A&O x 3, MAE, non-focal Pertinent Results: [**6-26**] Echo: PRE-BYPASS: 1. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with anterior apical and anteroseptal hypokinesis. Overall left ventricular systolic function is low normal (LVEF 50-55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the descending thoracic aorta. 5. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 6. Physiologic mitral regurgitation is seen (within normal limits). 7. There is a trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine and is in sinus rhythm. 1. LV function is improved. RV function is unchanged. 2. Aorta is intact post decannulation. 3. Other findings are unchanged. [**2187-6-28**] CXR In comparison with the study of [**6-27**], there is again widening of the postoperative mediastinum. Atelectatic changes scattered throughout both lungs are again seen in this patient with low lung volumes. [**2187-7-2**] 07:23AM BLOOD WBC-9.6 RBC-2.86* Hgb-8.5* Hct-24.4* MCV-85 MCH-29.6 MCHC-34.7 RDW-16.6* Plt Ct-270 [**2187-7-2**] 05:20AM BLOOD Hct-24.9* [**2187-7-2**] 07:23AM BLOOD PT-31.9* INR(PT)-3.3* [**2187-7-1**] 06:00AM BLOOD PT-23.4* INR(PT)-2.3* [**2187-6-30**] 06:45AM BLOOD PT-15.6* INR(PT)-1.4* [**2187-7-2**] 05:20AM BLOOD UreaN-33* Creat-1.2 K-3.8 [**2187-7-1**] 06:00AM BLOOD Glucose-149* UreaN-34* Creat-1.1 Na-135 K-3.8 Cl-97 HCO3-28 AnGap-14 Brief Hospital Course: Mr. [**Known lastname 34989**] was a same day admit on [**2187-6-26**] and brought to the operating room where he underwent a coronary artery bypass grafting to five vessels. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and was extubated. On post-op day one he was started on beta blockers, a statin and aspirin. Later on this day he was transferred to the telemetry floor for further care. Chest tubes and epicardial pacing wires were removed per protocol. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. He had rapid atrial fibrillation for which he received amiodaorne and increased lopressor, as well as coumadin. He converted to NSR. He was ready for discharge home on POD # 6. Spoke with Dr. [**Last Name (STitle) 69858**] office who has agreed to assume coumadin management. Medications on Admission: Gemfibrozil 600mg [**Hospital1 **], Enalapril 10mg [**Hospital1 **], Novolog, Atenolol 25mg qd, Glipizide 10mg [**Hospital1 **], Avandia 2mg qd, Allopurinol 100mg [**Hospital1 **], Aspirin 325mg qd, Toprol XL 150mg qd, Lipitor 80mg qd, Darvocet prn Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 5. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 6. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 7. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*1* 8. Rosiglitazone 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 9. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 10. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 5 days: for 5 days until [**7-7**]; then 200 mg [**Hospital1 **] for 7 days until [**7-14**], then 200 mg daily ongoing. Disp:*100 Tablet(s)* Refills:*1* 13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 weeks. Disp:*14 Tablet(s)* Refills:*0* 14. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 15. Warfarin 2 mg Tablet Sig: one-half Tablet PO ONCE (Once) for 1 days: 1 mg today only [**7-2**], then daily dosing per Dr. [**Last Name (STitle) **]. Disp:*50 Tablet(s)* Refills:*1* 16. Dipentum 250 mg Capsule Sig: One (1) Capsule PO three times a day. Disp:*90 Capsule(s)* Refills:*1* 17. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 7 days. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 18. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension Sig: 7 units in AM/9 units in PM Subcutaneous twice a day. Disp:*qs 1 month* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: CAD s/p CABGx5 PSVT Anemia Myelodysplastic syndrome Thyroid nodule Type II diabetes HTN Hyperlipidemia history of diverticulitis/ileitis Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Call with any questions or concerns. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**] Please follow-up with Dr. [**Last Name (STitle) 5686**] in 2 weeks. Please follow-up with Dr. [**Last Name (STitle) **] in [**1-24**] weeks. Please call all providers for appointments Completed by:[**2187-7-2**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

7030, 7088

3261, 4329

331, 451

7269, 7275

1510, 3238

8018, 8326

1185, 1228

4628, 7007

7109, 7248

4355, 4605

7299, 7995

1243, 1491

281, 293

479, 686

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1067, 1169

3,866

186,508

48960

Discharge summary

report

Admission Date: [**2132-3-11**] Discharge Date: [**2132-4-28**] Date of Birth: [**2084-5-28**] Sex: M Service: MEDICINE Allergies: Codeine / Enalapril Attending:[**First Name3 (LF) 2641**] Chief Complaint: HA x 2 days Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname **] is a 47 year old man s/p renal transplant (06/??????03) secondary to amyloid, who felt the onset of a frontal headache 3 days prior to admission. He also noted diarrhea, malaise, and pains in his back and legs. He decided to come for evaluation when he failed to improve at home. At the ED, he was seen by ENT after his sinus CT showed chronic sinusitis. A chest x ray showed RUL pulmonary consolidation. Chest CT showed no change but confirmed changes from aspergilloma. Mr. [**Known lastname **] received a renal transplant in ??????03 which was later showing signs of rejecion and was diagnosed with collapsing glomerulonephritis with worsening renal function. Over the last few months, he was admitted several times for hyperkalemia, acute renal failure with baseline creatinine [**5-6**], and acidosis. Pt on admission noted feeling very fatigued which is the similar complaint on previous admission with hyperkalemia. Patient is also on immunosuppressant medications for his post renal management. In the ED, the patient??????s potassium level was recorded as 5.8; he received kayexalate. Mr. [**Known lastname **] was admitted to the floor for the further management of his infections and electrolyte imbalances. ROS: negative for cough, photophobia, phonophobia, emesis, fevers, chills Past Medical History: 1. ESSRD s/p transplant on [**7-4**] now collapsing glomerulonephritis 2. Amyloidosis 3. Sarcoidosis 4. Hx of pulmonary aspergillosis 5. Hx of hyperkalemia 6. Hep B, C, D 7. HTN 8. Hx of IV drug use 9. sinusitis requiring drainage Social History: Lives with girlfriend, on disability; 1 packper day x30 years of tobacco use, still currently smoking.No alcohol, but previous history of abuse. Family History: Diabetes Physical Exam: VS: T 97.5 BP 1740/98 P 104 RR 16 O2 sat 98% on RA Gen: thin AA man, looks very uncomfortable, lying in fetal position on stretcher, HEENT: dry MM, bilateral proptosis, facial edema, PERRLA, conjunctiva injected, neck supple Lungs: CTA bilaterally Cor: tachycardic, regular rhythm no murmurs/rubs/gallops Abd: NTND, transplanted kidney palpable and nontender Ext: no edema, 2+ DP, strength 5/5 lower extremities Pertinent Results: Admission Labs: [**2132-3-11**] 09:30AM GLUCOSE-175* UREA N-73* CREAT-7.2* SODIUM-137 POTASSIUM-4.9 CHLORIDE-108 TOTAL CO2-19* ANION GAP-15 [**2132-3-11**] 09:30AM CALCIUM-9.3 PHOSPHATE-7.5* MAGNESIUM-2.6 [**2132-3-11**] 09:30AM FK506-18.4 [**2132-3-11**] 09:30AM URINE HOURS-RANDOM UREA N-379 CREAT-56 SODIUM-64 [**2132-3-11**] 09:30AM URINE OSMOLAL-339 [**2132-3-11**] 09:30AM WBC-14.7* RBC-3.95* HGB-12.4* HCT-37.3* MCV-94 MCH-31.5 MCHC-33.4 RDW-13.5 [**2132-3-10**] 09:36PM LACTATE-1.7 Head CT: No intracranial hemorrhage. Obviously, lumbar puncture with cytological analysis is necessary to exclude microscopic quantities of hemorrhage as well as to determine whether a meningeal infection is present. CXR: There has been interval development of a large area of right upper lobe consolidation. The mediastinum also appears more widened than on the prior examination. The right hilar adenopathy and left apical pleural thickening and scarring are again demonstrated Cardiac silhouette appears within normal limits. CT OF THE CHEST WITHOUT IV CONTRAST: At the left apex, again seen are soft tissue density opacities with crescentic segments of air with adjacent parenchymal reaction consistent with semi-invasive aspergellosis, which is not significantly changed from the prior study of [**2131-6-29**]. There are bilateral ground glass opacities, with calcified mediastinal and bilateral calcified lymph nodes, as well as fibrotic changes at both lung apices consistent with patient's history or sarcoidosis. There are no pleural effusions. There is no pneumothorax. The airways are patent at the level of the segmental bronchi bilaterally. No paracardial effusions are seen. There are coronary artery calcifications seen. A few images through the abdomen demonstrate some calcifications in the left renal artery. SINUS CT: Mucosal thickening and opacification of the paranasal sinuses, with bony changes consistent with prior history of chronic sinus disease and prior surgery. These findings are not significantly changed in comparison to prior study. CXR: An endotracheal tube and nasogastric tube remain in satisfactory position. Calcified mediastinal and bilateral hilar lymph nodes are stable. There has been interval increase in right pleural effusion, which is freely layering on the supine radiograph. Bilateral areas of apical pleural thickening appears stable. A hazy area of pulmonary opacification in the right upper lobe is considered stable allowing for differences in technique, and has previously been attributed to an improving area of pneumonia. CT ABDOMEN W/CONTRAST [**2132-3-25**]: 1) No definite intra-abdominal abscess. 2) Progression of the markedly abnormal small bowel and ascending colon with dilatation and wall edema. There is no definite transition point, and these findings are consistent with peritonitis. 3) Decreased amount of the interperitoneal air and ascites makes bowel perforation much less likely. 4) Gallbladder wall edema, which can be correlated with the recent ultrasound. 5) Bilateral pleural effusions and bibasilar atelectasis. 6) Low attenuation regions in the liver, which could represent fatty infiltration. Brief Hospital Course: Mr [**Known lastname **] is 45 yo man with MMP including failed Kidney transplant on HD [**3-5**] amyloid, h/o sarcoid, Hep B/C/D, h/o pulm asperigillosis, HTn, chronic sinusitis and h/o IVDU who originally presented on [**3-10**] with frontal HA times 2 days with back pain, malaise and diarrhea originally admitted to medical service with suspected PNA. Pt with long and complicated medical course over 6 weeks inculding being on medical service twice, surgical service and SICU stay. This discharge summary is being composed by the second medical service and details his stay after being transferred back from surgery. Surgical course as per Dr [**Last Name (STitle) 33863**] and I will attempt to outline medical course on admission as I was not the primary team; any questions may be adressed to Dr [**Last Name (STitle) 102810**]. MEDICAL COURSE Mr. [**Known lastname **] was initially admitted with fevers and cough with evidence of sinusitis and pneumonia. His cultures eventually grew Strep Pneumoniae and so he was initially treated with Unasyn/Azithro and this was then tailored to levofloxacin for a 14 day course. Since his cultures all remained negative for MRSA his vancomycin was eventually discontinued. Other issues included Atrial fibrillation with an echocradiogram showing a preserved Lv but evidence of an enlarged atrium. He was rate controlled with a beta blocker and with diltiazem as no other combinations appeared to work. He reverted to sinus rhythm. Attempts were made at starting heparin for anticoagulation but he kept having significant nosebleeds and so this was stopped with instead the plan to start low dose coumadin as an outpatient. He was noted to be guiaic positive before even teh noseblled started and so an EGD was done to rule out PUD on chronic steroids. This did not reveal significant disease. With respect to his renal failure his renal function continued to decline indicating failure of his transplant. He has known significant thrmobosis and narrowing of his chest vessels and so we consulted IR to see if any access was left. They felt that given the risk of sharp cannulation in teh chest we should proceed with either a leg access catheter or a PD catheter and arrangements were made for him to undergo PD catheter placement. On day of surgery he was oxygenating well, felt well with a normal exam, and was anxious to go home. SURGICAL COURSE After informed consent was Obtained, he was brought to the operating room and was placed On the operating table in the supine position. MAC Anesthesia was performed. An area on the right side of the Patient’s abdomen was identified, and he was prepped and Draped for placement of peritoneal dialysis catheter. One Percent lidocaine was used to infiltrate the skin overlying The insertion site of the catheter. A skin incision was made With a 15 blade scalpel. At this time, the patient began Having desaturations and difficulty maintaining his airway. This was precipitated by placement of nasal trumped by anesthesia and subsequent bleeding after. The procedure was aborted. A Respiratory code was called at this time, a direct laryngoscopy intubation was performed. The patient appeared to have suffered an epistaxis event and during the sedation Process was unable to clear his airway, resulting in airway Obstruction and desaturation. Once the endotracheal tube was Placed, then the position was confirmed with direct Auscultation of the chest as well as with end tidal CO2. The patient's saturations increased to 100 percent. He was Suctioned for a minimal amount of blood in his airways, and An orogastric tube was also placed, with very minimal blood Returned from his gastric cavity. The patient was Transferred to the surgical intensive care unit in stable Condition. The next day a second placement peritoneal dialysis catheter was attempted. The patient was taken to the Operating Room where general endotracheal anesthesia was maintained. SICU COURSE Once stable overnight, he was kept intubated and returned to the operating room the next day to place the catheter. Preoperative antibiotics were checked and had been administered. A 4 cm incision was made lateral to the umbilicus and taken down to expose the anterior rectus sheath. This was incised and the rectus muscle was split revealing the posterior sheath. This was incised and a hole was made in the peritoneum. The perineal dialysis catheter was placed and immediately on placing it, purulent material came out. This was sent for a stat gram stain, which demonstrated 3 plus polys but no organisms. Given this finding it was clear that the peritoneal dialysis catheter should not be placed at this time, however, there was the concern about some intra-abdominal pathology causing this problem. We then proceeded to an extensive exploratory laparoscopy including direct visualization of the liver which appeared nodular and possibly cirrhotic, the gallbladder which appeared normal and was easily distensible, the bowel looked normal. The pancreas was not visualized. There was a small amount of purulent fluid throughout the abdomen. The choice at this time was to do a full laparotomy for more definitive look, however I thought that in a patient with hepatitis C, possible cirrhosis, renal failure and the rest of his comorbidities that the risks of this procedure outweighed the benefits. In the ICU a CT scan of the abdomen with IV and Po contrast was done the same day. The finding were consistent with no evidence of intra-abdominal abscess. lab workup was consistent with a pancreatitis. ON CT a right femoral venous line was seen with the tip of the line located in the ascending lumbar vein branch. If the position desired is the common iliac vein, recommend withdrawal of this line 2-4cm. Pancreatic enzymes where send found to be elevated( lipase 3000's-[**3-21**]) and AST 1200/ALT 500([**3-23**]) While in SICU, volume controlled with CVH (started [**3-22**]). For persistent fevers, ABx regimen changed to include Vanc/Zosyn/Fluc ([**3-23**]) empirically. The etiology of his pancreatitis was never elucidated - perhaps related to his GI procedure or perhaps due to his excessive drinking in the day PTA. Patient remained intubated for the next 3 weeks for airway protection. Due to recurrent bleeding after ENT removed the nasal blaoon placed with need of immediate replacement 2 times prior to extubation; he underwent fiberoscopic eval of his nasopharynx without visualization of his source of bleed. He was fluid overload, due to delay in dialysis and intraop fluid replacement. Had no leak for the first 2 weeks. Patient was extubated without complications. Patient was always found to be confused especially at night pulled his picc line twice, his feeding tube 3 times and His dialysis catheter on [**4-5**]/5. AFTER PERM CATH WAS PLACED WITH OUT COMPLICATION PATIENT WAS TRANSFERRED TO MEDICINE. Medical Course: On the medical service his issues remained as follows until discharge: 1) ESRD: Pt with h/o ESRD [**3-5**] amyloidosis s/[**Name Initial (MD) **] failed CRT originally being immunosupressed with FK506 and prednisone. Pt followed closely by the renal transplant unit here at [**Hospital1 18**]. After SICU stay, surgical service placed a tunneled right femoral HD catheter and HD started. Prior to which Pt underwent CVH. Pt tolerated HD well without complication. However HD catheter displaced twice and replaced by IR. During which, angiographic evidence of Iliac DVT seen (see below for plan). Pt maintained on HD 3times daily. Pt discharged home with tunnelled femoral HD catheter. But he would benefit from PD catheter in future once recovered from this long hospital course. 2) ID: Pt with complex history as detailed above, but included sinusitis, PNA and purulent ascites. All of which were properly treated and seemingly resolved. After transfer pt had one episode of low grade fever (100.4) prompted evaluation for possible infectious sources. Pt started on Vancomycin and Ceftazidine empirically and in part due to positive urinalysis. CXR without PNA. CDiff came back positive and Flagyl added to antibiotic regimen. Pt remained afebrile and without leukocytosis. As BCx and UCX remained without growth, ABx scaled back to flagyl only to be continued for an additional 10 day course at Rehab. This will complete on [**5-8**]. 3) MS changes: As per notes, there was evidence that Mr [**Known lastname **] was sufferring from delerium and confusion most likely secondary to uremia during initial hospitalization. As Pt was extubated in SICU, he remained confused and agitated. He was slow to improve over the next 3 weeks and was still with evidence of baseline confusion, but obviously improved. Etiology of continued mental status changes unclear, but likely multifactorial including uremia, prolonged SICU stay, periods of hypoperfusion and possible hypoxia. Pt seen and evaluated by neurology service who agreed with assesment and saw no acute neurologic process. MRI obtained and reviewed which again showed evidence of old ischemic changes and increased signal in globi pallidi which could reflect metabolic abnormality. There was no evidence of acute infarction or any granulomatous masses. Lumbar puncture performed which ruled out possible infectious origins; as it was completely normal including opening pressure. Believed Pt will comtinue to slowly improve with maximum supportive care and has his health improves i.e. nutritional/functional status so will his mental status. Follow up with neurology as outpatient may be indicated if mental status change ceases to improve. 4) VTE: Pt with known history of extensive UE venous thrombosis. Later in course Pt found to have LE DVT while having femoral HD catheter replaced. During which the inferior venacavagram demonstrated a patent IVC. Venagram performed in the right iliac vein demonstrated thrombus surrounding the catheter within the common iliac, external iliac, and common femoral veins, with no significant venous flow around the thrombus. Flow was seen in the IVC from a patent left iliac vein. Catheter was replaced without difficulty. Pt without signs of clot propagation or extension. In an ideal situation, Mr [**Known lastname **] would have been fully anti-coagulated yet this was not felt to be without risk: his history of severe epistaxis requring intubation for airway protection and balloon tamponade. IVC filter not reasonable [**3-5**] high risk of thrombosis which would eliminate any chance of hemodialysis in future. Decsion made considering the risks of rebleeding vs continued thrombosis with input from Renal to anticoagulate with low dose coumadin for goal INR 1.5-2.0. He will required daily inr's and coumadin adjustments accordingly. He will need outpt f/u w/ coumadin clinic after dc/'d from rehab. 5) Pancreatitis: During SICU stay, Pt with ASx pancreatitis (Lipase 3000's) of unclear etiology but believed secondary to propofol. Pt placed on bowel rest and given TPN. Pancreatitis slowly resolved as Lipase trending down slowly during course of admission. Diet was advanced and tolerated well without pain or increased pancreatic enzymes. 6) Hepatitis: Pt with h/o Hep B,C,D without evidence of decompensated liver failure. LFts normal at admission, however elevated during SICU stay precipitated by hypotension and presumed shock liver. LFTs trended down and never with evidence of decreased synthetic function. 7) Nutrition: Mr [**Known lastname **] obviously sufferring from malnutrition secondary to prolonged hospitalization and poor PO. Pt tolerated PO but consumed little without encouragement. Pt on TPN for a good portion of admission. Unfortunately unable to get PICC secondary to UE thrombosis, so TPN could not be continued. Please give boost supplements with meals. 8) positive spep/upep: In w/u for hypercalcemia, found w/ elevated IGG on spep and [**Last Name (un) **] [**Last Name (un) **] proteins on upep. Has had elevated IgG spike from past SPEPS. He does not have previosu ct's or imaging showing bony erosion. In speaking w/ oupt renal and intpatient primary team, it was felt that further w/u could be done as outpt and for this reason, given number for hematology/oncology. 9) pulmonary aspergillus: continued on antifungals. Has oupt f/u appt w/ dr. [**Last Name (STitle) **] from id on [**5-22**]. Medications on Admission: 1. Tacrolimus 1 mg b.i.d. 2. Prednisone 5 mg q.d. 3. Itraconazole 200 mg b.i.d.. 4. Bactrim single strength 400/80 q.d. 6. Lisinopril 5 mg q.d. 7. Kayexalate 30 mg twice/week 8. Bicarb 650 [**Hospital1 **] 9. nephrocaps 10. lasix Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Itraconazole 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 3. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime for 1 doses: Please give 5 mg on night of [**2132-4-28**], then change to 3 mg. . Disp:*30 tabs* Refills:*2* 5. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*0* 6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Coumadin 3 mg Tablet Sig: One (1) Tablet PO at bedtime: please start on [**2132-4-29**]. Please adjust dose based on daily INR checks. (Goal INR 1.5-2.0). 8. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 9. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 10 days: to complete on [**5-8**]. 11. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day): please alternate with lopressor dose. 12. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day): hold for SBP<100, HR<60. 13. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 16. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-3**] Sprays Nasal QID (4 times a day). 17. Outpatient Lab Work please arrange for daily inr to be checked. Goal INR is 1.5 to 2.0. He will receive 5 mg coumadin [**4-28**] and then 3 mg following. Please check inr daily as above. Discharge Disposition: Extended Care Discharge Diagnosis: pancreatitis Lower extremity deep venous thrombosis epistaxis sinusitis pneumonia paroxysmal atrial fibrillation end stage renal disease on HD, s/p kidney transplant [**2130**] h/o aspergillosis, on itraconazole Cdiff Discharge Condition: Good Discharge Instructions: Please return to the hospital or see your primary care physician if you experience bleeding, chest pain, shortness of breath, fevers >100.4, or any other concerns. Please also return for recurrent epistaxis. Followup Instructions: The following appointments have been scheduled for you: 1. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] (TRANSPLANT) TRANSPLANT CENTER-MEDICINE Where: LM [**Hospital Unit Name 5628**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2132-5-22**] 2:30 2. Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2132-6-9**] 3:40 Please call [**Hospital6 733**] at [**Telephone/Fax (1) 250**] to set up an appoitment with a primary care physician after you are discharged. Please schedule an appointment at the [**Hospital **] Clinic ([**Telephone/Fax (1) 22**]) Contact information for the Anticoagulation Management Service (Goal INR 1.5-2.0): [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 102811**], [**Hospital **] [**Hospital3 **] [**Telephone/Fax (1) 10844**] 5. PLease call the Oncology Office at [**Telephone/Fax (1) 39833**] tomorrow [**4-29**] for arranging for appt in several weeks for SPEP/UPEP

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icd9cm

[ [ [] ] ]

[ "88.51", "96.04", "96.72", "39.95", "54.21", "48.24", "45.25", "03.31", "45.16", "00.17", "38.93", "21.09", "38.95", "96.6", "99.15", "86.09" ]

icd9pcs

[ [ [] ] ]

20396, 20411

5747, 18160

292, 299

20673, 20679

2539, 2539

20937, 22007

2082, 2092

18440, 20373

20432, 20652

18186, 18417

20703, 20914

2107, 2520

241, 254

327, 1650

3051, 5724

2555, 3042

1672, 1904

1920, 2066

17,478

194,615

3217

Discharge summary

report

Admission Date: [**2199-12-12**] Discharge Date: [**2199-12-19**] Date of Birth: [**2146-1-19**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: CABGx3, LIMA to LAD, SVG to OM, SVG to PDA History of Present Illness: 53 year old man w/ hx of: RCA and Cx stenting [**2189**] complicated by abrupt closure of both vessels/MI-> repeat PCI. Last cathed at [**Hospital1 18**] [**12-19**] and found to have 3vd- 80% RCA, 70% pLAD, 80% cx, 90% OM2. No intervention done at that time. Was not CABG candidate at that time due to carotid disease. Carotid angio in [**12-19**] with significant disease bilaterally but not treated. . Had a fight with his wife on night of presentation to OSH. Threw milk at his wife. [**Name (NI) 15068**] were called, and he was handcuffed and dragged down stairs, at which time he had chest pain. States that he has been having exertional CP x 1 mo when climbing stairs. Describes pain as sharp, radiation up to L jaw and down L arm. Relieved with rest after several minutes up to 1 hour. Occas CP at rest. . PTCA at OSH again showed 3vd, transferred to [**Hospital1 18**] for possible CABG. Ruled out at OSH. Past Medical History: CAD, S/P RCA & Cx stenting in '[**89**] carotid artery stenosis PVD hyperlipidemia + tobacco insulin dependent diabetes (dx'ed when 35 y/o) claudication retinopathy LE/right hand neuropathy hx of severe back pain, herniated disc bipolar D/O h/o TIAs Social History: Previously employed as brick layer. Quit smoking in [**2180**]. Family History: non-contrib Physical Exam: VS - T 98.6, BP 156/75, HR 59, RR 22, PO 96% RA gen - comfortable, NAD HEENT - MMM, OP clr, bilat carotid bruits CV - RRR, no m/r/g chest - CTAB anteriorly abd - obest, soft, NT ext - R groin catheter sheath intact, distal pulses 1+, extremities warm neuro - non-focal Pertinent Results: Cardiac cath ([**2199-12-12**]): 1. Selective coronary angiography of this right dominant system revealed three vessel disease. The LMCA was a short, ectatic vessel with no apparent flow-limiting lesions. The proximal LAD was mildly calcified with a tubular 60% stenosis. There was nild diffuse disease in the remainder of the LAD. The LCX had an eccentric 80-90% stenosis at its origin and was mildly diffusely diseased for the rest of its course. OM1 had mild diffuse disease and a 60% stenosis at its origin. The dominant RCA had an 80% stenosis in its proximal segment, a 90% stenosis in its mid segment, and a 90% stenosis in its distal segment prior to the crux. There was TIMI 2 flow into a PDA with mild diffuse disease. 2. Limited resting hemodynamics revealed severely elevated left sided filling pressures (LVEDP 35 mmHg). Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2199-12-12**] for further management of his worsening shortness of breath. He was taken to the catheterization lab where he was found to have a short calcified left main coronary artery, 70% stenosed proximal left anterior descending artery, and a 60% stenosed dominant proximal right coronary artery and a distal 90% stenosis of the same artery, his left circumflex artery had a 90% eccentric lesion. Given the severity of his disease, the cardiac surgical service was consulted for surgical revascularization. He was worked-up in the usual preoperative manner. On [**2199-12-13**], Mr. [**Known lastname **] was taken to the operating room. CABG was performed, LIMA to LAD, SVG to OM, SVG to PDA. He was on Cardiopulmonary bypass for 67 minutes and cross clamped for 52 minutes. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day (POD) one, he awoke neurologically intact and was extubated. On POD 2 His pressors were weaned and he was transferred to the cardiac stepdown unit. Beta blockade, plavix, coumadin thromboembolism prophylaxis, and aspirin were resumed. He was gently diuresed towards his preoperative weight. On POD 3 chest tubes, and epicardial wires were removed. The physical therapy service was consulted to assist him with postoperative strength and mobility. His oxygen saturations improved to 100% on room air. Social work was consulted regarding assessment of needs and availability of verteran resources after discharge to assist with psychosocial issues. Case management was consulted regarding placement of Mr. [**Known lastname **] in a Veterans homeless shelter due to domestic issues with his spouse. [**Name (NI) **] was discharged with an INR of 2.6 after Coumadin 7.5mg for four daily doses. His INR and coumadin dosage will be followed by Dr. [**Last Name (STitle) 15069**], PCP. [**Name10 (NameIs) 269**] arrangements were made for drawing his INR on [**2198-12-20**] and results to be called in to the PCP. [**Last Name (NamePattern4) **]. [**Known lastname **] was discharged to home in good condition on POD 6 with sternal precautions, cardiac/diabetic diet, and follow up with his PCP and cardiologist in [**12-16**] weeks. Medications on Admission: 70/30 insulin 70U QAM, 30 QPM Plavix 75 QD Neurontin 300-300-900 TID Atenolol 25 QD Protonix 40 QD coumadin 7 QAM B12 suppl folate QD clonazepam 0.5 TID PRN SL Nitro PRN Percocets PRN Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. 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. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed. Disp:*30 Tablet(s)* Refills:*0* 11. Coumadin 7.5 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* 12. Gabapentin 300 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 13. Gabapentin 300 mg Tablet Sig: Three (3) Tablet PO at bedtime. Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] [**Hospital1 269**] Discharge Diagnosis: CAD, HTN, hypercholesteremia, h/o TIA, IDDM, GERD, Chronic pain syndrome, PVD, colon polyps, diverticulosis Discharge Condition: good Discharge Instructions: Shower, wash incisions with mild soap and water and pat dry. No lotions, creams or powders to incisions. Call with fever >101.5, redness or drainage from incision, or weight gain more than 2 pounds in one day or five pounds in one week. No lifting more than 10 pounds for 10 weeks. No driving until follow up with surgeon. Followup Instructions: Dr. [**Last Name (STitle) **], in four weeks [**Telephone/Fax (1) 170**] Dr. [**Last Name (STitle) 6700**] in [**12-16**] weeks [**Telephone/Fax (1) 3183**] Dr. [**Last Name (STitle) **] in [**12-16**] weeks [**Telephone/Fax (1) 3183**] Completed by:[**2199-12-19**]

[ "429.9", "250.00", "440.21", "562.10", "530.81", "401.9", "211.3", "414.01", "296.80" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6941, 7012

2869, 5172

331, 376

7164, 7171

2010, 2846

7543, 7812

1693, 1706

5406, 6918

7033, 7143

5198, 5383

7195, 7520

1721, 1991

284, 293

404, 1322

1344, 1596

1612, 1677

31,392

118,870

34445

Discharge summary

report

Admission Date: [**2115-8-4**] Discharge Date: [**2115-8-28**] Date of Birth: [**2039-1-16**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 148**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [**8-4**] s/p ex-lap, SB resection (5ft, ileocecal valve spared), G-tube, [**State 19827**] patch closure [**8-6**] s/p reconnected [**8-8**] s/p wash-out [**8-12**] s/p abdominal wound closure History of Present Illness: This is a 76M p/w 2 wk h/o abdominal pain @ OSH, found to have SMV/Mesenteric vein thrombosis on CT, admitted to OSH ICU for resuscitation. He was stable but then deteriorated and a follow-up CAT scan on the day of transfer indicated that there was portal venous air, as well as possible pneumatosis intestinalis. He also had a mental status changes which were attributed to delirium tremens, but may have been the first signs of sepsis. Mr. [**Known lastname 3776**] upon his arrival to our SICU and found a gentleman with a distended abdomen with the bladder pressure of 29. He had a firm abdomen and his bile chemistries were suggestive of dead bowel. Past Medical History: (1) Lower extremity DVT treated with coumadin 9 years ago (2) hyperlipidemia Social History: lives w/ his wife [**Name (NI) **] in [**Name (NI) 1562**]. Of Italian descent. non-smoker x50 yrs, 10 ppy hx prior to that. Drinks 1-3 glasses of wine a day. No illegal or illicit drug use. Father and mother died of old age. Has 3 sisters and 1 brother, all in good health. No history of cancer, thrombophilia, or hemophilia in family. Physical Exam: HR 94 BP 140/74 97% SpO2 on vent Gen: sedated and intubated CV: Pulm: Abdomen: distended, tympanitic Ext: SCD's in place Pertinent Results: [**2115-8-4**] 08:41PM BLOOD WBC-4.1 RBC-3.85* Hgb-13.1* Hct-37.5* MCV-97 MCH-33.9* MCHC-34.8 RDW-12.7 Plt Ct-165 [**2115-8-12**] 11:18PM BLOOD WBC-12.5* RBC-3.55* Hgb-11.5* Hct-33.3* MCV-94 MCH-32.3* MCHC-34.4 RDW-14.6 Plt Ct-283 [**2115-8-18**] 09:10AM BLOOD WBC-9.0 RBC-3.23* Hgb-10.2* Hct-30.2* MCV-94 MCH-31.5 MCHC-33.7 RDW-15.0 Plt Ct-397 [**2115-8-21**] 06:20AM BLOOD PT-30.0* INR(PT)-3.1* [**2115-8-18**] 09:10AM BLOOD Glucose-124* UreaN-25* Creat-0.8 Na-141 K-4.0 Cl-111* HCO3-23 AnGap-11 [**2115-8-4**] 08:41PM BLOOD ALT-45* AST-74* LD(LDH)-221 AlkPhos-53 Amylase-35 TotBili-1.5 [**2115-8-11**] 02:54PM BLOOD ALT-44* AST-52* AlkPhos-147* TotBili-0.8 [**2115-8-4**] 08:41PM BLOOD Lipase-25 [**2115-8-19**] 02:30AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2115-8-18**] 09:10AM BLOOD Calcium-7.7* Phos-2.8 Mg-2.0 . SPECIMEN SUBMITTED: small bowel. DIAGNOSIS: Small bowel segments, two: 1. Focal hemorrhagic infarction of the mucosa. 2. Organizing venous thrombi in the mesentery. 3. Focal mucosal hemorrhage of the margins of larger segment. Clinical: Small bowel obstruction. . Radiology Report BILAT LOWER EXT VEINS PORT Study Date of [**2115-8-6**] 12:57 PM IMPRESSION: No evidence of DVT in the right or left lower extremity. . Radiology Report CHEST (PORTABLE AP) Study Date of [**2115-8-11**] 4:42 AM CHEST, SINGLE AP VIEW. An ET tube is present, tip approximately 3.3 cm above the carina. A right IJ central line is present, tip over distal SVC. An NG tube is present, tip extending beneath diaphragm off film. There is upper zone redistribution, with slight peribronchial cuffing, but no other evidence of CHF. There is increased retrocardiac density consistent with left lower lobe collapse and/or consolidation. There are small bilateral effusions and atelectasis at the right base. Compared with [**2115-8-9**], I doubt significant interval change. However, the degree of left lower lobe collapse and/or consolidation has progressed compared with [**2115-8-5**]. . Cardiology Report ECG Study Date of [**2115-8-17**] 11:26:32 AM Sinus rhythm with ventricular premature beats and couplets. Compared to the previous tracing of [**2115-8-13**] the findings are similar. TRACING #1 Read by: [**Last Name (LF) **],[**First Name3 (LF) **] D. Intervals Axes Rate PR QRS QT/QTc P QRS T 106 122 76 376/456 58 17 18 . [**Known lastname **],[**Known firstname **] [**Medical Record Number 79177**] M 76 [**2039-1-16**] Cardiology Report ECG Study Date of [**2115-8-19**] 10:12:08 AM Sinus rhythm with ventricular premature beats. Prolonged Q-T interval. Compared to the previous tracing of [**2115-8-18**] the findings are similar. Read by: [**Last Name (LF) **],[**First Name3 (LF) **] V. Intervals Axes Rate PR QRS QT/QTc P QRS T 85 126 84 [**Telephone/Fax (2) 79178**] 39 . MICRO [**2115-8-19**] All BLOOD CULTURE CATHETER TIP-IV MRSA SCREEN SPUTUM STOOL SWAB URINE [**2115-8-19**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [**2115-8-18**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [**2115-8-18**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2115-8-18**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2115-8-17**] CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT [**2115-8-17**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [**2115-8-17**] URINE URINE CULTURE-FINAL INPATIENT [**2115-8-12**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2115-8-12**] SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL INPATIENT [**2115-8-12**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2115-8-11**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {ENTEROBACTER AEROGENES} INPATIENT [**2115-8-6**] SWAB GRAM STAIN-FINAL; FLUID CULTURE-FINAL; ANAEROBIC CULTURE-FINAL INPATIENT [**2115-8-6**] SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL INPATIENT [**2115-8-5**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2115-8-5**] SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL INPATIENT [**2115-8-5**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2115-8-5**] SWAB GRAM STAIN-FINAL; WOUND CULTURE-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE}; ANAEROBIC CULTURE-FINAL INPATIENT . Radiology Report CTA ABD W&W/O C & RECONS Study Date of [**2115-8-26**] 11:16 AM IMPRESSION: 1. Nonocclusive thrombus in the SMV/portal vein confluence and in the portal vein and occlusive thrombus in the distal SMV and one of its branches. 2. Extensive pneumatosis intestinalis of the ileal segments which are abnormally distended and fluid filled. 3. No free air is seen in the abdomen or pelvis. 4. Mesenteric congestion and edema along with free fluid in the abdomen. 5. Bilateral pleural effusion. 6. Right liver dome hemangioma. 7. Degenerative changes. . BASIC COAGULATION PT INR(PT) [**2115-8-28**] 06:10AM 25.0* 2.4* [**2115-8-27**] 10:55AM 33.9 [**2115-8-27**] 06:10AM 25.3* 2.5* [**2115-8-26**] 06:25AM 25.7* 2.5* Brief Hospital Course: He now presents with a recent history of abdominal pain over the last few days and was analyzed and treated for this at [**Hospital 1313**] Hospital where a superior mesenteric vein thrombosis was identified. He was stable but then deteriorated and a follow-up CAT scan on the day of transfer indicated that there was portal venous air, as well as possible pneumatosis intestinalis He was admitted to the ICU and went to the OR for the following: [**2115-8-4**] 1. Exploratory laparotomy. 2. Resection of small bowel without anastomosis. 3. Gastric tube placement. 4. [**State 19827**] patch temporary abdominal wall closure. . [**2115-8-6**] 1. Relook laparotomy. 2. Enteroenterostomy. 3. Tightening of [**State 19827**] patch abdominal wall closure. . [**2115-8-8**] Re-look laparotomy (planned . [**2115-8-12**] 1. Re-exploration of a recent laparotomy (planned). 2. Ventral hernia repair. 3. AlloDerm mesh placement. He was extubated and transferred to the floor. Pain: His pain was well controlled with a PCA, he was then switched to PO pain meds. CV: Frequent PVC's. Otherwise stable with no chest pain. Resp: His O2 was weaned and he continued with IS and pulmonary hygiene. GI/ABD: He continued with tubefeedings. He passed his swallow evaluation and his diet was slowly advanced. He reported frequent, loose stool. C.diff was negative x 3. His tubefeeding formula was changed and Imodium was added. It is OK to wean tube feeds as patient tolerates more PO's. His bowel movements were less frequent and better consistency. His Abdomen had a wound VAC. The white foam was placed over the Alloderm and then black sponge was placed overtop. His next VAC change is Thursday [**2115-8-29**]. Impairment in Skin Integrity-coccyx pressure ulcer: Continue with wound care nursing recs. Heme: Due to hx of LLE DVT in [**2109**] who p/w acute superior MVT resulting in bowel ischemia, now s/p ex lap w/ SB resection and re-anastamosis. Patients w/ acute MVT are usually anticoagulated for 3-6 months if no etiology of the thrombosis is discovered. However, the etiology of the patient's thrombosis is currently unclear and could be acquired (neoplasm, myeloproliferative disorder) or inherited. In addition, given this patient's hx of previous DVT and now SMV thrombosis, it would be prudent to start an inherited coagulopathy work-up while in-hospital. Recommend anti-coagulation w/ Coumadin for 6 months with therapeutic INR of 2.5-3.5. Activity: He needs additional PT for stability and conditioning. Medications on Admission: lipitor Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. 2. Brinzolamide 1 % Drops, Suspension Sig: One (1) Ophthalmic TID (3 times a day). 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 5. Artificial Tear with Lanolin Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 6. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. 7. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day). 8. Psyllium Packet Sig: One (1) Packet PO BID (2 times a day). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day: Monitor INR. Goal INR 2.5-3.5. Adjust dose accordingly. Discharge Disposition: Extended Care Facility: [**Location (un) **] [**Hospital1 1562**] Discharge Diagnosis: SMV thrombosis and portal venous gas Ischemic bowel Discharge Condition: Good Discharge Instructions: Please call your doctor or return to the ER for any of the following: * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * 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. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to increase activity daily. * No heavy lifting (>[**10-30**] lbs) until your follow up appointment. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] on [**2115-9-20**] at 9:30am. Call [**Telephone/Fax (1) 1231**] with questions or concerns. . [**Hospital 18**] [**Hospital 17902**] Clinic. Provider: [**First Name4 (NamePattern1) 569**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2115-10-11**] 10:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5778**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2115-10-11**] 10:00 Completed by:[**2115-8-28**]

[ "553.21", "V12.51", "707.03", "E878.6", "293.0", "557.0", "789.59", "427.1", "452", "272.4", "998.31" ]

icd9cm

[ [ [] ] ]

[ "45.91", "99.15", "45.62", "96.6", "54.12", "54.11", "54.72", "53.61", "54.74", "43.19" ]

icd9pcs

[ [ [] ] ]

10307, 10375

6761, 9276

327, 523

10471, 10478

1821, 6738

11851, 12376

9334, 10284

10396, 10450

9302, 9311

10502, 11828

1680, 1802

273, 289

551, 1210

1232, 1310

1326, 1665

16,976

113,874

46827

Discharge summary

report

Admission Date: [**2166-6-3**] Discharge Date: [**2166-6-11**] Date of Birth: [**2105-6-4**] Sex: F Service: MEDICINE Allergies: Haldol / Darvon / Keppra Attending:[**First Name3 (LF) 53626**] Chief Complaint: rectal bleeding Major Surgical or Invasive Procedure: EUA, rigid sigmoidoscopy, ligation of bleeding hemorrhoids History of Present Illness: 60F w/ history of MGUS, COPD, HCV cirrhosis, iron deficiency anemia and previous admissions for GI bleed now being admitted to [**Hospital Unit Name 153**] for presumed lower gi bleed. Somewhat of vague historian but pt reports 4-5 episodes of bright red per rectum x 2 days. Denies melena. Also reports persistent nausea and non-bilious, non-bloody emesis. Reports metallic taste. Subjective fevers and chills. Has history of hemorrhoids and constipation that has been treated successfully with magnesium oxide. Not clear that she has experienced more constipation over the last several days preceding her bleeding from rectum. She has experienced some rectal pain which she attributes to hemorrhoids - this has now resolved. Good appetite but decreased po's for unclear reasons. Denies chest pain but reports dyspnea on exertion over the last several days. No cough. Reports light headed when standing. Of note, pt was hospitalized on 2 occasions in [**2166-2-12**] for bright red blood per rectum. Work-up included EGD which demonstrated duodenal angioectasias, Schatski's ring and duodenitis and portal gastropathy. A colonoscopy had been performed which was significant for large internal hemorrhoids without stigmata of recent bleedng. She did have a colonoscopy in [**1-16**] which demonstrated sigmoid diverticulosis. She required red cell transfusions on both admissions. It was felt that her bleeding was most likely related to hemorrhoidal bleeding and she had been advised to follow up with surgery. In ed, noted to be afebrile and hemodymically stable. She was found to be orthostatic however and crit was 23 and then 19 on recheck. She was guiac positive on rectal exam. NG lavage was negative. She received 1 unit prbc, Protonix 40, and benadryl Past Medical History: 1) iron deficiency anemia 2) GI bleed - presumed secondary to hemorrhoids 3) Sigmoid diverticulosis 4) Schatzki's ring 5) Duoenal polyps and duodenitis 6) MGUS 7) ?etoh/ HCV cirrhosis followed by Dr. [**Last Name (STitle) 497**] (vl 9k in [**5-15**]) 8) psychotic disorder 9) remote polysubstance abuse - etoh, cocaine, marijuana 10) COPD 11) compex partial seizures Social History: Lives alone in [**Location (un) **], has home physical therapy and a homemaker. She reports that she has quit tobacco ~ 1 month ago. She denies recent EtOH, howevert reported to have heavy drinking 6 months ago. She denies recent marijuana, cocaine use. Contacts: daughter ([**Doctor First Name **] [**Telephone/Fax (1) 99373**])' son (mark [**Doctor Last Name **]) [**Telephone/Fax (1) 99374**] Family History: M-asthma, GM-CAD, HTN, denies any h/o liver disease or bleeding disorders; great aunt with epilepsy; Physical Exam: Physical exam on admission (to [**Hospital Unit Name 153**]) PE: 118/70 89 16 100ra gen: cachexic african american female, lying in bed, looking uncomfortable secondary to pruritus, o/w pleasant heent: dry mm, anicteric sclera, flat jvp cv: s1, s2 regular w/ soft 2/6 sem throughout pulm: ctab abd: nabs, soft, ntnd, no cvat, guiac positive per ed extr: decreased skin turgor, no edema Pertinent Results: Laboratory studies on admission: [**2166-6-3**] 03:04PM WBC-11.5 RBC-2.73 HGB-7.5 HCT-23.4 MCV-86 RDW-22.8 PLT COUNT-325 NEUTS-87 BANDS-4 LYMPHS-2 MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-2* MYELOS-0 GLUCOSE-90 UREA N-6 CREAT-1.0 SODIUM-128* POTASSIUM-4.7 CHLORIDE-90 TOTAL CO2-22 URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2166-6-3**] 08:10PM HGB-6.2 HCT-19.6 EKG [**6-3**]: NSR @ 85 bpm, nl axis, nl intervals, qI, avL, isolated O.[**Street Address(2) 1755**] elevation V2, TWF avL, V2, V3 TTE [**6-5**]: LVEF>55%, 1+ AR, 1+ MR, mild pulmonary artery systolic hypertension. Trivial/physiologic pericardial effusion. . CXR [**2166-6-6**] IMPRESSION: Mild congestive heart failure with new small right pleural effusion and bibasilar atelectasis. . CT [**6-6**] IMPRESSION: 1. No evidence of free intraperitoneal air, drainable fluid collections, or regions of inflammation in the abdomen or pelvis. 2. Small amount of ascites, small amount of free fluid in the pelvis, bilateral pleural effusions, and subcutaneous edema are consistent with aggressive volume resuscitation. 3. Consolidation at both lung bases, likely related to compressive atelectasis. 4. Diffusely low attenuation liver is consistent with fatty infiltration. . [**6-10**] CXR IMPRESSION: Decreasing right lung base atelectasis and smaller right pleural effusion Brief Hospital Course: In the [**Hospital Unit Name 153**], the patient received an additional 1unit FFP, and 2 units PRBC (last [**6-4**] at 2 p.m.) with HCT 22,8 -> 24.6. She had a 16 beat run of NSVT, asymptomatic. She was evaluated by gastroenterology, who noted 2 large lacerated external hemorrhoids oozing on rectal exam. Surgery was consulted, and she underwent an EUA, rigid sigmoidoscopy, and ligation of bleeding internal hemorrhoids on [**2166-6-4**]. Following the procedure, she was observed overnight in the [**Hospital Unit Name 153**]. This morning, she had a large BM (brown with scan amount of blood) in which the surgical packing was expelled. . Floor course: # Lower GI bleed: This was most likely related to hemorrhoids, for which the patient underwentligation [**2166-6-4**]. She does have multiple other possible sources of UGI bleeding (portal gastropathy, duodenitis, and duodenal ectasias), however, these are unlikely contributors to current presentation, given (-) NG lavage in ED. She was transfused 1 unit PRBC on [**6-5**] with good response in hematocrit to 30. She was continued on PPI [**Hospital1 **] given portal gastropathy and continued on low dose propranolol (started in the ICU for portal hypertension). The patient was followed by the GI service throughout her hospital stay, who recommended high fiber diet, stool softners, and [**Last Name (un) **] baths [**2-14**] times daily as needed. Her hematocrit will need to be monitored closely as an outpatient to ensure stability. . # Blood loss anemia: The patients hematocrit, which was 19 on admission, was due to GI bleeding superimposed on chronic iron deficiency (baseline HCT high 20s). She was continued on iron therapy and, as mentioned above, received a total of 3 units PRBC (last [**2166-6-5**]) with stabilization of hematocrit. . # LLQ/RLQ abdominal tenderness: Following transfer to the general medical floor, the patient developed deep LLQ and RLQ tenderness with voluntary guarding on [**6-6**]. Given concern for possible perforation (recent hemorrhoidal ligation), inflammatory process/abscess, or biliary obstruction (as Tbili was 2.1, elevated from baseline), a CT abd/pelvis was obtained [**6-6**] which showed.... Surgery was consulted, who felt that surgical complication/perforation was unlikely. She was initially kept NPO with IVF, but her diet was then advanced. At time of discharge, she is tolerating a regular, high fiber diet. . # Bacteremia - Course was complicated by E.coli bacteremia, treated initially with levofloxacin. However, the patient became delerious one evening and a code purple was called. All narcotics were stopped and levofloxacin was changed to ceftriaxone as the former can cause mental status changes in patients. She was discharged on cefpodoxime, with a total course of 14 days from positive blood cultures. . # Fever - On the day prior to discharge, the patient had a low grade fever. Workup included CXR and UA/Urine culture, all of which were negative. Fever resolved and the patient was discharged on a total of 14 days of antibiotics starting from day of positive blood cultures for E.coli bacteremia. . # Altered mental status - Occurred 2 nights prior to discharge, and acutely resolved with removal of sedating meds and changing levofloxacin to ceftriaxone. The patient required and sitter transiently but the was stopped one day prior to discharge. No infectious etiology of delerium other than bacteremia. . # Alcohol abuse: On admission, the patient denied ongoing alcohol abuse, she was initially maintained on prn ativan for CIWA >10, which was discontinued as patient displayed no symptoms consistent with alcohol withdrawal. She was continued on multivitamin, thiamine, and folate. # NSVT: As mentioned above, the patient had one 16 beat run of NSVT [**6-4**] while in the ICU a transthoracic echocardiogram [**6-5**] showed LVEF >55%, 1+ AR, 1+ MR, 1+ TR, mild PA sys HTN, trivial physiologic pericardial effusion. Given that her EF was not suppressed, she is not currently a candidate for ICD. An outpatient holter may be pursued at the discretion of her primary care physician. [**Name10 (NameIs) **] function tests were obtained, which showed a high normal TSH and a mildly elevated free T4 at 1.8 (normal 0.9-1.7). These should be repeated in 6 weeks as an outpatient. # Hypoxia: On transfer to the floor, the patient was noted to be 96% 2L NC (had been 100% RA on admission to [**Hospital Unit Name 153**]). The patient has a reported history of COPD and reported an unchanged chronic non-productive cough. There was no evidence on clinical exam of fluid overload. A CXR PA was obtained [**6-6**] which showed mild CHF and new right pleural effusion with associated atelectasis. The patient was started on albuterol/atrovent nebs standing/prn. Her oxygen was titrated down and, at discharge, ambulatory sats were stable. # Partial complex seizure: The patient remained stable off anti-seizure medications. # Full Code Medications on Admission: protonix 40 qd senna colace hydrocortisone 2.5% [**Hospital1 **] ferrous sulfate 325 qd camphor-menthol prn Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(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. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. 6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Propranolol 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Albuterol 90 mcg/Actuation Aerosol Sig: [**1-13**] puff Inhalation four times a day as needed for shortness of breath or wheezing. Disp:*1 MDI* Refills:*2* 11. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 12. [**Last Name (un) **] bath 2-3 times a day as needed 13. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 9 days. Disp:*19 Tablet(s)* Refills:*0* 14. Hydrocortisone 2.5 % Lotion Sig: QS Topical twice a day. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: Hemorrhoidal bleeding Secondary: Hepatitis C, blood loss anemia, diverticulosis, MGUS, cirrhosis, chronic obstructive pulmonary disease, complex partial seizures. Discharge Condition: Stable Discharge Instructions: Please follow-up as indicated below. Please take all medications as prescribed. You have been prescribed stool softeners to avoid irritation of your hemorrhoids with bowel movements. You have also been prescribed propranolol, which will decrease portal hypertension. You are encouraged to stop smoking. Please follow-up with your primary care physician or come to the emergency room if you develop rectal bleeding, abdominal pain, nausea, vomiting, fevers, chills, or other symptoms that concern you. Please adhere to a high fiber diet. Followup Instructions: 1) Primary Care: Please follow up with your PCP on [**6-17**] at 3:45 with your primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10743**] ([**0-0-**]). 2) Liver Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2166-6-27**] 2:40 [**Initials (NamePattern5) **] [**Last Name (NamePattern5) **] Medical Building [**Location (un) **] 3) Surgery Dr. [**Last Name (STitle) 5182**] ([**Telephone/Fax (1) 5189**]) [**2166-6-24**] 9:30 [**Initials (NamePattern5) **] [**Last Name (NamePattern5) 23**] building, [**Location (un) 470**] 4) Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2166-8-6**] 4:30 5) Please call Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 410**], your hematologist, at [**Telephone/Fax (1) 3760**], to have your MGUS evaluated and followed. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 53627**]

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icd9cm

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5959

Discharge summary

report

Admission Date: [**2186-3-6**] Discharge Date: [**2186-3-8**] Date of Birth: [**2126-5-7**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4891**] Chief Complaint: dyspnea/wheezing Major Surgical or Invasive Procedure: none History of Present Illness: Briefly, this is a 59 yo M w/ COPD (FEV1 44%, [**First Name3 (LF) **] Stage III, not on home O2), lung nodules, likely benign, and chronic back pain, on narcotics contract, who was recently treated for COPD exacerbation as outpatient, presented to the ED with significant worsening of DOE and wheezing. . Pt. was in USOH until [**2-20**] when developed URI sx (nasal congestion, post nasal gtt, increading cough). Seen by PCP [**Last Name (NamePattern4) **] [**2-23**] for mild cough, shortness of breath and wheezing, pulse ox on RA was 91%. Tx for COPD exacerbation (azithro/prednisone x5 days). Noted minimal improvement in wheezing/doe w/ this course, but felt congestion improved. Does note new green sputum for several weeks. Last [**Doctor First Name **], noted increasing wheezing that prevented him from coming to work, along w/ this noted increasing fatigue and several episodes of green colored sputum (usually does not cough in AM). Feels that his exercise capacity decreased over the past 3 weeks from 50ft to 20ft due to DOE. Also noted feeling "squirley" and more anxious. He denied CP, diaphoresis, n/v or shoulder pain. No parox. noct. dyspnea or orthopnea. Reports intermittent LE edema after working long days, that resolves by AM. . On day of admission, noted worsening wheezing, had an episode of nausea/vomiting (food particles) and a loose bowel movement (watery stool) w/o associated sx. Given all this, came to the ED. Most recent hospitalization was [**10-29**] for COPD flare/CAP, tx w/ Levofloxacin and 5 day prednisone taper. . . Initial VS in the ED were 98.7F 80 120/67 18 98% NRB. On exam was tachypneic to mid 20, diffuse wheezes. Labs were notable for WBC of 15K, HCT 54%, bicarb of 21 w/ normal AG, lactate of 3.5 (baseline WBC < 10K, HCT 40, HCO3 24-30). CXR w/o infiltrate. He was given methylprednisolone 125mg IV, Duonebs, Azithromycin and CFTX. Over the next 1 hr, noted to have worsening tachypnea thus started on BiPAP, ABG, 7.46/30/165 after 5 minutes. Given persistent requirement for [**Hospital **] transferred to MICU. On transfer, VS 65 142/87 98% w/ FIO2 21%, RR 25-26 on [**9-22**] Bipap. Lactate normalized to 1.5. . On arrival to the MICU, Pt tachypneic on BiPap, but appeared comfortable. In the MICU Pt was treated w/ prednisone 60mg po daily and was started on levofloxacin 750mg po daily. Also on standing nebs. Pt then transitioned off BiPap after a few hours. Now on home tiotropium and increased home advair to 500/50. Now on 2L nc and sat 94%, transferred to floor. . On arrival to the floor, Pt's vitals were: 98.2, 101/60, 83, 22, 93% RA . Review of systems: (+) Per HPI, and fatigue, weakness. Weight loss has stabilized. Chronic LBP on narcotics, unchanged. + anhedonia, saddness, insomnia, concentration difficulty. (-) Denies fever, chills. Denies current sinus tenderness, rhinorrhea. Denies. Denies chest pain, chest pressure, palpitations. Denies constipation, abdominal pain. Denies dysuria, frequency, or urgency. Denies rashes or skin changes. Past Medical History: 1. COPD (moderate emphysema, 80 pkyrs, quit [**2180**]; two hospitalizations for COPD exacerbation, no intubations or ICU - last spirometry [**2185-6-29**]: FEV1 44% predicted, FEV1/FVC 50% predicted - not requiring home oxygen) 2. Chronic low back pain (on narcotic agreement and chronic benzodiazepines and opioids - renewed [**2186-1-17**], DJD Lumbar spine) 3. Hypertension 4. Insomnia 5. Depression 6. Lung nodules per recent CT [**Doctor First Name **]. eval, needs repeat CT [**4-/2186**], see below. 7. Abdominal aortic aneurysm on CT [**9-/2185**], 3.4 cm. 8. Unintentional weight loss (160s -> 120s over 6mo, [**Last Name (un) **] w/ hyperplastic polyp, PET-CT [**10-29**] = spiculated nodule in the LUL mild FDG uptake, prior nodules in LUL decr. in size. CT abd/pel w/o malignancy, PSA wnl). Social History: Lives at home in [**Location (un) **], MA w/ sister and brother in law. Works at the [**Hospital1 18**] in pharmaceutical distribution. Tobacco: 80 pk yr, quit 5yrs ago Alcohol use: denies Substance use: denies. Family History: diabetes in mother, father had unspecified heart disease and emphysema Physical Exam: Physical exam on admission: General: Alert, oriented, anxious appearing, thin man HEENT: Sclera anicteric, dMM, oropharynx clear, mild ptosis on left, no miosis Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: decr. air movement, wheezes throughout w/ prolonged expir. phase. 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: alert, oriented, attentive. VFF, EOMI, no nystagmus, 5-2mm b/l, symmetric face tongue midline, normal tone, UEs and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 23490**]. Toes down b/l Physical Exam on discharge: Vitals: 98.1, 105/61, 83, 20, 93% RA General: Alert, oriented, anxious appearing, thin man HEENT: PERRL, EOMI, drym mucous membranes, mild ptosis on left, no miosis Neck: supple, JVP not elevated, no LAD CV: distant heart sounds, regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: decr. air movement throughout, prolonged expir. phase, otherwise clear, no wheezes 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: alert, oriented, attentive. 5/5 strength in bilateral upper and lower extremities. Pertinent Results: Admission labs: [**2186-3-6**] 03:26PM BLOOD Lactate-3.5* [**2186-3-6**] 05:41PM BLOOD Lactate-1.5 K-3.3 [**2186-3-6**] 10:15PM BLOOD Lactate-1.3 [**2186-3-6**] 03:55PM BLOOD Type-ART Temp-36.8 pO2-165* pCO2-30* pH-7.46* calTCO2-22 Base XS-0 Intubat-NOT INTUBA [**2186-3-6**] 03:20PM BLOOD WBC-14.8*# RBC-5.55# Hgb-17.5# Hct-54.4*# MCV-98 MCH-31.5 MCHC-32.1 RDW-12.9 Plt Ct-349 [**2186-3-6**] 03:20PM BLOOD Neuts-82.8* Lymphs-11.7* Monos-4.8 Eos-0.2 Baso-0.5 [**2186-3-6**] 03:20PM BLOOD Glucose-111* UreaN-20 Creat-0.8 Na-139 K-7.2* Cl-110* HCO3-21* AnGap-15 [**2186-3-6**] 05:35PM BLOOD cTropnT-<0.01 proBNP-1515* [**2186-3-7**] 05:30AM BLOOD cTropnT-<0.01 Micro: [**3-6**] blood culture x 2 - no growth to date Imaging: [**2186-3-6**] Radiology CHEST (PORTABLE AP) FINDINGS: Single portable view of the chest is compared to previous exam from [**2185-11-18**]. As on prior, the lungs are hyperinflated with parenchymal changes suggestive of emphysema, particularly at the left lung apex. Increased interstitial markings are identified at the left lung base. Elsewhere, the lungs are grossly clear. Cardiomediastinal silhouette is within normal limits. Osseous and soft tissue structures are unremarkable. Linear patchy at the right lung base is compatible with atelectasis versus scarring. IMPRESSION: Increased interstitial markings at the left lung base, potentially due to chronic changes; however, in the proper clinical setting, component of infection is also possible. Two views of the chest may help further characterize. . [**2186-3-7**] Radiology CHEST (PA & LAT) FINDINGS: There is increased opacification in the left lung base with obscuration of the left hemidiaphragm when compared to [**3-6**]. Again noted is hyperinflation and flattening of the diaphragms suggesting emphysema. The cardiomediastinal silhouette is within normal limits. IMPRESSION: Left lower lobe pneumonia, more apparent than on [**3-6**]. . [**2186-3-7**] transthoracic echo: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF 70%). The right ventricular cavity is dilated with depressed free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Discharge Labs: [**2186-3-8**] 06:30AM BLOOD WBC-11.5* RBC-4.13* Hgb-12.7* Hct-40.1 MCV-97 MCH-30.8 MCHC-31.7 RDW-13.1 Plt Ct-321 [**2186-3-8**] 06:30AM BLOOD Glucose-81 UreaN-32* Creat-0.9 Na-145 K-3.2* Cl-110* HCO3-27 AnGap-11 [**2186-3-8**] 06:30AM BLOOD Calcium-8.3* Phos-2.4*# Mg-2.5 Brief Hospital Course: 59 yo M w/ COPD (FEV1 44%, [**Month/Day/Year **] Stage III, not on home O2), lung nodules and chronic back pain who was recently treated for COPD exacerbation as outpatient, presented to the ED with significant worsening of wheezing. . # dyspnea: Pt has known COPD, but CXR now supporting possible LLL pneumonia. Pt presented w/out fever, but had leukocytosis and lactic acidosis. Pt was treated with methylprednisolone 125mg iv x 1 in the ED, as well as azithromycin and ceftriaxone for possible LLL pneumonia. Pt required BiPAP for comfort and was transferred to MICU briefly, where his nebulizers were increased and he was transitioned off of BiPAP to 2L nc. Pt has remained afebrile and his lactate corrected from 3.5 on presentation to 1.3 with IVF. Pt reports having had bilateral lower extremity edema, but none currently visible. Troponins negative but BNP elevated at 1515 w/ no prior history of CHF and normal stress test in [**2182**]. Echo on [**3-7**] showed preserved L-sided function but evidence of R-sided heart failure w/ dilated RV cavity and depressed free wall contractility, likely due to long-standing pulmonary disease. Pt seems to to have responded to increased steroids, nebulizers, and antibiotics, but still w/ increased expiratory effort, though no wheezes. Pt states that he felt completely back to baseline by [**3-7**]. Pt was discharged on prednisone 60mg daily w/ taper of 10mg weekly and levofloxacin 750mg po daily for 6 more days (had received 1 dose each of ceftriaxone and azithromycin in the emergency room) D1 = [**3-6**], to finish an 8 day course. Pt's albuterol was continued and his Fluticasone-Salmeterol was doubled to 500/50 [**Hospital1 **]. Home tiotropium 18mcg daily was unchanged. Pt's QTc was 410s on levofloxacin and fluticasone. Blood cultures remained no growth to date. Arrangements were made for outpatient PCP and pulmonary clinic follow-up. Pt was also discharged w/ temporary home O2 because he would desaturate to 87% with ambulation on room air. His need for continued O2 will be addressed by PCP / pulmonologist. After discussion with his PCP, [**Name10 (NameIs) 23491**] Pt that he should not return work until he finishes his course of antibiotics and sees his PCP next week. . # nausea / vomiting. Pt reported some intermittent nausea and vomiting, but this seems to have resolved during first night of admission. Pt was ruled out for MI w/ negative troponins x 2. No abdominal pain or tenderness on discharge. . # Chronic low back pain [**1-19**] DJD, unchanged. Continued his home regimen of oxycondone ER 20mg [**Hospital1 **] and oxycodone 10mg qid PRN for breakthrough (outpt prescription ending [**3-9**]). Pt asked for an received an extra one-time prescription for 8 tabs of immediate release oxycodone 5mg tabs since he said that he ran out. He will get a refills from his PCP. [**Name10 (NameIs) **] states that he wants to taper this medication and his lorazepam because his sister feels that he is abusing them. Will defer taper to PCP. . # Depression/Anxiety, No SI., but reports depressive sx and worries about his recurrent pulmonary nodules. Continued fluoxetine 40mg daily, mirtazapine 15mg po qhs, and lorazepam 2mg po tid prn anxiety or insomnia (outpt prescription ending [**3-9**]). Pt states that he wants to taper his benzos because his sister feels that he is abusing them. Informed his sister, who was quite concerned that Pt was very forgetful and perhaps a danger in the house (fire risks, etc) when he is on benzos, that Pt has lots of anxiety and will need to taper off these medications slowly. Will defer taper to PCP. . # GERD: continued home ranitidine 150mg po bid . # supplements / preventative health: continued vitamins D and E, calcium, aspirin 81. . TRANSITIONAL ISSUES: -Pt is on a long prednisone taper, from 60mg daily down by 10mg weekly. This should be adjusted by his PCP and pulmonologist as required. -Will need to assess O2 requirement and ability to work at next PCP appointment [**Name9 (PRE) 23492**] strategy with patient regarding how to taper his opiates and his benzos. Pt states that he wants to "detox" and taper off the medications as much as possible. Medications on Admission: - ALBUTEROL SULFATE [PROAIR HFA] 2 puffs Q4H prn - FLUTICASONE-SALMETEROL 250 mcg-50 mcg 1p [**Hospital1 **] - TIOTROPIUM 18 mcg daily - HYDROCORTISONE - 2.5 % Cream not on face - MIRTAZAPINE - 15 mg HS - RANITIDINE 150 mg [**Hospital1 **] - ASPIRIN 81 mg daily - CALCIUM CARBONATE-VITAMIN D3 500 mg (1,250 mg)-400 unit [**Hospital1 **] - MELATONIN - SENNOSIDES/docusate 8.6 mg-50 mg [**Hospital1 **] - VITAMIN E - FLUOXETINE - 40 mg daily - Oxycontin 20mg [**Hospital1 **] - Oxycodone 10mg QID prn - Lorazapam 2mg TID prn anxiety Discharge Medications: 1. prednisone 10 mg Tablet Sig: as directed Tablet PO once a day for 4 weeks: take 6 tablets (60 mg) once daily for 1 week, then 5 tablets (50mg) once daily for 1 week, then 4 tablets (40mg) for 1 week, the 3 tablets (30mg) for 1 week until changed by your pulmonologist. Disp:*126 Tablet(s)* Refills:*0* 2. ProAir HFA 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 3. fluticasone-salmeterol 500-50 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. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 6 days. Disp:*6 Tablet(s)* Refills:*0* 5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 6. hydrocortisone 2.5 % Cream Topical 7. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO twice a day. 11. melatonin Oral 12. sennosides-docusate sodium 8.6-50 mg Tablet Sig: One (1) Tablet PO twice a day. 13. fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day. 14. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q12H (every 12 hours): do not drive or operate machinery on this medication. 15. oxycodone 10 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain: do not drive or operate machinery on this medication. 16. lorazepam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for anxiety: do not drive or operate machinery on this medication. 17. vitamin E Oral 18. oxycodone 5 mg Tablet Sig: One (1) Tablet PO four times a day as needed for severe pain for 2 days: do not drive or operate machinery on this medication. Disp:*8 Tablet(s)* Refills:*0* 19. oxygen oxygen via nasal canula at 2 liters per minute for pulse dose portability Discharge Disposition: Home Discharge Diagnosis: Primary: chronic obstructive pulmonary disease exacerbation possible left lower lobe pneumonia Secondary: chronic back pain hypertension insomnia depression lung nodules abdominal aortic aneurysm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 3077**], You came to the hospital because you had trouble breathing. You were found to have an exacerbation of your chronic obstructive pulmonary disease and possibly a pneumonia in your left lower lung. You also had a scan of your heart, which showed decreased function of the right side of your heart. You were treated with steroids, antibiotics, and bilevel respiratory support. Your symptoms improved markedly, and you will need to continue to take your prednisone and your antibiotics. We have made the following changes to your medications: -START taking prednisone 10mg tablets, 6 tabs (60mg) by mouth once daily for 1 week, then 5 tabs (50mg) by mouth once daily for 1 week, then 4 tabs (40mg) by mouth once daily for 1 week, then 3 tabs (30mg) by mouth once daily for 1 week. This medication will likely be adjusted by your pulmonologist. ***Please be sure to go to your appointment on [**3-23**] and discuss your steroid taper with him.*** -START taking levofloxacin 750 mg tablets, 1 tab by mouth daily for 6 days. -INCREASE your fluticasone-salmeterol discus from 250/50 to 500/50mcg 1 puff twice daily. -START oxygen at home, 2 liters nasal canula. You will likely only need this on a temporary basis. Please address this with your primary care doctor. We have provided you with a temporary prescription for oxycodone 5mg tablets, 1 tab every 6 hours as needed for severe pain, 8 tabs total. You should get a new prescription from your primary care physician. You have mentioned that you would like to taper off of your lorazepam. We have made an appointment for you to see your primary care physician next week, who will guide you in how to safely come off of this medication gradually. Please continue to take your other medications as previously prescribed. We have also made an appointment for you to be established with a new pulmonologist, Dr. [**Last Name (STitle) **], and to see your previous primary care doctor, Dr. [**First Name (STitle) 3535**]. Followup Instructions: Department: [**Hospital3 249**] When: WEDNESDAY [**2186-3-15**] at 1:40 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PULMONARY FUNCTION LAB When: THURSDAY [**2186-3-23**] at 12:40 PM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES/PULMONARY When: THURSDAY [**2186-3-23**] at 1 PM With: [**Name6 (MD) 610**] [**Name8 (MD) **] RN/DR. [**Last Name (STitle) 611**] [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2186-3-8**]

[ "491.21", "401.9", "793.11", "300.4", "441.4", "787.01", "780.52", "721.3", "338.29", "110.4", "486", "530.81" ]

icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

15760, 15766

8838, 12595

319, 326

16007, 16007

5926, 5926

18185, 19106

4444, 4516

13600, 15737

15787, 15986

13044, 13577

16158, 16700

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4531, 4545

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12616, 13018

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354, 2956

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16022, 16134

3393, 4199

4215, 4428

70,794

127,361

42050

Discharge summary

report

Admission Date: [**2112-9-27**] Discharge Date: [**2112-10-3**] Date of Birth: [**2095-5-26**] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1835**] Chief Complaint: status post 15-20 ft fall Major Surgical or Invasive Procedure: [**2112-9-27**] Left craniotomy for evacuation of left Epidural Hematoma History of Present Illness: This is a 17 yea old male who fell 15-20 feet with Loss Of Consiousness. It is unclear at this time where he fell from. He was awake when EMS arrived and was transferred to [**Hospital **] Hospital where he had a mental status change and began vomiting. He was intubated and medflighted to [**Hospital1 18**] Neurosurgery. Past Medical History: None Social History: The patient lives at home with his mother and father Family History: non contributory Physical Exam: Gen: Intubated, sedated HEENT: Normocephalic Neck: Cspine collar on Extrem: Warm and well-perfused. + lacerations Neuro: Intubated, off sedation, no EO, L pupil 2mm and reactive, R pupil is 2mm and fixed. No corneals bilaterally. BUE appear to flex but may be reflexive. BLE withdraw to noxious. Overbreathing the vent. On the Day of discharge [**2112-10-3**]: The patient speaks spanish only. He is alert and oriented to person place and time. He is sitting up out of bed in the chair. The face is symetric, there is no pronator drift, the pupils are equal and reactive. Strength is full. The patient is able to ambulate with a steady gait without assistance. The patient is slightly impulsive and will require 24 hour supervision at home. Pertinent Results: CT HEAD W/O CONTRAST Study Date of [**2112-9-27**] 5:15 PM interval enlargement of an epidural hematoma. at the temporal tip now measures up to 13mm (prior 8mm), at parietal lobe 18mm (prior 12mm). 6mm rightward shift of midline. no new areas of hemorrhage. minimally displaced parietal and temporal skull fx. possible non-displaced left zygomatic arch fx. sinus opacification [**1-13**] intubation. CT C-SPINE W/O CONTRAST Study Date of [**2112-9-27**] 5:15 PM minimal rotation of c1 on c2, could indicate rotation subluxation, but otherwise no traumatic injury to the spine. CT ABD & PELVIS WITH CONTRAST Study Date of [**2112-9-27**] 5:16 PM congenital limbic vertebrae at L5, but no evidence for traumatic injury to the torso. CT CHEST W/CONTRAST Study Date of [**2112-9-27**] 5:16 PM IMPRESSION: No traumatic injury to the chest, abdomen or pelvis. TRAUMA #2 (AP CXR & PELVIS PORT) Study Date of [**2112-9-27**] 4:55 PM IMPRESSION: 1. Endotracheal tube and nasogastric tubes are within standard positions. 2. No acute traumatic injury within the chest. 3. No fracture or dislocation within the pelvis. CT HEAD W/O CONTRAST Study Date of [**2112-9-27**] 8:06 PM 1. Status post left epidural hematoma evacuation. 2. Persistent mass effect on the left hemisphere. Mild interval increase in mass effect on the left frontal lobe. 3. Mild increase of rightward shift of midline structures now measuring 5 mm. 4. No new interval hemorrhage. 5. Left temporal and parietal skull fracture, as seen on prior. MR CERVICAL SPINE W/O CONTRAST Study Date of [**2112-9-28**] 12:14 AM Mild soft tissue edema is identified in the posterior neck at the level of C3-C4, probably involving the interspinous ligament (image 8 series #4). No focal or diffuse lesions are noted throughout the cervical spinal cord to indicate edema or cord expansion. The paravertebral soft tissues are maintained, however there is a pool of secretions in the oropharynx, the patient is intubated. There is mild straightening of the normal cervical lordosis. The intervertebral disc spaces are maintained with no evidence of neural foraminal narrowing or spinal canal stenosis. WRIST(3 + VIEWS) RIGHT PORT Study Date of [**2112-9-28**] 5:55 AM No fracture or other osseous abnormality is identified. There is overlying intravenous tubing. CT HEAD W/O CONTRAST Study Date of [**2112-9-28**] 5:02 AM IMPRESSION: 1. Status post evacuation of hematoma via left frontal craniotomy, with significant interval decrease in amount of pneumocephalus, and no significant change in degree of shift of midline structures. BILAT LOWER EXT VEINS Study Date of [**2112-10-2**] 12:10 PM IMPRESSION: No bilateral lower extremity DVT. [**2112-10-2**] 06:40AM BLOOD WBC-7.7 RBC-4.19* Hgb-12.4* Hct-35.5* MCV-85 MCH-29.6 MCHC-34.9 RDW-13.2 Plt Ct-276 [**2112-10-2**] 06:40AM BLOOD Plt Ct-276 [**2112-10-2**] 06:40AM BLOOD PT-12.7 PTT-26.2 INR(PT)-1.1 [**2112-10-2**] 06:40AM BLOOD Glucose-89 UreaN-10 Creat-0.6 Na-141 K-3.6 Cl-106 HCO3-23 AnGap-16 [**2112-10-2**] 06:40AM BLOOD Calcium-8.9 Phos-3.9 Mg-1.8 [**2112-9-27**] 05:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2112-9-27**] 08:12PM PT-13.9* PTT-28.3 INR(PT)-1.2* [**2112-9-27**] 08:12PM GLUCOSE-147* UREA N-13 CREAT-0.8 SODIUM-136 POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-21* ANION GAP-16 [**2112-9-27**] 05:05PM WBC-16.8* RBC-4.50* HGB-13.2* HCT-39.0* MCV-87 MCH-29.4 MCHC-33.9 RDW-12.9 [**2112-9-27**] 08:12PM GLUCOSE-147* UREA N-13 CREAT-0.8 SODIUM-136 POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-21* ANION GAP-16 Brief Hospital Course: This is a 17 year old man who was admitted to the Neurosurgery Service and taken to the OR emergently for Left craniotomy for evacuation of Epidural Hematoma on [**2112-9-27**].The pre-operative Head Ct was consitent with a large left-sided epidural hematoma with a minimally displaced left parietal and temporal lobe skull fracture This patient tolerated this procedure well with no complications. Post operatively he remained intubated and was taken to the ICU for further care including SBP control and neuro checks. A post op head ct showed good evacuation of Epidural Hematoma and he was started on FiO2 100% for pneumocephalus. The post operative neurological exam revealed that he opened eyes and move all extremities spontaneously. He was following commands intermittently, he had Left eye periorbital edema as well but pupils were equal and reactive. A Ct of the chest abdomen and pelvis was performed which was consistent with no traumatic injury to the chest, abdomen or pelvis. A CT of the C spine was performed which was consistent with no cervical spine fracture. On [**9-28**], the patient was extubated. The neurological assessment was changed from every 1 hour to every 2 hours.A xray of the right wrist was performed which was consistent with No fracture or other osseous abnormality is identified. A head Ct was performed which was consistent with expected post operative changes.A cervical spine MR was performed which wa consistent with C3 and C4 ligamentous injury. On [**9-29**], The patient was transferred to the floor. patient opened eyes to voice and followed commands. He complained of pain that was controlled with pain medication. His R wrist x-ray was negative and he was transferred to the floor. He will remain in his hard c-collar for ligamentus injury. He was transitioned from dilantin to keppra. On [**9-30**] The patient worked with PT and OT and was awaiting workers compensation information and disposition planning.The patient experienced some nausea and emesis which later resolved. The potassium level was 3.2 and was repleated. A urine culture was sent which was negative. On [**10-1**], The patient's serum potassium level was low and was repleated. The patient's foley was discontinued ad the patient was able to void independently without difficulty. The patient was out of bed to the chair. On [**10-2**], The serum potassium and magnesium were low and repleated. Bilateral lower extremity venous ultrasounds of the legs were performed for routine screening of deep vein thrombosis as the patient had been in bed most of the day during his stay. On exam, The patient is alert and oriented with full strength. The patient was encouraged to ambulate in the halls. Physical therapy evaluated the patient and felt that he would be safe to go home with 24 hour supervision for safety. On [**10-3**], Physical therapy again assessed the patient and they confirmed that the patient may be discharge home with 24 hour supervision. On the day of discharge the patient was ambulating independently with a steady gait. The patient was tolerating a regular diet. He had bowel sounds and was voiding independently. Neurologically, the patient was doing well. His strength was full there was no pronator drift. The smile was symetric. Pupils were equal and reactive. Staples were intact and the wound was well approximated. There was no drainage from the wound. Medications on Admission: None Discharge Medications: 1. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain: do not drive , hold if lethargic. Disp:*60 Tablet(s)* Refills:*0* 3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*50 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Epidural hematoma parietal and temporal skull fx. left zygomatic arch fx. C3-C4 interspinous ligament Discharge Condition: spanish speaking only, alert and oriented. pupils equal and reactive, strength and sensation are full. No pronator drift. patient is ambulating independently with a steady gait. slightly impulsive Discharge Instructions: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after staples have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? You haven been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. You will be discharged with 24 hour supervision at home as discussed prior to your discharge. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in 10 days(from your date of surgery [**2112-9-27**]) for removal of your staples and a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in 8 weeks. ??????You will need a CT scan of the brain without contrast. -You will need cervical spine flexion extension xrays on your follow up visit in 8 weeks in the Neurosurgery office for your neck injury ??????We recommend you see Dr [**First Name (STitle) **] in the Traumatic Brain Injury (TBI) clinic the phone number is [**Telephone/Fax (1) 6335**]. If you have any problems booking this appointment please ask for [**First Name8 (NamePattern2) 16367**] [**Last Name (NamePattern1) 16368**]. Completed by:[**2112-10-3**]

[ "800.12", "518.51", "E884.9", "952.00", "801.12", "802.4" ]

icd9cm

[ [ [] ] ]

[ "02.02", "01.24", "96.71", "02.12" ]

icd9pcs

[ [ [] ] ]

9498, 9504

5272, 8686

335, 410

9649, 9848

1677, 5249

11512, 12566

877, 895

8741, 9475

9525, 9628

8712, 8718

9872, 11489

910, 1658

269, 297

438, 763

785, 791

807, 861

5,739

196,032

9234

Discharge summary

report

Admission Date: [**2163-12-26**] Discharge Date: [**2163-12-30**] Date of Birth: [**2131-3-8**] Sex: M Service: TRAUMA SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 32 year old male, unrestrained driver, involved in a motor vehicle accident with positive loss of consciousness found to be seizing by passers-by and upon paramedic arrival appeared postictal. The patient was transferred to [**Hospital1 346**]. PAST MEDICAL HISTORY: The only past medical history known was hypertension. PHYSICAL EXAMINATION: In the Trauma Bay, he was confused but hemodynamically stable. His trauma workup included a negative trauma series and a negative head CT and negative completion cervical spine. The patient also had a CT of his abdomen which demonstrated a hematoma in the third portion of the duodenum along with a tear at the base of the mesentery resulting in superior mesenteric vein thrombosis at one focal area. HOSPITAL COURSE: During the patient's hospitalization, he experienced a second seizure for which a follow-up head CT revealed no lesion. Neurology service was consulted and the patient was started on Dilantin. Their workup revealed their suspicion that the seizures were related to his postconcussive state, however, may represent primary epilepsy although that is unlikely. The patient continued to do well and diet was advanced which he tolerated. His amylase and lipase were followed. They were initially elevated related to the hematoma, however, began trending downward on the day of discharge. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To home. MEDICATIONS ON DISCHARGE: 1. Dilantin 500 mg p.o. q.d. 2. Atenolol 37.5 mg p.o. q.d. 3. Aspirin 81 mg p.o. q.d. FOLLOW-UP: The patient is to follow-up with the [**Hospital 875**] Clinic with Neurology the first available appointment. No trauma follow-up is necessary. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**] Dictated By:[**Last Name (NamePattern1) 22409**] MEDQUIST36 D: [**2163-12-30**] 08:55 T: [**2164-1-1**] 14:05 JOB#: [**Job Number **]

[ "276.2", "V71.4", "401.9", "780.09", "780.39", "276.8", "E812.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

1638, 2161

960, 1549

538, 942

173, 437

460, 515

1574, 1612

50,996

140,357

37771

Discharge summary

report

Admission Date: [**2172-12-8**] Discharge Date: [**2172-12-18**] Date of Birth: [**2108-5-9**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2597**] Chief Complaint: AAA Major Surgical or Invasive Procedure: Resection and repair of abdominal aortic aneurysm with 18 x 9 bifurcated Dacron graft. History of Present Illness: 64 year old male presented to OSH for chest and arm pain [**10-27**]. He recieved a coronary artery stent and was placed on plavix. While in hospital patient has concerns of left hip pain. Hip pain was investigated with MRI which revealed a 7cm infrarenal AAA. On CTA done [**2172-12-4**] the left external iliac was aneurysmal with possible thrombus possibly contributing to patient's left hip pain. Patient was scheduled for open repair of his AAA, when it was discovered that his creatinine was elevated to 2.3 on preoperative testing. Patient's baseline creatinine noted by PCP [**Name Initial (PRE) **] 1.5. Patient had CTA for preoperative planning on friday and although he was pre-hydrated with bicarb and mucomyst subsequent testing showed rising creatinine. He reports feeling of pulsating left sided lower abdominal mass with exertion and that his hip pain also worsens with exertion. Patient denies back pain, fever, chills, nausea/vomitting, claudication and rest pain. Past Medical History: PAST MEDICAL HISTORY: CRI , MI PAST SURGICAL HISTORY: PTCA/stent [**10-21**], wrist surgery, discectomy Social History: SOCIAL HISTORY: Tobacco use: No. Previous smoker: Yes: Number of years: 40. Alcohol use: 0 drinks per week. Recreational drugs (marijuana, heroin, crack pills or other): No. SOCIAL HISTORY: Tobacco use: No. Previous smoker: Yes: Number of years: 40. Alcohol use: 0 drinks per week. Recreational drugs (marijuana, heroin, crack pills or other): No. Family History: FAMILY HISTORY: Father: CAD, Deceased. Mother: CAD. Physical Exam: PHYSICAL EXAM Vital Signs: Temp: 98 RR: 20 Pulse: 60 BP: 120/70 Neuro/Psych: Oriented x3, Affect Normal, NAD. Neck: No masses, Trachea midline, Thyroid normal size, non-tender, no masses or nodules, No right carotid bruit, No left carotid bruit. Nodes: No clavicular/cervical adenopathy, No inguinal adenopathy. Skin: No atypical lesions. Heart: Regular rate and rhythm. Lungs: Clear, Normal respiratory effort. Gastrointestinal: Non distended, No masses, Guarding or rebound, Rectal: Not Examined. Extremities: No femoral bruit/thrill, No RLE edema, No LLE Edema, No varicosities, No skin changes. Pulse Exam (P=Palpation, D=Dopplerable, N=None) RUE Radial: P. LUE Radial: P. RLE Femoral: P. DP: P. PT: P. LLE Femoral: P. DP: P. PT: P. Other: Left weaker than right. Pertinent Results: [**2172-12-18**] 06:35AM BLOOD WBC-9.5 RBC-3.37* Hgb-10.0* Hct-29.9* MCV-89 MCH-29.8 MCHC-33.6 RDW-15.3 Plt Ct-242 [**2172-12-18**] 06:35AM BLOOD PT-13.1 PTT-32.9 INR(PT)-1.1 [**2172-12-18**] 06:35AM BLOOD Glucose-84 UreaN-60* Creat-3.1* Na-134 K-5.1 Cl-102 HCO3-23 AnGap-14 [**2172-12-18**] 06:35AM BLOOD CK-MB-NotDone cTropnT-0.26* [**2172-12-18**] 06:35AM BLOOD Calcium-8.3* Phos-3.8 Mg-2.4 [**2172-12-14**] 10:08AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.018 URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG URINE RBC-3* WBC-2 Bacteri-FEW Yeast-NONE Epi-0 Conclusions The left atrium is mildly dilated. The estimated right atrial pressure is 0-5 mmHg. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Brief Hospital Course: Pt admitted for AAA repair. In pre-op area creatinine was elevated. Case was canceled. Pt did receive CTA 3 days prior, Renal consulted. Hydration. On day of AAA repair creatinine was normalized. 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 preparations were made. It was decided that she would undergo a: PROCEDURE: Resection and repair of abdominal aortic aneurysm with 18 x 9 bifurcated Dacron graft. 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 Intra op complication of st depression Post-operatively, he was extubated and transferred to the CVICU for further stabilization and monitoring. He was extubated. R/I for MI. Had increase in her creatinine. Cardiology and Renal were consulted. Meds were adjusted. When stable he was transferred to the VICU for further care. His high creatinine was 3.5 on DC 3.1. On admission 1.8. He has a follow-up arranged with renal for creatinine check in one week. He is making good urine. His potassium is stable. He was then transferred to the VICU for further recovery. While in the VICU he received monitored care. When stable he was delined. His diet was advanced. A PT consult was obtained. When he was stabilized from the acute setting of post operative care, he was transferred to floor status. Pt did experience more chest pain while on the floor. He had EKG changes. Cardiology did see the patient. Chest pain resolved with nitrates. His EKG on DC shows no ischemia. Was put on Imdur and his BB was increases. His troponin high was .62 on DC .27. He will be followed by cardiology as an outpatient. On the floor, she 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. Medications on Admission: lopressor 25", Aspirin, plavix 75', simvastatin 80' Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*6* 2. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*6* 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Imdur 30 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:*6* 5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: prn. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 10 days. Disp:*20 Capsule(s)* Refills:*0* 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation for 10 days. Disp:*10 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 10. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: prn for pain. Disp:*40 Tablet(s)* Refills:*0* 11. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*6* Discharge Disposition: Home Discharge Diagnosis: AAA MI ARF on CRF Discharge Condition: Stable Discharge Instructions: Division of Vascular and Endovascular Surgery Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel weak and tired, this will last for [**7-20**] weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? You may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have incisional and leg swelling: ?????? Wear loose fitting pants/clothing (this will be less irritating to incision) ?????? Elevate your legs above the level of your heart (use [**3-17**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? You should get up every day, get dressed and walk, gradually increasing your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (let the soapy water run over incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 101.5F for 24 hours ?????? Bleeding from incision ?????? New or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 721**] Date/Time:[**2172-12-24**] 1:00 Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2172-12-31**] 1:50 Call Dr[**Name (NI) 5452**] office and schedule an appointment. He is you cardiologist wwhile you were here. You should see him in [**2-14**] weeks. Your wife has his phone number. Completed by:[**2172-12-18**]

[ "414.01", "442.2", "276.1", "584.9", "585.3", "V45.82", "403.90", "272.4", "410.71", "441.4" ]

icd9cm

[ [ [] ] ]

[ "39.25", "38.44" ]

icd9pcs

[ [ [] ] ]

7742, 7748

4168, 6221

319, 408

7810, 7819

2807, 4145

10560, 11078

1963, 2001

6323, 7719

7769, 7789

6247, 6300

7843, 10107

10133, 10537

1507, 1559

2016, 2788

275, 281

436, 1430

1474, 1484

1769, 1931

18,353

102,727

52576

Discharge summary

report

Admission Date: [**2165-4-24**] Discharge Date: [**2165-7-19**] Date of Birth: [**2101-6-19**] Sex: M Service: SURGERY Allergies: Benadryl / Morphine Attending:[**First Name3 (LF) 1781**] Chief Complaint: right lower extremity ischemia Major Surgical or Invasive Procedure: - s/p fem-fem bipass Status post right groin exploration, evacuation of hematoma, VAC dressing placement. History of Present Illness: 63M s/p fem-fem bypass [**4-25**] c/b R groin hematoma. 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 vascular 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: [**Location (un) 686**], lives with wife, has older children, tob: 1 ppd x 60 yrs. quit 3 months ago, no EtOH Family History: Non contributary Physical Exam: On discharge vital: 97.9 88 116/69 16 99%ra FS 113-161 WD, WN, NAD CTAB no w/c/r RRR, no m/r/g soft, nt, nd, nabs Groin: Right - VAC dressing in place / wound C/D / exposed graft L foot w/well granulated wound on W->D dressing changes; right foot warm Pulses: R DP.PT dop, L DP/PT dop, graft palp Pertinent Results: [**2165-7-19**] 08:00AM BLOOD WBC-8.7 RBC-3.51* Hgb-12.3* Hct-38.6* MCV-110* MCH-35.2* MCHC-31.9 RDW-26.8* Plt Ct-336 [**2165-7-15**] 07:25AM BLOOD Neuts-75* Bands-0 Lymphs-10* Monos-6 Eos-7* Baso-0 Atyps-2* Metas-0 Myelos-0 NRBC-1* [**2165-7-4**] 05:08AM BLOOD PT-15.0* PTT-36.5* INR(PT)-1.4* [**2165-7-17**] 07:30AM BLOOD Glucose-120* UreaN-58* Creat-6.9* Na-135 K-5.7* Cl-96 HCO3-20* AnGap-25* [**2165-6-18**] 01:23PM BLOOD ALT-34 AST-30 LD(LDH)-149 AlkPhos-177* Amylase-182* TotBili-0.2 [**2165-7-12**] 07:55AM BLOOD Albumin-3.9 Calcium-8.7 Phos-5.5* Mg-2.2 UricAcd-5.0 [**2165-6-10**] 01:09AM BLOOD calTIBC-213* Ferritn-678* TRF-164* [**2165-6-18**] 09:18AM BLOOD PTH-609* [**2165-6-28**] 8:30 am BLOOD CULTURE **FINAL REPORT [**2165-7-4**]** AEROBIC BOTTLE (Final [**2165-7-4**]): NO GROWTH. ANAEROBIC BOTTLE (Final [**2165-7-4**]): NO GROWTH [**2165-7-11**] 1:19:38 PM Sinus rhythm. Left anterior fascicular block QT interval prolonged for rate Lateral ST-T changes may be due to myocardial ischemia Since previous tracing of earlier [**2165-7-11**], no significant change Intervals Axes Rate PR QRS QT/QTc P QRS T 83 170 100 416/455.71 -4 -48 128 [**2165-7-3**] 2:09 PM FINDINGS: Subcutaneous edema was present in the left lower extremity. The left greater saphenous vein has been previously harvested. The left lesser saphenous vein is patent with diameters varying between 0.16 and 0.23 cm. The vein measures 0.18 cm superiorly, 0.23 cm in its mid portion, and 0.16 cm inferiorly. The right greater saphenous vein has been previously harvested. The right lesser saphenous vein contains mural calcifications but is patent. The diameters of the right lesser saphenous vein vary between 0.14 and 0.18 cm. A PICC line is present in the left cephalic vein, which is otherwise patent. The left basilic vein is patent with diameters of 0.25 cm superiorly, 0.14 cm in the mid arm, 0.39 cm at the antecubital fossa, and 0.14 cm in the forearm. The right forearm has an arteriovenous fistula. The right cephalic vein has diameters varying between 0.35 and 0.52 cm and is patent. There is pulsatility of the flow in the right cephalic vein and this possibly represents an outflow vein from the arteriovenous fistula. The right basilic vein is patent in the arm with diameters varying between 0.29 and 0.51 cm. IMPRESSION: Prior harvesting of the greater saphenous veins bilaterally. Small caliber lesser saphenous veins bilaterally with calcifications in the right lesser saphenous vein murally. Patent left cephalic vein containing a PICC. The left basilic vein is patent with some diameters less than 0.20 cm. There is an AV fistula on the right forearm. The cephalic and basilic veins on the right are patent. [**2165-6-18**] 10:58 AM CT HEAD W/O CONTRAST TECHNIQUE: Noncontrast head CT scan. COMPARISON STUDIES: [**2164-10-28**]. Noncontrast head CT scan, also performed for mental status changes and interpreted by Dr. [**Last Name (STitle) **] as showing "small area of low attenuation involving the right occipital lobe, suggestive of a small infarct of uncertain age." FINDINGS: The present study has a few images which are degraded by streak artifacts. Allowing for this deficiency, no overt interval change is noted. Once again, a small area of low density is noted within the right occipital lobe region, which likely represents an area of chronic infarction. Also, both studies disclose a small linear area of low density within the left parietal white matter, again probably representing an area of chronic infarction within border zone distribution. Upon referral to the prior MR report of [**2164-10-31**] (the images not being available on PACS at this time), apparently areas of T2 hyperintensity within the white matter were detected by Dr. [**Last Name (STitle) **], and may well conform to the CT abnormalities noted above. There is no hydrocephalus or shift of normally midline structures. The surrounding osseous and extracranial soft tissues are otherwise unremarkable. IMPRESSION: Stable, abnormal study as noted above. [**2165-6-20**] 7:26 PM MRA NECK W/O CONTRAST; MRA BRAIN W/O CONTRAST MRA OF THE NECK: The neck MRA demonstrates normal flow signal within the carotid and vertebral arteries. No evidence of vascular occlusion or stenosis is identified. The left vertebral origin is not well visualized. If further evaluation is clinically indicated consider gadolinium-enhanced MRA. IMPRESSION: No evidence of stenosis or occlusion in the arteries of neck. The left vertebral origin is not well visualized and if clinically indicated, gadolinium-enhanced MRA would help for further assessment. MRA OF THE HEAD: The head MRA demonstrates normal flow signal within the arteries of anterior and posterior circulation. The distal left vertebral artery is small in size secondary to the left cervical vertebral artery ending in posterior inferior cerebellar artery, a normal variation. IMPRESSION: Normal MRA of the head. [**2165-6-12**] ECHO MEASUREMENTS: Left Atrium - Long Axis Dimension: *5.2 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *6.7 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: *5.7 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: *1.4 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: *7.1 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 6.3 cm Left Ventricle - Fractional Shortening: *0.11 (nl >= 0.29) Left Ventricle - Ejection Fraction: 20% (nl >=55%) Aorta - Valve Level: *3.8 cm (nl <= 3.6 cm) Aorta - Ascending: *3.6 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.9 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.9 m/sec Mitral Valve - A Wave: 1.0 m/sec Mitral Valve - E/A Ratio: 0.90 Mitral Valve - E Wave Deceleration Time: 228 msec TR Gradient (+ RA = PASP): *35 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement. Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Mild symmetric LVH. Severely dilated LV cavity. Severe global LV hypokinesis. Severely depressed LVEF. TVI E/e' >15, suggesting PCWP>18mmHg. LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior - akinetic; mid inferior - akinetic; basal inferolateral - akinetic; mid inferolateral - akinetic; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; RIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. RV function depressed. AORTA: Mildly dilated aortic root. Mildly dilated ascending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. TRICUSPID VALVE: Mild [1+] TR. Mild PA systolic hypertension. PERICARDIUM: No pericardial effusion. Conclusions: 1The left atrium is moderately dilated. The left atrium is elongated. 2. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is severely dilated. There is severe global left ventricular hypokinesis. Overall left ventricular systolic function is severely depressed. Tissue velocity imaging E/e' is elevated (>15) suggesting increased left ventricular filling pressure (PCWP>18mmHg). Resting regional wall motion abnormalities include basal and mid inferior and inferolateral akinesis.. 3. Right ventricular chamber size is normal. Right ventricular systolic function appears depressed. 4.The aortic root is mildly dilated. The ascending aorta is mildly dilated. 5.The aortic valve leaflets are mildly thickened. Trace aortic regurgitation is seen. 6.The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 7.There is mild pulmonary artery systolic hypertension. 8.There is no pericardial effusion. Compared to the previous report of [**2164-4-30**], there has been a decrease in the severtiy of the MR while the EF has unchanged. The PA pressure has decreased from 44 mmHg. [**2165-6-11**] PERSANTINE MIBI Left ventricular cavity size is markedly enlarged during rest and stress. The EDV=331 cc. Resting and stress perfusion images reveal a mild reversible lateral wall perfusion defect. The inferior wall perfusion defect seen in the prior study is not apparent in this study. Gated images reveal severe global systolic dysfunction. The calculated left ventricular ejection fraction is 18%. IMPRESSION: 1. Mild reversible lateral wall perfusion defect. The inferior wall perfusion defect seen in the prior study is not apparent in this study. 2.Dilated LV with severe global systolic dysfunction. EDV=331 cc and EF=18%. The findings are consistent with dilated ischemic cardiomyopathy. [**2165-6-11**] Stress TOTAL EXERCISE TIME: 4 % MAX HRT RATE ACHIEVED: 45 SYMPTOMS: NONE ST DEPRESSION: NONE INTERPRETATION: This 63 year old type 2 IDDM man with a history of CAD and PVD was referred to the lab for evaluation. The patient was infused with 0.142 mg/kg/min of dipyridamole over 4 minutes. No arm, neck, back or chest discomfort was reported by the patient throughout the study. There were no significant ST segment changed during the infusion or in recovery. The rhythm was sinus with frequent isolated apbs and several isolated vpbs. Appropriate hemodynamic response to the infusion. The dipyridamole was reversed with 125 mg of aminophylline IV. IMPRESSION: No anginal type symptoms or significant EKG changes. Brief Hospital Course: Pt had a very long hospital course. The hospital course was uneventful for the patient. He did have the below procedures done. [**2165-4-25**] Fem-fem bypass using the pre-existing axillary femoral bypass as our inflow on the left and our outflow was the pre-existing profunda to popliteal bypass on the right with PTFE 8 mm ringed graft. [**2165-5-23**] Status post right groin exploration, evacuation of hematoma, VAC dressing placement. The patient was kept in the hospital for an exposed graft / IV Antibiotics / VAC dressing changes. Pt recieved HD on his scheduled days. M/W/F PT worked with the patient On DC pt is taking PO / ambulating with asst. / pos BM / he does make urine, but is on HD Most importantly the patient is groin is closing in considerably around the graft site. Medications on Admission: heparin 5000"" lasix 80" sevelamer 1600" protonix 40' metoprolol 25" epoetin 4000"" lisinopril 5' amiodarone 200' atorvastatin 10' lactulose 30' [**Month/Day/Year 4532**] 75' [**Month/Day/Year **] 81' tylenol 650 prn albuterol mdi prn regular isulin sliding scale ipratropium mdi prn Discharge Medications: 1. Ascorbic Acid 500 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). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 5. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 7. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 9. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 13. Ceftazidime-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One (1) Intravenous Q48H (every 48 hours). 14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 15. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 17. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 19. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 20. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily). 21. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 22. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 23. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 24. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 25. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 26. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 27. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 28. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 29. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 30. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 31. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 32. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 33. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 34. PICC Care Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 35. Heparin Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Regular Glucose Insulin Dose 0-50 mg/dL 4 oz. 51-150 mg/dL 0 Units 0 Units 0 Units 0 Units 151-200 mg/dL 2 Units 2 Units 2 Units 2 Units 201-250 mg/dL 4 Units 4 Units 4 Units 4 Units 251-300 mg/dL 6 Units 6 Units 6 Units 6 Units 301-350 mg/dL 8 Units 8 Units 8 Units 8 Units 351-400 mg/dL 10 Units 10 Units 10 Units 10 Units 36. Imipenem-Cilastatin 500 mg Recon Soln Sig: One (1) Intravenous once a day: On Hemodilaysis days give after hemodilaysis. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: s/p fem-fem bipass CRI Mental status changes / hypotension Discharge Condition: - good Discharge Instructions: - you may shower; no bath or swimming pool for several weeks - you should take all medications as instructed to in the hospital - you should take pain medication as needed - do not drive while taking pain medicaiton - every day you take pain medication you should also take stool softeners: colace, senna, or dulcolax are all good options - [**Name8 (MD) 138**] MD or return to ED if T>101.5, chills, nausea, vomiting, chest pain, shortness of breath, severe pain in leg or at incision site, redness or smelly drainage from incision site, or any other concern Followup Instructions: - You will need to follow-up with Dr. [**Last Name (STitle) **] in 1 week for follow-up and staple removal. Please call her office at ([**Telephone/Fax (1) 1804**] to schedule an appointment. Completed by:[**2165-7-19**]

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icd9cm

[ [ [] ] ]

[ "39.95", "86.22", "93.59", "99.04", "39.49", "39.29", "39.57", "86.04", "38.93" ]

icd9pcs

[ [ [] ] ]

16277, 16349

11636, 12436

310, 419

16452, 16461

2107, 6779

17069, 17293

1751, 1769

12770, 16254

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16485, 17046

1784, 2088

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447, 505

6797, 11613

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13,254

171,934

50789

Discharge summary

report

Admission Date: [**2198-4-6**] Discharge Date: [**2198-4-9**] Date of Birth: [**2147-1-3**] Sex: F Service: MEDICINE Allergies: Aspirin / Codeine / Penicillins / Dilaudid / Flagyl Attending:[**First Name3 (LF) 1711**] Chief Complaint: Chest pressure Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: The patient is a 51-year-old femlae with history of HTN, DM, Hyperlipidemia who presented to her PCP's office with 2 week history of episodic chest pain radiating to shoulder as well as dyspnea on exertion. . The patient reports that over the last 2-4 weeks she has been experiencing chest discomfort with exertion that is new for her. The patient walks often including a daily walk to the bustop, less than [**1-16**] mile. The patient reports over last 4 weeks she has had new onset of chest pressure, [**5-24**] in intensity towards end of walk with associated dyspnea. She denies this is associated with cold weather and reports this to be different than her asthma symptoms which is otherwise well controlled per her report. She is limited in her ability to climb stairs as well secondary to exertional dyspnea. . In addition to the above, the patient reports 3 episodes of chest pain/pressure while at rest, the most recent occurring last night. The patient reports while she was lying in bed she developed severe [**10-24**] chest pressure, like "multiple people or a small elephant sitting on my chest" with associated dyspnea and severe diaphoresis. The patient went outside for fresh air and her symptoms abated over 20-30 minutes. She went to her PCPs office today and again developed similar symptoms, although less intense than last pm. ECG performed in the office did not show any acute ST or TW changes. . The patient additionally reports increasing orthpnea over last 2-4 weeks although reports recumbency to be limited by pressure rather than dyspnea. No PND or LE edema. . ED Course: In the ED the patient was given Plavix 75mg given ASA allergy, SL Nitro x 2 and Albuterol nebulizer. ECG without dynamic change, first set of cardiac biomarkers WNL. Past Medical History: #. HTN #. DM - x 2 years, no HgA1C available for review #. Hyperlipidemia - no recent panel for review #. Asthma #. ? Borderline Personality Disorder given previous cutting behavior Social History: Patient is a self-employed computer consultant. She is single with one child and lives in [**Location 1411**] Family History: Mother - passed age 47 [**2-16**] Breast CA, Rheumatic heart disease Father - passed age 77 [**2-16**] ?? Siblings - alive and well - no family history of premature CAD or sudden death Physical Exam: Vitals: T- 98.7 BP- 124/74 HR-76 RR-18 O2-96% on RA . GEN: Patient is a pleasant African American female, excitable, no acute distress HEENT: NCAT, EOMI, sclera anicteric. OP: MMM, no lesions Neck: Supple. JVP hyperdynamic, 8cm. + multiple healed linear scars (reported to be self inflicted injury 20 years ago) Chest: Poor airmovement (? not well heard [**2-16**] body habitus), but no wheezing. No rales, rhonchi. Cor: RRR, soft I/VI systoliv murmur at LUSB. No R/G Abd: Obese, soft, NT, ND. +BS Ext: No cyanosis, clubbing, or edema. DP 2+ bilat. Multiple well healed linear scars over arms [**2-16**] self-inflicted cutting years ago Pertinent Results: Imaging: . Micro: . Labs: Brief Hospital Course: Patient is a 51 year old female with cardiac risk factors including DM, HTN, Hyperlipidemia and tobacco abuse who presents with symptoms concerning for crescendo angina. . #. Chest pain - patient with intermittent chest pain while on the floor that required a Nitro gtt for resolution of symptoms. Patient also started on heparin gtt due to lateral ST changes. Patient has underlying ASA allergy and patient required transfer to CCU for possible ASA desensitization. Allergist to see patient while in the CCU for official recommendations. Given ASA allergy, patient has been on Plavix daily. Patient was also started on a statin given suboptimal lipid profile. . #. Pump - Patient on HCTZ as an outpatient, although switched to a BB given hx of chest pain. Patient also started on a low dose ACE given hx of DM. Patient has been normotensive while on the floor. Hemodynamics during catheterization revealed ____. . #. Rhythm - Patient remained in NSR throughout hospital stay without events on telemetry. . #. DM - patient on Oral hypoglycemics and Byetta as outpatient, although these were held and patient was maintained on a HRSS. Her outpatient medications were restarted upon discharge. . #. Asthma - Paitent was given Atrovent nebs while in house. Albuterol was held int this setting to reduce myocardial strain. Patient was also continued on Singulair. . . After discussion with the patient and the medical staff, all were in agreement that [**Known firstname 730**] [**Known lastname **] was a suitable candidate for discharge. Medications on Admission: Glucotrol (Glipizide) Avandamet (Metformin/Rosiglitazone) Byeta Metformin HCTZ Singulair Combivent Tramadol Soma (Carisoprodol) Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Chest Pain . Secondary Diagnoses: #. HTN #. DM - x 2 years, no HgA1C available for review #. Hyperlipidemia - no recent panel for review #. Asthma #. ? Borderline Personality Disorder given previous cutting behavior Discharge Condition: Afebrile, stable vital signs, tolerating POs, ambulating without assistance. Discharge Instructions: You were admitted with chest pain and had an aspirin desensitization followed by cardiac catheterization. You had a/no stent(s) placed in the arteries of your heart. . 1. Please take all medication as prescribed. 2. Please attempt to make all medical appointments. 3. Please return to the Emergency room if you have any concerning symptoms. Completed by:[**2198-5-30**]

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Discharge summary

report+report

Admission Date: [**2124-1-26**] Discharge Date: Date of Birth: [**2069-5-9**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 54 year old male with multiple medical problems transferred from [**Hospital1 33995**] for management of left ventricular dysfunction and worsening renal failure. The patient's history is notable for Hodgkin's disease at age 27, at which time he underwent mantel radiation and splenectomy. Complications of radiation therapy included early coronary artery disease in [**2115**], with an inferior myocardial infarction complicated by a left ventricular thrombus, history of left circumflex stent placed in 03/00, ICD implant as well for nonsustained ventricular tachycardia and inducible ventricular tachycardia in Electrophysiology Laboratory. The patient presented in [**Month (only) 205**] with pulmonary edema, acute renal failure, evaluated by catheterization revealing ejection fraction of 30%, restrictive hemodynamics. He ultimately underwent pericardial stripping and received at St. [**Male First Name (un) 1525**] prosthetic mitral and tricuspid valve. He underwent a tracheostomy and percutaneous endoscopic gastrostomy placement after failing to wean off the ventilator in the same month. He had two admissions since then requiring Intensive Care Unit care. His most recent prior to this admission that I am dictating was [**12-2**], and it was notable for congestive heart failure/renal failure. He had trials of multiple regimens to improve left ventricular dysfunction and increase renal perfusion. Milrinone was attempted at that time because hypotension, Dopamine and Lasix were unsuccessful. Dopamine and Lasix were successful for a short amount of time, improved left ventricular function and end organ perfusion temporarily. His hospital course was also notable for Methicillin resistant Staphylococcus aureus positive sputum and excessive bleeding on Coumadin, thus making him not an anticoagulation candidate. Ultimately he was discharged to [**Hospital1 **] Rehabilitation for further management and returned to [**Hospital1 1444**] after four to five days of worsening renal function with a creatinine that was 3.4, up from his discharge creatinine of 1.2 and his baseline at [**Hospital1 5593**] of 1.5 and also elevated blood urea nitrogen at 186. PAST MEDICAL HISTORY: 1. Hodgkin's disease at age 27, status post mantel radiation therapy and splenectomy. 2. Coronary artery disease history, status post inferior myocardial infarction in [**2115**], complicated by left ventricular thrombus and cerebrovascular accident. History of left circumflex stent in 03/00. History of nonsustained ventricular tachycardia and inducible ventricular tachycardia, status post ICD in 03/00. History of constrictive pericarditis and valvular dysfunction secondary to mantel radiation therapy, status post mitral valve replacement, tricuspid valve replacement, both St. [**Male First Name (un) 1525**], pericardial stripping [**2123-8-10**]. The patient not anticoagulated because of consistent bleeding risk. He is not anticoagulation candidate. 3. History of congestive heart failure, ejection fraction 20 to 30%. 4. History of Methicillin resistant Staphylococcus aureus pneumonia. 5. History of aspiration pneumonia, status post tracheostomy and status post percutaneous endoscopic gastrostomy placement. 6. Hypercholesterolemia. 7. Status post cervical discectomy. 8. History of hypothyroidism. 9. History of iron deficiency anemia. ALLERGIES: The patient prior to this admission was listed as allergic to Imipenem causing a rash. SOCIAL HISTORY: The patient was married, lived at [**Hospital1 5593**] Rehabilitation. No alcohol and no tobacco and no intravenous drug abuse. FAMILY HISTORY: Colon cancer in his father who ultimately died of that ailment. MEDICATIONS ON ADMISSION: 1. Epogen 5000 units Monday, Wednesday and Friday. 2. Lasix 40 mg q.d. 3. Ceptaz 2.25 q8hours. 4. Amiodarone 400 mg q.d. 5. Captopril 18.75 mg t.i.d. 6. Celexa 10 mg q.d. 7. Benadryl 25 mg q.i.d. 8. Lactulose 15 b.i.d. 9. Lansoprazole 30 q.d. 10. Levothyroxine 30 mcg q.d. 11. L-Thyroxine 5 mcg b.i.d. 12. Reglan 10 intravenous t.i.d. 13. Albuterol two puffs q4hours. 14. Tylenol 650 mg q4hours p.r.n. 15. Ativan 0.5 mg q6hours p.r.n. 16. Fleets q.d. p.r.n. PHYSICAL EXAMINATION: On admission, the patient is 75 kilograms, temperature 97.9, blood pressure 105/43, pulse 80 paced, respiratory rate 28, 100% on 50% FIO2 on assist control. Inputs and outputs not recorded at the time of admission. Ventilatory was assist control at 500/16 50%, PEEP of 5, PIP 36, plateau not recorded. Generally speaking, the patient was in no apparent distress. Head, eyes, ears, nose and throat - tracheostomy site clean, dry and intact. Neck - unable to assess jugular venous distention. Cardiovascular regular rate and rhythm, S1 and S2, no murmurs, mechanical valve sounds auscultated for S1. Respiratory - ventilated breath sounds, rhonchi bilaterally, no rales. The abdomen is soft, distended, normoactive bowel sounds. Back - 3.0 by 4.0 centimeter times 5.0 centimeter deep sacral decubitus. Extremities - cachectic, no edema, bilateral heel ulcers. Lines - Left hand PICC. Skin - bilateral left upper and lower extremity warm and well perfused. LABORATORY DATA: On admission, white count 11.7, hematocrit 28.8, platelets 295,000. Sodium 131, potassium 5.0, chloride 97, bicarbonate 21, blood urea nitrogen 186, creatinine 3.4. The patient had a differential of 81 neutrophils, 1 bands, 12 eosinophils, 3 lymphocytes with positive toxic granulation. HOSPITAL COURSE: The patient was admitted for possible Dobutamine or Dopamine trial. Ultimately, the decision was made not to try that and the patient was dry so he initially received fluid boluses for the goal of improving his urinary output. Initially, his urinary output was on the low side making 500 ccs in his first twelve hours in the Intensive Care Unit ultimately with the creatinine that stayed stable or elevated to 3.4 on [**2124-1-27**]. We continued to give the patient fluid boluses, checked the fractional excretion of urea given the fact that he was on a diuretic prior to admission that revealed that he was prerenal. On deciding this, we gave him fluid and the patient started to have a slightly increased urinary output with a total of 796 on his second hospital day although his creatinine remained stable. The patient had a blood pressure that continued to be on the low side even for him though there have been frequent issues in the past of him being hypotensive while still perfusing his brain and also having good renal function. He has had a history of multiple A lines, all of which have been complicated resulting in the decision to no longer place A lines. Also because of peripheral vascular disease, his blood pressure tends to run about 30 to 40 points lower than his A line tracing when he was on the [**Hospital Ward Name 517**] on a prior admission. On [**2124-1-29**], the patient's TSH returned at 40 so a full set of thyroid function laboratories were ordered, ultimately revealing that he was profoundly hypothyroid. We continued to give the patient fluids with mildly improved renal function with a creatinine that went down to 2.8 on [**2124-1-31**]. He, however, continued to have a blood urea nitrogen elevated to 148. He received a unit of packed red blood cells during this hospitalization to improve his hematocrit to 35.0. He continued his dose. It was felt that he had a large decubitus on his back. Plastic surgery was consulted and they felt that he was not a surgical candidate and that they could not probe down to bone on [**2124-1-31**]. He also was noted to have a heel ulcer that was evaluated by podiatry. Ultimately, he had noninvasive arterial studies that revealed iliac disease bilaterally. We are still awaiting the podiatry plan regarding his heel ulcer given that it is down to his bone and does qualify as an osteomyelitis. Throughout the hospital course, the patient also was weaned off his ventilator, ultimately being on a tracheostomy mask for ten to twelve hours a day. He was started on Bicitra. Ultimately his Captopril was discontinued and on renal consultation it was noted that the patient had high eosinophils peripherally, eosinophils in his urine, prompting them to discontinue his Zosyn and his Celexa for fear that those were causes interstitial nephritis. Endocrine was also asked to see the patient because of his profound hypothyroidism with both reduced T3 and T4 and very elevated TSH, ultimately recommending intravenous repletion of his thyroid hormone. The patient was started simultaneously on intravenous thyroid replacement as well as on steroids on [**2124-2-4**]. His blood pressure was slightly improved after that and his creatinine began to improve rapidly within a day after initiation of those two interventions. Ultimately, the patient at the time of this dictation had a creatinine that returned to the 2.2 range with urine outputs greater than one liter a day, not on diuretic. Based on the interstitial nephritis, there is a plan to continue his steroids and ultimately to shoot for tapering after two weeks to off. There is no plan for discontinuing his Levothyroxine intravenous. Also another issue that came up are his multiple infectious issues in the hospital. He was started on Levofloxacin, Flagyl and Vancomycin, the Vancomycin dosed for levels because of his osteomyelitis in his heel and because of his sacral decubitus. The patient's white count remained stable and he has been afebrile throughout his entire course. He has several swabs that are growing Methicillin resistant Staphylococcus aureus from his heel. He has a sputum culture that is growing Klebsiella sensitive to Ceftazidime only in his sputum and a pseudomonas growing from his sacral decubitus that is highly resistant with sensitivity to Gentamicin. The patient ultimately does not appear infected at the moment but because he is on steroids, also started Diflucan. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**] Dictated By:[**Name8 (MD) 24764**] MEDQUIST36 D: [**2124-2-8**] 16:32 T: [**2124-2-8**] 17:02 JOB#: [**Job Number **] Admission Date: [**2124-1-26**] Discharge Date: [**2124-2-11**] Date of Birth: [**2069-5-9**] Sex: M Service: ADDENDED MEDICINE LIST: 1. Reglan 10 mg by gastrostomy tube q8hours. 2. Epogen 5000 units subcutaneous every Sunday, Tuesday, Thursday. 3. Amiodarone 400 mg by gastrostomy tube q.d. 4. Albuterol four puffs MDI q.i.d. 5. Vitamin C 500 mg by gastrostomy tube q.d. 6. Zinc Sulfate 220 meq by gastrostomy tube q.d. 7. Digoxin 0.125 mg by gastrostomy tube every other day. 8. TUMS two tablets by gastrostomy tube three times a day. 9. Prevacid 30 mg by gastrostomy tube every day. 10. Levofloxacin 250 mg by gastrostomy tube q.d., date started [**2124-2-4**], duration six weeks. 11. Flagyl 500 mg p.o. b.i.d., date initiated [**2124-2-4**], continue for six weeks. 12. Vancomycin dosed for levels less than 12.0. Continue for six weeks, start date [**2124-2-4**]. 13. Prednisone current dose 40 mg which is continued through [**2124-2-12**], then should be dose reduced to 35 which would continue through [**2124-2-16**], then reduced to 30 and continued through [**2124-2-20**], then reduced to 25 and continued through [**2124-2-24**], then reduced to 20 and continued through [**2124-2-28**], then reduced to 15 and continued through [**2124-3-4**], then reduced to 10 and continued to [**2124-3-8**], then reduced to 5 and continued until [**2124-3-12**], ultimately to discontinue on [**2124-3-13**]. 13. Diflucan 200 mg by gastrostomy tube q.d. while on steroids. 14. Levothyroxine 75 mcg intravenous q.d. 15. Free water boluses 350 ccs by gastrostomy tube q.i.d. 16. Tube feeds are currently 3/4 strength Nepro with 45 grams ProMod powder at 45 cc/hour. 17. Ativan 0.5 mg intravenous q6hours p.r.n. and q.h.s. 18. Benadryl 25 mg by gastrostomy tube q6hours p.r.n. and q.h.s. 19. Tylenol 650 mg by gastrostomy tube q4-6hours p.r.n. 20. Lactulose 15 ccs by gastrostomy tube b.i.d. p.r.n. 21. Hystatin cream topical p.r.n. 22. Sarna cream topically p.r.n. 23. Atarax 10 mg by gastrostomy tube q.i.d. p.r.n. for pruritus. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**] Dictated By:[**Name8 (MD) 24764**] MEDQUIST36 D: [**2124-2-9**] 17:55 T: [**2124-2-9**] 18:23 JOB#: [**Job Number **]

[ "201.90", "V45.02", "428.0", "518.81", "276.1", "707.0", "730.28", "V44.0", "584.5" ]

icd9cm

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Discharge summary

report

Admission Date: [**2110-10-4**] Discharge Date: [**2110-10-8**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 106**] Chief Complaint: STEMI Major Surgical or Invasive Procedure: Cardiac Catheterization x 2 History of Present Illness: 88 year old female with hx of anterior STEMI s/p DES to mid-LAD in [**2100**], breast cancer s/p lumpectomy and XRT, thyroid cancer s/p thyroidectomy, sensineural deafness s/p cochlear implant, type II DM, HTN and HLD presenting with left arm pain and found to have inferior STEMI. The patient reports the onset of left arm pain radiating from the elbow to the shoulder with associated nausea and shortness of breath while eating breakfast this morning. She lay down to rest, but the pain didn't improve. She denies any associated chest pain, did have some vomiting and diaphoresis. She called her PCP's office and was instructed to come to the ED for evaluation. In the ED, initial vitals were 96.7, 90, 168/67, 20, 98% Labs and imaging significant for troponin of 0.28, EKG showing ST elevations in the inferior leads. Patient given aspirin and plavix and started on a heparin drip. Sent to cath lab, where she was found to have obstruction of a distal branch of PDA, too tight to pass stent and balloon angioplasty of the lesion was performed. Also found to have 90% in-stent restenosis of LAD stent. On arrival to the floor, vitals were 97.6, 111/83, 71, 13, 100% on 4L/NC. REVIEW OF SYSTEMS On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: s/p anterior STEMI and DES to mLAD(3.0 x 18 and 2.5 x 18 mm Cypher). EF initially 30% improved to >55%. -PACING/ICD: none -mild aortic and mitral regurgitation 3. OTHER PAST MEDICAL HISTORY: -breast cancer, diagnosed [**2097**] (infiltrating ductal carcinoma, estrogen receptor positive, HER-2/neu negative s/p breast-conserving surgery followed by adjuvant radiation therapy) -papillary thyroid carcinoma diagnosed in [**2102**] treated with a completion thyroidectomy and radioactive iodine therapy -sensorineural hearing loss at age 3 and status post cochlear implants -type 2 diabetes -Chronic renal insufficiency: Cr 1.2 -osteoporosis Social History: Ms. [**Known lastname 44818**] lives alone in independent living, splitting her time between here and [**State 108**]. She will be leaving for Palm Beach on [**2110-10-8**]. Retired from department store. Artist, paints watercolors. Cigarettes, denied. ETOH, occasional wine with dinner. Exercise, she continues to golf when the weather is good 2 to 3times per week. Family History: Family history significant for premature CAD, brother MI age 50 and mother MI ? age 60. Physical Exam: On Admission: VS: 97.6, 111/83, 71, 13, 100% on 4L/NC GENERAL: WDWN 88yo female in NAD. Alert and oriented x 3, hard of hearing. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 8 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. DP and PT pulses dopplerable bilaterally. Right femoral cath site dressing c/d/i. No hematoma or bruit. SKIN: venous insufficiency changes of bilateral ankles On Discharge: Unchanged from above. Pertinent Results: Labs on Admission: [**2110-10-4**] 01:00PM BLOOD WBC-6.9 RBC-3.72* Hgb-10.6* Hct-33.2* MCV-89 MCH-28.5 MCHC-31.9 RDW-13.8 Plt Ct-204 [**2110-10-4**] 01:00PM BLOOD Neuts-78.6* Lymphs-15.6* Monos-2.9 Eos-2.3 Baso-0.5 [**2110-10-4**] 01:00PM BLOOD PT-10.0 PTT-26.8 INR(PT)-0.9 [**2110-10-4**] 01:00PM BLOOD Glucose-165* UreaN-21* Creat-1.4* Na-132* K-5.5* Cl-98 HCO3-22 AnGap-18 [**2110-10-4**] 08:40PM BLOOD Mg-1.8 [**2110-10-4**] 02:33PM BLOOD Hgb-8.8* calcHCT-26 O2 Sat-98 [**2110-10-4**] 02:33PM BLOOD Glucose-152* Lactate-0.8 Na-131* K-4.2 Cl-100 [**2110-10-4**] 02:33PM BLOOD Type-ART pO2-157* pCO2-37 pH-7.41 calTCO2-24 Base XS-0 Cardiac Labs: [**2110-10-4**] 01:00PM BLOOD cTropnT-0.28* [**2110-10-4**] 08:40PM BLOOD CK-MB-86* cTropnT-2.17* [**2110-10-5**] 06:18AM BLOOD CK-MB-44* MB Indx-12.7* cTropnT-1.95* [**2110-10-5**] 06:18AM BLOOD CK(CPK)-347* [**2110-10-7**] 12:10AM BLOOD CK-MB-4 Other Labs: [**2110-10-5**] 06:18AM BLOOD %HbA1c-7.1* eAG-157* Studies/Images: EKG [**2110-10-4**]: Sinus rhythm. Borderline diagnostic Q waves recorded in leads II, III and aVF and continued ST segment elevation in these leads and slight ST segment elevation in leads V4-V6. Rule out active inferolateral ischemic process. Followup and clinical correlation are suggested. Cardiac Cath [**2110-10-4**]: 1. Selective coronary angiography of this right dominant system demonstrated no angiographically-apparent flow-limiting stenosis of the LMCA. The LAD has diffuse disease and a 90% in-stent re-stenosis in its mid-portion with flow distal to the stenosis. The LCx has mild, angiographically apparent disease with no flow limiting lesions. The RCA has diffuse mild disease with occluded small PDA that was deemed the culprit vessel. 2. Limited resting hemodynamics revealed a normal LVEDP of 11 mmHg and normal systolic arterial pressure. There was no aortic valve gradient seen on careful pullback from the left ventricle to aorta. 3. Left ventriculography was deferred. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Acute inferior myocardial infarction, managed by acute ptca. PTCA of vessel. EKG [**2110-10-5**]: Sinus rhythm and significant Q waves in leads II, III and aVF and continued ST segment elevation in leads II, III, aVF and V5-V6 with now biphasic T waves in leads III and aVF. These findings are consistent with further evolution of acute inferolateral myocardial infarction. Followup and clinical correlation are suggested. Cardiac Cath [**2110-10-6**]: Findings ESTIMATED blood loss: <100 cc Hemodynamics (see above): Coronary angiography: right dominant LMCA: No angiographically apparent CAD LAD: mid vessel in-stent restenosis and disease between prior stents 80% LCX: Mild luminal irregularities RCA: Not injected Interventional details Change for 6 French XB3. Crossed with Prowater wire. Predilated with a 2.5 mm balloon. Deployed a 2.75 x 18 mm Resolute stent. Postdilated to 3.0 mm. Final angiography revealed normal flow, no dissection and 0% residual stenosis. Assessment & Recommendations 1. Secondary prevention CAD. 2. ASA indefinitely. 3. Plavix 75 mg PO daily. ECHO [**2110-10-7**]: The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. There is mild functional mitral stenosis (mean gradient 4 mmHg) due to mitral annular calcification. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. Mild calcific mitral stenosis. Mild aortic regurgitation. Mild pulmonary hypertension. Compared with the prior study (images reviewed) of [**2110-7-18**], the findings are similar. CXR [**10-8**]: IMPRESSION: Right basilar subsegmental atelectasis. No pneumonia or pulmonary edema. Labs on Discharge: [**2110-10-8**] 06:05AM BLOOD WBC-5.3 RBC-2.89* Hgb-8.4* Hct-25.8* MCV-89 MCH-29.1 MCHC-32.5 RDW-13.8 Plt Ct-204 [**2110-10-8**] 06:05AM BLOOD Glucose-128* UreaN-18 Creat-1.1 Na-140 K-4.2 Cl-105 HCO3-28 AnGap-11 Brief Hospital Course: 88 yo F with hx CAD s/p anterior STEMI and DES to mid-LAD, breast cancer, papillary thyroid cancer, diabetes presenting with left arm pain and found to have inferior STEMI s/p balloon angioplasty of R-PDA as well as 90% in-stent restenosis of LAD. # STEMI/CAD: Patient presented with left arm pain and was found to have inferior STEMI. The patient was taken to cath lab and balloon angioplasty of the R-PDA was preformed for inferior MI. The patient had STEMI in [**2100**] and is s/p DES to LAD and was found to have evidence of 90% in-stent restenosis. The patient was initially admitted to CCU for monitoring. She was continued on ASA, plavix, statin, and metoprolol. Home lisinopril was held initially given elevated Cr and recent dye load from cath. On [**2110-10-6**] the patietn was taken back to cath lab for elective procedure to place DES to LAD for the re-instent stenosis. The patient tolerated both procedures well. She was monitored on the cardiology floor following the second cath. Physical therapy worked with patient and felt that she was safe to discharge home. # PUMP: Previous history of decreased EF following MI in [**2100**], with subsequent improvement. No history of CHF symptoms. The patient appeared euvolemic on exam and was without signs/symptoms of CHF. ECHO was done and showed normal global and regional biventricular systolic function. Mild calcific mitral stenosis. Mild aortic regurgitation. Mild pulmonary hypertension. EF>55%. # Diabetes: HbA1c 6.7 in [**2110-4-22**] and 7.1% on this admission. Patients home metformin and glipizide were held during admission and she was maintained on ISS. On [**10-7**] the patient had elevated glucose and was restarted on glipizide and ISS increased. # Hypothyroidism: Home levothyroxine continued. # Hypertension: Home metoprolol continued. Home lisinopril initially held [**1-23**] rising Cr and dye load with cath. Lisinopril was restarted on day of discharge. Transitional: -A1C not at goal, will need outpatient management for improvement of glycemic control. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. GlipiZIDE XL 10 mg PO DAILY 2. Levothyroxine Sodium 100 mcg PO 6X/WEEK (MO,TU,WE,TH,FR,SA) 3. Lisinopril 10 mg PO DAILY 4. MetFORMIN (Glucophage) 500 mg PO TID 5. Metoprolol Succinate XL 25 mg PO DAILY 6. risedronate *NF* 75 mg Oral weekly 7. Simvastatin 20 mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Cal-Citrate *NF* (calcium citrate-vitamin D2) 250-100 mg-unit Oral daily Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. GlipiZIDE XL 10 mg PO DAILY 3. Levothyroxine Sodium 100 mcg PO 6X/WEEK (MO,TU,WE,TH,FR,SA) 4. Lisinopril 5 mg PO DAILY RX *lisinopril 5 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 5. Atorvastatin 80 mg PO DAILY RX *atorvastatin 80 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 6. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 7. Metoprolol Succinate XL 50 mg PO DAILY RX *metoprolol succinate 50 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 8. Cal-Citrate *NF* (calcium citrate-vitamin D2) 250-100 mg-unit Oral daily 9. MetFORMIN (Glucophage) 500 mg PO TID 10. risedronate *NF* 35 mg Oral weekly Discharge Disposition: Home Discharge Diagnosis: ST elevation myocardial infarction Diabetes Mellitus type 2 Hypertension Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had a heart attack and needed to have a balloon angioplasty to open up the artery that was blocked. The heart attack was small and your heart is still strong. During the catheterization, it was seen that a previous stent was also blocked and another stent was placed inside this stent to open it up. You will need to take aspirin and clopidogrel every day without fail to keep the stent open and prevent another heart attack. Do not stop taking aspirin and clopidogrel or miss [**First Name (Titles) 691**] [**Last Name (Titles) 11014**]s unless Dr. [**Last Name (STitle) **] says that it is OK. You will need to see Dr. [**Last Name (STitle) **] before you leave for [**State 108**]. Followup Instructions: Department: DR. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9052**], MD When: MONDAY [**2111-5-25**] at 1:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9052**], MD [**Telephone/Fax (1) 49151**] Building: [**Street Address(2) 3001**] ([**Location (un) 620**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Parking on Site Department: MEDICAL SPECIALTIES When: WEDNESDAY [**2111-6-10**] at 9:30 AM With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 13645**], M.D. [**Telephone/Fax (1) 1803**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: FRIDAY [**2111-7-10**] at 12:00 PM With: [**Name6 (MD) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: TUESDAY [**2110-10-14**] at 1:30 PM With: [**Name6 (MD) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2110-10-9**]

[ "244.0", "E879.8", "403.90", "E849.0", "272.4", "250.00", "V10.87", "733.00", "996.72", "410.41", "V10.3", "414.01", "585.9", "285.9", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "36.07", "00.66", "88.56", "88.53", "00.45", "37.22", "00.40" ]

icd9pcs

[ [ [] ] ]

11859, 11865

8570, 10619

256, 285

11997, 11997

4154, 4159

12861, 14190

3243, 3332

11104, 11836

11886, 11976

10645, 11081

6143, 8315

12148, 12838

3347, 3347

2147, 2358

4112, 4135

211, 218

8334, 8547

313, 2043

4173, 5051

12012, 12124

2389, 2840

2065, 2127

2856, 3227

5063, 6126

29,484

104,022

32567

Discharge summary

report

Admission Date: [**2126-1-16**] Discharge Date: [**2126-1-20**] Date of Birth: [**2044-9-4**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2901**] Chief Complaint: Patient was admitted for hypotension post-catheterization Major Surgical or Invasive Procedure: Cardiac catheterization with Graftmaster stenting x 5 History of Present Illness: Ms. [**Known lastname 75926**] is a 81yoF w/h/o CAD s/p prior MIs and CABG [**2110**](SVG->[**Last Name (LF) 8714**],[**First Name3 (LF) **], LIMA->diagonal, LAD) c/b pseudoaneurysm formation at her SVG. In [**2118-4-4**] she underwent thrombectomy and stenting x 4 of the SVG to the OM at [**Location (un) 20338**] Community Hospital with three Wall stents and one Tristar stent. In [**2118**] the patient had her proximal RCA stented. Prior catheterization in [**2120**] had revealed [**2-5**] pseudoaneurysms (1-1.5cm) of the SVG to the OM. Most recently a CXR revealed evidence of a hilar mass. Follow up CT reported the pseudoaneurysms to be enlarging. She was referred for cardiac catheterization at [**Hospital1 18**] on [**2125-12-3**] which confirmed these aneurysms. Cardiac MR was then completed which showed 6.3x5x5cm pseudoaneurysm w/ significant thrombus accumulation w/ mild compression of the main and left pulmonary artery as well as a smaller pseudoaneurysm but preserved intraluminal flow. Plavix and aspirin were discontinued and she was discharged to home with plans for return for compassionate use of a Jomed covered stent. She was reloaded with 300mg Plavix on [**2126-1-15**] and Aspirin was restarted. . She returned for [**Hospital1 18**] for catheterization today. In the cath lab she had evidence of extravasation of contrast into the mediastinum which resolved following Graftmaster stents x5. Following cath, patient became vagal and hypotensive with groin pressure and was noted to have a significant hematocrit drop to 21.2. Her Hct on admission was 41 and most recent value of 39 [**2125-12-4**]. . Upon arrival to the CCU, patient complaining of significant nausea which improved w/ IV Zofran. The patient otherwise denies any recent complaints. She has felt well recently except for "the flu" a few weeks ago. She denies any chest pain, SOB, orthopnea, PND, LE swelling, presyncope or syncope, joint pains, cough, hemoptysis, black stools or red stools. Past Medical History: PAST MEDICAL HISTORY: Cardiac Risk Factors: Hypertension, Hyperlipidemia . Cardiac History: CABG ([**Hospital1 2025**]) in 4/93 anatomy as follows: SVG to OM, LIMA to diagonal and LAD (70% narrowing of proximal second marginal artery, 60% narrowing of anterior descending artery, 70% narrowing of first septal and first diagonal branch) -s/p MI x3 -s/p PTCA [**4-/2118**]: 3 Wall stents and 1 TriStar stent placed in severely diseased and degenerated SVG to OM, EF >60% -s/p Cardiac Cath [**8-5**]: patent LIMA to LAD, patent SVG to AOMB with 50-60% stenosis at the ostium (not hemodynamically significant), RCA 75% stenosis proximally s/p Penta stent placement -s/p Cardiac Cath [**1-6**]: patent LIMA to LAD, patent SVG to OM with 60% stenosis at the ostium, and patent RCA, EF >60% -[**2-5**] aneurysms/pseudoaneurysms of proximal mid segment of SVG to OM found in [**1-6**] cardiac cath . Other Past History: -COPD (mild) -h/o Factor 8 Deficiency -h/o asthma -h/o depression -s/p endovascular stent graft repair of infrarenal AAA [**1-6**], stents placed endovascularly in aorta and in left common iliac artery -"head aneurysm" -s/p lumbar disc surgery -s/p left breast biopsy for lump -s/p total abdominal hysterectomy, bilateral salpingo-oophorectomy -s/p appendectomy Social History: Social history is significant for the absence of current tobacco use as of 1/[**2125**]. Prior to that she smoked 6 cigarettes/day for many years. She has a history of alcohol abuse, but is currently sober for [**5-11**] yrs. Denies illicit drug use. Lives in [**Hospital3 **] w/her husband. There is no family history of premature coronary artery disease or sudden death. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: T 95.0, BP 127/68, HR 97, RR 23, O2 97% on RA Gen: Elderly female in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP low. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2.2/6 holosys murmur at LLSB. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi appreciated anteriorly. Abd: Midline lower surgical scar. +BS. Soft, NTND, No HSM or tenderness. Mobile superficial 2-3 cm mass below the umbilicus which is nontender. No abdominial bruits. Groin: Sheath in place in R groin. R groin soft w/o obvious hematoma. Scar over L groin. Ext: LE warm. No cyanosis or edema. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. +actinic keratoses on LE Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP 1+ PT [**Name (NI) 2325**]: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP 1+PT Pertinent Results: ADMISSION LABS: [**2126-1-16**] 06:01PM BLOOD WBC-11.6* RBC-3.50* Hgb-10.2*# Hct-29.8*# MCV-85 MCH-29.3 MCHC-34.4 RDW-13.7 Plt Ct-114* [**2126-1-16**] 11:45AM BLOOD Plt Ct-101* [**2126-1-16**] 06:01PM BLOOD K-4.0 CARDIAC ENZYMES [**2126-1-19**] 11:30PM BLOOD CK-MB-NotDone cTropnT-0.20* [**2126-1-20**] 07:30AM BLOOD CK-MB-NotDone cTropnT-0.18* [**2126-1-19**] 11:30PM BLOOD CK(CPK)-28 [**2126-1-20**] 07:30AM BLOOD CK(CPK)-26 ECG [**2126-1-16**]: Sinus tach @ ~100. Nl axis and intervals. TWF in I, aVL. CARDIAC CATH performed on [**2126-1-16**] (see report for further details): PA sat 69%, CO 3.39, CI 2.18, RA 2, RV 17/2, PA [**11-6**], PCWP 1 SVG->OM w/ large aneurysmal disease w/ serial dilation and free extravasation into the mediastium. Ostial 80% stenosis s/p Graftmaster stenting x 5 w/ stoppage of all angiographic evidence of leakage Brief Hospital Course: Ms. [**Known lastname 75926**] was admitted after her cardiac catheterization with hypotension, likely multifactorial in origin. Low filling pressures were noted on right heart catheterization, and her Hct was significantly lower on admission than prior values suggesting blood loss and hypovolemia. She was also in considerable pain after the procedure, and it is possible increased vagal tone also contributed to her hypotension. Following the cathterization, she was transfused three units of RBC's. Hct stabilized overnight and blood pressures normalized to 100-110's/50-60's with the transfusions and IVF boluses. On [**2126-1-19**], Ms. [**Known lastname 75926**] complained of substernal chest pain that came on at rest. Two sets of cardiac enzymes were negative and she had no new EKG changes concerning for ischemia. Her chest pain was relieved with morphine and Imdur (she gets headaches with SLNG), and no further intervention was performed. Medications on Admission: asa 325 mg daily plavix 75 mg daily (300 mg on [**2126-1-15**]) lipitor 80 mg daily lasix 20 mg daily Toprol XL 50 mg daily Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Primary Diagnoses 1. Vein graft aneursym s/p stenting 2. Anemia 3. CAD Secondary Diagnoses 1. COPD Discharge Condition: HD stable, Hct stable. Discharge Instructions: You were admitted to the hospital for a cardiac catheterization. Your blood pressure was low after the catheterization likely from blood loss, and you were given 2 units of red blood cells. Your blood pressure improved. The following changes have been made to your medications: 1. You are now taking Toprol XL 25 mg daily (half of your previous dose) 2. You should not take your lasix. You should discuss restarting this with Dr. [**Last Name (STitle) 911**] 3. You were started on Imdur 30 mg daily. If you develop chest pain, shortness of breath, dizziness, bleeding from your groin site, fevers, or any other concerning symptoms, you should call your doctor or come to the emergency room. Please take all of your medications as directed. Please keep all of your follow up appointments. Followup Instructions: You should follow up with your cardiologist, Dr. [**Last Name (STitle) 911**], in [**1-6**] weeks. Please call([**Telephone/Fax (1) 24798**] to schedule an appointment if you are not contact[**Name (NI) **] by his office directly. Please follow up with your Primary Care Provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**12-5**] weeks. You can call [**Telephone/Fax (1) 10688**] to schedule an appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

[ "414.01", "414.11", "287.5", "276.52", "458.29", "280.0", "414.02" ]

icd9cm

[ [ [] ] ]

[ "00.40", "00.66", "88.56", "00.48", "36.06" ]

icd9pcs

[ [ [] ] ]

7382, 7433

6246, 7207

330, 386

7577, 7602

5369, 5369

8447, 9012

4120, 4202

7454, 7556

7233, 7359

7626, 8424

4217, 4227

4249, 5350

232, 292

414, 2412

5385, 6223

2456, 3711

3727, 4104

75,502

197,747

54784

Discharge summary

report

Admission Date: [**2185-9-25**] Discharge Date: [**2185-9-26**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3565**] Chief Complaint: biliary sepsis Major Surgical or Invasive Procedure: ERCP ([**2185-9-25**]) History of Present Illness: Mr. [**Known lastname 7518**] is 87M with history of Alzheimer's disease who initially presented to [**Hospital3 **] on 8.18 with complaints of N/V, abdominal pain, and RUQ discomfort. The patient reports that day before presentation he developed abdominal cramping pain. Reports that the pain started after he ate breakfast; initially thought that his pain was due to eating. Reports that the pain was primarily on the R side of abdomen, reports that it self resolved. However, as per the patient's family, his primary reason for going to the hospital was because he was having nausea and vomit; cream colored vomitus, no blood or [**Hospital3 **]. As [**First Name8 (NamePattern2) **] [**Hospital1 **] outside records, patient was recently hospitalized 08.08-08.12 with epigastric pain. He underwent nuclear stress testing and EGD and was diagnosed with gastric ulcers, which were cauterized. He was discharge to an [**Hospital3 **] facility on an oral PPI. He was also noted to have nonsustaned vtach in teh steting of negative nuclear stress test with plan to start a low dose beta blocker. As per the patient's family, prior to that admission, he presented to OSH with abdominal pain, bloating, and increased belching was noted to have elevated LFTs. As per the family, the patient was treated for sepsis which was thought to be from a pulmonary source. Of note, the patient's daughter reports that he is more altered than his baseline; reports that this mental status has been off for the last two weeks. While at [**Hospital1 **], labs were notable for a total bili of 2.0, with transaminases in the 900s. CT showed evidence of distended gallbladder and e/o GB stones; no biliary dilation was noted. As per report, the patient had temperature of [**Age over 90 **] yesterday, and overnight developed hypotension and started on neo 20 mcg, prompting him for transfer to [**Hospital1 18**] for ERCP. While at [**Hospital1 **], the patient received Vancomycin, Cipro/Flagyl. The plan is to transfer him back to [**Hospital1 **] tomorrow post procedure for laparascopic cholecystectomy. On arrival to the MICU, patient's VS: 99/46 HR 79 17 97% on RA. The patient reports feeling well, no acute complaints. Denies having any current abdominal pain. Denies any nausea or vomit. Denies any light headedness or dizziness. Reports feeling very comfortable. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies shortness of breath, cough, dyspnea or wheezing. Denies chest pain, chest pressure, palpitations. Denies constipation, abdominal pain, diarrhea, dark or bloody stools. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Alzheimer's disease prostate cancer pulmonary fibrosis diabetes hyperlipidemia gastric ulcers Medications: HOME MEDS (as [**First Name8 (NamePattern2) **] [**Hospital1 **] d/c summary, 8.13) Januvia 100 mg by mouth daily Lipitor 40 mg by mouth each bedtime Ferrous sulfate 325 mg by mouth daily Multivitamin 1 tab by mouth daily Niaspar thousand milligrams by mouth daily Prilosec 20 mg by mouth twice daily Carafate 1 g by mouth 4 times a day Tylenol 650 mg by mouth every 6 when necessary Colace 100 mg by mouth daily when necessary Lopressor 12.5 mg by mouth twice a day(to be held for systolic blood pressure less than 100, heart rate less than 50). MEDS ON TRANSFER Heparin 5000 SQ Q8H Phenylephrine drip Cipro 200 IV Q12H Flagyl 500 IV Q6H Tylenol 1000 Q6H PRN Dilaudid 0.5 mg IV Q6H PRN Atropine 1mg IV PRN Milk of Magnesia QD PRN Nitrostat 0.4 mg SL PRN Duonebs Q6H PRN D51/2NS + 40 meq KCl Social History: The patient reports that he lives with his wife. Family History: denies Physical Exam: ADMITTING EXAM Vitals: 71 113/42 13 98% RA (phenylephrine dc'd x>3h) General: Alert, oriented to person only, NAD, laying comfortably in bed, some delayed speech, slight Parkinsonian facies Skin: notable for slight jaundice HEENT: slight scleral icterus, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated CV: Regular rate and rhythm, normal S1 + S2, + systolic murmur, no rubs, gallops Lungs: crackles bilateral bases, otherwise clear to auscultation no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: no foley Ext: Warm, well perfused, 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. DISCHARGE EXAM 98.1 127/57 70 17 96% ra General: Alert, oriented, NAD, laying comfortably in bed, some delayed speech, slight Parkinsonian facies Skin: notable for slight jaundice HEENT: slight scleral icterus, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated CV: Regular rate and rhythm, normal S1 + S2, + systolic murmur, no rubs, gallops Lungs: crackles bilateral bases, otherwise clear to auscultation no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: no foley Ext: Warm, well perfused, 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: [**2185-9-25**] 12:21PM GLUCOSE-94 UREA N-15 CREAT-1.0 SODIUM-137 POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-26 ANION GAP-9 [**2185-9-25**] 12:21PM ALT(SGPT)-903* AST(SGOT)-1133* LD(LDH)-320* ALK PHOS-333* TOT BILI-2.0* [**2185-9-25**] 12:21PM ALBUMIN-2.9* CALCIUM-7.4* PHOSPHATE-2.0* MAGNESIUM-1.4* [**2185-9-25**] 12:21PM WBC-22.3* RBC-3.23* HGB-9.6* HCT-28.5* MCV-88 MCH-29.8 MCHC-33.8 RDW-15.0 [**2185-9-25**] 12:21PM PLT COUNT-161 [**2185-9-25**] 12:21PM PT-20.3* PTT-48.8* INR(PT)-1.9* CXR 8.19 Cardiac silhouette is mildly enlarged without evidence of vascular congestion. There is prominence of interstitial markings, especially at the bases and in the retrocardiac region. This is consistent with the clinical diagnosis of pulmonary fibrosis. Although not optimally seen, in the retrocardiac region there is suggestion of some bronchiectatic change. No acute focal pneumonia is appreciated, though this would be difficult to exclude in the appropriate clinical setting. ERCP 8.19 Procedures: A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. One round black stone was extracted successfully using a balloon. Occlusion cholangiogram revealed no other filling defects in the biliary tree. The PD stent was removed with a snare. Impression: A large periampullary diverticulum was seen causing distortion of the papilla. Cannulation of the biliary duct was performed with a sphincterotome using a free-hand technique. Biliary cannulation was initially difficult due to the large diverticulum. A PD 5Fr x 4cm straigth stent was placed in the pancreatic duct to facilitate cannulation. Biliary cannulation was then successful Cholangiogram revealed a single 6 mm round stone was seen in the lower common [**Month/Day/Year **] duct. There was mild post-obstructive dilation. Successful biliary sphincterotomy was performed Successful balloon extraction of a single round black stone from the CBD. There was no evidence of additional stones, and the [**Month/Day/Year **] duct was draining clear [**Last Name (LF) **], [**First Name3 (LF) **] the decision was made not to place a biliary stent. The PD stent was then removed Otherwise normal ERCP to 3rd portion of duodenum. NOTE: endoscopic images could not be permanently stored in GCARE. Recommendations: NPO overnight with aggressive IV hydration with LR at 200 cc/hr Cholecystectomy with Dr. [**Last Name (STitle) **] tomorrow or Tuesday depending on clinical course. Continue antibiotics for cholecystitis. Additional notes: FINAL DIAGNOSES are listed in the impression section above. Estimated blood loss = zero. Specimens taken for pathology: none. MICRO: none Brief Hospital Course: MICU COURSE: 87 year old male hx Alzheimer's disease, prostate cancer, pulmonary fibrosis, presented to OSH with epigastric pain, found to have choledocholethiasis, transferred here sepsis with cholangitis picture. # Choledocholethiasis with cholangitis: Had elevated LFTs, bilirubin, rising white count and febrile concerning for infection. Patient underwent ERCP on 8.19 with stone removal and sphincterotomy. Patient was continued on antibiotics from [**Hospital3 4107**] (IV Vanc, ciprofloxacin, flagyl) as well as IVF to maintain appropriate urine output. He was kept NPO. Patient was stable after procedure and transferred 8.20 to [**Hospital1 **] for planned cholecystectomy. # Sepsis: patient became hypotensive, febrile, with elevated white count on day of transfer. Likely [**3-10**] to choledocholethiasis that has progressed to cholangitis. Patient was initially on phenylephrine drip from [**Hospital1 **]. His pressure were responsive to fluids and the drip was dc'd within an hour of arrival. His pressures remained stable throughout his stay here. He was continued on broad coverage abx. given biliary sepsis and concern from gram negative and enterococcus. # Pulmonary fibrosis: his respiratory status remained stable on room air. He was continued on duonebs PRN as per outside hospital administration record. # Chest pain: Patient developed positional chest pain after ERCP. EKG was unchanged. Was positional, likely musculoskeletal, and improved with toradol. Chronic Issues # Nonsustained Vtach on prior hospitalization: he was apparently started on lopressor on previous hospitalization for concern for nonsustained V-tach. Patient's lopressor was held in the context of his hypotension. # Dementia: has significant Alzheimer's dementia at baseline. Per family, they feel he is at his baseline mental status. # Diabetes: on januvia per OSH records. We did finger sticks and covered him with ISS as needed. TRANSITIONAL ISSUES Patient will need cholecystectomy in [**Hospital1 **]. Patient's antibiotic regimen will need to be tailored to culture results. Further management of chronic issues as [**First Name8 (NamePattern2) **] [**Hospital1 **] team. Of note, on day of discharge from [**Hospital1 18**] ICU, [**Hospital3 4107**] staff and his attending surgeon, Dr. [**Last Name (STitle) **] requested that pt be transferred to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], as it is the policy of [**Hospital1 **] that if a patient has been out of house for >24h, he must be readmitted through the ED. Dr. [**Last Name (STitle) **] of the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] was informed of the impending transfer over the phone. Medications on Admission: MEDICATIONS FROM [**Hospital3 **] Heparin 5000 SQ Q8H Phenylephrine drip Cipro 200 IV Q12H Flagyl 500 IV Q6H Tylenol 1000 Q6H PRN Dilaudid 0.5 mg IV Q6H PRN Atropine 1mg IV PRN Milk of Magnesia QD PRN Nitrostat 0.4 mg SL PRN Duonebs Q6H PRN D51/2NS + 40 meq KCl Discharge Medications: MEDICATIONS ON DISCHARGE Duonebs Q6H PRN Cipro 200 IV Q12H Flagyl 500 IV Q6H Vancomycin 1000 mg IV Q12H Heparin 5000 SQ Q8H Tylenol IV PRN Discharge Disposition: Extended Care Facility: [**Hospital3 **] TCU Discharge Diagnosis: Primary: Cholangitis Secondary: Choledocholithiasis Sepsis Pulmonary Fibrosis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure to take care of you at [**Hospital1 18**]. You were transferred here from [**Hospital3 4107**] for an ERCP. You were found to have gallstones and sludge, which were removed. You were treated with IV antibiotics and fluids. You tolerated the procedure well. You are being transferred back to [**Hospital1 **] for a cholecystectomy. Any changes to your medications upon discharge will be addressed by the [**Hospital3 **] physicians. Followup Instructions: Follow-up will be arranged for you by your team assuming your care at [**Hospital3 **]. Completed by:[**2185-9-26**]

[ "331.0", "790.92", "294.10", "038.9", "272.4", "562.00", "250.00", "574.50", "515", "576.1", "995.91", "185", "575.0" ]

icd9cm

[ [ [] ] ]

[ "51.85", "51.88" ]

icd9pcs

[ [ [] ] ]

11731, 11778

8513, 11253

266, 291

11923, 11923

5794, 8490

12573, 12692

4138, 4146

11567, 11708

11799, 11902

11279, 11544

12060, 12550

4161, 5775

2711, 3131

212, 228

319, 2692

11938, 12036

3153, 4056

4072, 4122

59,664

145,082

28230

Discharge summary

report

Admission Date: [**2160-10-27**] Discharge Date: [**2160-11-7**] Date of Birth: [**2088-4-29**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: s/p fall down 10 stairs Major Surgical or Invasive Procedure: None History of Present Illness: 72F s/p fall down 10 stairs (likely secondary to diabetic foot neuropathy), has multiple injuries. CT facial bones shows isolated, minimally displaced right zygomatic arch fracture. Minimal comminution. Neurosurgery following for L parietal subdural & intra-parenchymal hemorrhage L temporal lobe and ? basilar skull fracture. Past Medical History: DM Social History: lives at home with husband Family History: noncontributory Physical Exam: O: T:97.0 HR:73 BP: 140/80 R18 O2Sats 98% RA Gen: NAD. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Neuro:WNL Pertinent Results: [**2160-10-27**] Admission labs WBC-16.3* RBC-4.07* Hgb-11.7* Hct-35.0* MCV-86 MCH-28.6 MCHC-33.3 RDW-13.3 Plt Ct-126* PT-15.0* PTT-26.1 INR(PT)-1.3* Glucose-266* UreaN-14 Creat-0.8 Na-139 K-4.0 Cl-107 HCO3-23 AnGap-13 Lipase-23 ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Type-ART Temp-35.7 Rates-/14 FiO2-100 pO2-73* pCO2-35 pH-7.39 calTCO2-22 Base XS--2 AADO2-605 REQ O2-99 Intubat-NOT INTUBA Comment-SIMPLE FAC Glucose-209* Na-141 K-3.8 Cl-105 calHCO3-20* freeCa-1.09* [**2160-11-3**] WBC-5.5 RBC-3.55* Hgb-10.3* Hct-30.6* MCV-86 MCH-29.2 MCHC-33.8 RDW-14.9 Plt Ct-111* PT-13.7* PTT-22.7 INR(PT)-1.2* Glucose-177* UreaN-12 Creat-0.6 Na-134 K-3.5 Cl-107 HCO3-19* AnGap-12 Calcium-8.1* Phos-2.4* Mg-1.8 [**2160-11-4**] Discharge labs WBC-4.6 RBC-3.68* Hgb-10.7* Hct-31.3* MCV-85 MCH-29.0 MCHC-34.0 RDW-15.6* Plt Ct-153 Glucose-144* UreaN-11 Creat-0.6 Na-136 K-3.4 Cl-111* HCO3-15* AnGap-13 Calcium-8.1* Phos-3.2 Mg-2.0 Brief Hospital Course: 72F s/p fall down 1 stairs was admitted on [**2160-10-27**]. Pt was admitted to Trauma ICU and was found to have hct that fell to 24.6 and one unit pRBC was transfused. Hematocrit [**First Name9 (NamePattern2) 68562**] [**Last Name (un) 7162**] later in the evening and pt received 2 units pRBC. Pt had guaiac postitive stool, however FAST was negative. CXR was repeated to r/o expanding hemopneumothorax. HD3 - Pt was intubated for airway protection + flail chest. Right chest tube placed with 800cc blood produced, then 400cc over next 12 hours. Hct [**Last Name (un) 68562**] to 23 with hypotension requiring neo gtt. Pt transfused 2 units pRBC had post transfusion hct was 29.7. 1 unit platelets were given for platelet count [**Numeric Identifier **] (repeat [**Numeric Identifier 68563**]), post transfusion platelet was [**Numeric Identifier 68564**]. HD4 - Neurosurgery recommended logroll precautions until TLsO brace was fitted for epidural hematoma. Tube feeds were started and statin was restarted. Lower extremity non-invasive were negative for DVT. HD5 - Pt was extubated in the morning. Pt received TLSO brace and was allowed to sit at 30 degrees angle. Pt spiked a fever and was empirically started on vanc/zosyn for assumed pneumonia. HD6 - analgesics adjusted with chronic pain service. Sputum cultures grew strep pneumo. Pt was made out of bed to chair. Pt passed swallow eval and diet was started. HD7 - Diet was advanced. Zosyn was stopped based on culture data and was started on 5day course of dicloxacillin. Chest tube kept to suction. Pt was transferred to floor. HD9 - Pt's family was approached about IVC filter placement and pt and family refused. Neurosurgery prohibited anticoagulation based on epidural hematoma. HD10 - Chest tube was discontinued and portable CXR was ordered. Patient being discharge afebrile, tolerating diet, voiding and having Bowel movements. Medications on Admission: baby ASA, simvastatin, metformin, glyburide, detrol, macrodantin Discharge Medications: 1. Tramadol 50 mg Tablet [**Numeric Identifier **]: 0.5 Tablet PO Q6H (every 6 hours). 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Numeric Identifier **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 3. Senna 8.6 mg Tablet [**Numeric Identifier **]: One (1) Tablet PO DAILY (Daily) as needed. 4. Artificial Tear with Lanolin Ointment [**Numeric Identifier **]: One (1) Appl Ophthalmic PRN (as needed). 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 6. Simvastatin 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 7. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H (every 6 hours) as needed. 8. Acetazolamide 250 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q12H (every 12 hours). 9. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2 times a day). 10. Dicloxacillin 250 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO Q6H (every 6 hours) for 1 days. 11. Oxycodone 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q3-4H () as needed. 12. Ondansetron HCl (PF) 4 mg/2 mL Solution [**Last Name (STitle) **]: One (1) Injection Q8H (every 8 hours) as needed. 13. Metoprolol Tartrate 5 mg/5 mL Solution [**Last Name (STitle) **]: One (1) Intravenous Q4-6H () as needed for hypertension. 14. Hydromorphone (PF) 1 mg/mL Syringe [**Last Name (STitle) **]: One (1) Injection Q4-6H PRN (). 15. insulin sliding scale [**Last Name (STitle) **]: One (1) every six (6) hours: see d/c instructions for sliding scale. 16. NPH [**Last Name (STitle) **]: Five (5) unit every twelve (12) hours. Discharge Disposition: Extended Care Facility: [**Hospital1 **] Cape & Islands Discharge Diagnosis: - Left parietal SDH, Right subgaleal hematoma, - Right zygomatic arch fx, Right orbital wall fx - Epidural hematoma T8-L1 - Fracture T10 (body) and L2 (body and pedicles) w/o retropulsion - Rib fracture R2-8 with flail, small-mod Right hemopneumothorax - Right scapula fx - Right clavicular fx Discharge Condition: stable Discharge Instructions: Please call your doctor or return to the ER for any of the following: * Increased work of breathing or SOB * 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 skin, or the whites of your eyes become yellow. * 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. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to ambulate several times per day. Insulin regimen Sliding scale Glucose Insulin Dose 0-60 mg/dL [**1-30**] amp D50 61-120 mg/dL 0 Units 121-140 mg/dL 2 Units 141-160 mg/dL 4 Units 161-180 mg/dL 6 Units 181-200 mg/dL 8 Units 201-220 mg/dL 10 Units 221-240 mg/dL 12 Units 241-260 mg/dL 14 Units 261-280 mg/dL 16 Units 281-300 mg/dL 18 Units > 300 mg/dL Notify M.D. fixed insulin dose NPH 5units q12 hours Followup Instructions: Please call to schedule follow up appointment with Trauma clinic ([**Telephone/Fax (1) 22750**] Please call Dr.[**Name (NI) 2845**] office to schedule follow up appointment. ([**Telephone/Fax (1) 11314**] Completed by:[**2160-11-6**]

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icd9cm

[ [ [] ] ]

[ "34.04", "38.91", "38.93", "96.71", "04.81", "96.6", "99.07", "99.04", "96.04" ]

icd9pcs

[ [ [] ] ]

5735, 5793

1955, 3863

339, 346

6131, 6140

984, 1932

8005, 8242

792, 810

3979, 5712

5814, 6110

3889, 3956

6164, 7982

825, 965

276, 301

374, 705

727, 731

747, 776

56,642

114,934

3051

Discharge summary

report

Admission Date: [**2120-1-8**] Discharge Date: [**2120-1-13**] Date of Birth: [**2060-1-28**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2009**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: Colonoscopy History of Present Illness: The patient is a 59 yo F with a psychiatric history, colectomy s/p anastamosis, A fib recently started on dabigutran, COPD and hepatitis C who presents with several weeks of BRBPR. The patient came to the ED yesterday complaining of 2 weeks of bloody stools, which have been intermittent since [**12-25**]. The patient reports that she began taking Dabigutran at the end of [**Month (only) 1096**], without evidence of any bleeding until mid-[**Month (only) 404**]. Since that time, she has been having approximately [**4-12**] stools per day, which she describes as red liquid and clots. No fever, chills, nausea, vomiting or abdominal pain. She initially came to the ED over the weekend and was admitted for monitoring and possibly colonoscopy, but left AMA after being told that she could not leave the hospital to smoke a cigarette. According to the patient, she went home last night, ate fish filet, Ziti and milk, and then had a BM that consisted of blood mixed with stool this AM. She spoke to her PCP today and was advised to return to the ED for further workup. . In the ED, initial vitals were: 0 98.9 88 86/57 22 98%. Patient triggered for hypotension on arrival, received 1.5 L IVF and BP improved to 90s/50s. Her rectal exam was notable for maroon stool. Labs were significant for a leukocytosis to 14 (down from 17.5 yesterday) with a mild neutrophilia and a Hct of 40.2 (stable >24hrs). U/A and CXR were unremarkable and the patient was admitted to the medical service for further monitoring. Vitals on transfer were HR low 100s in atrial fibrillation, rr 18, BP 91/54 and 96% RA. . On the floor, patient reports feeling excellent, and being annoyed with her liquid diet. She denies any chest pain, worsened SOB (patient has baseline chronic SOB [**1-10**] COPD), dizziness, abdominal pain, fever, chills, nausea or vomiting. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Has chronic cough and SOB. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, constipation or abdominal pain. No recent change in bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: s/p colectomy for unclear reasons AFib back pain COPD ? Hepatitis C ? paranoid schizophrenia and borderline personality disorder - as told to psychiatry to the patient over the weekend Social History: Has a longstanding relationship with her boyfriend, [**Name (NI) 1169**] [**Name (NI) **] (w[**Telephone/Fax (1) 14520**], c[**Telephone/Fax (1) 14521**]). Lives independently with 7 animals. Currently, her son lives with her as well. Also has an extensive trauma history. Currently smokes > 1.5 ppd, sober from EtOH > 16 years, smokes marijuana regularly. Denies other illicits. Family History: Son with Bipolar disorder, DM on mother's side of family, psychiatric illness on father's side of family. . Physical Exam: Admission Exam: Vitals: T: 98 BP: 106/71 P: 50-140s in afib/flutter R: 18 O2: 100% on RA General: Alert, extremely agitated, swearing, shaking and shouting throughout interview. HEENT: NCAT, Sclera anicteric, MMM, oropharynx clear, very poor dentition Lungs: Coarse breath sounds throughout, otherwise no discrete wheezes, rales, ronchi CV: irregularly irregular and tachycardic, 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 Rectal: Several small nonbleeding external hemorrhoids, no stool in vault Psych: labile, tangential with pressured speech and extremely agitated to the point of shaking bed and self during interview Discharge Exam: VS: 99 122/89 100s AFib 22 99% RA GEN: hyperalert and oriented, pleasant HEENT: PERRL, EOMI, anicteric, dry MM, OP without lesions RESP: decreased breath sounds throughout, no wheezes CV: irregular rhythm, tachycardic, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e, warm and well-perfused, good distal pulses SKIN: no rashes, jaundice or ecchymosis Pertinent Results: Admission Labs: [**2120-1-8**] 03:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2120-1-8**] 11:05AM GLUCOSE-111* UREA N-22* CREAT-1.0 SODIUM-137 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-22 ANION GAP-15 [**2120-1-8**] 11:05AM PT-12.5 PTT-28.8 INR(PT)-1.1 [**2120-1-8**] 11:00AM WBC-14.0* RBC-4.36 HGB-13.9 HCT-40.2 MCV-92 MCH-31.8 MCHC-34.6 RDW-15.0 [**2120-1-8**] 11:00AM NEUTS-78.7* LYMPHS-17.8* MONOS-2.3 EOS-0.8 BASOS-0.4 [**2120-1-7**] 10:51AM WBC-13.2* RBC-4.32 HGB-13.5 HCT-40.1 MCV-93 MCH-31.2 MCHC-33.6 RDW-14.8 [**2120-1-7**] 02:23AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2120-1-7**] 01:11AM ALT(SGPT)-29 AST(SGOT)-33 LD(LDH)-280* ALK PHOS-69 TOT BILI-0.4 [**2120-1-7**] 01:11AM LIPASE-42 [**2120-1-7**] 01:11AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2120-1-7**] 01:11AM WBC-17.4* RBC-4.43 HGB-13.7 HCT-40.9 MCV-93 MCH-31.0 MCHC-33.5 RDW-14.6 Discharge Labs: [**2120-1-13**] 06:30AM BLOOD WBC-7.2 RBC-4.22 Hgb-13.5 Hct-39.2 MCV-93 MCH-31.9 MCHC-34.3 RDW-16.2* Plt Ct-183 [**2120-1-13**] 06:30AM BLOOD Plt Ct-183 [**2120-1-13**] 06:30AM BLOOD PT-13.0 PTT-28.8 INR(PT)-1.1 [**2120-1-13**] 06:30AM BLOOD Glucose-87 UreaN-15 Creat-0.6 Na-142 K-3.6 Cl-111* HCO3-21* AnGap-14 [**2120-1-13**] 06:30AM BLOOD Calcium-8.0* Phos-3.5 Mg-1.8 Imaging: CXR: IMPRESSION: 5-mm right granuloma. Dense opacity projecting over the left heart may reflect costochondral calcifications, however a parenchymal opacity is possible and a PA and lateral chest radiograph is recommended to further assess initially. CXR: FINDINGS: A single upright AP view of the chest was obtained. The cardiomediastinal silhouette is stably enlarged. A streaky retrocardiac opacity likely in the left lower lobe is new compared to the prior study possibly representing a developing pneumonia. A calcified granuloma is again noted inferior to the right minor fissure. Calcification projecting over the lower left heart border likely represents mitral annular calcifications. There are no pleural effusions or pneumothorax. No osseous abnormalities are identified. Colonoscopy Findings: Protruding Lesions: Non-bleeding grade 1 internal hemorrhoids were noted. Excavated LesionsL: End to side small bowel to colon anastomosis at about 20 cm from anal verge. At the anastomosis there was a large area of ulceration with stigmata of recent bleeding (red spots). No active bleeding. No intervention performed. No biopsies secondary to anticoagulation and bleeding. Impression: Ulcer in the colon Grade 1 internal hemorrhoids Otherwise normal colonoscopy to 30 cm Recommendations: End to side small bowel to colon anastomosis at 20 cm from anal verge with ulceration with stigmata of recent bleeding (red spots) at site. Recommend repeat colonoscopy with biopsies in 2 weeks. If continued bleeding recommend surgical evaluation as likely result of ischemia at site of anastomosis. Brief Hospital Course: This is a 59 yo F with A fib on dabigutran, COPD, hx of colectomy and bipolar d/o who presented with several weeks of BRBPR which is attributed to an ulcer at the site of a previous colonic anastamosis. . # LGIB: The patient was immediately transferred to the MICU upon admission for brisk LGIB and tachycardia. She was intubated for a colonoscopy which revealed a ulcer at the site of her anastamoses from a previous colonic anastamosis ([**Hospital1 2025**] records obtained, and colectomy was apparently performed for severe constipation). She received 2 units PRBCs and HCT remained stable. Patient's HCT was stable for 3 days upon discharge and without recurrent rectal bleeding. GI recommmended a followup colonoscopy in 2 weeks which they will schedule during a followup appointment. Upon their recommendation, her anticoagulation will be held until then. This was discussed with her outpatient cardiologist, Dr. [**Last Name (STitle) 14522**] who agreed to holding anticoagulation until after colonoscopy in two weeks. . # Afib with RVR: The patient had a history of atrial fibrillation prior to admission. She developed RVR in the MICU. This was thought to be secondary to hypovolemia secondary to bleeding and she was rate controlled with an esmolol gtt and diliazem gtt; she was subsequently transitioned back to PO medication. The patient had one episode of afib with RVR after being transferred to the floor, but was well rate controlled in the HR 80s before discharge. She was discharged on her home dose of Diltiazem with increased dose Metoprolol. . # Cardiomyopathy: The patient's cardiac history was discussed with her cardiologist Dr. [**Last Name (STitle) 14522**], who reported that a recent Echo showed LVEF 40-45%, Mod MR, Asymmetrical septal hypertrophy, LA 5.2cm. She has a question of non-obstructive hypertrophic cardiomyopathy. He also reported that she has no history of CAD on Cath. He had started her on Dabigatran for anti-coagulation for afib because she had variable INRs on Coumadin. . # Schizophrenia/borderline personality d/o: Upon transfer to the MICU, the patient became agitated and required risperdal and haldol. She was seen by psychiatry who did not feel she had capacity at that time to make decisions regarding code status, etc. She was much more calm upon transfer to the floor, but was started on Risperdal and Clonazepam upon discharge per Psychiatry reccs. Psychiatry spoke to her PCP who states that she is willing to follow the patient on these new medications. . # COPD: Continue inhalers . # Tobacco: Nicotine patch daily Medications on Admission: metoprolol XR 100 mg qd MgO 400 mg qd diltiazem 240 mg qd furosemide 20 m qd advair 250/50 [**Hospital1 **] Spiriva daily Tylenol 1000 gm q4-6 hr prn Albuterol inh prn prednisone 10 mg qd as part of a steroid taper since [**12-28**] Bactrim recently finished a 10 day course "for COPD" Dabigitran/Pradaxa 150 mg daily since end of [**Month (only) 1096**] Discharge Medications: 1. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 2. metoprolol succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day: Take with 50mg Tablet for total daily dose of 150mg once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 3. Mag-Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day. 4. diltiazem HCl 240 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 5. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 7. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 8. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain or fever. 9. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 10. clonazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*0* 11. Risperdal 2 mg Tablet Sig: Two (2) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*0* 12. metoprolol succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day: Take with 100mg tablet, for total daily dose of 150mg each day. . Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Lower GI bleed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [**Known lastname 185**], You were admitted to the hospital because you were bleeding from you GI tract. You were treated in the ICU and we performed a colonoscopy that showed the location of the bleeding. The blood thinner darbigatran likely caused the bleeding. You will have to stay OFF this medication until your next endoscopy. Please speak with your cardiologist about restarting the darbigatran. You were also treated for atrial fibrillation with a rapid heart beat while you were here. On discharge, your heart rate had decreased back to your baseline. We have made the following changes to your medications: STOP Dabigatran. This medication contributed to your bleeding. You will need to stay off this medication until you have an EGD in 2 weeks. Thereafter, you should talk to your primary provider and cardiologist about when to restart this or other anti-coagulation. START Clonazepam 0.5 mg by mouth twice daily and Clonazepam 1 mg at night daily START Risperidone 2 mg by mouth at night daily INCREASED Metoprolol XL to 150 mg once daily - 100 mg XL Daily and 50 mg XL daily Please go to the scheduled followup appointments with GI and your primary care doctor. Followup Instructions: 1. GI followup: Department: GASTROENTEROLOGY When: TUESDAY [**2120-1-30**] at 9:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1983**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage You have an appointment to see you primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 14523**], on Monday [**1-15**] at 8AM. She will followup your new psychiatric medications and make decisions about when to restart your anticoagulation.

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icd9cm

[ [ [] ] ]

[ "45.23" ]

icd9pcs

[ [ [] ] ]

12099, 12105

7606, 10187

309, 323

12164, 12164

4539, 4539

13525, 14153

3188, 3298

10593, 12076

12126, 12143

10213, 10570

12315, 12911

5603, 7583

3313, 4119

4136, 4520

12940, 13502

2213, 2566

264, 271

351, 2194

4556, 5586

12179, 12291

2588, 2775

2791, 3172

73,509

144,674

39021

Discharge summary

report

Admission Date: [**2120-9-20**] Discharge Date: [**2120-9-23**] Date of Birth: [**2057-7-15**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4691**] Chief Complaint: * Major Surgical or Invasive Procedure: [**2120-9-20**] EXPLORATORY LAPAROTOMY, REPAIR OF MULTIPLE ABDOMINAL HERNIA , REVERSE COLOSTOMY WITH EXCISION OF PELVIC TUMOR History of Present Illness: The patient is a 62-year-old woman, who presented approximately 8 months ago with a perforated sigmoid colon secondary to an obstruction from a large pelvic tumor. The patient had fecal peritonitis and was in septic shock. She originally underwent a damage control procedure with colostomy for abdominal sepsis. Subsequently, the pelvic tumor began to bleed and she underwent a second procedure for resection of the pelvic tumor to achieve hemostasis. Subsequent to that, she had an open abdomen for several days, but she rapidly recovered and eventually went home. During the intervening period, she had several episodes of admission for abdominal abscesses which we felt were due to some mucous leakage from the top of the rectum. On study, however, we could find no obstruction of the distal rectum. So eventually, when the patient resolved her inflammatory processes, it was determined to take her back to the OR and reverse her colostomy. Past Medical History: Transient ischemic attack Open hysterectomy and BSO left ovarian tumor resection sigmoid colectomy splenectomy colostomy gastrojejunostomy Social History: lives at home with husband, denies tobacco, EtOH Family History: denies family history of cancer Pertinent Results: [**2120-9-20**] 07:00PM POTASSIUM-4.5 [**2120-9-20**] 07:00PM MAGNESIUM-2.0 [**2120-9-20**] 07:00PM HCT-45.7 Brief Hospital Course: She was admitted to the ACS service and taken to the operating room for takedown of colostomy and reversal of Hartmann's procedure, resection of 10 x 15 cm pelvic mass, probably benign, resection of multiple drain tracts through the abdomen secondary to prior drainage of abdominal abscesses, one of which was essentially a fistula to the top of the rectum and repair of multiple ventral hernias. Postoperatively she has progressed well, her diet was advanced slowly and she is tolerating this well. Her pain is adequately controlled with non narcotics at her request, she is being discharged on prn Ultram. She is ambulating independently. Medications on Admission: CLOPIDOGREL 75'; FUROSEMIDE 40'; QUINAPRIL 10'; SIMVASTATIN 20'; ACETAMINOPHEN 500' Q8H prn pain; ASPIRIN 325'; CHOLECALCIFEROL 1,000U'; DOCUSATE SODIUM 100'' prn constipation; MULTIVITAMIN 1Tab'; OMEGA-3 FATTY ACIDS Discharge Medications: 1. quinapril 5 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO DAILY (Daily). 2. simvastatin 10 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO DAILY (Daily). 3. acetaminophen 325 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO every [**3-12**] hours as needed for headache/fever/pain. 4. multivitamin Tablet [**Month/Day (3) **]: One (1) Tablet PO DAILY (Daily). 5. docusate sodium 100 mg Capsule [**Month/Day (3) **]: One (1) Capsule PO BID (2 times a day) as needed for constipation. 6. omega-3 fatty acids Capsule [**Month/Day (3) **]: One (1) Capsule PO BID (2 times a day). 7. cholecalciferol (vitamin D3) 400 unit Tablet [**Month/Day (3) **]: 2.5 Tablets PO DAILY (Daily). 8. Ultram 50 mg Tablet [**Month/Day (3) **]: 1/2-1 Tablet PO every six (6) hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital **] home health care Discharge Diagnosis: Colostomy reversal Secondary diagnoses: 1. Obstructed sigmoid colon. 2. Pelvic tumor of unknown malignant potential, status post resection of large tumor. 3. Status post multiple abdominal abscesses related to procedures 1 and 2. 4. Multiple ventral hernias. 5. Benign (frozen section) pelvic mass 10 x 15 cm. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**4-15**] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. 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: Follow up in 2 weeks with Dr. [**Last Name (STitle) **] specifically, call [**Telephone/Fax (1) 600**] for an appointment. Completed by:[**2120-9-23**]

[ "569.81", "553.20", "V55.3", "V12.54", "789.30", "568.0", "V45.89" ]

icd9cm

[ [ [] ] ]

[ "46.52", "46.76", "54.3", "54.59" ]

icd9pcs

[ [ [] ] ]

3622, 3685

1854, 2497

316, 443

4047, 4047

1715, 1831

6187, 6340

1663, 1696

2766, 3599

3706, 3726

2523, 2743

4197, 5655

5671, 6164

3747, 4026

275, 278

471, 1418

4062, 4173

1440, 1580

1596, 1647

57,573

165,655

30001

Discharge summary

report

Admission Date: [**2171-3-16**] Discharge Date: [**2171-3-22**] Date of Birth: [**2126-10-20**] Sex: F Service: MEDICINE Allergies: Aspirin Attending:[**First Name3 (LF) 71612**] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy (EGD) History of Present Illness: 44M with Bipolar and alcohol abuse who presents with 1 day of epigastric pain and vomitting of bloody emesis (red and black). She also reports black stools recently. She reports that she drinks vodka daily (or every other day). She has not been sober for over a year. She has not had withdrawl before. She denies any sob/cp/urinary sxs. . In the ED, initial vs were: 99.4 148 116/50 37 90% on NRB but BP dropped to 60/42 transiently and improved when patient was given 2LNS and 1 upRBCs. Pt also given protonix, octreotide, and vanco. Labs with severe anion gap acidosis, ARF, leukocytosis. NG lavage with light yellow liquid. No stool in the vault. GI saw and deferred scope unless actively bleeding. . In the MICU she was normotensive, tachycardic, nauseous with some coffee ground emesis. She denies any ingestion of asa/nsaids/other pills/other fluids. Denies suicidal ideation. Past Medical History: Bipolar, h/o suicidal ideation Alcohol abuse, denies prior withdrawal. Percocet abuse Tobacco abuse Social History: lives in group home. Daily EtOH drinks. + Tobacco. Denies IVDU, any other ingestions. Family History: Strong family h/o alcohol abuse. Physical Exam: General: Alert, uncomfortable, oriented HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, Tender in epigastrum, non-distended, bowel sounds present. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. right pressure dressing over femoral artery. Left Fem CVL. Pertinent Results: CHEST (PORTABLE AP) [**2171-3-16**]: FINDINGS: Minimal atelectasis at the left lung base, otherwise the radiograph is normal. No focal parenchymal opacities, no overhydration, no masses, normal size of the cardiac silhouette. CT CHEST; CT ABDOMEN; CT PELVIS W/CONTRAST [**2171-3-16**]: IMPRESSION: 1. No definite etiology for leukocytosis and pain identified. No pneumoperitoneum. 2. Colon is decompressed, no definite colitis. If needed, CT with oral contrast can be obatined. 3. Active extravasation or pseudoaneurysm formation involving a branch of the right superficial femoral artery with surrounding hematoma. LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2171-3-20**]: IMPRESSION: 1. Mildly echogenic liver is consistent with mild diffuse fatty infiltration. However, more advanced liver disease such as cirrhosis or fibrosis cannot be excluded. No focal solid liver lesion seen. 2. No evidence of cholelithiasis or biliary obstruction. HEMATOLOGY: [**2171-3-15**] 11:15PM BLOOD WBC-17.7* RBC-3.93* Hgb-14.8 Hct-44.9 MCV-115* MCH-37.6* MCHC-32.8 RDW-14.9 Plt Ct-211 [**2171-3-15**] 11:15PM BLOOD Neuts-86.1* Lymphs-6.5* Monos-6.7 Eos-0.5 Baso-0.3 [**2171-3-17**] 12:50PM BLOOD WBC-6.7 RBC-2.64* Hgb-9.9* Hct-27.6* MCV-105* MCH-37.4* MCHC-35.8* RDW-16.9* Plt Ct-71* [**2171-3-22**] 07:30AM BLOOD WBC-7.8 RBC-3.11* Hgb-11.4* Hct-33.4* MCV-107* MCH-36.6* MCHC-34.0 RDW-16.5* Plt Ct-340# [**2171-3-15**] 11:15PM BLOOD PT-14.6* PTT-69.7* INR(PT)-1.3* [**2171-3-19**] 07:15AM BLOOD PT-13.8* PTT-24.4 INR(PT)-1.2* [**2171-3-15**] 11:15PM BLOOD Fibrino-429* CHEMISTRY: [**2171-3-15**] 11:15PM BLOOD Glucose-213* UreaN-8 Creat-1.2* Na-138 K-5.5* Cl-97 HCO3-5* AnGap-42* [**2171-3-16**] 02:55AM BLOOD Glucose-288* UreaN-7 Creat-1.1 Na-134 K-6.3* Cl-100 HCO3-6* AnGap-34* [**2171-3-16**] 07:15AM BLOOD Glucose-375* UreaN-6 Creat-0.8 Na-136 K-4.2 Cl-102 HCO3-15* AnGap-23* [**2171-3-17**] 09:14AM BLOOD Glucose-99 UreaN-3* Creat-0.4 Na-145 K-2.9* Cl-112* HCO3-23 AnGap-13 [**2171-3-17**] 12:50PM BLOOD Glucose-141* UreaN-3* Creat-0.4 Na-143 K-3.5 Cl-111* HCO3-24 AnGap-12 [**2171-3-22**] 07:30AM BLOOD Glucose-103 UreaN-10 Creat-0.5 Na-139 K-4.3 Cl-105 HCO3-27 AnGap-11 LIVER STUDIES: [**2171-3-15**] 11:15PM BLOOD ALT-39 AST-124* AlkPhos-155* TotBili-0.5 [**2171-3-16**] 07:15AM BLOOD ALT-25 AST-64* LD(LDH)-311* CK(CPK)-66 AlkPhos-99 TotBili-0.7 [**2171-3-19**] 07:15AM BLOOD ALT-27 AST-68* AlkPhos-111 TotBili-0.7 [**2171-3-20**] 07:15AM BLOOD ALT-26 AST-42* LIPASE TREND: [**2171-3-15**] 11:15PM BLOOD Lipase-397* [**2171-3-16**] 02:55AM BLOOD Lipase-723* [**2171-3-16**] 03:01PM BLOOD Lipase-885* [**2171-3-17**] 01:44AM BLOOD Lipase-565* [**2171-3-19**] 07:15AM BLOOD Lipase-1050* [**2171-3-20**] 07:15AM BLOOD Lipase-897* CARDIAC ENZYMES: [**2171-3-16**] 02:55AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2171-3-16**] 07:15AM BLOOD CK-MB-4 cTropnT-<0.01 MISCELLANEOUS: [**2171-3-20**] 07:15AM BLOOD Triglyc-149 [**2171-3-17**] 11:01AM BLOOD %HbA1c-5.4 [**2171-3-18**] 07:20AM BLOOD VitB12-449 URINE: [**2171-3-15**] 11:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG MICROBIOLOGY: [**2171-3-19**] URINE URINE CULTURE-FINAL (Negative) [**2171-3-16**] BLOOD CULTURE Blood Culture, Routine-FINAL (Negative) [**2171-3-16**] BLOOD CULTURE Blood Culture, Routine-FINAL (Negative) [**2171-3-16**] URINE URINE CULTURE-FINAL (Negative) [**2171-3-16**] MRSA SCREEN MRSA SCREEN-FINAL (Negative) Brief Hospital Course: This is a 44F with EtOH, abdominal pain, hemetemesis and significant metabolic acidosis. # Acidosis: Patient presented with Metabolic Anion Gap acidosis, with likely some non gap metabolic alkalosis given emesis and respiratory compensation. Her Osm Gap was elevated at 23 (nl<10). Most likely this was alcoholic ketoacidosis with a few urine ketones (mostly not captured by ketone assay in alcoholic ketoacidosis). She has mild lactate elevation at admission. She had a good respiratory compensation for this. Was initially rehydrated with bicarb with dextrose, then normalized and switched the D5NS prior to transfer to the medical floor. Was initially on insulin gtt and dextrose, which was stopped concurrent with gap closure. Was initially hyperkalemic, then resolved. Hypophosphatemia was aggressively repleted. # Hematemesis: Shortly after admission had EGD showing esophagitis, duodenitis, gastritis and [**Doctor First Name **] [**Doctor Last Name **] tear. Patient was started initially on IV PPI [**Hospital1 **] then switched to and discharged on PO PPI [**Hospital1 **]. Bleeding stabilized during ICU stay and HCT was followed daily without need for transfusion. # Abdominal Pain: Pt with epigastric pain, nausea, vomitting, elevated lipase. Patient had elevated WBC and appeared hemoconcentrated. Thought to be pancreatitis given presention of epigastric pain, nausea, vomiting, elevated lipase, and active alcohol intake prior to admission. Though alcohol most likely etiology of pancreatitis given her history, performed RUQ US [**2171-3-20**] which showed "No evidence of cholelithiasis or biliary obstruction." Also ruled out hypertriglyceridemia (triglycerides were WNL at 149) as cause of pancreatitis. Overnight patient required no IV morphine. She denies abdominal pain or nausea on morning of discharge after eating full regular meal on morning prior to discharge. #. Right groin hematoma: As complication of femoral line placement, patient developed a pseudoaneurysm and hematoma surrounding right SFA. This was initially identified on CT scan from [**2171-3-16**]. Was initially without bruit and was stable in size and appearance. Starting on [**2171-3-21**], patient reporting increased pain and fullness at site of known right groin hematoma. Tenderness at site and new bruit present. Ultrasound revealed an old pseudoaneurysm as well as an active AV fistula from the right SFA. Vascular surgery consulted and revealed no need for surgery at this time; however, they will follow-up with her in two weeks as an outpatient. Patient instructed about warning signs of pain, pallor, paresthesias in right leg that should prompt her to seek medical care. #. Alcohol abuse: Patient told that her hospital presentation predominantly related to alcohol abuse and she appears interested in lasting cessation. She has been counseled in the importance of alcohol cessation to ongoing health care. Social work has provided her with information of programs to help her in this goal. In addition, she lives in a community with resources available to assist in alcohol cessation. #. Peripheral neuropathy: Most predominant symptoms are in left foot and ongoing for > 1 month. B-12 level within normal limits during hospitalization. Received folate supplementation while in the hospital. Will be followed in primary care for further issues with peripheral neuropathy. #. Bipolar Depression: Stable at this time. While in ICU she was off of her home citalopram, lamotrigine, and trazadone. Upon transfer to floor was put back on citalopram and lamotrigine. Was given quetiapine QHS to assist with insomnia while in hospital. Upon discharge, quetiapine was discontinued and she was restarted on previous home dose of trazadone 200 mg QHS. Medications on Admission: seroquel celexa lamictal percocet Discharge Medications: 1. 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* 2. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Tylenol Extra Strength 500 mg Tablet Sig: One (1) Tablet PO every six (6) hours: Take no more than 4 tablets per day while leg pain resolves. 4. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 5. Trazodone 100 mg Tablet Sig: Two (2) Tablet PO at bedtime as needed for insomnia. Discharge Disposition: Home Discharge Diagnosis: Primary: Alcoholic Ketoacidosis Gastrointestinal bleeding (upper) [**Doctor First Name **]-[**Doctor Last Name **] of esophagus Gastritis Esophagitis Duodenitis Acute Alcoholic Pancreatitis Arteriovenous (AV) fistula of right leg (at superficial femoral artery) Secondary: Bipolar depression Alcohol abuse Discharge Condition: Stable and normal vital signs with no further evidence of gastrointestinal bleeding or inflamed pancreas. Discharge Instructions: You were admitted with concerns for abdominal pain, bloody vomiting, and metabolic disarray. The metabolic disarry was related to having poor nutrition in the setting of driking alcohol. We performed an Esophagogastroduodenoscopy (EGD) and discovered that you had tearing and inflammation of your esophagus that likely caused your bloody vomit. You also had inflammation of your stomach lining known as gastritis. The abdominal pain was thought to be pancreatitis, which is an inflammation of your pancreas. All of these conditions are related to alcohol intake, so we strongly encourage you to seek help in stopping your alcohol intake. You have a connection between the artery and vein in your right leg known as an arteriovenous fistula. We asked the vascular surgeons to come assess your leg and they felt that there was nothing to do at this time; however, they will contact you to follow-up with Dr. [**Last Name (STitle) 1391**] (vascular surgeon) in two weeks from discharge to have your leg assessed by ultrasound again. For pain you may use 500 mg of tylenol every 6 hours. Please try to keep under [**2162**] mg total of tylenol daily. We have continued you on your previous psychiatric medications. You have a new prescription for pantoprazole, a stomach acid blocker that you should take twice a day. Please see the attached medication list for further details. We have scheduled appointments for you to see Dr. [**Last Name (STitle) **] on [**2171-4-22**] at 11:20 AM. In addition, you will be contact[**Name (NI) **] by Dr. [**Name (NI) 4436**] office from the vascular surgery department to set up follow-up within two weeks. Please call the vascular surgery clinic at [**Telephone/Fax (1) 1393**] if they have not contact[**Name (NI) **] you by Wednesday of next week. As we discussed it is important to call your doctor or report to an emergency room if your right leg has increased pain, numbness and tingling, cold feeling, or pale appearance. Also please call your doctor or report to an emergency room if you experience difficulty breathing while walking around or laying flat. In addition if you have any symptoms that are concerning to you, please seek medical care. Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7869**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2171-4-22**] 11:20 You will be contact[**Name (NI) **] by Dr.[**Name (NI) 1392**] office ([**Telephone/Fax (1) 1393**]) from the vascular surgery department to set up follow-up within two weeks. Completed by:[**2171-3-24**]

[ "276.2", "296.89", "535.10", "530.7", "365.9", "303.91", "535.60", "530.19", "998.6", "577.0" ]

icd9cm

[ [ [] ] ]

[ "45.13", "38.93" ]

icd9pcs

[ [ [] ] ]

9865, 9871

5456, 9217

282, 317

10221, 10329

2012, 4740

12572, 12930

1472, 1506

9302, 9842

9892, 10200

9243, 9279

10353, 12549

1521, 1993

4757, 5433

231, 244

345, 1230

1252, 1353

1369, 1456

20,854

120,046

24133

Discharge summary

report

Admission Date: [**2157-4-27**] Discharge Date: [**2157-5-1**] Date of Birth: [**2121-5-31**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: The patient is a 35 year old male with a history of tetralogy of Fallot, pulmonary atresia, who presented to the cardiac surgery service for redo heart surgery to repair his aortic valve as well as repair his aortic root. The patient is status post right BT shunt in [**2133-3-25**], status post VSD closure and RV to PA conduit in [**2137-4-24**], status post replacement of said conduit in [**2145-1-25**], and a repeat repair of this conduit again in [**2153-2-22**]. The patient is normally seen at [**Hospital3 18242**] as part of the [**Location (un) 86**] Adult Congenital Heart Disease Program. He presented to the [**Hospital1 188**] for AVR and aortic root replacement. PAST MEDICAL HISTORY: Tetralogy of Fallot. Pulmonary atresia. Atrial flutter. History of endocarditis. Hepatitis C. History of alcohol abuse. PAST SURGICAL HISTORY: As stated above, however, briefly: Right BT shunt in [**2132**]. RV to PA conduit and VSD closure in [**2135**]. Homograft RV to PA conduit with reoperation for bleeding [**2136**]. Pacemaker insertion. Excision of RV to PA homograft conduit in [**2152**]. MEDICATIONS ON ADMISSION: 1. Digoxin 0.25 mg p.o. daily. 2. Lisinopril 5 mg p.o. daily. 3. Coumadin 5 mg p.o. daily. 4. Amiodarone 400 mg p.o. daily. 5. Colace 40 mg p.o. daily. 6. BuSpar 15 mg p.o. b.i.d. ALLERGIES: Codeine which causes hives. FAMILY HISTORY: Unremarkable. SOCIAL HISTORY: Significant for alcohol abuse in the past unspecified. PHYSICAL EXAMINATION: On physical examination, the patient is afebrile, vital signs were stable. No apparent distress and alert. Neck showed 2+ carotid bruits, but no JVD. The heart was regular rate and rhythm with a IV/VI systolic ejection murmur. Chest was clear to auscultation bilaterally. The belly was soft, nontender. Extremities with no edema. Pulse examination was 2+ palpable bilaterally throughout. HOSPITAL COURSE: The patient was admitted on [**2157-4-27**], for preoperative heparinization prior to going to the operating room. On [**2157-5-1**], the patient went to the operating room for Ventol procedure, right ventricular outflow tract reconstruction, pulmonic valve replacement, right pulmonary artery angioplasty. Postoperatively, the patient came to the CSRU where the patient was critically ill after a long bypass run. The patient had postoperative bleeding and coagulopathy which was corrected with massive blood product transfusion. The patient was bronchoscoped on a number of occasions, also placed on CAVHD per the renal recommendations. On postoperative day #1, general surgery was consulted for metabolic acidosis and extreme abdominal distention, question abdominal compartment syndrome. On postoperative day #1, the patient was subjected to laparotomy at the bedside. In addition, the patient had an open chest. This was from postoperative course. On postoperative day #1, vascular consultation was obtained as well for cold and mottled extremities. A four quarter fasciotomy was performed via vascular surgery as well as plastic surgery. Throughout this time, the patient continued to be extremely coagulopathic, bleeding from all cut and raw edges. Postoperative day #1, and into #2, the patient had [**Last Name (un) 4161**] electrocautery at the bedside to try to stem the bleeding with minimal results. On the morning of postoperative day #2, the patient was increasingly hypotensive after fasciotomy secondary to bleeding from all open wounds, acidosis and hypoxemia. Chest was reopened and cleared out of collections and there was no evidence of tamponade. Second left chest tube was placed more anteriorly and drained approximately 450 cc of old blood. Chest x-ray showed some improvement in the left lung expansion. The patient continued to have a constant need for transfusion to maintain a blood pressure greater than 80 and mixed venous gas of oxygen saturation of greater than 50, massive correction of coagulopathy with fresh frozen plasma, cryoprecipitate and platelets. All wounds were reopened and bleeding points were cauterized with minimal results. It was noted at this time that the right leg and arm were probably not viable and unsalvageable. The patient progressively had a decrease in blood pressure to approximately 70 systolic with a mixed venous oxygen saturation of 40% and a CVP of greater than 23. Lactate also was at greater than 27 with a base excess of negative 7, cardiac index of less than 2 and increasing inotropic support. The patient proceeded not to respond to volume resuscitation. EKG showed increasing widening of the QRS complex. CKs at this time were greater than 10,000 indicative of severe rhabdomyolysis. Lactate continued to increase despite bicarbonate infusion with CAVHD. It was determined at this time that the patient would not survive over the next couple of hours. The patient did indeed expire at 9:14 a.m. [**2157-5-1**], from cardiopulmonary arrest. The family was at the bedside and postmortem was granted by the mother. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Location (un) 18193**] MEDQUIST36 D: [**2157-5-1**] 12:05:47 T: [**2157-5-1**] 15:00:43 Job#: [**Job Number 61321**]

[ "785.4", "V15.1", "V53.31", "303.93", "V15.82", "512.1", "424.3", "428.0", "729.9", "441.2", "995.94", "518.5", "424.1", "427.31", "998.11", "584.5", "286.9", "745.2", "728.88", "070.70", "785.59", "728.89" ]

icd9cm

[ [ [] ] ]

[ "83.09", "33.22", "39.61", "54.11", "36.99", "34.04", "39.95", "00.17", "38.45", "35.22", "35.25", "35.39" ]

icd9pcs

[ [ [] ] ]

1548, 1563

1308, 1531

2066, 5398

1019, 1282

1659, 2048

164, 846

869, 995

1580, 1636

69,170

155,270

42633

Discharge summary

report

Admission Date: [**2121-1-8**] Discharge Date: [**2121-1-10**] Date of Birth: [**2061-8-26**] Sex: F Service: NEUROSURGERY Allergies: Sulfa (Sulfonamide Antibiotics) / ibuprofen / E-Mycin / Xylocaine / Penicillins / Cipro / prednisone / wine / artificial sweetners / Diphenhydramine Attending:[**First Name3 (LF) 1835**] Chief Complaint: newly diagnosed brain metastasis. Major Surgical or Invasive Procedure: [**2121-1-8**]: Left occipital crani and resection of lesion History of Present Illness: Ms. [**Known lastname 92193**] is a very pleasant 59-year-old lady with a known history of endometrial cancer for which she has had a TAH-BSO. In addition, she also suffers from rheumatoid arthritis, acid reflux, and she was treated for her adenocarcinoma of uterus in [**2117**]. She had TAH-BSO and systemic chemotherapy including Taxol and carboplatin in [**2118**]. She had brachytherapy in [**Hospital6 **] Hospital with vaginal cylinder completed [**2118**]. In [**2119**], She had lung mass treated with Taxol, carboplatin, and she progressed and she is currently on topotecan. Her [**Last Name 3545**] problem started earlier this month when she noticed to have some bright light in some spots in the right-sided field of vision. An MRI revealed a left occipital ring enhancing lesion for which she now presents electively to have resected. Past Medical History: Adenocarcinoma of the uterus, rheumatoid arthritis, pancytopenia from chemotherapy, hemorrhoids, and acid reflux. Social History: She is seen with her husband. She is married and lives in [**Location 3320**]. They have a son and three grandchildren. She works as a legal secretary in [**Location (un) 86**] and does not smoke or abuse alcohol. Family History: Her mother had brain cancer Physical Exam: Her Karnofsky Performance Score is 70. She is awake, alert, and oriented times 3. There is no right-left confusion or finger agnosia. Her language is fluent with good comprehension. Her recent recall is good. Cranial Nerve Examination: Her pupils are equal and reactive to light, 4 mm to 2 mm bilaterally. Extraocular movements are full. Visual fields are full to confrontation. Funduscopic examination reveals sharp disks margins bilaterally. Her face is symmetric. Facial sensation is intact bilaterally. Her hearing is intact bilaterally. Her tongue is midline. Palate goes up in the midline. Sternocleidomastoids and upper trapezius are strong. Motor Examination: She does not have a drift. Her muscle strengths are [**5-16**] at all muscle groups. Her muscle tone is normal. Her reflexes are absent throughout. Her ankle jerks are absent. Her toes are down going. Sensory examination is intact to touch and proprioception. Coordination examination does not reveal dysmetria. Her gait is steady. She can do tandem gait. She does not have a Romberg. Pertinent Results: [**1-8**] CT Head- Expected post-operative appearance status post left occipital craniotomy and apparent resection of the mass demonstrated on the preoperative MRI. [**1-9**] MRI Brain- S/P tumor resection. Small amount of residual tumor remains. Brief Hospital Course: 59yo woman whom electively presented and underwent a left occipital craniotomy and resection of brain lesion. Surgery was without complication. She was extubated and transferred to the SICU. Post operative head CT revealed no hemorrhage. She remained neurologically stable overnight and was without complaint. On [**1-9**] she was cleared for transfer to the floor. Her decadron was tapered and she underwent an MRI of the brain which revealed good resection of tumor with minimal residual. She was OOB on [**1-9**] and able to void on her own without difficulty. She had no other issues while in the hospital, her pain was well controlled. On DOD, the patient is neurologically intact, pain is controlled, she is tolerating a PO diet, voiding without difficulty and ambulating independently. She is cleared for discharge home. Medications on Admission: Keppra, Omeprazole, Dexa Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. T>38.5. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 5. dexamethasone 2 mg Tablet Sig: 1.5 Tablets PO q6h () for 2 days. Disp:*12 Tablet(s)* Refills:*0* 6. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO q6h () for 2 days. Disp:*90 Tablet(s)* Refills:*2* 7. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*75 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Left Occipital brain lesion Discharge Condition: AOx3. Activity as tolerated. Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Dressing may be removed on Day 2 after surgery. ?????? You have dissolvable sutures, you may wash your hair and get your incision wet day 3 after surgery. You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin, prior to your injury, do not resume these until cleared by your surgeon. ?????? You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. Followup Instructions: Follow-Up Appointment Instructions ** No wound check needed if being seen in BTC within 14 days. ??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2121-1-23**] at 9am. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your appointment, or require additional directions. Completed by:[**2121-1-10**]

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icd9cm

[ [ [] ] ]

[ "01.59" ]

icd9pcs

[ [ [] ] ]

5028, 5034

3197, 4027

447, 510

5106, 5137

2925, 3174

6522, 7059

1782, 1811

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4053, 4079

5161, 6499

1827, 2906

373, 409

538, 1393

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46,763

174,292

5916

Discharge summary

report

Admission Date: [**2117-2-10**] Discharge Date: [**2117-2-14**] Date of Birth: [**2052-12-15**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 3290**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 64yoM with PAD s/p stents to L CIA/SFA, CAD s/p BMS to D1, DM, dyslipidemia, idopathic pulmonary fibrosis (unproven biopsy) presenting with fever, non-productive cough, and chest pain for the past four days. Pt notes worsening SOB with any exertion, productive cough of clear-white sputum (more then usual), and some chest pain that has been getting progressively worse in 4 days. Denies any sudden SOB symptoms, no new pedal edema or calf tenderness. He has been checking his Temp in the morning daily and it is 96, but never took it in the PM. Denies any chills, rigors, sweats. He called pulmonary clinic this AM with complaints of SOB, fatigue and weakness, bed-ridden for the past few days. No sick contacts. [**Name (NI) 227**] his prior history, he was referred to the ED for further evaluation. . Of note, per last pulmonary note in [**12/2116**]: He was previously followed for IPF at [**Hospital1 112**], had initial plans for lung transplant but decided not to pursue lung transplantation. (although, when talking to me, pt reports that he did in fact want the transplant) He is on 2-4L NC O2, on NAC, although he reportedly stopped taking this in [**Month (only) 1096**]. (however, pt tells me today that he still takes it). He has undergone pulm rehabilitation. He is known to feel SOB all the time, even at night. He has a chronic cough productive of clear white sputum. Known to have a little blood coming out of his nose when he sneezes a lot. Uses flonase nasal spray, combivent nebs at night for cough/sob. He is known to be losing weight. . In the ED inital vitals were, Tm 101.2, HR 100 BP 79/47 RR 44 Sat 90% on 100%NRB. DNI but will accept NIV. His labs were notable for Na 129 (baseline low 130s), K 4.2, Cl 98, HCO3 22, BUN 13, Cr. 0.7, Gluc 115. Trop-T: <0.01 proBNP: 220 wbc 14.9, hgb 11.1, hct 34, plt 492 PT: 13.5 PTT: 28.6 INR: 1.3; He was given Acetaminophen, Vancomycin, and Cefepime. Got 2L NS. Most recent vitals: temp 101, BP 99/57, rr 30, sat 90% (baseline 90% on 2L at home) on BIPAP. . On arrival to the ICU, pts vitals: T 98.4, 95/61 (baseline BP is 70-90s per son), HR 82, RR 40, 95% on 100% non-rebreather. He says he is currently feeling at his baseline when he lies still. But when he ambulates, he feels significantly worse. He notes at home that he uses CPAP at home for OSA and uses 2L NC during the day all day long. Occasionally he will use 4 L NC. He notes that he had back surgery performed 2 months ago, denies any clots in his legs, no calf pain. Does have known mild pedal edema, for which he uses compression stalkings. He notes that he has not been drinking very much lately because he is worried about taking the trip to the bathroom, concerned he will be too SOB. Thus, drinking only very little daily and mainly coffee. . Review of systems: (+) Per HPI. Known to be losing weight. (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies palpitations, no 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: Interstitial lung disease-- on 2L home O2, CPAP at night, used to take NAC daily CAD s/p angioplasty with BMS to D1, DM Peripheral vascular disease, s/p stents to L CIA and L SFA DM x10 yrs, c/b peripheral neuropathy Hyperlipidemia GERD Colitis Bilateral hearing loss/cholesteatoma Sleep apnea, on CPAP every night s/p bilateral ear surgery s/p right cataract surgery Prior positive IgG for strongyloides- says he took medications for this about 10 yrs ago. Positive [**Doctor First Name **] titer 1:40 Social History: He is married and lives with his wife. [**Name (NI) **] is a former three pack a day smoker, quit in [**2107**], 60-90 pk year smoking hx. He previously worked in construction doing wiring for fences, also painting at a body shop. Originally from [**Male First Name (un) 1056**] but in the United States since [**2073**]. No drugs. Family History: Mother died of lung CA, father died of throat CA. Brother died of gastric CA at age 56. Sister died of lung CA at age 43. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T 98.4, 95/61 (baseline BP is 70-90s per son), HR 82, RR 40, 95% on 100% non-rebreather General: Alert, oriented, breathing quickly but looks comfortable HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: velcro fine crackles throughout lung fields bilaterally, most prominant at the bases. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley , put out 400 cc Ext: warm, well perfused, 2+ pulses, clubbing in all fingers and does, cyanosis or edema Pertinent Results: LABS: On admission: [**2117-2-10**] 10:50AM BLOOD WBC-14.9* RBC-4.01* Hgb-11.1* Hct-34.1* MCV-85 MCH-27.6 MCHC-32.5 RDW-13.3 Plt Ct-492* [**2117-2-10**] 10:50AM BLOOD Neuts-87.0* Lymphs-7.1* Monos-4.3 Eos-1.2 Baso-0.4 [**2117-2-10**] 10:50AM BLOOD PT-13.5* PTT-28.6 INR(PT)-1.3* [**2117-2-10**] 10:50AM BLOOD Glucose-115* UreaN-13 Creat-0.7 Na-129* K-4.2 Cl-98 HCO3-22 AnGap-13 [**2117-2-10**] 10:50AM BLOOD cTropnT-<0.01 proBNP-220 [**2117-2-10**] 09:00PM BLOOD Calcium-9.2 Phos-3.4 Mg-2.2 Iron-17* [**2117-2-10**] 07:33PM BLOOD Type-ART pO2-67* pCO2-37 pH-7.47* calTCO2-28 Base XS-3 [**2117-2-10**] 10:56AM BLOOD Lactate-1.4 IMAGING: [**2-10**] CXR: IMPRESSION: Increased markings bilaterally may be due to the combination of underlying pulmonary fibrosis and moderate pulmonary edema, superimposed infectious process cannot be excluded. [**2-11**] Echo: The left atrium is elongated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal regional and global biventricular systolic function. Moderate pulmonary artery systolic pressure. Compared with the prior study (images reviewed) of [**2113-1-23**], the pulmonary artery systolic pressures can be estimated on the current study and are moderately elevated. The other findings are similar. [**2-11**] CTA chest: 1. Worsened air space disease on a background of emphysema and chronic fibrotic changes consistent with reported idiopathic pulmonary fibrosis. Differential includes acute exacerbation of IPF, infectious process, or ARDS. The pulmonary vasculature is well opacified and without filling defect to suggest pulmonary embolism. Brief Hospital Course: 64yoM with PAD s/p stents to L CIA/SFA, CAD s/p BMS to D1, DM, dyslipidemia, idopathic pulmonary fibrosis (on [**2-20**] L NC at home), OSA on CPAP, presenting with fever, worsening productive cough, and chest pain for the past four days, suggestive of underlying pneumonia vs IPF exacerbation. . # Dyspnea, Hypoxia: Etiology pneumonia vs IPF exacerbation, progression of underlying IPF. Urine legionella, UA, blood cultures negative. CTA showed extensive GGO, consistent w/ worsening IPF exacerbation, infectious process, or ARDS, but no filling defects. CTA showed severe progression of disease when compared to [**2115**] CTA. He was placed on broad spectrum antibiotics: cefepime, vanco, azithro. Patient was given lasix for question of pulmonary edema, with good UOP. He was additionally given methylprednisolone for possible IPF flare. Bronchoscopy was deferred, as patient has been too hypoxic to tolerate one. He was been maintained on a non-rebreather, refusing CPAP machine, and is DNI. A d-dimer was checked and elevated at 3027, which is a poor prognosis for IPF. He was started on a lovenox, as one study (see details below in ILD) showed decreased mortality with anticoagulation in IPF flares. Patient reports feeling better, however oxygen saturation remained in the mid 70s to upper 60s. Palliative care was consulted. Patient and his Health Care Proxy decided that it would be best for a focus on comfort given his severe ILD. They wanted a continuation of antibiotics and his chronic medications. # ILD: Pt with underlying IPF although never biopsy proven. He also has history of strongyloides in the past with positive IgG, but unknown if there is any association. CT chest appears to show significantly worsened IPF from [**2115**] CT scan. D-dimer, elevated at 3027, consistent w/ poor prognosis but suggests anticoagulation may provide benefit based on study in Chest in [**2110**] (Anticoagulant Therapy for Idiopathic Pulmonary Fibrosis). Patient was started on methylprednisolone and lovenox. Palliative care was consulted and patient was transferred to the floor for further management and observation. . # Hyponatremia: Baseline is 133-140, but was 129 on admission. Improved to 132 with small fluid boluses. Likely hypovolemic hyponatremia as pt has had poor POs for several days plus element of SIADH (from pulm disease), suggested on urine electrolytes. #Leukocytosis: Since [**10/2116**], pt has had leukocytosis of 15-20. Diff shows 87% neutrophils. Might be reflective of underlying infection/pneumonia, although unclear why it has been elevated since [**15**]/[**2116**]. No recent steroids to explain leukocytosis. Can also see a leukocytosis in setting of acute inflammatory processes or physiological stress. . # DM2: 10 years of DM2, on metformin at home. Metformin was held and patient was managed with 5units of glargine and an ISS. . # GERD: Continued pantoprazole 40mg daily. . # CAD s/p angioplasty and BMS: Continued ASA 81mg, plavix 75mg, imdur 60mg, simva 20mg, lisinopril 2.5mg, ranolazine 150mg qhs. . # Anemia: HCT baseline 32-40. Currently 34. Ferritin 31 (checked 1 mo ago), Iron 27 (checked in [**2112**]). Given his significant pulmonary disease, would expect an elevated HCT. However, he possibly has anemia of chronic disease (although would expect to see elevated Ferritin) vs Iron def anemia, esp since MCV has been in the low 80s in the past. Iron studies consistent with iron deficiency anemia. Continued home ferrous sulfate. . # OSA: Uses home CPAP at night, however patient was uncomfortable using it here. **Patient was transferred to the medical floor on [**2117-2-12**]. During the day of [**2117-2-13**] he was surrounded with close family and friends. In the early am on [**2117-2-14**] he was seen to have some respiratory distress, but then he improved. The RN found that he had passed away. Time of death is 5:44 AM on [**2117-2-14**]. I emailed the PCP and spoke to the family who came to the hospital to pay their last respects. They have decided against an autopsy.** Medications on Admission: (reviewed with patient. Of note, pt states he does NOT take any steroids) ASA 81mg daily Plavix 75mg daily Pantoprazole 40mg daily Imdur 60mg daily Clonazepam 1.5mg QHS Simvastatin 20mg daily Lisinopril 2.5mg daily NAC 600mg TID Oxycodone 5 mg TID Ranolazine [Ranexa] 500 mg ER [**Hospital1 **] Ranitidine 150mg QHS Metformin 500mg [**Hospital1 **] Relafen 750mg daily prn FERROUS GLUCONATE [FERGON] - 240 mg (27 mg iron) Tablet - 1 Tablet(s) by mouth once a day NABUMETONE [RELAFEN] - (Prescribed by Other Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 1790**] [**Last Name (NamePattern1) 1789**]) - 750 mg Tablet - 1 Tablet(s) by mouth daily as needed for pain CODEINE-GUAIFENESIN - 100 mg-10 mg/5 mL Liquid - 1 tsp by mouth at bedtime disp 4 hours FLUTICASONE - 50 mcg Spray, Suspension - 2 sprays in each nostril once a day IPRATROPIUM-ALBUTEROL - 0.5 mg-2.5 mg/3 mL Solution for Nebulization - 1 neb inhaled four times a day as needed for SOB IPRATROPIUM-ALBUTEROL [COMBIVENT] - 18 mcg-103 mcg (90 mcg)/Actuation Aerosol - 2 puffs inhaled four times a day as needed Discharge Medications: None. Patient expired Discharge Disposition: Expired Discharge Diagnosis: Interstitial Lung Disease Pulmonary Edema Pneumonia Diabetes Coronary Artery Disease Discharge Condition: Patient deceased. Discharge Instructions: Patient deceased. Followup Instructions: None

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12640, 12649

7391, 11445

326, 332

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5258, 5265

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267, 288

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82,754

118,328

36039

Discharge summary

report

Admission Date: [**2129-11-12**] Discharge Date: [**2129-11-14**] Date of Birth: [**2100-6-10**] Sex: M Service: MEDICINE Allergies: Peanut Attending:[**First Name3 (LF) 2108**] Chief Complaint: admitted with GI Bleed, called out of ICU Major Surgical or Invasive Procedure: EGD on [**2129-11-12**] History of Present Illness: Mr. [**Known lastname **] is a 29 year old male with a history of abdominal pain and hemetemesis with a inflammatory gastric polyp resected two days prior to admission who presents with melena, lightheadedness, and new anemia. He was admitted from the [**Hospital1 18**] ER to the [**Hospital Unit Name 153**] on [**11-12**] after an episode of presyncope associated with melena. In addition he had extreme thirst. In the ED, initial vs were: pain 0, T 97.3, HR 114, BP 130/74, RR 16. O2 sat 100% RA. Exam was notable for dark, guaiac + stool per rectum. Labs were notable for hct 27.6 down from baseline of 44. CXR was unremarkable. EKG was sinus tach at 106 with T wave inversions in the lateral leads. Patient was given protonix 40 mg IV bolus and protonix gtt as well as 1L NS and 1 unit of blood. Vital signs on sign-out were BP 120, HR 84 127/77, RR 18, 98% RA, afebrile. In the ICU the patient underwent an EGD which revealed a deep ulcer, no vessel was seen, no active bleeding. His HCT was relatively stable. hemodynamically stable so called out to the medical floor in the p.m. on [**11-13**]. He underwent transfusion of 2 units PRBC, last at 2 a.m. on [**11-13**]. He ruled out for an MI. Currently feeling well. Tolerating a regular diet, no nausea, abdominal pain, diaphoresis, lightheadedness, 1 episode of melena the day prior but none since, no BRBPR. No chest pain or SOB. Rest of ROS is negative. Past Medical History: Genital Herpes Gastric polyp s/p ex-lap for abdominal stab wound Social History: Works as an anesthesia tech at [**Hospital1 18**]. Formerly was in the military. Smokes [**2-16**] cigarettes daily. Used to drink 1 bottle of beer or hard liquor once or twice on the weekends but has cut back. Last drink was [**1-16**] of 12 oz bottle of beer on [**11-11**]. Family History: Unknown, adopted Physical Exam: VS: T 97.6 HR 82 BP 106/67 RR 19 O2 97% on RA GEN: NAD, AOX3 HEENT: MMM, unable to assess JVP CARD: RRR, no m/r/g PULM: CTAB ABD: soft, NT, ND, no masses or organomegaly EXT: WWP, no c/c/e NEURO: AOx3, grossly normal Pertinent Results: [**2129-11-13**] 12:40PM BLOOD WBC-8.2 RBC-3.52* Hgb-10.1* Hct-29.4* MCV-84 MCH-28.7 MCHC-34.3 RDW-13.2 Plt Ct-196 [**2129-11-13**] 04:21AM BLOOD WBC-9.5 RBC-3.61* Hgb-10.8* Hct-29.7* MCV-82 MCH-29.9 MCHC-36.3* RDW-13.6 Plt Ct-218 [**2129-11-13**] 12:38AM BLOOD Hct-27.8* [**2129-11-12**] 08:05PM BLOOD WBC-13.2*# RBC-3.25*# Hgb-9.5*# Hct-27.6*# MCV-85 MCH-29.3 MCHC-34.5 RDW-13.4 Plt Ct-263 [**2129-11-13**] 04:21AM BLOOD Neuts-54.3 Lymphs-36.2 Monos-6.5 Eos-2.5 Baso-0.5 [**2129-11-13**] 04:21AM BLOOD PT-13.6* PTT-28.0 INR(PT)-1.2* [**2129-11-13**] 04:21AM BLOOD Glucose-93 UreaN-24* Creat-0.8 Na-139 K-3.6 Cl-108 HCO3-23 AnGap-12 [**2129-11-12**] 08:05PM BLOOD Glucose-87 UreaN-43* Creat-1.0 Na-138 K-3.3 Cl-103 HCO3-26 AnGap-12 [**2129-11-13**] 12:40PM BLOOD CK(CPK)-200 [**2129-11-13**] 04:21AM BLOOD CK(CPK)-187 [**2129-11-12**] 08:05PM BLOOD CK(CPK)-253 [**2129-11-13**] 12:40PM BLOOD CK-MB-2 cTropnT-<0.01 [**2129-11-13**] 04:21AM BLOOD CK-MB-3 cTropnT-<0.01 [**2129-11-12**] 08:05PM BLOOD cTropnT-<0.01 [**2129-11-13**] 04:21AM BLOOD Calcium-7.9* Phos-2.5* Mg-1.9 [**2129-11-14**] 06:55AM BLOOD WBC-7.8 RBC-3.62* Hgb-10.6* Hct-30.8* MCV-85 MCH-29.2 MCHC-34.4 RDW-13.7 Plt Ct-221 [**2129-11-12**] chest x ray: No acute cardiopulmonary process. No significant interval change. [**2129-11-12**] EGD: Ulcer in the pylorus Otherwise normal EGD to duodenal bulb [**2129-11-10**] EGD: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] A esophagitis was seen in the GE junction A small size hiatal hernia was seen. An approximately 1.5cm erythematous nodule was seen in the prepyloric antrum along the greater curvature. A mucosal resection was performed and the lesion was totally removed using a band EMR. Otherwise normal EGD to third part of the duodenum [**2129-8-25**] EUS: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] A esophagitis A 1.5cm prepyloric antral nodule was noted EUS: Nodule showed ill-defined expansion of the superficial and deep mucosal layer with normal appearing submucosa and muscularis. This appearance was suggestive of a mucosal based polyp e.g. inflammatory, hyperplastic or adenomatous polyp. EUS appearance was not typical for GIST, carcinod or lymph node. EGD [**2129-4-1**] PERFORMED FOR DYSPEPSIA: Friability, erythema and congestion in the antrum compatible with gastritis (biopsy) Nodule in the pylorus (biopsy) Otherwise normal EGD to third part of the duodenum Brief Hospital Course: This is a 29 year old male with a history of recently ressected inflammatory gastric polyp who presents with melena, presyncope, and hct drop concerning for upper GI bleed. Upper GI Bleed - likely etiology of melena, presyncope, and hct drop to 27.6 from baseline of 43.8. Likely related to recently ressected gastric polyp. The patient was treated with high dose PPI and will continue for at least 6 weeks. Pathology of gastric polyp pending at the time of discharge. Hct stable at the time of discharge. In total the patient rec'd 2 units of PRBC. EKG changes - likely related to tachycardia. No complaints of chest pain or shortness of breath. Ruled out for MI. Medications on Admission: HOME MEDICATIONS: prednisone 50mg daily from [**Date range (1) 81788**] omeprazole 40mg po bid TRANSFER MEDICATIONS: PROTONIX 40MG IV BID Discharge Medications: 1. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Diagonsis: Peptic ulcer disease, gastrointestinal bleeding, anemia of acute blood loss Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with bleeding from your stomach. You should continue your medications as prescribed and make your follow up apointments. Please continue to take omeprazole twice daily for at least 6 weeks unless instructed otherwise by your gastroenterologist. Please avoid alcohol, aspirin, and ibuprofen or naproxen for the next 6 weeks. Followup Instructions: Please follow up with your primary care physician for [**Name Initial (PRE) **] check up and to have your blood counts checked (hematocrit) within 1 week of discharge from the hospital.

[ "305.1", "285.1", "276.52", "211.1", "531.00", "998.11", "E878.8" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

5977, 5983

4920, 5596

311, 337

6122, 6122

2466, 4897

6641, 6830

2191, 2209

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230, 273

5740, 5762

365, 1792

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1814, 1881

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57,765

186,338

42587

Discharge summary

report

Admission Date: [**2179-5-11**] Discharge Date: [**2179-5-19**] Date of Birth: [**2099-2-23**] Sex: M Service: CARDIOTHORACIC Allergies: Ivp Dye, Iodine Containing Attending:[**First Name3 (LF) 922**] Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: [**2179-5-13**] Mitral Valve repair (30 mm [**Company 1543**] ring)/ Ligation of left atrial appendage History of Present Illness: 80 yo male with known mitral regurgitation and recent stenting of RCA in [**3-22**]. Continues to have severe dyspnea, and was referred for mitral valve repair vs. replacement. Past Medical History: mitral regurgitation coronary artery disease s/p RCA stenting [**3-22**] premature vent. contractions with ventricular tachycardia hypertension chronic diastolic heart failure prostate cancer obstructive sleep apnea glaucoma arthritis chronic back pain ? Parkinson's disease Social History: lives alone, widowed occasional ETOH use remote cigar use works as a part-time headhunter Family History: no premature CAD Physical Exam: 98% RA sat 146/79 HR 70-90 SR, frequent PVCs, occ. runs of VTach RR 18-22 T 98.4 98.1 kg 73" NAd skin /HEENT unremarkable elevated JVP neck supple, full ROM, no carotid bruits appreciated CTAB Irregular, [**5-17**] holosystolic murmur radiates to precordium mild hepatomegaly, soft NT, ND warm, well-perfused, no edema no varicosities noted neuro grossly intact 2+ bil. fems/ radials 1+ bil. DP/PTs Pertinent Results: [**2179-5-19**] 06:00AM BLOOD Hct-28.9* [**2179-5-18**] 05:40AM BLOOD WBC-6.2 RBC-3.01* Hgb-9.9* Hct-29.0* MCV-97 MCH-32.8* MCHC-34.0 RDW-13.4 Plt Ct-196 [**2179-5-11**] 05:58PM BLOOD WBC-5.4 RBC-4.28* Hgb-13.4* Hct-40.6 MCV-95 MCH-31.4 MCHC-33.1 RDW-14.0 Plt Ct-162 [**2179-5-18**] 05:40AM BLOOD Plt Ct-196 [**2179-5-13**] 11:56AM BLOOD PT-15.5* PTT-41.6* INR(PT)-1.4* [**2179-5-11**] 05:58PM BLOOD PT-14.6* PTT-26.5 INR(PT)-1.3* [**2179-5-11**] 05:58PM BLOOD Plt Ct-162 [**2179-5-19**] 06:00AM BLOOD Glucose-94 UreaN-37* Creat-1.6* Na-136 K-5.1 Cl-101 HCO3-23 AnGap-17 [**2179-5-18**] 05:40AM BLOOD Glucose-89 UreaN-34* Creat-1.3* Na-137 K-4.9 Cl-103 HCO3-25 AnGap-14 [**2179-5-11**] 05:58PM BLOOD Glucose-113* UreaN-31* Creat-1.4* Na-141 K-4.5 Cl-107 HCO3-26 AnGap-13 [**2179-5-11**] 05:58PM BLOOD ALT-23 AST-26 CK(CPK)-189* AlkPhos-68 Amylase-42 TotBili-0.3 [**2179-5-11**] 05:58PM BLOOD Lipase-36 [**2179-5-11**] 05:58PM BLOOD CK-MB-8 [**2179-5-19**] 06:00AM BLOOD Phos-4.7*# Mg-2.5 [**2179-5-11**] 05:58PM BLOOD %HbA1c-5.8 [**Known lastname **], [**Known firstname 396**] [**Hospital1 18**] [**Numeric Identifier 92143**]Portable TTE (Complete) Done [**2179-5-17**] at 2:25:44 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 177**] C. [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2099-2-23**] Age (years): 80 M Hgt (in): 73 BP (mm Hg): 112/60 Wgt (lb): 213 HR (bpm): 70 BSA (m2): 2.21 m2 Indication: S/p mitral valve repair. ICD-9 Codes: 423.9, 424.1, 424.0 Test Information Date/Time: [**2179-5-17**] at 14:25 Interpret MD: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1661**], RDCS Doppler: Full Doppler and color Doppler Test Location: West Echo Lab Contrast: None Tech Quality: Suboptimal Tape #: 2009W008-0:41 Machine: Vivid [**8-18**] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *5.2 cm <= 4.0 cm Left Atrium - Four Chamber Length: *6.4 cm <= 5.2 cm Right Atrium - Four Chamber Length: *5.3 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *5.8 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 4.0 cm Left Ventricle - Fractional Shortening: 0.31 >= 0.29 Left Ventricle - Ejection Fraction: >= 60% >= 55% Aorta - Sinus Level: *4.0 cm <= 3.6 cm Aorta - Ascending: 3.4 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.3 m/sec <= 2.0 m/sec Aortic Valve - LVOT diam: 2.1 cm Mitral Valve - Mean Gradient: 3 mm Hg Mitral Valve - Pressure Half Time: 87 ms Mitral Valve - MVA (P [**2-12**] T): 2.5 cm2 Mitral Valve - E Wave: 1.3 m/sec Mitral Valve - A Wave: 0.8 m/sec Mitral Valve - E/A ratio: 1.63 Mitral Valve - E Wave deceleration time: *287 ms 140-250 ms TR Gradient (+ RA = PASP): *32 to 36 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Moderate LA enlargement. No LA mass/thrombus (best excluded by TEE). LEFT VENTRICLE: Mild symmetric LVH. Top normal/borderline dilated LV cavity size. Normal regional LV systolic function. Overall normal LVEF (>55%). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. Paradoxic septal motion consistent with prior cardiac surgery. AORTA: Mildly dilated aortic sinus. Normal ascending aorta diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mitral valve annuloplasty ring. Well-seated mitral annular ring with normal gradient. Mild thickening of mitral valve chordae. No MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [[**2-12**]+] TR. Mild PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Conclusions The left atrium is moderately dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is top normal/borderline dilated. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. A mitral valve annuloplasty ring is present. The mitral annular ring appears well seated and is not obstructing flow. No mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Normal functioning mitral valve ring. Mild pulmonary artery systolic hypertension. Dilated ascending aorta. Compared with the prior study (images reviewed) of [**2179-4-27**], the mitral valve has been repaired with a normal functioning mitral annular ring. The estimated pulmonary artery systolic pressure is higher. CLINICAL IMPLICATIONS: Based on [**2177**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis IS recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2179-5-17**] 15:39 [**Known lastname **],[**Known firstname 396**] [**Medical Record Number 92144**] M 80 [**2099-2-23**] Cardiology Report ECG Study Date of [**2179-5-16**] 7:46:18 AM Normal sinus rhythm with frequent ventricular couplets. Leftward axis. Except for the change in rhythm, compared to previous tracing of [**2179-5-15**], no diagnostic interval change. Compared to the previous tracing of [**2179-5-14**], except for the rhythm and taller voltage in the lateral precordial leads, no diagnostic interval change. TRACING #2 Read by: [**Last Name (LF) **],[**First Name3 (LF) 125**] M. Intervals Axes Rate PR QRS QT/QTc P QRS T 78 [**Telephone/Fax (3) 92145**]/453 77 -23 12 Brief Hospital Course: Admitted preoperatively for bridge off plavix, started on intravenous integrilin and underwent preoperative workup. On [**5-13**] he was brought to the operating room where he underwent a mitral valve repair and left atrial appendage ligation. Please see operative report for surgical details. He received vancomycin for perioperative antibiotics because he was in the hospital greater than twenty four hours preoperatively. Following surgery he was transferred to the CVICU for invasive monitoring. He was weaned from sedation, awoke neurologically intact and was extubated. He had episodes of ectopy that progressed to runs of ventricular tachycardia and received bolus of lidocaine with short resolution, with reoccurance was bolused with amiodarone and EP was consulted. Pain medications were adjusted to control pain without oversedation which was achieved with dilaudid. He contined to have episodes of NSVT and was started on sotalol per EP service recommendations with lopressor. He remained in the intensive care unit for hemodynamic monitoring. Physical therapy worked with him on strength and mobility. He was transferred to the floor on postoperative day four for the remainder of his care. He continued to progress and was ready for discharge to rehab on post operative day six with plan for twice weekly BUN/CR, and potassium. Medications on Admission: ASA 325 mg daily, Plavix 75 mg daily ( LD [**5-9**]), Atenolol 25 mg daily, Lisinopril 20 mg [**Hospital1 **], Xalatan eye gtts, Fish oil, Melatonin, Hyaluronic acid, Tylenol prn, Aleve prn Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): for stent. 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 8. Sotalol 120 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Artificial Tears Drops Sig: [**2-12**] Ophthalmic three times a day as needed for dry eyes. 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 11. Psyllium Packet Sig: One (1) Packet PO TID (3 times a day) as needed. 12. Outpatient Lab Work please check BUN/cr, potassium twice weekly while on lasix Monday and thrusday, please call if concerns baseline cr 1-1.4 First draw [**5-20**] Discharge Disposition: Extended Care Facility: [**Location (un) 582**] of [**Location (un) 583**] Discharge Diagnosis: Mitral regurgitation s/p mitral valve repair Secondary: Coronary artery disease s/p RCA stenting [**3-22**], premature ventricular contractions with ventricular tachycardia, Hypertension, Chronic diastolic heart failure, Prostate cancer, Obstructive sleep apnea, Glaucoma, Arthritis, Chronic back pain, ? Parkinson's disease Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Please call to schedule appointments Dr [**Last Name (STitle) **] (opthamologist to follow up stopping eye gtt) Dr. [**Last Name (STitle) **] after discharge from rehab [**Telephone/Fax (1) 719**] Dr. [**Last Name (STitle) **] in [**3-16**] weeks Dr. [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**] Completed by:[**2179-5-19**]

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Discharge summary

report

Admission Date: [**2126-12-1**] Discharge Date: [**2126-12-10**] Date of Birth: [**2061-2-21**] Sex: M Service: MEDICINE Allergies: Motrin / Codeine / Nortriptyline Attending:[**First Name3 (LF) 1070**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: Dialysis, midline placed History of Present Illness: 65y/o M with PMH of HIV/AIDs on HAART (VL undectable and CD4 392 in [**6-16**]), ESRD on HD, DM2, PVD recently admitted with line sepsis treated with vancomycin and now presenting with abd pain X 5days. He says the pain is all over his abdomen. Denies N/V. No fever/chills. Denies constipation or diarrhea. He took percocet at home and says that it did not help. . In the ED, his initial vitals signs were T 98.3, BP 162/106, HR 130, RR 18, O2sat 100% RA. He was given dilaudid for pain control. They felt he might have melana in his rectal vault and a GI consult was obtained. CT abdomen/pelvis without contrast was performed and showed a question of pancreatic mass. GI repeated the rectal exam and said it was guiac positive brown stool with no melana. He was admitted to the ICU for further care. . Currently, he is lethargic but easily arousable. Says his pain is much improved. Denies fevers, chills, nausea, vomiting. No chest pain, no shortness of breath. No diarrhea, no constipation. . Past Medical History: 1) HIV: diagnosed in [**2106**], on HAART. followed by Dr. [**Last Name (STitle) 1057**] at [**Hospital1 18**]. 2) Diabetes Mellitus, type 2, since ~[**2106**] with neuropathy, charcot foot, nephropathy, and ? mild retinopathy. 2) Chronic renal failure on Hemodialysis and graft infections, thrombus: dx approx. [**2115**]. Started HD in 2/[**2118**]. On HD on tues, thurs, sat at [**Doctor Last Name **] hospital. Dialysis unit - ([**Telephone/Fax (1) 17592**] / Nephrologist - Dr. [**Last Name (STitle) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] -([**Telephone/Fax (1) 94989**] 3) [**Female First Name (un) 564**] esophagitis 4) Hepatitis C: genotype IB 5) Congestive heart failure: echocardiogram [**10-15**] w/ EF 50%. 6) Necrotizing Fasciitis: [**2112-10-17**]- [**2113**]: multiple surgeries and circumcision during hospitalization. 7) Hypertension 8) Hypercholesterolemia 9) LE Diabetic ulcers 10) Herpes zoster of the left mandibular distribution of the trigeminal nerve. [**2115**] 11) R suprapatellar abscess: [**2115**]. 12) IVDU (heroin and cocaine) [**2079**]-[**2102**], none since [**2102**] 13) Obesity 15) GI Bleed: [**2117**]. OB positive stool. 16) Anemia 18) Colonic Polyps 19) Gastritis with large hiatal hernia. 20) Lipodystrophy 21) Charcot foot: dx in [**9-13**]. 22) Colonic AVM: seen on [**3-9**] colonoscopy on the ileocecal valve. Treated with thermal therapy. 23) Positive AFB in sputum: [**2119-11-17**]. MYCOBACTERIUM GORDONAE. No abnormalities on CT chest in [**2121**]. 24) VISA/MRSA- grew out from culture from R anterior chest wound Social History: Lives in extended care facility. Quit smoking 20 years ago. History of IVDU and alcohol abuse. Quit both over 20 years ago. Has a fiance who says she is the HCP. Family History: Patient not close to family and is thus unaware of family history. Physical Exam: vitals: T: 97.4 HR 70, BP 158/104, RR 20, O2 sat 97% RA General: obese male in NAD HEENT: non-injected conjunctiva. cataract in right eye. disconjugate gaze. MMM CV: RR tachycardic. No murmur appreciated. Chest wound dressing C/I/D Lungs: CTAB no w/r/r appreciated Abdomen: soft +mild tenderness epigastric and right quadrants, ND, +BS obese Ext: no e/c/c, PVD changes, Charcot foot deformity Neuro: disconjugate gaze. right cataract. non-injected conjunctiva. Other cranial nerves in tact. Bilateral lower extremities are laterally rotated. toes mute. Pertinent Results: [**2126-12-10**] 09:07AM BLOOD WBC-6.4 RBC-3.23* Hgb-10.1* Hct-32.2* MCV-100* MCH-31.2 MCHC-31.2 RDW-22.6* Plt Ct-307 [**2126-12-10**] 09:07AM BLOOD PT-14.8* PTT-67.9* INR(PT)-1.3* [**2126-12-10**] 09:07AM BLOOD Glucose-129* UreaN-38* Creat-5.2* Na-136 K-5.6* Cl-104 HCO3-25 AnGap-13 [**2126-12-10**] 09:07AM BLOOD Calcium-8.3* Phos-2.3* Mg-1.812/01/08 06:00AM BLOOD WBC-5.9 RBC-3.41* Hgb-10.8* Hct-33.6* MCV-98 MCH-31.7 MCHC-32.2 RDW-22.8* Plt Ct-271 [**2126-12-9**] 06:00AM BLOOD PT-16.7* PTT-90.3* INR(PT)-1.5* [**2126-12-8**] 06:25AM BLOOD ESR-49* [**2126-12-9**] 06:00AM BLOOD Glucose-98 UreaN-34* Creat-4.7*# Na-137 K-5.9* Cl-105 HCO3-26 AnGap-12 [**2126-12-6**] 06:00AM BLOOD ALT-4 AST-9 LD(LDH)-169 AlkPhos-73 Amylase-83 TotBili-0.3 [**2126-12-6**] 06:00AM BLOOD Lipase-19 [**2126-12-9**] 06:00AM BLOOD Calcium-9.9 Phos-1.9* Mg-2.1 [**2126-12-8**] 06:25AM BLOOD CRP-18.4* [**2126-12-1**] 05:55AM BLOOD WBC-6.9# RBC-3.70* Hgb-11.7* Hct-36.0* MCV-97# MCH-31.5 MCHC-32.4 RDW-21.7* Plt Ct-145* [**2126-12-1**] 05:55AM BLOOD PT-36.1* PTT-52.9* INR(PT)-3.8* [**2126-12-1**] 05:55AM BLOOD Glucose-79 UreaN-20 Creat-3.6* Na-139 K-3.8 Cl-97 HCO3-34* AnGap-12 [**2126-12-1**] 05:55AM BLOOD ALT-1 AST-11 LD(LDH)-271* AlkPhos-85 TotBili-0.8 [**2126-12-1**] 05:55AM BLOOD Lipase-14 [**2126-12-2**] 07:12AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.2 [**2126-12-1**] 05:55AM BLOOD TSH-3.2 [**2126-12-1**] 06:36PM BLOOD Type-ART pO2-63* pCO2-41 pH-7.55* calTCO2-37* Base XS-11 [**2126-12-1**] 06:36PM BLOOD Glucose-85 Lactate-1.1 Na-140 K-4.3 Cl-91* [**2126-12-1**] 06:36PM BLOOD Hgb-13.1* calcHCT-39 [**2126-12-1**] 06:36PM BLOOD freeCa-1.12 CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2126-12-8**]): Feces negative for C.difficile toxin A & B by EIA. HELICOBACTER PYLORI ANTIBODY TEST (Final [**2126-12-6**]): POSITIVE BY EIA. Blood Culture, Routine (Final [**2126-12-7**]): NO GROWTH CHEST (PORTABLE AP) [**2126-12-1**] 6:12 AM IMPRESSION: No free intraperitoneal air CT ABDOMEN/PELVIS W/O CONTRAST [**2126-12-1**] 6:31 AM IMPRESSION: 1. A 4.3 x 4.1 cm ill-defined soft tissue in the pancreatic head. 2. Bilateral pleural effusion and compressive atelectasis. Cannot exclude consolidation. 3. Large hiatal hernia. 4. Stable compression deformity involving L3 and L4 with narrowing of the spinal canal at this level. MRI is recommended for further characterization. 5. Right renal hypodensity, not fully characterized in this non-contrast study. 6. Residual left groin hematoma. 7. No evidence of free air or bowel obstruction. Portable TTE (Complete) [**2126-12-2**] The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is mild-moderate global left ventricular hypokinesis (LVEF = 35-40 %). Systolic function of apical segments is relatively preserved (suggestive of non-ischemic cardiomyopathy). Right ventricular chamber size is normal with mild global free wall hypokinesis. The aortic valve is not well seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is a very small pericardial effusion without evidence for hemodynamic compromise. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with mild-moderate global hypokinesis with relative preservation of apical segments most suggestive of a non-ischemic cardiomyopathy. Mild right ventricular free wall hypokinesis. Moderate pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [**2125-11-17**], biventricular systolic function is now depressed (global). The estimated pulmonary artery systolic pressure is similar. CT ABD W&W/O CON [**2126-12-2**] IMPRESSION: 1. Bilateral pleural effusion and adjacent atelectasis/consolidation. 2. Large hiatal hernia. 3. Atrophic kidneys with multiple bilateral hypoattenuating lesions too small to fully characterize. 4. Slightly heterogeneous appearance of the pancreatic head although without discrete mass. These findings may relate to focal fatty infiltration. MRI may be helpful for further characterization. 5. Diffuse atherosclerotic disease involving the aorta and branch vessels. 6. Compression deformity involving the L3 vertebral body with retropulsion of bony fragments incompletely characterized. MRI L-spine [**12-6**] FINDINGS: There is an unusual L-shaped deformity of the L3 vertebral body, and a corresponding deformity of the L4 vertebral body. The intervening disc space also has an L-shaped configuration. Arising from the posterior aspect of the L3-4 disc space remnant is a moderate posterior spondylitic [**Month/Year (2) **] which appears to cause moderate central canal stenosis. While there are no axial images available, there does appear to be prominent L3-4 foraminal stenosis due to the abnormal morphology of the L3 and L4 vertebrae. On the STIR images, there is very slight edema within these vertebral bodies, with more linear areas of edema in what are presumably the L2-3 and L4-5 discs. Despite these findings, there does not appear to be bone destruction to suggest an ongoing inflammatory process nor is there prevertebral soft tissue swelling. Nevertheless, given the immunocompromised state of this patient, it is conceivable that a low-grade infectious process could be present. The L2-3 disc is also mildly desiccated. The imaged distal spinal cord, conus medullaris and remainder of the uncompressed cauda equina are normal. CONCLUSION: Unusual deformity of the L3 and L4 vertebral bodies. Some edema in this locale. A low-grade infection cannot be excluded. MRI Abd [**12-6**] FINDINGS: There are bilateral pleural effusions and a large hiatal hernia. Diffuse hypointensity of the spleen and liver is seen on all sequences, consistent with hemosiderosis. There is a 1.1 cm T2 hyperintense, T1 isointense splenic lesion which likely represents a hemangioma. The common bile duct measures up to approximately 11 mm and is unchanged when compared to the prior CT scans dating back to [**2125-2-7**]. Pancreatic duct is top normal at 4 mm. Gallbladder is unremarkable. No evidence of intrahepatic bile duct dilation. Adrenal glands and pancreas are unremarkable. Kidneys are atrophic and contain multiple small cystic lesions, most of which appear simple. In the upper pole of the left kidney, there are two T1 hyperintense, T2 iso-to- hypointense lesions. The largest of these lesions measures approximately 1 cm (image 24, series 10 and image 14, series 4) and appears new since the prior CT dated [**2125-2-7**]. A followup MR of this hemorrhagic cystic lesion is recommended in six months. Again seen is compression of the L3 vertebral body. This finding is unchanged when compared to the prior CT dated [**2125-2-7**]. IMPRESSION: 1. No evidence of cholelithiasis. Gallbladder appears normal. 2. Pancreas is unremarkable. 3. Bilateral pleural effusions. 4. Large hiatal hernia. 5. Hemosiderosis of the liver and spleen. 6. Atrophic kidneys with superior pole left kidney 1 cm hemorrhagic cystic lesion that appears new since the prior CT scan dated [**2-7**], [**2125**]. A followup multiphase CT is recommended in 6 months with the patient's dialysis dependence. 7. Unchanged L3 compression fracture. Brief Hospital Course: 65 yo M with PMH of HIV on HAART, DM2, hepatitis C, ESRD on HD who presents with abdominal pain for several days. # Abdominal pain: In the ED the patient had a CT-scan of the abdomen/pelvis without contrast and showed a question of pancreatic mass. He was also evaluated by GI and was found to have guaic positive stool. The patient has a history of gastritis and esophageal erosions on previous EGD [**2125**]. The GI team recommended EGD/colonscopy at some point in the future, but because his INR was elevated the evaluation was deferred. He was subsequently started on an IV PPI. The patient was transferred to the MICU continued to have abdominal pain requiring IV dilaudid. He underwent repeat CT-scan of the abdomen with contrast ([**12-2**]) that did not reveal a pancreatic mass and showed heterogeneous appearance of the pancreatic head without discrete mass. These findings could be related to focal fatty infiltration and MRI was recommended. Additionally, a L3 compression deformity with retropulsion of bony fragments. The patient's pain was improved with oxycodone 10mg q4prn and would flucutate in intensity. It was not associated with meals, nausea/vomiting, diarrhea, or constitutional symptoms. Additionally, his LFT and pancreatic enzymes were wnl. A H. pylori serology and stool antigen were sent along with C.diff toxin. The patient's H. pylori serology was positive (previously treated in [**2119**] and last serology of equivocal). The patient was treated empirically with amox/clarithro x14. The stool antigen was still pending at the time of discharge. The patient underwent MRI on [**12-6**] that showed did not show a clear source for the pain. . # Anticoagulation: Patient was on warfarin for anticoagulation at home. The warfarin was held during hospitalization, however, INR still climbing, likely because patient is not eating. The patient's INR reached a peak of 6.0 and then declined as the patient began to eat po. The patient's INRo drifted down and the patient was started on a heparin gtt on [**12-8**] when his INR was 1.7. The INR was monitored and it was decided to defer GI workup and restart coumadin on [**12-9**]. The heparin gtt was discontinued on [**12-10**]. His INR was 1.3. He will be continued on coumadin 7.5mg and should have his INR checked at dialysis with goal [**2-10**]. . #L3, L4 Deformity: A CT-scan performed on [**12-1**] and [**12-2**] showed deformity in the L3 and L4 vertebrae. The patient did not complain of back pain or other compliants. He underwent MRI of the L-spine that showed deformity of the L3 and L4 vertebral bodies with local edema. A low-grade infection could not be excluded on imaging. The patient was evaluated by Neurosurgery and they did not want to intervene at this time. It is recommended that the patient have a flexsion/extension x-ray of the lumbar spine when able to walk. # Tachycardia: The patient was admitted in sinus tach with rates in the 120s. The patient's pain could be contributing. The patient was continued on metoprolol and started on nifedipine. Additionally, his pain was intially controled with IV dilaudid and transitioned to po oxycodone 10mg q4. The patient's TSH was normal. An ECHO was performed that showed global hypokinesis with decreased EF from prior (35-40%). The patient's tachycardia resolved on [**12-2**]. . # Hypertension: Patient is likely chronically hypertensive. The patient's home medicaitons of diazoxide was not carried by the hospital. The patient was started on metoprolol and nifedipine for BP control. He also had fluid removal at HD. The patient's blood pressure was under better control with metoprolol, nifedipine, HD and pain control. The patient's Nifedipine was titrated up to 30mg daily and Metoprolol was increased to 75mg [**Hospital1 **] on [**12-6**]. . # DM2: The patient's FS were monitored QID and covered with ISS. The patient's FS were never above 150 and the patient was continued on a regular diet to encourage po intake. . # Chronic systolic and diastolic CHF: The patient remained clinically euvolemic during his stay. An ECHO was performed that showed global hypokinesis with decreased EF from pior (35-40%), likely non-ischemic etiology. Additionally, the patient had fluid removal at HD. It is recommended the patient have repeat ECHO in the future to re-evaluate his cardiac function. . # ESRD on HD: The patient had HD on [**12-18**], and [**12-7**], [**12-10**]. The patient's usual schedule is Tues, Thurs, Sat. The patient was followed by the renal team. His sevelamer was held on [**12-5**] because of low phosphorus. The patient received Zemplar at HD. . # HIV/AIDs: The patient was continued on HAART. . # access: The patient has history of clots and femoral line with HD cath is last possible site for dialysis catheter. The patient had a midline placed on [**12-3**] in his left arm and removed on [**12-10**]. . # FEN: regular diet . # PPX: coumadin & heparin gtt . # Code: full Medications on Admission: 1. Gabapentin 200 mg Capsule PO HS 2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet PO DAILY 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID 4. Indinavir 400 mg Capsule Sig: One (1) Capsule PO BID 5. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical [**Hospital1 **] 6. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical DAILY 7. Lamivudine 150 mg Tablet Sig: One (1) Tablet PO Q TUESDAY AND THURSDAY 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY 9. Stavudine 20 mg Capsule Sig: One (1) Capsule PO Q NOON AFTER DIALYSIS 10. Citalopram 60 mg Tablet PO DAILY 11. Sevelamer HCl 800 mg Tablet Sig: One Tablet PO TID W/MEALS 12. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID 13. Diazoxide Powder Sig: One Hundred (100) mg Miscellaneous TID 14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H as needed. 15. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] 16. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous HD PROTOCOL (HD Protochol) for 10 days. Should have ended on the [**2126-11-28**] as discharge was [**2126-11-18**] Discharge Medications: 1. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 2. Ferrous Sulfate 325 mg (65 mg Iron) 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. Indinavir 400 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Topical twice a day: topical to R chest wound. 6. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical DAILY (Daily). 7. Lamivudine 150 mg Tablet Sig: One (1) Tablet PO 2X/WEEK (TU,TH). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 9. Stavudine 20 mg Capsule Sig: One (1) Capsule PO 3X/WEEK (TU,TH,SA). 10. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID (3 times a day). 12. Diazoxide Powder Sig: One (1) Miscellaneous TID (3 times a day). 13. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 14. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 15. Amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q24H (every 24 hours) for 14 days: day1: [**12-7**]. 16. Clarithromycin 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 14 days: day1: [**12-7**]. 17. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 18. Insulin Lispro 100 unit/mL Solution Sig: as directed Subcutaneous ASDIR (AS DIRECTED). 19. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 20. Nifedipine 10 mg Capsule Sig: Three (3) Capsule PO Q8H (every 8 hours). 21. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 22. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**] Discharge Diagnosis: Primary: H. Pylroi PUD L3, L4 Deformity Secondary: HIV Diabetes Mellitus, type 2 Neuropathy Charcot foot Chronic renal failure on Hemodialysis [**Female First Name (un) 564**] esophagitis Hepatitis C: genotype IB Congestive heart failure. Necrotizing Fasciitis Hypertension Hypercholesterolemia LE Diabetic ulcers Herpes zoster of the left mandibular distribution of the trigeminal nerve. R suprapatellar abscess IVDU (heroin and cocaine) Obesity GI Bleed Anemia Colonic Polyps Gastritis with large hiatal hernia. Lipodystrophy Charcot foot Colonic AVM MRSA/ VISA Discharge Condition: stable, good O2 sat on room air, tolerating regular diet Discharge Instructions: It was a pleasure taking care of you while you were in the hospital. You were admitted to [**Hospital1 18**] because of abdominal pain. You had a CT scan and MRI of your abdomen to determine a source of your infection, but it did not reveal a clear cost. We tested your blood for an infection in your stomach that could be the source of the pain and is called H. pylori. This bacteria can cause ulcers and you were treated empricially with antibiotics for 14 days. You also underwent a MRI of your spine that showed a deformity. You were evaluated by neurosurgery and they did not feel you needed intervention at this time. Please follow the medications prescribed below. Please follow up with the appointments below. Please call your PCP or go to the ED if you experience chest pain, palpitations, shortness of breath, nausea, vomiting, fevers, chills, or other concerning symptoms. Followup Instructions: Please follow-up with your PCP [**Last Name (NamePattern4) **] [**1-9**] weeks: PCP: [**Name10 (NameIs) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 250**] **Patient should have extension/flexsion X-ray as outpatient when able to stand. **A followup multiphase CT of kidneys is recommended in 6 months with the patient's dialysis dependence. ** F/u H/ pylori stool studies ** Please repeat ECHO as outpatient in a few months (EF declined to 35% this admission) Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1085**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2126-12-25**] 10:30 Completed by:[**2126-12-10**]

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icd9cm

[ [ [] ] ]

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139,032

37642

Discharge summary

report

Admission Date: [**2104-10-2**] Discharge Date: [**2104-10-11**] Date of Birth: [**2031-12-13**] Sex: F Service: ORTHOPAEDICS Allergies: adhesive tape / furosemide / Oxycodone Attending:[**First Name3 (LF) 8587**] Chief Complaint: Intracranial hemorrhage and right hip pain. Major Surgical or Invasive Procedure: [**2104-10-6**]: Right Craniotomy and resection of frontal lesion [**2104-10-8**]: Prophylactic nailing, right femur. History of Present Illness: Ms [**Known lastname 84430**] is a 72 yo woman with a recent diagnosis of met. melanoma transferred from an outside hospital with a rt frontal hemorrhage. Pt presented to OSH on [**2104-09-30**] with a 2 day h/o progressive lethargy. Head CT w/o contrast revealed a 4x4 cm rt frontal ICH. Pt was on warfarin for a PE recently diagnosed and INR was 6.7. Pt received FFP and vitamin K and had an IVC filter placed.She was also started on decadron and dilantin.Her mental status improved significantly and repeat CT scan on [**2104-10-1**] shows no progression of bleed. On arrival, pt c/o hiccups and rt rib pain which she attributes to intractable hiccups. She has no headache/nausea/vision changes/muscle weakness or sensory changes. Family reports that mental status back to baseline although she is fatigued and her speech is slower. Pt continues to suffer from rt shoulder pain attributed turn rt rotator cuff as well as left hip pain and left shin pain.She denies fevers, chills, cough, sob, hemoptysis, abdominal pain, dysuria/frequency. All other ROS is negative. Past Medical History: Oncology history: 1.Diagnosed with stage IIIa melanoma in [**10-24**] excisional biopsy showed invasive malignant melanoma with a depth of 2.1 mm, [**Doctor Last Name 10834**] level IV, no ulceration and 2 mitoses per 10 high-powered fields. She then underwent a wide local excision with sentinel lymph node biopsy on [**2102-10-3**] and there was no residual melanoma identified. In the wide local excision specimen, there was a metastatic deposit in the sentinel lymph node. Imaging showed no areas of metastatic disease. 2. [**2104-8-27**] presented to OSH with acute SOB and found to haev a PE, pulmonary nodules, and mult bone lesions on bone scan , CT guided biopsy of vertebral body lytic lesion was c/w metastatic melanoma. B-RAf mutation status pending. . Other PMH: 1. HTN. 2. Hyperlipidemia. 3. Basal cell CA, s/p excision. 4. Osteoarthritis, s/p bilateral knee replacements. 5. Cholecystectomy, 6/[**2104**]. Social History: She smoked briefly in high school and drinks alcohol rarely. She denies drug use. She is a widow and has 3 children. Family History: Father with possible prostate cancer. Her mother had skin cancer of unknown type. Physical Exam: T 98.3 P 83 BP 158/82 RR 20 Os sat 94% General: AAOx3, no asd, +hicccups during interview. HEENT: Pupils equal and reactive, sclerae non-icteric, o/p clear, MMM. Neck: Supple, no JVD, no thyromegaly. Lymph nodes: No cervical, supraclavicular or axillary LAD. CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops. RESP: Good air movement bilaterally, no rhonchi or wheezing. ABD: Soft, non-tender, non-distended, + bowel sounds. EXTR: No edema, good pedal pulses. DERM: No rash. Neuro: Cranial nerves [**3-29**] grossly intact, muscle strength 5/5 in all major muscle groups, sensation to light touch intact,knee reflexes symetrical , toes down going,no pronator drift. PSYCH: Appropriate and calm. Pertinent Results: ADMISSION LABS: [**2104-10-2**] 05:45PM BLOOD WBC-10.9 RBC-4.47 Hgb-13.0 Hct-36.9 MCV-83 MCH-29.0 MCHC-35.1* RDW-14.0 Plt Ct-244 [**2104-10-2**] 05:45PM BLOOD Neuts-80.0* Lymphs-13.5* Monos-5.5 Eos-0.6 Baso-0.5 [**2104-10-2**] 05:45PM BLOOD PT-15.1* PTT-23.9 INR(PT)-1.3* [**2104-10-2**] 05:45PM BLOOD Glucose-118* UreaN-18 Creat-0.6 Na-142 K-3.8 Cl-105 HCO3-27 AnGap-14 [**2104-10-2**] 05:45PM BLOOD ALT-11 AST-13 LD(LDH)-331* AlkPhos-103 TotBili-0.4 [**2104-10-2**] 05:45PM BLOOD Albumin-4.0 Calcium-10.3 Phos-2.1* Mg-2.0 [**2104-10-2**] 05:45PM BLOOD Phenyto-9.0* . [**10-3**] MRA BRAIN- IMPRESSION: Although no vascular occlusion or abnormal vascular structures are seen. Slight protuberance in the region of anterior communicating artery is seen which likely is due to a vascular loop. However, this area is not well evaluated due to motion artifacts. When the patient returns for gadolinium-enhanced image, a repeat study can be obtained for further confirmation. [**10-3**] MRI T Spine- IMPRESSION: Bony abnormalities at the T6-7 and T10 levels, suspicious for bony metastasis. The examination is limited with only sagittal T2 images were obtained. Consider repeat study with sedation if clinically indicated. [**10-4**] CT Torso- IMPRESSION: 1. Similar degree of bilateral pulmonary metastases. 2. Probably similar appearance to metastatic involvement and vertebral body height loss of T6-T7 vertebral bodies, though direct comparison is not possible to the outside films provided. Osseous destruction within the left hemisacrum, which is also probably similar compared with prior, though is incompletely imaged on the comparison study. 3. Hypodensities within the liver and spleen are stable but highly suggestive of metastatic disease. [**10-6**] CT Femur- *** [**10-6**] LENI's- IMPRESSION: DVT in the right common femoral vein. No left-sided DVT. [**10-6**] Head CT- 1. Expected post-operative changes status post resection of right frontal hemorrhagic mass with some blood products in the surgical bed. MRI would be more sensitive for a residual lesion. 2. 3 mm hemorrhagic mass abutting the body of the left lateral ventricle, as seen previously. Other small intracranial masses were better seen on the recent MRI WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2104-10-10**] 06:05 13.4* 3.47* 9.9* 28.5* 82 28.6 34.8 14.7 163 [**2104-10-9**] 05:20 15.6* 3.80* 10.7* 32.1* 84 28.2 33.4 15.1 175 [**2104-10-8**] 16:05 20.7* 4.20 11.8* 35.9* 85 28.1 33.0 15.0 239 [**2104-10-7**] 08:30 21.0* 4.22 12.1 34.6* 82 28.8 35.1* 14.5 237 [**2104-10-7**] 04:17 21.9* 4.37 12.5 35.7* 82 28.5 34.9 14.8 264 Source: Line-aline [**2104-10-6**] 08:54 14.0* 4.55 12.9 37.6 83 28.3 34.2 14.0 252 [**2104-10-5**] 07:21 13.2* 4.75 13.4 40.0 84 28.3 33.6 14.5 233 [**2104-10-4**] 07:47 10.6 4.72 13.1 39.0 83 27.7 33.5 13.8 247 [**2104-10-3**] 08:10 12.2* 4.57 12.8 37.8 83 28.0 33.9 13.9 267 [**2104-10-2**] 17:45 10.9 4.47 13.0 36.9 83 29.0 35.1* 14.0 244 Glucose UreaN Creat Na K Cl HCO3 AnGap [**2104-10-10**] 06:05 157*1 26* 0.7 137 4.0 103 26 12 [**2104-10-9**] 05:20 146*1 28* 0.6 140 4.1 106 26 12 [**2104-10-7**] 08:30 164*1 20 0.7 142 4.1 106 25 15 [**2104-10-6**] 19:25 212*1 21* 0.8 136 3.6 102 21* 17 Source: Line-Aline [**2104-10-6**] 08:54 981 20 0.6 139 3.8 104 26 13 [**2104-10-5**] 07:21 821 19 0.7 137 3.8 101 22 18 [**2104-10-4**] 07:47 [**Telephone/Fax (2) 84431**] 3.7 103 25 14 [**2104-10-3**] 08:10 [**Telephone/Fax (2) 84432**] 3.6 104 26 15 [**2104-10-2**] 17:45 118*1 18 0.6 142 3.8 105 27 14 TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2104-10-10**] 06:05 9.8 2.1* 2.0 [**2104-10-9**] 05:20 10.0 2.2* 2.1 [**2104-10-7**] 08:30 10.2 3.4 2.1 [**2104-10-6**] 19:25 9.7 3.6 1.9 Source: Line-Aline [**2104-10-6**] 08:54 10.3 2.7 2.0 [**2104-10-5**] 07:21 10.5* 2.9 2.1 [**2104-10-4**] 07:47 10.2 2.8 1.9 [**2104-10-3**] 08:10 4.1 9.7 2.5* 1.9 [**2104-10-2**] 17:45 4.0 10.3 2.1* 2.0 NEUROPSYCHIATRIC Phenyto [**2104-10-2**] 17:45 9.0* Blood Gas BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2 pH calTCO2 Base XS [**2104-10-6**] 17:12 ART 123* 32* 7.43 22 -1 WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Lactate Na K Cl [**2104-10-6**] 17:12 149* 0.8 128* 3.2* 100 HEMOGLOBLIN FRACTIONS ( COOXIMETRY) Hgb calcHCT [**2104-10-6**] 17:12 10.9* 33 CALCIUM freeCa [**2104-10-6**] 17:12 1.20 Brief Hospital Course: 72 yo woman with recent diagnosis of metastatic melanoma with lung and bone mets and recent diagnosis of PE on anticoagulation presented to OSH with an right frontal intracranial hemorrhage and right pathological hip fracture admitted to the Hem/Onc service on [**2104-10-2**]. #. ICH: -Neurosurgery consulted and appreciate assistance. they feel that since pt 3 days from diagnosis of bleed and stable both clinically and imaging that pt can be on the oncology floor. -Neuro checks q 4hrs. -Decadron 4 TID. -Keppra 500 mg [**Hospital1 **] x2 days and then increase to 1000 mg [**Hospital1 **]. -MRI of brain tonight. - INR goal 1.3 or below. -Systolic blood pressure to maintain below 140. . #Met melanoma: Results of B-Raf mutation status pending. -Will need x-rays of bilateral femurs to asses stability/risk of fracture as well as likely MRI of spine to better evaluate spinal mets. . #PE: Pt had an IVC filter placed at outside hospital. . #HTN: Pt was on Toprol XL 100 mg at home. Dose was deceased to 25 mg at OSH d/t bradycardia. -start metoprolol 25 mg po bid and will monitor pulse and BP closely. -Cont losartan 80 mg. . #Hypercalcemia: Mild hypercalcemia at OSH. -D/c calcium and Vit. -Will need bisphosphonates in the future for bone mets. . #Pain:Will minimize narcotics given ICH and need to asses neurological status. -Scheduled Tylenol. -Low dose IV morphine ( 0.5 mg IV q hrs prn) -Lidocaine patch . FEN: Regular, ISS ( given Decadron), replete phos. DVT prophylaxis: S/P IVC filter, no heparin. Lines :PIC placed with the assistance of anesthesia. Pt with poor peripheral veins and likely will need a PICC line placed. Full code On [**2104-10-6**] the patient was transferred to the Neurosurgery service. She underwent a right frontal craniotomy and resection of the frontal brain lesion. She was extubated and transferred to the ICU. Post op head CT revealed post operative changes and pneumocephalus therefore she was placed on a non-rebreather. On [**10-5**] she was started on Levetiracetam. On [**10-7**] she was neurologically stable therefore her neuro checks were changed to Q and SBP was liberalized to 160. Orthopedic's had previously been consulted and they recommend surgical fixation for her pathological hip fractures. On [**2104-10-8**] she underwent open reduction internal fixation of the right hip without complication. She was transferred to the Orthopedic service post operatively. She was started on Lovenox for DVT prophylaxis. A lower extremity US on [**2104-10-8**] showed no evidence of DVT. The patient is being discharge to rehab in stable condition. Medications on Admission: Meds on transfer toprol 25 mg daily phenytoin 100 mg TID valsartan 80 mg daily tylenol #3 q4hrs prn zofran prn lipitor 20 mg daily calcium and vit D Discharge Medications: 1. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for hiccups. 2. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 6. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for Pain. 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. acetaminophen-codeine 300-30 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 11. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous QPM (once a day (in the evening)) for 1 weeks: End date [**2104-10-18**]. Start Coumadin when Lovenox is discontinued. 12. dexamethasone sodium phosphate 4 mg/mL Solution Sig: One (1) injection Injection Q6H (every 6 hours). 13. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: Adjust daily according to INR. Goal INR [**3-20**]. Start date [**2104-10-18**]. Discontinue Lovenox once Coumadin started. 14. Outpatient Lab Work Daily PT/INR for Coumadin dosing to start [**2104-10-18**]. Target INR [**3-20**]. Discharge Disposition: Extended Care Facility: [**Location (un) **] [**Doctor Last Name **] Discharge Diagnosis: Right Frontal Brain Mass Right hip Fracture Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: General Instructions/Information ****** DO NOT START COUMADIN THERAPY UNTIL 7 DAYS AFTER YOUR NEUROSURGICAL PROCEDURE ON [**10-6**] ********* ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after 5 days. Your wound closure uses dissolvable sutures, you must keep that area dry for 5 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. Continue to take Keppra as prescribed. ?????? You are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: increasing redness, increased swelling, increased tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Physical Therapy: Activity: Activity: Activity as tolerated Right lower extremity: Full weight bearing Left lower extremity: Full weight bearing Encourage turn, cough and deep breathe q2h when awake Treatments Frequency: Remove staples 14 days from date of surgery from right hip. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the Neurosurgery office in [**8-24**] days (from your date of surgery) for a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**10-27**] at 2 pm. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 5074**] 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. Please call the Orthopedic department at [**Telephone/Fax (1) 1228**] to schedule a follow up appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP.

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icd9cm

[ [ [] ] ]

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icd9pcs

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12353, 12424

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349, 470

12512, 12512

3490, 3490

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Discharge summary

report

Admission Date: [**2110-10-2**] Discharge Date: [**2110-11-1**] Date of Birth: [**2053-12-9**] Sex: M Service: SURGERY Allergies: Keflex / Oxycodone Attending:[**Doctor First Name 5188**] Chief Complaint: Toxic megacolon s/p TAC/end ileostomy, septic shock, ARDS, ARF Major Surgical or Invasive Procedure: TAC/end ileostomy at [**Hospital3 3583**] US guided paracentesis Post-pyloric Dobhoff Thoracostomy tube palcement History of Present Illness: 56 M presented to [**Hospital3 3583**] on [**2110-10-1**] hypotensive to systolic of 50s, tachycardia to 140s and with a firm & distended abdomen. CT scan was perfomred and showed distended colon and small bowel with cecum & transverse colon measuring up to 9 cm id diameter. Distention extended to rectosigmoid area wihtout obvious obstruction. Patient taken emergently to OR this AM at OSH - diffusely gangrenous colon identified without perforation. Patient is s/p TAC/end ileostomy/Hartmann's pouch at [**Hospital3 3583**]. He remained intubated on pressors postop with maximal vent suppport. He has been transferred to [**Hospital1 18**] for SICU-level care. On arrival to SICU, patient was on Levophed at 0.25 mcg/kg/min. He had been on Pitressin at OSH, but this was d/c'd upon transfer. He is on, vanc, [**Last Name (un) 2830**], flagyl for Abx covergae. Past Medical History: GERD, HTN, fibromyalgia, nephrolithiasis s/p appendectomy, L ureteral stent Social History: No tobacco, no ETOH, no IVDA Family History: Parents with HTN Physical Exam: A and O x 2 person/place V.S.S RRR no mrg LSCTA with coarse lung sounds at bases, productive cough. Soft, NT, ND, abd wound pink, granulation no s/s of infection, ostomy with loose stool no c/c/e Pertinent Results: CT Torso [**10-7**]: Diffusely dilated fluid-filled small bowel loops down to the rectus sheath tunnel may reflect postoperative ileus, though stenosis at the level of the tunnel is another diagnostic consideration. Apparent flattening of SMV mesenteric branches is of unknown etiology, but concerning in the setting of recent colectomy for gangrenous colon. Bilateral predominantly upper lobe confluent lung consolidation is most consistent with the radiographic sequela of acute respiratory distress syndrome. Enhancing small right hepatic lesions may represent hemangiomas, though MRI should be pursued to further evaluate on a nonurgent basis once the patients acute clinical issues have resolved. LENI's [**10-8**]: no DVT UE U/S [**10-10**]: L brachial vein thrombus RUQ US [**10-10**]: Three hepatic lesions, two of which have a typical appearance for hemangiomas. The third has an atypical appearance, but may also represent a hemangioma. Tiny gallbladder polyp. No gallstones and no signs of cholecystitis and no biliary dilatation. CT A/P [**10-14**]: Bilateral pleural effusions, right greater than left and ARDS. Two nonspecific hypodense liver lesions as described on previous study. Large stable renal cysts without evidence of hydronephrosis or pyelonephritis. Status post total colectomy and ileostomy without evidence of suture line leak or upstream obstruction CT torso [**10-28**]: Diffuse multifocal bilateral airspace disease, worse in the superior segment of the left lower lobe since the prior consistent with pneumonia. Circumferential bowel wall thickening involving the Hartmann's pouch. Moderate ascites throughout the abdomen. Mild left-side hydronephrosis likely due to compression of the ureter between a focal area of fluid and the left psoas muscle. Two probable hemangiomas in the right hepatic lobe. Indeterminate 1.2 cm hypodensity in the lower pole of the left kidney. MRI head [**10-20**]: Numerous T2 hyperintense lesions in the supratentorial white matter, without associated contrast enhancement, blood products, or diffusion abnormalities, which are nonspecific. Diagnostic considerations include advanced chronic small vessel ischemic disease if the patient has longstanding diabetes or hypertension, demyelinating disease, other inflammatory/infectious etiologies, and vasculitis. No specific evidence of septic emboli. Questionable signal abnormality in some of the superior cerebral sulci on FLAIR images, which could be an artifact of technique, since the flare images have been acquired following intravenous gadolinium administration. UE US [**10-24**]: no DVT [**2110-10-29**] 05:30AM BLOOD WBC-15.8* RBC-3.65* Hgb-10.7* Hct-33.3* MCV-91 MCH-29.2 MCHC-32.0 RDW-16.2* Plt Ct-583* [**2110-10-28**] 02:56AM BLOOD WBC-16.7* RBC-3.61* Hgb-10.5* Hct-32.3* MCV-90 MCH-29.2 MCHC-32.6 RDW-16.4* Plt Ct-627* [**2110-10-2**] 07:19PM BLOOD WBC-1.6* RBC-4.31* Hgb-13.0* Hct-40.5 MCV-94 MCH-30.1 MCHC-32.0 RDW-15.4 Plt Ct-160 [**2110-10-3**] 02:13AM BLOOD WBC-2.7*# RBC-3.74* Hgb-11.9* Hct-34.6* MCV-92 MCH-31.7 MCHC-34.3 RDW-15.6* Plt Ct-128* [**2110-10-28**] 02:56AM BLOOD Neuts-79.2* Lymphs-11.7* Monos-4.6 Eos-4.2* Baso-0.3 [**2110-10-25**] 02:34AM BLOOD Neuts-80.9* Lymphs-9.4* Monos-5.4 Eos-4.1* Baso-0.3 [**2110-10-2**] 07:19PM BLOOD Neuts-20* Bands-24* Lymphs-56* Monos-0 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2110-10-3**] 02:13AM BLOOD Neuts-47* Bands-15* Lymphs-26 Monos-9 Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-0 [**2110-10-23**] 03:23AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL Stipple-OCCASIONAL [**2110-10-2**] 07:19PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-2+ Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL Burr-2+ Tear Dr[**Last Name (STitle) 833**] [**2110-10-29**] 05:30AM BLOOD Plt Ct-583* [**2110-10-22**] 02:12AM BLOOD Plt Smr-HIGH Plt Ct-678* [**2110-10-16**] 02:12AM BLOOD PT-13.7* PTT-31.0 INR(PT)-1.2* [**2110-10-2**] 07:19PM BLOOD PT-22.7* PTT-61.5* INR(PT)-2.1* [**2110-10-3**] 02:13AM BLOOD PT-21.5* PTT-61.2* INR(PT)-2.0* [**2110-10-2**] 07:19PM BLOOD Fibrino-457* [**2110-10-20**] 12:46PM BLOOD ESR-38* [**2110-10-29**] 05:30AM BLOOD Glucose-118* UreaN-34* Creat-0.9 Na-142 K-4.6 Cl-102 HCO3-33* AnGap-12 [**2110-10-28**] 02:56AM BLOOD Glucose-83 UreaN-29* Creat-0.8 Na-141 K-4.1 Cl-102 HCO3-32 AnGap-11 [**2110-10-2**] 07:19PM BLOOD Glucose-158* UreaN-49* Creat-1.6* Na-149* K-3.9 Cl-119* HCO3-21* AnGap-13 [**2110-10-3**] 02:13AM BLOOD Glucose-106* UreaN-52* Creat-2.0* Na-148* K-4.0 Cl-117* HCO3-22 AnGap-13 [**2110-10-27**] 02:44AM BLOOD ALT-42* AST-22 AlkPhos-171* TotBili-0.4 [**2110-10-2**] 07:19PM BLOOD ALT-62* AST-146* LD(LDH)-339* CK(CPK)-5091* AlkPhos-25* Amylase-48 TotBili-0.6 [**2110-10-20**] 03:09PM BLOOD Lipase-33 [**2110-10-14**] 02:02AM BLOOD GGT-134* [**2110-10-3**] 02:13AM BLOOD CK-MB-86* MB Indx-2.0 cTropnT-0.01 [**2110-10-2**] 07:19PM BLOOD CK-MB-124* MB Indx-2.4 cTropnT-<0.01 [**2110-10-29**] 05:30AM BLOOD Calcium-9.7 Phos-3.8 Mg-2.2 [**2110-10-27**] 02:44AM BLOOD Albumin-2.9* [**2110-10-2**] 07:19PM BLOOD Albumin-1.0* Calcium-6.1* Phos-5.7* Mg-2.0 [**2110-10-3**] 02:13AM BLOOD Albumin-1.9* Calcium-7.1* Phos-4.9* Mg-2.0 [**2110-10-12**] 03:55AM BLOOD calTIBC-88* Ferritn-695* TRF-68* [**2110-10-15**] 02:02AM BLOOD Triglyc-99 [**2110-10-20**] 03:09PM BLOOD Ammonia-19 [**2110-10-7**] 04:18AM BLOOD Osmolal-332* [**2110-10-20**] 03:09PM BLOOD TSH-5.4* [**2110-10-26**] 07:09AM BLOOD Cortsol-30.1* . MRSA SCREEN (Final [**2110-10-31**]): No MRSA isolated . OVA + PARASITES (Final [**2110-10-24**]): NO OVA AND PARASITES SEEN. Brief Hospital Course: 10 /22 -[**10-11**] Mr. [**Known lastname 174**] was admitted to the [**Hospital1 18**] SICU on [**2110-10-2**] after being transferred from [**Hospital3 3583**] with multi organ system failure after total abdominal colectomy. He remained in critical condition with sepsis and ARDS for the first week in the ICU. He was placed on broad spectrum IV antibiotics and was gradually weaned off vasopressors. He continued to spike high fevers despite no positive cultures (aside from yeast in sputum). Wound treated with wound vac. [**10-12**] Pt was treated with fluconazole for yeast Pt was also started on TPN [**10-13**] pt with brachial thrombosis on UE u/s. until [**10-15**] . [**10-15**] Paracentesis of abdominal ascites, TTE without vegetations, continued fevers to 103.8. wound vac dc'd. Coag negative bacteremia secondary to + cathter tip. [**10-17**] Enteral feeds started , continued fevers to 105 requiring aggressive cooling. [**10-18**] percutaneous tracheostomy placed [**10-19**] urology consulted for hydronephrosis of the left ureter- no indication for intervention. Ct scan showed worsening LLL PNA. [**10-20**] Thoracostomy tube placement for pleural effusion drainage. Cont fever, agitation. NGT . LP performed with elevated opening pressure. [**10-21**] TEE performed, no vegetations noted. [**10-22**] Trach collar tolerated Mental status improving as patient weaned off sedatives and started on Precedex and fentanyl. MRI performed showing diffuse parenchymal changes. Tagged WBC scan with ? loculated ascites in RLQ. Anca negative. [**10-23**]: Us of renal artery without RAS, CT abd pelvis, with ? Right kidney mass and renal calculus [**10-25**] GI consulted for ? sigmoidoscopy/ ileoscopy. Fevers improved. [**10-26**] afebrile Deferred scope , ABX dcd tolerated trach collar x 24 hours. Doboff replaced. Intermittent agitation. Speech and swallow eval for passy muir valve. [**10-27**] pt transferred to the floor. . General surgery Mr. [**Known lastname 174**] returned to the floor. Physical therapy continued to work the the patient. Pt's dobboff was self d/c'd. Speech and swallow evalutated the pt and he failed video swallow. A new dobboff was placed and tube feeds were restarted at goal. Trach care was continued per protocol. . He will be d/c'd to rehab. Pt again discontinued his Doboff tube and refused replacement. A bedside swallow demonstatrated no choking or evidence of aspiration with ensure. As discussed with Dr. [**Name (NI) 5182**] pt may use ensure supplementation and take nectar thickened liquids. The patient was confused at times but oriented x 2 person, place. Easily reoriented. He will follow up with Dr. [**Last Name (STitle) 5182**] in 1 week. Medications on Admission: Home meds: Zocor 10 mg daily, Prilosec 20 mg daily, Amitriptyline 100 mg daily, Cymbalta 60 mg daily, Lisinopril 10 mg daily, Toprol XL 25 mg daily Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic Q2H (every 2 hours) as needed for dry eyes. 3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for orsal hygeine. 4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for rash. 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 7. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily) as needed for depression. 8. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. Methadone 5 mg Tablet Sig: One (1) Tablet PO once a day: please titrate down as needed. 10. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 11. Heparin Flush (10 units/ml) 1 mL IV PRN line flush Temporary Central Access-Floor: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN. 12. HYDROmorphone (Dilaudid) 0.25 mg IV Q3H:PRN pain 13. Saline Flush 0.9 % Syringe Sig: One (1) Injection twice a day. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] Discharge Diagnosis: septic shock, ARF, ARDS s/p TAC for C Diff colitis Discharge Condition: Stable. Tolerating tube feed at goal rate. Pain well controlled. Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Incision Care: Please continue to apply wet to dry dressings twice a day and as needed to abd wound. . Monitoring Ostomy output/Prevention of Dehydration: -Keep well hydrated. -Replace fluid loss from ostomy daily. -Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. -Try to maintain ostomy output between 1000mL to 1500mL per day. -If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with each episode of loose stool. Do not exceed 16mg/24 hours Followup Instructions: 1. Please call Dr.[**Name (NI) 6045**] office, [**Telephone/Fax (1) 5189**], to make a follow up appointment in [**12-13**] weeks. [**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**] Completed by:[**2110-11-1**]

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27814

Discharge summary

report

Admission Date: [**2185-7-10**] Discharge Date: [**2185-8-11**] Date of Birth: [**2133-3-29**] Sex: M Service: PLASTIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 10416**] Chief Complaint: Redness and swelling of scrotum and thigh for five days. Major Surgical or Invasive Procedure: Incision and drainage of scrotal abscess/necrotizing fasciitis of left posterior thigh [**2105-7-10**] Debridement of necrotic tissue from aforementioned abscess [**2185-7-12**] Closure of scrotum/thigh wound [**2185-8-1**] History of Present Illness: Mr. [**Known lastname **] was transferred from [**Hospital 1474**] Hospital where he presented with left posterior thigh abscess that extended to his scrotum. He was nauseated and vomitted. Pt felt like he was going to pass out. He complained of low grade fever and pain in his scrotal area. Past Medical History: Morbid obesity 465lbs, IDDM, anxiety, perirectal abscess ([**6-19**]), L Knee injury and repair ([**5-18**]) Social History: Married, lives in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1475**], no tobacco, no alcohol Family History: Noncontributory Physical Exam: Temp 99.3 HR 119 BP 134/65 RR 18 Sat 99% Weight 465 Lbs, Height 6'8" General: No acute distress, alert and oriented X3 Chest: Regular rate and rhythm, breath sounds clear to auscultation bilaterally Abdomen: Obese, soft, non-tender, non-distended Perineum: L scrotal erythema, induration, and tenderness. Difficult to examine appropriately secondary to pain and obesity Lower extremeties: Warm and well-perfused Pertinent Results: [**2185-7-10**]: Pathology DIAGNOSIS: Scrotal abscess: Fragments of fibrous connective tissue with acute and chronic inflammation, and abscess formation. [**2185-7-10**] - Operative note: PREOPERATIVE DIAGNOSIS: Left thigh perineal and scrotal soft tissue infection. POSTOPERATIVE DIAGNOSIS: Left thigh perineal and scrotal soft tissue infection. PROCEDURE: Incision and drainage left thigh abscess and necrotizing fasciitis. INDICATION: Mr. [**Known lastname **] is a 52 year-old diabetic who presents with a 1 week history of worsening pain, erythema and drainage from his medial superior right thigh extending into his scrotum. This is a combined procedure with the urology team. PROCEDURE IN DETAIL: The patient was identified. Consent was confirmed. He was taken to the operating room, placed supine on the operating table and general endotracheal anesthetic was initiated by anesthesiology staff. Please note the patient received intravenous antibiotics prior to the procedure. Once adequate anesthesia was established he was placed in the lithotomy position. The perineum was shaved, prepped and draped in the usual sterile fashion. The urology team commenced with debridement of the scrotal abscess. That part of the procedure will be dictated under separate cover. Upon completion of their portion of the procedure attention was turned to the left medial thigh. A horizontal incision was made parallel to the inguinal ligament approximately 4 cm distal on the side. This was continued down to the fascia which was necrotic and contained several large abscesses. Loculations were broken up using blunt dissection. The fascia was undermined in all directions with loose undermining tissues distally onto leg. A second cut incision was made approximately 8 cm distal to the first. Again the fascia was explored and it was found to be intact at the outer reaches of this wound. The wounds were then irrigated with 6 liters of normal saline using the pulse irrigator. Necrotic fascia was debrided from all aspects of the wound. Hemostasis was achieved with electrocautery. At this point the incision were packed using Betadine soaked Kerlix, one in each incision in the leg and then a second in the scrotum. Care was taken to not torse the testes. Dry sterile dressing were applied and secured with mesh underwear. The patient was then transferred to the Intensive Care Unit bed. He was taken from the operating room to the Intensive Care Unit intubated, hemodynamically stable on propofol drip. Patient received 1800 cc of Crystalloid, made 200 cc of urine and had an estimated blood loss of 250 cc. Dr. [**Last Name (STitle) **] was present and scrubbed throughout the procedure. Sponge, instrument and needle counts were correct x2. [**2185-7-12**] Operative note PREOPERATIVE DIAGNOSIS: Necrotizing fasciitis of left upper thigh and perineum. POSTOPERATIVE DIAGNOSIS: Necrotizing fasciitis of left upper thigh and perineum. PROCEDURE PERFORMED: Re-excision, drainage and debridement of left thigh and perineal necrotizing fasciitis. FIRST ASSISTANT: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD (RES) INDICATIONS: Mr. [**Known lastname **] is a 52-year-old gentleman who presented with a week's history of worsening erythema, pain and drainage from his left thigh and perineum. He subsequently underwent incision and drainage of his left thigh and perineal wounds on [**2185-7-10**]. He presents today for re-exploration, drainage and debridement. PROCEDURE IN DETAIL: The patient was identified, consent was confirmed and he was taken to the operating room from the intensive care unit. He was transferred to the operating table. A general anesthetic was initiated by anesthesiology staff in this previously intubated patient. Once satisfactory anesthesia had been achieved, the patient was positioned in the dorsal lithotomy position. The perineum and bilateral upper thighs were prepped and draped in the usual sterile fashion. The previous packing was removed and the wounds were inspected. An area of skin on the perineum had demarcated and was excised using electrocautery and scissors. Minimal further debridement was carried out within the scrotum to remove fibrinous tissue. Attention was then turned to the left thigh wound. The previously created skin bridge between the uppermost and lowermost incisions was felt to be demarcating. This area of skin was excised to facilitate dressing changes and to remove any potential necrotic tissue. A small amount of debridement was continued at the uppermost aspect of this wound. The pulse irrigator was used to copiously irrigate both areas of the wound with approximately 6 liters of crystalloid. Hemostasis was achieved with electrocautery and suture ligatures as needed. Upon final inspection, it was felt that there was no further tissue and that hemostasis was adequate. Betadine-soaked Kerlix gauze was then packed into the 2 wounds. Dry sterile dressings were applied, and the dressings were held in place with mesh underwear. The patient was transferred back to his ICU bed and taken intubated in stable condition to the intensive care unit. INTRAVENOUS FLUIDS: He received 1 liter of crystalloid. ESTIMATED BLOOD LOSS: 10 cc. URINE OUTPUT: Not recorded. Sponge, instrument and needle counts were correct x2. Chemistry RENAL & GLUCOSE Glu BUN Cre Na K Cl HCO3 AnGap [**2185-7-31**] 09:40AM 214* 10 1.3* 137 3.8 98 32 11 [**2185-7-27**] 06:50AM 84 11 1.4* 140 4.0 101 32 11 [**2185-7-26**] 02:05PM 100 12 1.4* 138 4.0 99 32 11 [**2185-7-25**] 03:42PM 130* 10 1.4* 140 4.1 102 31 11 [**2185-7-24**] 04:00AM 168* 13 1.3* 137 4.1 101 31 9 [**2185-7-23**] 05:38PM 15 1.6* [**2185-7-23**] 07:00AM 114* 15 2.1* 137 4.3 99 30 12 [**2185-7-22**] 05:26AM 147* 11 1.1 137 4.0 98 34* 9 [**2185-7-21**] 04:10AM 105 8 0.8 138 4.0 99 33* 10 [**2185-7-20**] 04:29AM 210* 9 0.9 135 4.0 101 32 6* [**2185-7-19**] 05:07AM 91 6 0.8 137 3.7 97 34* 10 [**2185-7-18**] 06:20AM 67* 5 0.9 141 4.3 98 35* 12 [**2185-7-17**] 01:56AM 80 5 0.7 141 3.9 101 32 12 [**2185-7-16**] 02:17AM 88 8 0.6 140 3.8 102 30 12 [**2185-7-15**] 04:41AM 142* 12 0.5 138 3.8 105 27 10 [**2185-7-14**] 02:50AM 139* 15 0.6 140 3.9 107 25 12 [**2185-7-13**] 02:30AM 127* 21* 0.6 139 4.1 108 23 12 [**2185-7-12**] 03:46PM 178* 22* 0.7 140 4.1 109*21* 14 [**2185-7-12**] 03:46PM 190* 21* 0.6 140 4.1 108 22 14 [**2185-7-12**] 02:33AM 145* 25* 0.8 140 3.8 108 20* 16 [**2185-7-11**] 04:23AM 337* 27* 1.3* 134 4.8 103 Brief Hospital Course: The patient was admitted to the trauma surgery service after being transferred to [**Hospital1 18**] from [**Hospital 1474**] Hospital on [**2185-7-10**]. The patient was taken to the operating room on [**2185-7-10**] where he was diagnosed with necrotizing fascitis and underwent surgical debridement of the left medial upper thigh and scrotum. He tolerated the procedure well. Postoperatively he was admitted to the SICU where he remained intubated and sedated. The patient was taken back to the operating room for dressing changes/debridement on [**2185-7-11**] and [**2185-7-12**]. On [**2185-7-13**] he was extubated without event. Once Mr. [**Known lastname 67799**] wound was stabilized operatively, wet-to-dry dressings were initiated twice daily with close monitoring by the trauma team. Pain control, antibiotic therapy and glycemic management were provided. Nutrition was consulted and made recommendations to promote wound healing. Orthopaedic surgery was consulted in regard to right shoulder pain with history of right shoulder dislocation and osteoarthritis. Xray and MRI were recommended but patient declined. Orthopaedics felt that there was no acute process present and that Mr. [**Known lastname **] could be managed with pain medication and physical therapy. Physical and Occupational therapy were consulted to increase functional ability and increase right shoulder ROM. Increased activity was encouraged throughout his stay. [**Hospital **] Clinic was consulted for glycemic control on [**2185-7-21**]. Improved glycemic control was reached and maintained with recommendation and continued evaluation. He had one episode of decreased urine output and elevated BUN and creatinine on [**2185-7-23**]. This was managed by IV hydration which resolved without complication. Social work was consulted on [**2185-7-28**], as the patient expressed negative feelings related to his current medical condition and lack of family presence. The patient was counseled and encouraged. Trazadone was initiated by trauma service for potential sleep and antidepressant benefits. Plastic surgery and Urology were consulted to evaluate and plan for wound closure. He was transferred to the Plastic Surgery service and was physically transferred to the [**Hospital Ward Name 1827**] building on [**2185-8-4**]. He was taken to the operating room on [**2185-8-5**] where the wound was successfully closed. Mr. [**Known lastname **] did well after surgery and remained stable. He did complain of some right sided shoulder pain 3 days post-op but said it was the same pain he had chronically from shoulder arthritis. Due to his body habitus, recent surgery, and IDDM, he was ruled out for acute coronary syndrome. Two sets of cardiac enzymes and EKGs were negative for evidence of ACS. Mr. [**Known lastname **] did have extensive watery diarrhea while on the Plastic Surgery service. He had been having it for 2-3 days prior to transfer and continued to have it most days while on PRS. He was ruled out for clostridium difficile but started on Flagyl empirically. Once his stool studies came back negative, he was started on Lomotil and taken of bisacodyl and sulcrufate. Mr. [**Known lastname 67799**] wounds were maintained with dry gauze dressings with dressing changes three times a day. His scrotal penrose drain was pulled on [**8-9**] and left thigh JP fell out on [**8-11**]. His wounds became slightly more edematous [**8-10**] and both showed signs of dehiscence on [**8-11**]. His scrotal wound was reapproximated and his left high wound was packed with wet to dry dressings before his discharge. Mr. [**Known lastname **] was a challenging patient from a nursing standpoint. He frequently had anxiety and claimed to have frank anxiety attacks, when he would "pass out in his sleep...feel sweaty...heart racing," although his vital signs remained stable, he was not diaphoretic, and seemed calm at those times. He additionally ate very poorly, for lunch having an omelet, bacon, and a grilled cheese [**Location (un) 6002**], and refused to work with both physical therapy and occuptional therapy on multiple occasions. Mr. [**Known lastname **] was discharged in stable condition to an acute rehabilitation facility on [**2185-8-11**] for ambulation concerns, dietary needs, and wound healing. Medications on Admission: Insulin 70/30 50 units AM, 28 units PM Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Take until drains are removed. Disp:*30 Tablet(s)* Refills:*1* 3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): Take until drains are removed. Disp:*30 Tablet(s)* Refills:*1* 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for Pain: DO NOT DRIVE OR OPERATE HEAVY MACHINERY WHILE TAKING THIS MEDICATION. IT [**Month (only) **] MAKE YOU DROWSY. Disp:*60 Tablet(s)* Refills:*0* 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): Give until patient ambulating regularly. Disp:*1 * Refills:*2* 6. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed: for diarrhea. Disp:*30 Tablet(s)* Refills:*0* 7. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed: for breakthrough pain. Disp:*60 Tablet(s)* Refills:*0* 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 9. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Insulin Pen Sig: Fifty (50) units Subcutaneous qam. Disp:*30 units* Refills:*2* 10. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Insulin Pen Sig: Twenty Eight (28) units Subcutaneous at bedtime. Disp:*30 * Refills:*2* 11. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale units Injection before meals and at bedtime: sliding scale B. Disp:*30 * Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Fournier's Gangrene and left posterior thigh necrotizing fascitis Discharge Condition: Good Discharge Instructions: You have a scrotal wound and need to keep it clean and dry. You may sponge bath the rest of your body but try to keep your scrotum and thigh as dry as possible. The dry gauze dressings should be changed three times a day and should be applied in a large cushion around the scrotum. It would be helpful to hold the gauze in place with disposable underwear. Your left thigh dressings should be changed three times a day as wet-to-dry dressings. Take the prescribed antibiotics until that drain has been removed by a doctor. Contact [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 20912**] or go to the Emergency room for: Fever >101.5, Testicular pain, Wound that fails to heal, Severe Abdominal Pain, Nausea/Vomiting, Severe Dizziness, Loss of Consciousness You are being prescribed a narcotic pain medication. DO NOT DRIVE OR OPERATE HEAVY MACHINERY WHILE TAKING THIS MEDICATION. IT [**Month (only) **] MAKE YOU DROWSY. It is very important that you work with physical and occupational therapy during your rehabilitation to increase your ability to move. This will help decrease your pain and ultimately make you more comfortable. The more you move around, the more strength you will have, and the less pain you should feel. Followup Instructions: Follow up next friday [**8-19**] in the General Plastic Surgery Clinic. You can make an appointment at [**Telephone/Fax (1) 274**].

[ "728.86", "787.91", "608.4", "278.01", "682.6", "V58.67", "719.41", "608.83", "401.9", "998.32", "785.4", "357.2", "250.60" ]

icd9cm

[ [ [] ] ]

[ "93.57", "86.89", "38.93", "61.49", "86.22", "61.3", "83.39" ]

icd9pcs

[ [ [] ] ]

14463, 14560

8353, 12677

372, 600

14669, 14676

1672, 8330

15964, 16100

1198, 1215

12766, 14440

14581, 14648

12703, 12743

14700, 15941

1230, 1653

276, 334

628, 924

946, 1056

1072, 1182

54,929

170,779

38319

Discharge summary

report

Admission Date: [**2140-7-25**] Discharge Date: [**2140-7-31**] Date of Birth: [**2056-10-5**] Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamide Antibiotics) / Clindamycin / Ciprofloxacin Attending:[**First Name3 (LF) 1234**] Chief Complaint: 6cm AAA Major Surgical or Invasive Procedure: [**2140-7-25**] EVAR [**2140-7-31**] Exploratory laparotomy History of Present Illness: 83yoF with chronic renal insufficiency and an enlarged AAA (6cm, from 3cm in [**2136**]), presented for elective endovascular repair of the aneurysm. Past Medical History: VASCULAR HISTORY: AAA. PAST MEDICAL HISTORY: chronic renal insufficiency, PNA, AAA, severe COPD, congestive heart failure, HTN, hyperlipidemia, hypercholesterolemia, arthritis, depression PAST SURGICAL HISTORY: AV fistula Social History: SOCIAL HISTORY: Former [**Hospital1 18**] nurse, Former smoker (quit 11yr ago) Family History: FAMILY HISTORY: CVA, ulcers, cirrhosis, diabetes. Brief Hospital Course: 83F with juxtarenal AAA s/p EVAR ([**2140-7-25**]) complicated by splenic infarct, retroperitoneal hematoma, renal insufficiency, and bowel ischemia. Of note, preoperatively she had calcific aortic stenosis distally and a right common iliac calcified stenosis. Intraoperatively, the renal arteries were covered with the endovascular stent to achieve an optimal seal. Postoperatively, there was concern for mesenteric ischemia due to persistent abdominal pain, however, no BRBPR. CTA on [**2140-7-25**] demonstrated a new hyperdense left perinephric collection tracking from a hyperdense hematoma abutting the EVAR graft, approximately 1.7 cm inferior to bifurcation, concerning for a graft leak. In addition, findings demonstrated a newly occluded [**Female First Name (un) 899**] flow with early proximal reconstitution, although there were no secondary signs of bowel ischemia. Sigmoidoscopy was performed on [**2140-7-26**], which demonstrated relatively normal-appearing sigmoid mucosa. Given that the renal arteries were occluded, the patient was started on hemodialysis [**2140-7-26**], and was expected to be on permanent hemodialysis postoperatively. Throughout this time, she had persistent abdominal pain. On [**2140-7-29**], she was triggered on the floor for mental status changes as well as tachypnea/respiratory distress, and was subsequently transferred to the ICU. She was intubated and placed on pressors due to hypotension. Sigmoidoscopy was repeated on [**2140-7-30**], which demonstrated normal mucosa. Postoperatively, she had hct 25.9 - 33.0, wbc elevated to 24.3, and lactate ranged from 0.6 - 2.2. She did receive pRBC tranfusion. On [**2140-7-31**], the patient developed an increasing pressor requirement and rapid atrial fibrillation. After extensive discussion with her family, she was taken to the operating room with Dr [**Last Name (STitle) **], underwent exploratory laparotomy, and found to have patchy ischemia of the small intestine in addition to full thickness necrosis of the left / sigmoid colon. Findings were discussed with the family, and a decision was made not to resect any bowel or perform a colostomy. The patient returned to the CVICU intubated, on pressors, and was subsequently made CMO following arrival of her family. The ICU team met with the family regarding prognosis, and Dr [**Last Name (STitle) **] spoke with the family. Following these discussions, the patient was placed on a morphine drip, the pressors were discontinued, and she was extubated. She expired and was pronounced dead at 3:53pm. She stopped breathing and asystole occurred; an examination was performed to confirm death. The organ bank, admissions office, medical examiner, the ICU (Dr [**Last Name (STitle) 5856**] and vascular surgery attending (Dr [**Last Name (STitle) **] were notified. The medical examiner accepted the case. The report of death was completed and brought to the admission office. The family refused an autopsy. Medications on Admission: allopurinol, amlodipine, atacand, furosemide, lovastatin, metalazone, omeprazole, sertraline, silodosin, tylenol Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: AAA s/p EVAR complicated by splenic infarct, retroperitoneal hematoma, renal insufficiency, ischemic bowel Discharge Condition: Patient expired Discharge Instructions: Patient expired Followup Instructions: Patient expired

[ "496", "447.2", "593.81", "427.31", "585.6", "272.4", "289.59", "428.0", "997.1", "441.4", "V45.11", "518.81", "998.12", "403.91", "557.0", "444.89", "V64.41" ]

icd9cm

[ [ [] ] ]

[ "39.95", "54.11", "45.24", "96.71", "39.71", "88.47" ]

icd9pcs

[ [ [] ] ]

4159, 4168

1005, 3966

329, 391

4319, 4337

4401, 4420

946, 982

4130, 4136

4189, 4298

3992, 4107

4361, 4378

804, 817

282, 291

419, 570

637, 781

849, 914

26,500

165,235

51697

Discharge summary

report

Admission Date: [**2171-12-23**] Discharge Date: [**2171-12-28**] Date of Birth: [**2089-12-19**] Sex: F Service: MEDICINE Allergies: Demerol Attending:[**First Name3 (LF) 2078**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Left heart catheterization History of Present Illness: 82 yr old female with history of fractured hip, hypothroidism no cardiac hx who presented to [**Hospital3 1443**] ER this am with chest pain. Reports onset of pain at 7:45 AM when walking, severe crushing substernal pain. Associated nausea and bilateral arm pain. Stuttering pain, with no resolution to ED. Anterior ST elevations, which improved during ED course. Troponin 0.71, CK 155, MB 11. Heparin and nitro drip, morphine 2 mg, ASA, BB, plavix load 600 mg total, sent [**Hospital1 **] for cath. Vitals stable. Catheterization revealed small hazy LAD lesion possibly consistent with plaque rupture and question aortic dilatation. Perhaps plaque lysed or with heparin. Pt reports pressure sensation at this time, with no associated nausea, diaphoresis, or arm pain. . ROS: (+) pressure sensation on chest (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. 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: Hypothyroidism Hip fracture x 2 Social History: Lives with husband, he is ill and she reports caring for him. Children present and active in the care of parents. Denies alcohol or smoking. Primary care giver for husband with dementia. Family History: father expired from MI age 73. Physical Exam: Vitals: T: 97.5 P: 60 BP: 108/60 R: 18 SaO2: 94% RA General: Awake, alert, NAD. HEENT: NC/AT, PERRL, EOMI, no scleral icterus noted, MMM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Pulmonary: Few crackles in bases bilaterally Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, Feet cool but 2+ radial and DP pulses. Pertinent Results: [**2171-12-23**] 10:20PM WBC-5.7 RBC-3.77* HGB-12.2 HCT-35.3* MCV-94 MCH-32.4* MCHC-34.7 RDW-12.6 [**2171-12-23**] 10:20PM MAGNESIUM-2.0 [**2171-12-23**] 10:20PM CK-MB-13* MB INDX-7.4* cTropnT-0.65* [**2171-12-23**] 10:20PM CK(CPK)-176* [**2171-12-23**] 10:20PM estGFR-Using this [**2171-12-23**] 10:20PM GLUCOSE-101 UREA N-6 CREAT-0.5 SODIUM-142 POTASSIUM-3.6 CHLORIDE-110* TOTAL CO2-22 ANION GAP-14 . [**12-23**] Sinus rhythm, Low QRS voltages in limb leads. ST segment elevation in lead V2 with T wave inversion in leads V1-V2, flat T waves in leads V3-V4 . Cardiac cath [**12-23**] 1. Selective coronary angiography revealed a right dominant system with patent LMCA. LAD had a proximal 20-30% non-hemodynamically significant lesion and was otherwise free of angiographically apparent disease. LCX was small. The RCA had no angiographically apparent disease. 2. Left ventriculography showed EF of 40-45% with hypokinetic anterior wall and hyperdynamic base. 3. Limited hemodynamic assessment showed normal systemic pressures and mildy elevated LVEDP. 4. Ascending aorta was dilated. There was no evidence of dissection. FINAL DIAGNOSIS: 1. Coronary arteries are normal. 2. Moderate systolic and diastolic ventricular dysfunction. . CTA CHEST W&W/O C&RECONS, NON-; CTA ABD W&W/O C & RECONS [**12-24**] CTA: There is aneurysmal dilatation of the ascending aorta, which measures 4.2 cm in diameter at the level of the pulmonary vein confluence (series 4, image 31). The aortic arch and descending thoracic aorta are of normal caliber. There is an aberrant right subclavian artery arising from a diverticulum of Kommerell off the aortic arch. There is caliber narrowing at the origin of the celiac with post- stenotic dilatation noted. The superior mesenteric, both renal arteries, and inferior mesenteric arteries are patent. The common iliac, external and internal iliac, and both femoral arteries are patent. No abdominal aortic aneurysm is identified. There are no filling defects in the pulmonary arterial vasculature. No pulmonary embolism is identified. . [**12-24**] CT CHEST WITH CONTRAST: Calcified nodule with associated linear atelectasis is seen on series 4, image 37 in the right lower lobe measuring approximately 6 mm in diameter. There is biapical scarring noted. Small opacity is seen in the lingula which could reflect atelectasis. There is a small amount of bibasilar atelectasis present. No lung masses are present. No pericardial or pleural effusion is present. The airways are patent to the level of the segmental bronchi bilaterally. Small fat-containing axillary lymph nodes are present bilaterally. No enlarged mediastinal or hilar nodes are present. . [**12-24**] CT ABDOMEN: There are multiple nonobstructing stones within the collecting systems of both kidneys. In the left upper pole, there is a 3.5-mm stone. In the left mid pole, there is a 2-mm nonobstructing stone. There is an additional 5- mm nonobstructing stone in the mid pole of the left kidney. In the left lower pole, there is a 4-mm nonobstructing stone. In the upper pole of the right kidney, there is a 5.5-mm nonobstructing stone, and in the interpolar region of the right kidney, there is a 3-mm nonobstructing stone present. There is a simple cyst in the interpolar region of the right kidney measuring 13 mm in diameter. The adrenal glands, spleen, pancreas, are normal in appearance. The caliber of the loops of small and large bowel is normal in appearance. Patient is status post cholecystectomy. There are numerous low attenuation lesions throughout both lobes of the liver, the largest of these is in the left lobe measuring approximately 3.9 x 2.7 cm and is a simple cyst. Lesions smaller than 5 mm are too small to characterize. Near the dome of the liver, there is a 5-mm area of low attenuation that is incompletely characterized on this study due to size (series 2, image 50), of relative low attenuation. There is no ascites. . [**12-24**] CT PELVIS: There is diverticulosis of the sigmoid colon without diverticulitis. There is a Foley catheter in the bladder. Patient has a prosthetic right hip screw fixation device which creates significant artifact in this region. There are phleboliths seen in the pelvis. There is no free fluid in the pelvis. No enlarged inguinal or pelvic lymph nodes are seen. There is ectasia of the abdominal aorta. BONE WINDOWS: No suspicious lytic or blastic lesion. Degenerative changes are seen at L1-2 and L5-S1 consistent with disc space narrowing. Lucent lesions are seen in the iliac bones bilaterally adjacent to the sacroiliac joint, likely related to cystic degenrative change. . Conclusions: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). There is mild regional left ventricular systolic dysfunction with focal hypokinesis of the mid to distal anterior septum and anterior wall. The remaining segments contract well. 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 valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Mild (1+) 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 an anterior space which most likely represents a fat pad. IMPRESSION: Regional left ventricular dysfunction consistent with single vessel coronary artery disease. Mild aortic regurgitation. Moderately dilated aortic root and ascending aorta. . CHEST (PA & LAT) [**2171-12-27**] 3:37 PM CHEST PA AND LATERAL: The heart size, mediastinal and hilar contours are unremarkable. The lungs are clear. There are no pleural effusions. The pulmonary vasculature is normal. Small hiatal hernia is present. Aorta is tortuous. Mild left apical pleural thickening noted. Brief Hospital Course: 82 yr old female with no known CAD, good functional capacity with hx of chest pain x 10 yrs, presenting with severe chest pain, elevated enzymes, with cardiomyopathy. Chest pain: At the OSH ED, she was found to have an EKG with ST elevations in the anterior leads. Her troponin was positive: Troponin 0.71, CK 155, MB 11. She was started on Heparin and nitro drips, and given morphine 2 mg, ASA, BB, plavix load 600 mg total. She was transferred to [**Hospital1 18**] with stable vitals. At cath [**12-23**], she was found to have normal coronary arteries but apical ballooning consistent with possible [**Last Name (un) **]-Tsubo's cardiomyopathy. Aortic aneurysmal dilatation, followed up by CTA no evidence of dissection, worsening diameter. On the first day after cath, she again complained of substernal chest pain which was not associated with exertion. She was started on a nitro gtt on the floor, causing her SBP to fall to 70. She had ST elevations on EKG but decision was made not to cath her, given previous cath with clean coronaries. Cath reviewed, no missed lesion. She was transferred to the CCU for management of her hypotension related to nitro. In the CCU, she received nitro boluses for pain control, taken off nitro given chest pain free. Her BP improved, in the high 90s. chest pain free 2 days prior to admission, but decreased to 80's systolic day prior to admission. Patient had been started on Isosorbide and captopril in the CCU. Meds DC'd and patient was hydrated with return of BP to baseline systolic 90's. Considered chest pain and resultant ST elevations in anterior and precordial leads, elevated enzymes, but clean cath, all due to stress induced cardiomyopathy stress. No evidence of precipitating URI, or major stressor change, though patient does report increased stress related to ailing husband as she is the primary care giver. Pt discharged on low dose ACE, SL nitro and ASA, to follow up with primary care physician [**Name Initial (PRE) 7891**]. . Cystitis: Day prior to discharge patient had temp to 101.1. Complaining of dysuria and incontinence. UA + for UTI. Discharged on Cipro x 3 days. Foley had been placed for procedures likely instigator. Cultures pending, Blood and urine. CXR with no evidence if infiltrate. To follow up with PCP [**Name9 (PRE) **] [**Name9 (PRE) **] Cx Urine Cx Medications on Admission: Synthroid 100 mcg Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 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. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain: every 5 minutes not more than 2 times, if still not pain free, call 911. Disp:*30 Tablet, Sublingual(s)* Refills:*0* 9. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*0* 10. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO twice a day for 3 days. Disp:*6 Tablet(s)* Refills:*0* 11. Amlodipine 5 mg Tablet Sig: 0.5 Tablet PO QAM (once a day (in the morning)). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary: ?Takotsubo's cardiomyopathy hypotension . Secondary: Hypothyroidism Discharge Condition: Stable, chest pain free Discharge Instructions: You were admitted with chest pain and elevated enzymes. You underwent a cardiac catheterization which demonstrated clean coronaries. You had a second episode of chest pain with a drop in blood pressure from nitrates and were observed in the cardiac care unit. You are stable and chest pain free now, with a diagnosis of likely stress induced cardiomyopathy which should resolve within one to 4 weeks. You also developed a urinary tract infection and were given antibiotics. Please take all medications as prescribed to you. Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Name (STitle) 1968**] in [**Location (un) 1468**]. You should be on an ACE I, as your blood pressure allows, please follow up with your PCP. [**Name10 (NameIs) 357**] return to the hospital if you are experiencing severe chest pain. shortness of breath, fainting, or any other symptoms concerning to you. Followup Instructions: Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Name (STitle) 1968**] in the upcoming week. Please call to make an appointment, if on vacation, please make appoitment with coverage. Please call ([**Telephone/Fax (1) 19380**] to schedule an Echocardiogram for [**12-3**] weeks before your cardiology appointment. You need to follow-up with a Cardiologist. Please call [**Telephone/Fax (1) 6197**] on Monday to make an appointment after your ECHO.

[ "599.0", "E942.4", "429.83", "458.29", "441.2", "996.64", "244.9" ]

icd9cm

[ [ [] ] ]

[ "88.55", "88.53", "37.22" ]

icd9pcs

[ [ [] ] ]

12016, 12074

8332, 10671

283, 312

12194, 12220

2280, 3415

13209, 13724

1760, 1793

10739, 11993

12095, 12173

10697, 10716

3432, 8309

12244, 13186

1808, 2261

232, 245

340, 1484

1506, 1540

1556, 1744

32,453

141,149

32353

Discharge summary

report

Admission Date: [**2134-10-17**] Discharge Date: [**2134-10-21**] Date of Birth: [**2089-3-19**] Sex: M Service: MEDICINE Allergies: Morphine / Codeine / Ciprofloxacin Attending:[**First Name3 (LF) 633**] Chief Complaint: Inebriated, [**First Name3 (LF) 1676**] pain, hematemesis. Major Surgical or Invasive Procedure: [**2134-10-19**]: Endoscopy with three grade 3 varices which were successfully band ligated. History of Present Illness: Mr. [**Known lastname 53917**] is a 45 y/o M with h/o Etoh cirrhosis c/b esophageal varices s/p 3 bands on [**2134-9-22**] presents with a variety of complaints including [**Date Range 1676**] pain x2.5days consistent with his chronic pancreatitis, hematemesis, and hard brown stool with streaks of bright red blood. Patient recently left AMA after episodes of hematemesis on [**2134-10-10**]. Patient states since discharge he has continued to have epigastric pain, and today had a couple episodes of bloody emesis (food, brown fluid and clumps of bright red blood). States this comes after a week of nausea and dry heaving/wretching, related to social stressors in his life right now. He also has noted small hard brown pellet-like stools streaked with blood recently. He denies any recent fevers or chills, lightheadness, melena, chest pain, shortness of breath, changes in his urinary habits. No recent NSAIDS (>2yrs). In the ED, VS: 98.8 96 117/79 16 97% ra. Labs significant for Hct 31.4 (above baseline), WBC 2.7 (baseline), plt 90, Chem7 unremarkable with the exception of a glucose of 143, lactate 2.7, AST 113, ALT 23, AP 329, lipase 38, Tbili 0.8, Alb 3.7. Serum ETOH 170, Serum benzos positive. Serum ASA, Acetmnphn, Barb, Tricyc negative. Patient was given dilaudid 1mg IV x3, zofran 2mg IVx2, ceftriazone 1g, octreotide ggt, and pantoprazole ggt. He was additionally given 1L IVF. Blood cultures sent, patient was typed and crossed. NGT was placed and food with scant blood was suctioned out. Prior to transfer, VS: 97.9 86 117/71 18 95%RA. In the MICU, patient states he is having throbbing [**Date Range 1676**] pain radiating through to his spine, which is the primary reason for his coming to the ED. States his last drink was today (2 [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5261**]). Past Medical History: EtoH cirrhosis Esophageal Varices - Grade II and s/p banding procedures - s/p multiple variceal bleeds, 6 episodes from [**2128**] to [**11-27**] s/p multiple bandings - [**11-30**] EGD: 1 cord of grade 2 varices, 2 cords of grade 1 varices were seen in the lower third of the esophagus; changes consistent with Barrett's Chronic pancreatitis EtOH abuse Bipolar disorder S/p CCY in [**5-29**] S/p Right ACL replacement and meniscectomy in [**2126**] Social History: Drinks 1-1.5 pints of whiskey per day. Denies ever smoking, denies ilicits. Lives in an apt in [**Location (un) 86**] with roommates, does not have a close relationship with his family Family History: h/o alcoholism and kidney cancer. Physical Exam: Admission Exam: Vitals: T: 98.4, BP: 120/85, P: 76, R: 12, O2: 95% RA General: Alert, oriented, no acute distress, seemingly intoxicated HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL but sluggish 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, rhonchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly. Winced with pain prior to my touching his abdomen, so pain was hard to judge Ext: warm, well perfused, 2+ pulses in DP b/l, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, gait deferred, no tremor or asterixis. Discharge Physical Exam: T 98.7, HR 61, BP 115/78, RR 13, Sat 96%RA Exam otherwise unremarkable. Moist mucous membrane. Abdomen mildy tender at epigastrium but non-tender with pressing the stethoscope. Pertinent Results: Admission Labs: [**2134-10-17**] 07:20PM BLOOD WBC-2.7* RBC-3.76* Hgb-10.0* Hct-31.4* MCV-84 MCH-26.7* MCHC-32.0 RDW-16.7* Plt Ct-90* [**2134-10-17**] 07:20PM BLOOD Neuts-69.0 Lymphs-21.0 Monos-5.6 Eos-3.7 Baso-0.6 [**2134-10-17**] 07:20PM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-2+ Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-2+ Tear Dr[**Last Name (STitle) **]1+ Bite-1+ [**2134-10-17**] 09:29PM BLOOD PT-16.8* PTT-37.2* INR(PT)-1.5* [**2134-10-17**] 07:20PM BLOOD Glucose-143* UreaN-7 Creat-0.6 Na-144 K-3.4 Cl-107 HCO3-24 AnGap-16 [**2134-10-17**] 07:20PM BLOOD ALT-23 AST-113* AlkPhos-329* TotBili-0.8 [**2134-10-17**] 07:20PM BLOOD Lipase-38 [**2134-10-17**] 07:20PM BLOOD Albumin-3.7 [**2134-10-17**] 07:20PM BLOOD ASA-NEG Ethanol-170* Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [**2134-10-17**] 07:25PM BLOOD Lactate-2.7* Discharge Labs: [**2134-10-20**] 06:55AM BLOOD WBC-2.1* RBC-3.81* Hgb-10.4* Hct-31.6* MCV-83 MCH-27.4 MCHC-33.0 RDW-16.8* Plt Ct-71* [**2134-10-20**] 06:55AM BLOOD Glucose-110* UreaN-6 Creat-0.6 Na-140 K-4.2 Cl-105 HCO3-26 AnGap-13 [**2134-10-18**] 05:27AM BLOOD ALT-21 AST-100* LD(LDH)-220 AlkPhos-303* TotBili-1.1 [**2134-10-20**] 06:55AM BLOOD Calcium-7.9* Phos-3.6 Mg-1.9 Micro: [**10-17**] blood culture pending. MRSA screen [**10-18**]: negative. [**2134-10-18**] CXR In comparison with the study of [**9-22**], the endotracheal tube has been removed. Nasogastric tube is coiled in the upper stomach. Minimal atelectatic changes at the left base, but no evidence of vascular congestion or acute focal pneumonia. . [**2134-10-18**] DUPLEX DOPP ABD/PEL 1. Coarse and nodular liver echotexture consistent with cirrhosis. No discrete liver mass is identified, although nodularity limits visualization of possible small lesions. 2. Patent hepatic vasculature with appropriate direction of flow. 3. Splenomegaly, increased compared to most recent prior imaging. Trace of ascites. EGD: Findings: Esophagus: Protruding Lesions 4 cords of grade II-III varices were seen. 3 cords of grade 3 varices and one additional cord of a grade 2 varix were seen. One grade 3 varix had a cherry red spot signifying recent bleed. The three cords of grade 3 varices were successfully band ligated. The fourth grade 2 varix disappeared after the first three were band ligated. Other [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] tear was seen. Barrett's esophagus and esophagitis were seen. Stomach: Contents: Food was found in the stomach Other Antral erosions were seen. Portal gastropathy was seen. Duodenum: Normal duodenum. Impression: Esophageal varices [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] tear was seen. Antral erosions were seen. Barrett's esophagus and esophagitis were seen. Food in the stomach Portal gastropathy was seen. Otherwise normal EGD to third part of the duodenum Recommendations: [**Hospital1 **] PPI, Carafate slurry x 14 days Repeat EGD in [**2-21**] weeks (see discharge paperwork and appointments please). Brief Hospital Course: 45 y/o M with h/o Etoh cirrhosis c/b esophageal varices s/p 3 bands on [**2134-9-22**] presents with a variety of complaints including [**Date Range 1676**] pain, hematemesis, and brown stool with streaks of bright red blood. H/H remained stable throughout the stay. Had 3 varices banded upon repeat EGD on this admission. Will require outpatient follow up with repeat EGD. He was well known to the Social work team at [**Hospital1 **], who felt strongly that he warranted a section 35 for inpatient alcohol abuse treatment. This was granted by the court, and he was discharged to [**Hospital3 75584**] for mandatory treatment. . # Possible upper GIB: Concern was for variceal bleed, especially as patient is s/p variceal banding, however with history of a week of wretching and dry heaving could also be [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 329**] [**Doctor Last Name **] tear. No recent NSAIDS, but would consider PUD as well. Hct elevated from baseline, likely [**1-21**] dehydration, not tachycardic. NGT did not bring up more than food and scant blood. Overnight patient was maintained on an octreotide and pantoprazole ggt in the ICU for monitoring purpose, given ceftriaxone 1g in ED for SBP prophylaxis. Type and screen and 2 PIVs were maintained, NGT was removed, patient was given 3 liters of IVFs, prior to transfer out of the ICU. Hepatology was consulted and recommended discontinuing the ggts as they had low suspicion for the validity of the patient's history. - Had EGD on this admission during which three cords of grade 3 varices were successfully band ligated. His H/H remained stable throughout his stay in the hospital on this admission. IV ceftriaxone was continued for SBP prophylaxis which was eventually switched to bactrim (given hives on cipro per patient) and completed 5 days of antibiotics on [**2134-10-21**]. - In addition, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear, Barrett's esophagus, and esophagitis was seen on the EGD. He should continue pantoprazole and sucralfate slurry for at least two weeks. . -PT WILL NEED A REPEAT EGD IN [**2-21**] WEEK'S TIME. . # [**Date Range **] Pain: Patient stated his abd pain was consistent with chronic pancreatitis, however his exam was reassuring and patient was not tachycardic or hypertensive. He was managed with 1mg IV dilaudid Q6h prn in IVFs in the ICU. Pancreatic enzymes were initially held given NPO status and patient was fluid resuscitated. Pancrealipase was restarted when patient began tolerating regular diet. Dilaudid was not given on the medical floor given concern of prior history, as well as previous hypoxia. . # Lactate/hemoconcentration: Appeared hypovolemic on admission, though hemodynamically stable. With adequate fluid resuscitation, UOP increased, lactate trended down to normal, and hct fell to within baseline. . # Hypoxia: Patient was down to 89% on RA shortly after coming to the floor which is a clear change from admission in ED when he was 97% on RA. Risk for aspiration, could also be atelectesis [**1-21**] with opioid administration. No known history of CHF, no rales, JVD or edema on exam. CXR showed minimal atelectasis. Opioids were minimized and discontinued, and O2 supplementation was weaned as tolerated and remained on room air. . # ETOH Cirrhosis: MELD 11. History and LFTs suggestive of active drinking. Patient presented with ethanol level of 170. Nadolol and lactulose were held given NPO status in MICU. Nadolol restarted on floor, lactulose held given normal mental status. RUQ US was obtained which showed continued cirrhosis. . # ETOH abuse: Per his prior PCP (who was contact[**Name (NI) **]), he does have a history of overdose with opiates and alcohol roughly one year ago. Last drink was on the day of admission, Etoh level 170. Patient was managed on a CIWA scale and given IV thiamine, folate, MV. CIWA was discontinued however as patient was getting ativan without actually [**Doctor Last Name **] on the scale. Social work, who knows him very well, was consulted and strongly recommended section 35 due to patient's inability to seek help once discharged, 50+ ED visits and 39 MICU admissions recently. Psychiatry evaluated him and noted that patient will be discharged into a very-anxiety provoking environment (his mother passed away 4 days prior to admission). Section 35 was granted, and he was discharged to [**Hospital6 **] for mandatory alcohol abuse treatment. . # Psychiatric: Held 'home' meds while NPO in ICU. (Seroquel 200 mg Qhs, trazodone 100 mg Tab 2 QHs, Ambien 10 mg Qhs, Ativan 1 mg TID prn, gabapentin 600 mg TID). Patient has not seen his PCP in many months. Many psychiatric medications were provided as short courses, and patient has not followed up with any PCP after multiple hospital discharges. He was evaluated by Psychiatry, and per their recommendations, he was continued on low-dose ativan q4hours per CIWA scale, trazodone and ambien were stopped. He was also started on mirtazapine for insomnia and depression. . # Pancytopenia: Stable, likely due to chronic ETOH abuse. . Transitional Issues: - Studies pending at discharge: [**10-17**] blood culture. - MICU team reported that the patient's self-reported history on admission was questionable. Per them, "he has poor insight into his health issues, but often knows what to say to get admitted, get pain medications, and score on a CIWA." - He needs follow-up with community-based therapy as an outpatient for (1) Grief surrounding his recent losses (2) Alcohol dependence. - Please use caution when attempting med reconciliation as he has not had PCP [**Name9 (PRE) 702**] in many months. His prior PCP is aware and very helpful (Dr. [**First Name4 (NamePattern1) 6382**] [**Last Name (NamePattern1) **] [**Doctor First Name 1557**]). - Repeat EGD in [**2-21**] weeks per GI and per discharge appointments. - Carafate for 14 days (another 12 days post discharge) Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Pancrelipase 5000 1 CAP PO TID W/MEALS 2. Multivitamins 1 TAB PO DAILY 3. traZODONE 100 mg PO HS:PRN insomnia 4. Zolpidem Tartrate 10 mg PO HS 5. Lorazepam 1 mg PO Q8H:PRN anxiety 6. Gabapentin 600 mg PO TID 7. Lactulose 15 mL PO TID w/ meals 8. Omeprazole 20 mg PO DAILY 9. Ferrous Sulfate 325 mg PO DAILY 10. Nadolol 10 mg PO DAILY 11. Thiamine 100 mg PO DAILY 12. FoLIC Acid 1 mg PO DAILY Discharge Medications: 1. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg one tablet(s) by mouth twice per day Disp #*28 Tablet Refills:*0 2. Sucralfate 1 gm PO QID RX *sucralfate 1 gram/10 mL one gram (10mL) Suspension(s) by mouth four times per day Disp #*1 Vial Refills:*0 3. Ferrous Sulfate 325 mg PO DAILY 4. Lactulose 15 mL PO TID w/ meals 5. FoLIC Acid 1 mg PO DAILY 6. Gabapentin 600 mg PO TID 7. Lorazepam 1 mg PO Q8H:PRN anxiety 8. Multivitamins 1 TAB PO DAILY 9. Nadolol 10 mg PO DAILY 10. Pancrelipase 5000 1 CAP PO TID W/MEALS 11. Thiamine 100 mg PO DAILY 12. Mirtazapine 15 mg PO HS RX *mirtazapine 15 mg one tablet(s) by mouth each night Disp #*14 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: [**Hospital6 **] Discharge Diagnosis: Primary: Esophageal varices s/p banding on this admission [**Doctor First Name **]-[**Doctor Last Name **] tears Barrett's esophagus Portal gastropathy Esophagitis Secondary: Alcoholic cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 53917**], You were admitted to [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) 1676**] pain, blood-streaked vomit, and constipation with streaks of blood. You were initially admitted to the ICU, where you were stable enough to be transferred to the floor. You underwent an endoscopy, which showed inflammation, varices, and tears in the mucosal lining of your esophagus. You also had 3 of these varices banded. As a result you were started on medications to protect your stomach lining. As evidenced on your endoscopy, there is a great deal of damage to your stomach lining. In addition, you reported a history of chronic pancreatitis. Stopping your intake of alcohol should improve both the pain associated with these conditions, as well as the status of your stomach lining. While you were here, some changes were made to your medications. Please START sucralfate for another 12 days after discharge (total of 2 weeks) Please CHANGE your omeprazole to pantoprazole. Please follow up with your new PCP and with the liver team. You also have repeat endoscopy as illustrated below. Followup Instructions: Department: [**Hospital3 249**] When: TUESDAY [**2134-10-26**] at 12:40 PM With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor in follow up Department: DIGESTIVE DISEASE CENTER When: TUESDAY [**2134-11-16**] at 8:30 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**] Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**] Campus: EAST Best Parking: Main Garage Department: LIVER CENTER When: WEDNESDAY [**2134-11-24**] at 2:00 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: [**Hospital3 249**] When: TUESDAY [**2134-10-26**] at 12:40 PM With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ENDO SUITES - FOR ENDOSCOPY When: TUESDAY [**2134-11-16**] at 8:30 AM

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icd9cm

[ [ [] ] ]

[ "42.33" ]

icd9pcs

[ [ [] ] ]

14267, 14310

7113, 12207

355, 450

14549, 14549

4019, 4019

15854, 17493

3003, 3038

13582, 14244

14331, 14528

13076, 13559

14700, 15831

4871, 7090

3053, 3797

12260, 13050

12228, 12246

257, 317

479, 2308

4035, 4855

14564, 14676

2330, 2782

2798, 2987

3822, 4000

24,675

107,059

15530

Discharge summary

report

Admission Date: [**2130-12-23**] Discharge Date: [**2130-12-30**] Date of Birth: [**2075-4-19**] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: This is a 55-year-old man admitted to the Coronary Care Unit after four left anterior descending artery stents were placed for an acute anterolateral ST-elevation myocardial infarction. The patient has a history of hypertension and a family history of coronary artery disease. No known history of personal coronary artery disease, hypercholesterolemia, or diabetes mellitus. He was washing his bus today when he noted the onset of severe left-sided chest pain (like "knives"), diaphoresis, and nausea. He was taken by Emergency Medical Service to [**Hospital3 417**] Hospital in [**Location (un) **] where an acute anterolateral myocardial infarction was noted on the electrocardiogram. He received aspirin, nitroglycerin, heparin, and was transferred to [**Hospital1 188**] for percutaneous coronary intervention. In the Catheterization Laboratory, the patient had an Angio-Jet of a complete mid left anterior descending artery lesion and four stents placed. He was briefly hypotensive during the procedure and was given dopamine until an intra-aortic balloon pump was placed. He was transferred to the Coronary Care Unit stable off of dopamine. PAST MEDICAL HISTORY: 1. Hypertension. 2. Multiple sclerosis (Symptoms include dysarthria and left leg weakness worse with exertion. The patient has just completed a 6-month regimen of chemotherapy and steroids; alternating months). 3. Possible nephrotic syndrome (lower extremity edema, protein in urine). MEDICATIONS ON ADMISSION: Medications at home included lisinopril b.i.d., tizanidine, Lasix 20 mg p.o. b.i.d., albuterol, and famotidine. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He lives in [**Location **] with his wife and four children. He drives a [**Hospital1 **] bus. He has no history of smoking or alcohol use. FAMILY HISTORY: Family history positive for coronary artery disease; his sister was deceased at the age of 58, status post coronary artery bypass graft times three. His mother had coronary artery disease. PHYSICAL EXAMINATION ON PRESENTATION: Examination upon admission revealed vital signs were stable and unremarkable. He had no carotid bruits. His lungs were clear to auscultation bilaterally. His heart was regular in rate and rhythm with soft heart sounds. His abdomen was benign. His right groin catheter site was soft and without hematomas or bruits. He had dorsalis pedis pulses present bilaterally. His neurologic examination revealed alert and mentating well with dysarthria. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on admission revealed white blood cell count was 14.6, hematocrit was 37, platelets were 263. INR was 1.3, PTT was 98.2. Sodium was 139, potassium was 4, chloride was 103, bicarbonate was 22, blood urea nitrogen was 25, creatinine was 0.8, and blood glucose was 133. Calcium was 9.6. His first creatine kinase was 300. His blood gas was 7.41/38/302. RADIOLOGY/IMAGING: Electrocardiogram prior to catheterization demonstrated a sinus rhythm at the rate of 88, normal axis and normal intervals. ST elevations in I, aVL, V2 through V5. ST depressions in III and aVF. Catheterization results with pressures which revealed right atrial pressure mean of 9 mmHg, pulmonary artery was 42/21, right ventricular was 50/5. Arteries revealed left anterior descending artery with diffuse 30% proximal lesion, 100% mid lesion, 90% origin first diagonal lesion. The left circumflex with diffuse 30% ostial/proximal 40% mid, 70% left posterior descending artery. The right coronary artery with mild luminal irregularities. HOSPITAL COURSE BY SYSTEM: 1. CARDIOVASCULAR SYSTEM: (a) Coronaries: As above, the patient had 2-vessel coronary artery disease and had four stents placed in his left anterior descending artery. He was enrolled in the Cool-MI trial. The patient was treated with aspirin, Plavix, Lipitor, captopril, and metoprolol status post myocardial infarction. His peak creatine kinase was 7436 with a MB fraction of 830. The creatine kinases after this trended downward. After his intervention, the patient did not have any evidence of ischemia by symptoms or by electrocardiogram. (b) Pump: The patient was maintained on an intra-aortic balloon pump for one day following his percutaneous coronary intervention. The balloon pump was weaned without event. He had an echocardiogram on day three status post myocardial infarction which revealed an left ventricular ejection fraction of 25% to 30%, with severe regional left ventricular systolic dysfunction; comprising septal, anterior, and apical akinesis. The patient was placed on heparin for this akinesis; which was converted to warfarin prior to discharge. (c) Rhythm: The patient had multiple runs of nonsustained ventricular tachycardia after his myocardial infarction. The longest run consisted of 15 beats to 20 beats and occurred within 48 hours of his infarction. He had several shorter runs of 5 beats to 10 beats occurring more than two days status post myocardial infarction. The Electrophysiology Service was consulted regarding implantable cardioverter-defibrillator placement. They elected to see the patient in one month when his course of Plavix was completed and he was at less of a risk of bleeding. He was to have a T wave alternans study at this time and follow up with Dr. [**Last Name (STitle) 284**] of the Electrophysiology Service. 2. PULMONARY SYSTEM: The patient oxygenated well throughout his admission and did not have pulmonary problems. 3. RENAL SYSTEM: The patient's creatinine remained stable at a level under 1 throughout his admission. 4. HEMATOLOGY: The patient had a drop in his hematocrit from 37 to 31.4 after his catheterization. His hematocrit remained stable around 30 to 31 after that initial drop, and he did not receive any blood transfusions. 5. ENDOCRINE SYSTEM: The patient was noted to have multiple fasting blood sugars of greater than 126 during this admission. He had a hemoglobin A1c that was in the upper limits of normal range. He was to follow up with his primary care physician for further diagnosis and management of possible type 2 diabetes mellitus. DISCHARGE DIAGNOSES: 1. Acute ST-elevation myocardial infarction. 2. Status post left anterior descending artery stents. CONDITION AT DISCHARGE: Condition on discharge was fair. MEDICATIONS ON DISCHARGE: 1. Coumadin 5 mg p.o. q.h.s. 2. Lisinopril 10 mg p.o. q.d. 3. Metoprolol-XL 150 mg p.o. q.d. 4. Aspirin 325 mg p.o. q.d. 5. Lipitor 10 mg p.o. q.d. 6. Plavix 75 mg p.o. q.d. (times one month). 7. Protonix 40 mg p.o. q.d. 8. Lasix 40 mg p.o. b.i.d. DISCHARGE STATUS: Discharge status was to home. DISCHARGE FOLLOWUP: 1. The patient was to follow up with the Cardiology Clinic at [**Hospital1 69**] in one to two weeks. 2. The patient was to follow up with Electrophysiology in three to four weeks. 3. The patient was to follow up with primary care physician in one to two weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15176**], M.D. [**MD Number(1) 15177**] Dictated By:[**Last Name (NamePattern1) 5596**] MEDQUIST36 D: [**2131-1-4**] 09:00 T: [**2131-1-5**] 11:42 JOB#: [**Job Number 28155**]

[ "410.11", "790.01", "340", "414.01", "458.2", "401.9", "427.89", "428.0", "V70.7" ]

icd9cm

[ [ [] ] ]

[ "99.20", "37.61", "36.01", "39.64", "88.56", "37.23", "97.44", "36.06" ]

icd9pcs

[ [ [] ] ]

1986, 3745

6355, 6468

6543, 6850

1658, 1809

3773, 6334

6483, 6517

6870, 7414

163, 1319

1341, 1631

1826, 1969

65,741

173,092

39159+58265

Discharge summary

report+addendum

Admission Date: [**2122-3-16**] Discharge Date: [**2122-3-27**] Date of Birth: [**2051-8-4**] Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 922**] Chief Complaint: chest pressure Major Surgical or Invasive Procedure: coronary artery bypass grafts x3(Lima->LAD,SVG->OM/SVG->PDA)Ao-biSC BPG/Reimplant L)vert art History of Present Illness: This 70 year old white female has a long history of coronary artery disease, having an infarction at age 36. At age 60 another infarction occurred and 4 stents were deployed. Recurrent chest pressure began last week and she went to to ED. Again several days later she went to the ED with this complaint and infarction was ruled out. Catheterization [**3-16**] revealed triple vessel disease and she was transferred for surgical revascularization. There was a question of aortic occlusive disease at catheterization, although there was no difficulty to access the right femoral artery or closing it with a device. Past Medical History: h/o gastointestinal bleed s/p coronary angioplasty and stents claudication/peripheral vascular disease coronary artery disease myocardial infarction x 2 hypertension hyperlipidemia brady arrhythmia s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] chamber permanent pacemaker depression esophageal spasm chronic obstructive pulmonary disease gastroesophageal reflux disease anxiety Social History: Last Dental Exam:6 months Lives with:alone Occupation: factory worker Tobacco: [**1-3**] ppd ETOH: social Family History: mom died 77 brain cancer, dad died 60 heart disease, 2 brothers with h/o MI Physical Exam: admission: Pulse:80 Resp: 16 O2 sat: B/P Right: 134/76 Left: 134/76 Height: 60" Weight: 77.1 kg General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur n Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] ADB bruit Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right:2 Left:2 DP Right: 0 Left:0 PT [**Name (NI) 167**]:0 Left:0 Radial Right: 0 Left:0 Carotid Bruit Right:n Left:n Pertinent Results: Pre-op: [**2122-3-16**] 06:50PM GLUCOSE-108* UREA N-25* CREAT-0.9 SODIUM-141 POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-30 ANION GAP-12 [**2122-3-16**] 06:50PM ALT(SGPT)-26 AST(SGOT)-27 LD(LDH)-155 ALK PHOS-78 TOT BILI-0.3 ALBUMIN-3.8 MAGNESIUM-2.0 [**2122-3-16**] 06:50PM %HbA1c-6.3* eAG-134* [**2122-3-16**] 06:50PM WBC-11.6* RBC-3.83* HGB-11.5* HCT-34.4* MCV-90 MCH-30.0 MCHC-33.4 RDW-14.2 [**2122-3-16**] 06:50PM PLT COUNT-280 [**2122-3-16**] 06:50PM PT-11.1 PTT-19.9* INR(PT)-0.9 [**2122-3-17**] Carotid Ultrasound Impression: Right ICA stenosis 70-79%. Left ICA stenosis 40-59%. [**2122-3-17**] CTA 1. Aberrant right subclavian artery, with an abnormal configuration of the aortic arch as described above. There is significant atherosclerotic disease involving the right subclavian artery, with a thrombosed and slightly enlarged proximal portion, which may represent a thrombosed aneurysm/pseudoaneurysm, measuring 1.5cm, with mass effect on the esophagus. Rec. Vascular/INR consult for dx angiogram for better assessment. 2. Atherosclerotic disease involving the carotid bifurcations bilaterally, with approximately 50% stenosis on the right and 25% stenosis on the left by NACET criteria. 3. Unremarkable CTA of the head. 4. Small focal area of hypodensity in the inferior left occipital lobe may represent an area of old encephalomalacia. There are no findings to suggest an acute infarct. Other details as above. 5. Multilevel DJD changes are noted in the cervical spine, inadequately assessed. A few sclerotic lesions noted which are indeterminate. Consider clinical correlation and if necessary radionuclide study as the pt. cannot have MRI due to pacemaker. Radiology Report CHEST (PORTABLE AP) Study Date of [**2122-3-25**] 9:45 AM Final Report INDICATION: 70-year-old female with chest tube removal. CHEST, AP: A left pleural drain has been removed, with no residual pneumothorax or effusion. The lungs are clear. A left chest wall pacemaker has leads overlying the right atrium and ventricle. Median sternotomy wires and mediastinal clips from prior CABG. Mild cardiomegaly is unchanged. The mediastinal and hilar contours are normal. IMPRESSION: Left chest tube removal, without complications. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 10307**] HO DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**] Approved: WED [**2122-3-25**] 9:13 PM [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *4.3 cm <= 4.0 cm Left Atrium - Four Chamber Length: 4.9 cm <= 5.2 cm Right Atrium - Four Chamber Length: 4.6 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.4 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 50% >= 55% Left Ventricle - Lateral Peak E': 0.14 m/s > 0.08 m/s Left Ventricle - Septal Peak E': *0.08 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 9 < 15 Aorta - Sinus Level: 2.9 cm <= 3.6 cm Aorta - Ascending: 3.1 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.5 m/sec <= 2.0 m/sec Aortic Valve - LVOT diam: 1.6 cm Mitral Valve - E Wave: 1.0 m/sec Mitral Valve - A Wave: 1.1 m/sec Mitral Valve - E/A ratio: 0.91 Mitral Valve - E Wave deceleration time: 205 ms 140-250 ms TR Gradient (+ RA = PASP): *31 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA and extending into the RV. LEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV systolic dysfunction. Low normal LVEF. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. RV hypertrophy. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Physiologic MR (within normal limits). TRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic TR. Mild PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS. Physiologic PR. PERICARDIUM: There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. Conclusions The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with focal hypokinesis of the inferior and inferolateral walls. Overall left ventricular systolic function is low normal (LVEF 50-55%). The remainder of the ventricle contracts well. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). There is mild pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. IMPRESSION: Mild regional left ventricular systolic dysfunction. Mild right ventricular hypertrophy. Mild pulmonary hypertension. Electronically signed by [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2122-3-17**] 13:19 Brief Hospital Course: Ms. [**Known lastname 86745**] was transferred to the [**Hospital1 18**] on [**2122-3-16**] from [**Hospital **] Hospital after a cardiac catheterization revealed severe triple vessel disease. She was worked-up in the usual preoperative manner including a carotid ultrasound which revealed a 70-79% right and 40-59% left internal carotid artery stenosis. A CT scan was also obtained which showed an aberrant right subclavian artery, with an abnormal configuration of the aortic arch. There was also significant atherosclerotic disease involving the right subclavian artery, with a thrombosed and slightly enlarged proximal portion, which may represent a thrombosed aneurysm/pseudoaneurysm, measuring 1.5cm, with mass effect on the esophagus. Given these findings, the vascular surgery service was consulted for assistance in her care. It was elected to perform a concommittant subclavian revascularization in addition to her coronary artery bypass grafting. On [**2122-3-20**], Ms. [**Known lastname 86745**] was taken to the operating room where she underwent coronary artery bypass grafting to three vessels, arch Debranching Procedure with a bifurcated dacron graft from the ascending aorta to the Left and Right subclavian arteries and vertebral Artery Transposition to the dacron graft to the left subclavian artery. Please see operative note for details. Postoperatively she was taken to the intensive care unit for unit monitoring. She was transfused for postoperative anemia. She did have some postoperative confusion and delerium which slowly improved. The electrophysiology service was consulted to interrogate her pacemaker. She developed atrial fibrillation which was treated with amiodarone with conversion back to sinus rhythm. A methylene blue test was ordered prior to chest tube removal to be sure there was no chylothorax. The test was negative and her chest tube was removed without incident. On [**2122-3-25**], she was transferred to the step down unit for further recovery. She continued to work with physical therapy daily. Speech and swallow was consulted for evaluation of swallowing. Upon further investigation Ms.[**Known lastname 86745**] reported that this is her baseline swallowing. She states that she has had a previous workup regarding her "severe reflux". Speech and swallow evaluation felt the oropharnyx was not contributing to any difficulty with swallowing. She continued to make steady progress and was discharged to rehab on postoperative day #7. All follow up appointments were advised. Medications on Admission: crestor 40mg daily, nifedipine ER 60mg daily, zoloft 150mg daily, ECASA 81mg daily, ativan1 mg [**Hospital1 **], advair 250/50 2 puffs [**Hospital1 **], proair inh 2 puffs q4h prn, MVI, Vit D 400u daily Discharge Disposition: Extended Care Facility: [**Hospital 5682**] Rehab and Skill Nursing Center Discharge Diagnosis: coronary artery disease s/p permanent dual chamber pacemeker depression s/p coronary artery bypass grafts s/p percutaneous coronary interventions/stents ho/ gastointestinal bleed peripheral vascular disease Discharge Condition: alert and oriented,stable vital signs ambulatory and steady pain controlled with Percocet Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Please call to schedule appointments Surgeon: Dr. [**Last Name (STitle) 914**] [**2122-5-5**] at 1:15 pm [**Telephone/Fax (1) 170**] Primary Care: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 10508**]) in [**1-3**] weeks Cardiologist: Dr. [**Last Name (STitle) 4455**] in [**1-3**] weeks Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse will schedule Completed by:[**2122-3-27**] Name: [**Known lastname 13722**],[**Known firstname 3989**] A Unit No: [**Numeric Identifier 13723**] Admission Date: [**2122-3-16**] Discharge Date: [**2122-3-27**] Date of Birth: [**2051-8-4**] Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 1543**] Addendum: It should be noted that during the resusitation of [**Last Name (un) 13724**] patient post-operatively she received many liters of crystalloid fluid. This fluid resuscitation made it somewhat more difficult to wean the patient from the ventilator as she needed to be aggressively diuresed before she could be extubated. The patient was ultimately extubated on POD3. During the patients diuresis her creatinine changed from a baseline of 0.9 to a peak of 1.4 indicateing some degree of acute kidney injury likely from aggressive diuresis. After her diuretic regime was scaled back the patient's creatinine level began to return more toward her baseline, it was 1.2 on the day of discharge. Discharge Disposition: Extended Care Facility: [**Hospital 13725**] Rehab and Skill Nursing Center [**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**] Completed by:[**2122-4-7**]

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icd9cm

[ [ [] ] ]

[ "39.61", "39.22", "36.15", "39.59", "36.12" ]

icd9pcs

[ [ [] ] ]

13249, 13485

7848, 10380

311, 406

10963, 11055

2355, 7825

11680, 13226

1611, 1689

10733, 10942

10406, 10611

11079, 11657

1704, 2336

257, 273

434, 1050

1072, 1471

1487, 1595

54,166

101,039

39146

Discharge summary

report

Admission Date: [**2132-2-11**] Discharge Date: [**2132-2-15**] Date of Birth: [**2080-12-24**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Fatigue/Dyspnea on exertion Major Surgical or Invasive Procedure: [**2132-2-11**] Minimal Invasive Mitral Valve Repair (32mm St. [**First Name4 (NamePattern1) 923**] [**Last Name (NamePattern1) **]) History of Present Illness: 51 year old male with known mitral valve prolapse and mitral regurgitation followed by serial echocardiograms. Most recent echocardiogram has shown progression of his mitral regurgitation to moderate/severe with a flail posterior leaflet. The patient, complaining of fatigue and some dyspnea on exertion, presents for surgical evaluation for mitral valve repair versus replacement. Past Medical History: Mitral Valve Prolapse/Mitral Regurgitation Hypertension Arthritis Past Surgical History: s/p inguinal herniorrhaphy s/p femoral herniorrhaphy s/p left knee surgery s/p skin grafts for fingers on left had following traumatic injury s/p removal of basal cell carcinoma from forehead Social History: Race: Caucasian Last Dental Exam: 2 years ago Lives with: Wife Occupation: Retired but works as delivery driver Tobacco: Denies ETOH: Several/wk Family History: Family History: Father with MI age 51 s/p CABG @ 55 Physical Exam: Pulse: 70 Resp: 16 O2 sat: 98% B/P Right: 129/83 Left: 139/85 Height: 6' Weight: 204 lbs General: well-developed male in no acute distress Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur [**3-4**] holosystolic murmur Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema/Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right/Left: 2+ DP Right/Left: 2+ PT [**Name (NI) 167**]/Left: 2+ Radial Right/Left: 2+ Carotid Bruit Right/Left: none Pertinent Results: [**2132-2-11**] Echo: Pre-bypass: The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is posterior mitral leaflet flail at the P2 scallop. An eccentric, anteriorly directed jet of Severe (4+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). There is no pericardial effusion. Post-bypass: The patient is receiving no inotropic support post-CPB. An annuloplasty ring is well-seated in the mitral position and there is trace valvular regurgitation. There is a mean transmitral pressure gradient of 3 mm Hg at a cardiac output of 6.3 L/min. There is evidence of systolic anterior motion of the anterior mitral leaflet, but there is not evidence of outflow tract obstruction or pressure gradient. Biventricular systolic function is preserved. All other findings are consistent with pre-bypass findings. The aorta is intact post-decannulation. All findings were communicated to the surgeon. [**2132-2-14**] 05:25AM BLOOD WBC-8.3 RBC-3.55* Hgb-10.5* Hct-30.4* MCV-86 MCH-29.5 MCHC-34.4 RDW-12.6 Plt Ct-193 [**2132-2-11**] 04:14PM BLOOD PT-12.5 PTT-32.5 INR(PT)-1.1 [**Known lastname 86724**],[**Known firstname 488**] [**Age over 90 86725**] M 51 [**2080-12-24**] Radiology Report CHEST (PA & LAT) Study Date of [**2132-2-14**] 9:49 AM [**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2132-2-14**] 9:49 AM CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 86726**] Reason: eval for effusion [**Hospital 93**] MEDICAL CONDITION: 51 year old man s/p mini mv repair REASON FOR THIS EXAMINATION: eval for effusion Final Report CHEST RADIOGRAPH INDICATION: Evaluation for pleural effusion. COMPARISON: [**2132-2-12**]. FINDINGS: As compared to the previous radiograph, the extent of the right-sided pleural effusion has minimally increased. As a consequence, the right basal areas of atelectasis have also increased. On the other hand, the ventilation of the left lung base is slightly improved. Unchanged size of the cardiac silhouette, no evidence of newly appeared focal parenchymal opacities indicative of pneumonia. DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**] [**2132-2-15**] 06:45AM BLOOD Glucose-105* UreaN-12 Creat-0.8 Na-138 K-4.2 Cl-98 HCO3-35* AnGap-9 Brief Hospital Course: Mr. [**Known lastname **] was a same day admit after undergoing all pre-operative work-up as an outpatient. On [**2-11**] he was brought to the operating room where he underwent a minimal invasive mitral valve repair. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. Chest tubes were removed per cardiac surgery protocol. He was transferred to the step down unit on post operative day 1 in stable condition. He was started on Neurontin with plans for increased titration as needed due to right medial thigh numbness and tingling (right groin cannulation.) He was able to ambulate and weight bear with this numbness. He continued to work with physical therapy to increase strength and endurance. He was tolerating a full po diet, ambulating well and his incision was healing well. His CXR revealed a question of a moderate right pleural effusion and he had an ultrasound which showed less than 300 cc of fluid and he did not undergo thoracentesis. He was encouraged to continue frequent IS use. It was felt that he was safe for discharge home on post operative day 4. Medications on Admission: Carvedilol 12.5mg po BID Quinapril 40mg po daily Aspirin 91mg daily Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 4. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 7 days. 5. Quinapril 10 mg PO daily. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 5. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 7. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) for 1 months: Take with food. Disp:*120 Tablet(s)* Refills:*0* 8. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Mitral Valve Prolapse/Mitral Regurgitation s/p Mitral Valve Repair Hypertension Arthritis Past Surgical History: s/p inguinal herniorrhaphy s/p femoral herniorrhaphy s/p left knee surgery s/p skin grafts for fingers on left had following traumatic injury s/p removal of basal cell carcinoma from forehead Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with percocet prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Please call to schedule appointments Surgeon Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] [**3-20**] at 1:00 PM Primary Care Dr. [**Last Name (STitle) 4541**] in [**12-1**] weeks Cardiologist Dr. [**Last Name (STitle) **] in [**12-1**] weeks Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse will schedule Completed by:[**2132-2-15**]

[ "424.0", "429.5", "518.0", "401.9", "511.9", "782.0" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.12" ]

icd9pcs

[ [ [] ] ]

7538, 7596

5053, 6313

350, 484

7944, 8039

2129, 4215

8579, 8990

1393, 1430

6431, 7515

4255, 4290

7617, 7707

6339, 6408

8063, 8556

7730, 7923

1445, 2110

283, 312

4322, 5030

512, 895

917, 983

1215, 1361

4,905

108,634

27341

Discharge summary

report

Admission Date: [**2121-5-21**] Discharge Date: [**2121-5-26**] Date of Birth: [**2067-12-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3705**] Chief Complaint: Found lethargic on ground of prison; hyponatremia Major Surgical or Invasive Procedure: ICU monitoring History of Present Illness: This is a 53-year-old male prisoner who was admitted for hyponatremia. He was found on the ground of his cell lethargic and only opening his eyes to verbal stimuli. He was noted to have left eye and left hip hematomas. He was taken to an outside hospital where he was found to have a sodium of 97. He was started on hypertonic saline, and his sodium level climbed to 107. He was transferred to the [**Hospital1 18**] for further management. In the emergency department, He was found to have a sodium of 108, and he was admitted to the [**Hospital Unit Name 153**] for further management. In the [**Hospital Unit Name 153**], he denied any ingestion of water or any other substance. He denied any neurologic symptoms. He did complain of pain over his left temple. Past Medical History: Hyponatremia from primary polydipsia Depression Psychosis with violent behavior Traumatic Brain Injury Social History: He is a prisoner at [**Location (un) **]and has a history of violence. He is married and has two children. Per report, he was a National Merit Scholar in high school and went on to become an electrical engineer before he was in a motor vehicle accident and developed a psychotic disorder. Family History: Unknown Physical Exam: Vitals: Temperature:95.1 Pulse:64 Blood Pressure:98/59 Respiratory rate:16, Oxygen saturation:97% on room air. GENERAL: No acute distress. HEENT: Large hematoma over left temple/cheek with left conjunctival hemorrhage, moist mucous membranes. CARDIAC: Regular rate and rhyhtm, s1,s2, without murmurs, rubs, or gallops. LUNGS: Clear to auscultation anteriorly. ABDOMEN: Soft, nontender, nondistended, with normocative bowel sounds. EXTREMITIES: Warm and well perfused without cyanosis or edema NEURO: Alert and oriented x 3. Responds to questions. Moves all extremities spontaneously. Pupils reactive. Pertinent Results: Outside hospital: --Na+ 97 --> 107 --CT maxillofacial ([**5-23**], prelim read): soft tissue hematoma superior to L-orbit but no acute fracture; old L-orbital fracture; DJD in C-spine. --Urine Osm 62 at admission . Admission labs: WBC-9.4 HCT-38 PLT COUNT-584 NEUTS-83.1 BANDS-0 LYMPHS-11.5 MONOS-4.7 EOS-0.1 BASOS-0.5 . Sodium: 108 . PT-12.8 PTT-29.5 INR(PT)-1.1 . Serum and urine toxocology screen negative. Brief Hospital Course: This is a 53 year-old male with history of depression, psychosis, hyponatremia secondary to primary polydipsia who was admitted with hyponatremia. . 1. Hyponatremia: His hyponatremia is secondary to primary polydipsia (psychogenic polydipsia). His urine was dilute on admission (osmolarity = 62). His sodium corrected with fluid restriction. Once his sodium corrected, he had urine electrolytes and osmolarity checked, and these values were within normal limits. It is unclear whether he had access to free water, but presumedly he drank from a sink/toilet. He had a similar presentation 3 weeks prior. It is unclear if this was a suicide attempt verse secondary gain from hospitalization. It is recommended that he have strict monitoring upon discharge to prevent excessive fluid intake. He could benefit from periodic electrolyte checks at prison if possible. . 2. Trauma: He was found on floor in his cell. It is presumed that he seized or fell secondary to hyponatremia. He had left eye and left thigh ecchymoses on admission. His neurological exam was within normal limits. A CT scan at the outside hospital had a suggestion of a left lateral orbital fracture. A repeat CT scan here showed no evidence of fracture. Plastic surgery was consulted and recommended no intervention after maxillofacial CT was performed and negative for acute fracture. . 3. Report of melena and guaiac positive stool: His hematocrit remained stable. He had no further melena or hematochezia. He had no symptoms of active bleeding other than the old ecchymoses. His vitals remained stable. He will need an outpatient colonoscopy at some point to further evaluate. . 4. Vertigo: On hospital day 3, he complained on vertigo especially with turning his head to the left. He was evaluated by neurology who felt that he had peripheral vertigo given his rotatory nystagmus. It was recommended to try ativan for symptomatic relief and this did not work for him. He was educated in Epley's maneuver's to continue until his symptoms resolved. He still had some vertigo at the time of discharge. . 5. Psych: He has a history of depression and psychosis. It is possible that he is seeking secondary gain from hospitalizations. He was followed by psychiatry while in house. They recommended starting clozaril; however, his white count was low. Therefore, this was differed and should be considered as an outpatient. He was continued on his regular seroquel. . 6. FEN: He was maintained on fluid restriction up to 2L on the day of discharge. His hyponatremia was corrected as above. . 7. Prophylaxis: He was placed on SC heparin & pantoprazole for prophylaxis throughout hospital stay. . 8. Code: full. . 9. Dispo: He was discharged back to prison. Medications on Admission: seroquel 50 qAM, 100 qhs Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: [**12-23**] Tablet, Delayed Release (E.C.)s PO DAILY (Daily) 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. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Quetiapine 50 mg Tablet Sig: One (1) Tablet PO qAM. Discharge Disposition: Home Discharge Diagnosis: primary polydipsia with hyponatremia psychosis depression left eye and left thigh hematomas Discharge Condition: medically stable Discharge Instructions: --Contact MD if you develop chest pain, fever/chills, seizure-like activity, or other concerning symptoms. --Do not drink more than 2 liters of fluid per day maximum. --Take all medications as directed. --He may benefit for epley's maneuvers (see attached sheet) for his vertigo. Pt should be on both medical and suicide watch. The concern in terms of medical watch is that he was likely drinking water while not being watched. He will also need to have labs drawn periodically, particularly sodium. It is also strongly recommended that he be started on clozaril 12.5mg daily after his WBC count is normal (was 3.8 here on discharge). Followup Instructions: follow-up with medical team and mental health services at prison within 1 week It is strongly recommended by our psychiatrists that the pt be started on clozaril 12.5mg daily. This should be done after pt's WBC count is checked, as it has decreased while hospitalized to 3.8. Pt will also need an outpatient colonoscopy to further evaluate his guaiac positive stool. Completed by:[**2121-5-27**]

[ "E888.9", "907.0", "298.9", "783.5", "E849.7", "924.00", "276.1", "311", "728.88" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6053, 6059

2714, 5458

366, 383

6195, 6214

2279, 2494

6901, 7302

1634, 1643

5533, 6030

6080, 6174

5484, 5510

6238, 6878

1658, 2260

277, 328

411, 1184

2510, 2691

1206, 1310

1326, 1618

69,322

192,784

50076

Discharge summary

report

Admission Date: [**2176-7-17**] Discharge Date: [**2176-7-25**] Service: CARDIOTHORACIC Allergies: Codeine Attending:[**First Name3 (LF) 165**] Chief Complaint: aortic stenosis Major Surgical or Invasive Procedure: [**2176-7-17**] aortic valve replacement (21mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Epic Supra Porcine Valve) History of Present Illness: This 87 year old female presented to [**Hospital6 5016**] Emergency Room with complaints of chest discomfort in early [**Month (only) **]. Her discomfort resolved prior to presentation to the emergency room and apparently all testing was negative. She was to be transferred to [**Hospital1 18**] but left against advice. She saw Dr. [**Last Name (STitle) 696**] on [**2176-6-13**] in cardiology follow up but denied any recurrence of symptoms. Stress echocardiography on [**2176-6-27**] minute had no EKG changes and echo images revealed severe aortic stenosis with a peak gradient of 74 mmHg, a mean gradient of 48 mmHg and a valve area of 0.8-1.0 cm2. There was no evidence of inducible ischemia, though the workload was low and target heart rate not achieved. Her LVEF was 70%. She denies palpitations, pedal edema, or orthopnea but she reports she has a hospital bed at home and sleeps with her head up due to back pain. She also reports she is unable to walk any distance due to fatigue. Past Medical History: Aortic stenosis Aortic regurgitation Hypertension Hyperlipidemia Paroxysmal atrial fibrillation s/p percutaneous fundoplication chronic renal insufficiency Chronic anemia Left rotator cuff tear Compression fractures of the spine S/P multiple breast cyst removal s/p Right rotator cuff repair S/P bilateral Total knee replacements S/P subtotal gastrectomy in [**2125**] S/P Bilateral hammertoe surgery s/p Bilateral carpal tunnel repair s/p Cholecystectomy s/p total abdominal hysterectomy s/p Appendectomy Arthritis s/p Tonsillectomy S/P umbilical hernia repair Social History: Occupation: retired Lives alone and spends half her year in MA and the other half in [**Last Name (LF) 20338**], [**First Name4 (NamePattern1) 108**] [**Last Name (NamePattern1) 1139**]: remote smoking hx(20yr hx), Quit 20 yrs ago ETOH: drinks alcohol on rare social occasions Family History: brother had CABG at age 86 Physical Exam: admission: T 97.1 Pulse: 62 Resp: 16 O2 sat: 99% RA B/P Right: 149/64 Left: Height: 5 feet 2 inches Weight:150 lbs General: Skin: Dry [] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur 3/6 SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] no HSM Extremities: Warm [x], well-perfused [ ] Edema Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left:2+ DP Right: 2+ Left:2+ PT [**Name (NI) 167**]: 1+ Left:1+ Radial Right: 2+ Left:2+ Carotid Bruit Right: rad murmur Left: rad murmur Pertinent Results: [**2176-7-24**] 12:30PM BLOOD WBC-7.6 RBC-4.07* Hgb-11.9* Hct-36.2 MCV-89 MCH-29.3 MCHC-33.0 RDW-14.7 Plt Ct-392# [**2176-7-23**] 03:14AM BLOOD PT-13.2 PTT-26.4 INR(PT)-1.1 [**2176-7-24**] 12:30PM BLOOD Glucose-124* UreaN-35* Creat-1.3* Na-133 K-4.5 Cl-93* HCO3-31 AnGap-14 Radiology Report CHEST (PA & LAT) Study Date of [**2176-7-23**] 9:20 PM [**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2176-7-23**] 9:20 PM CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 104552**] Reason: eval for pleural effusions s/p [**Hospital 1291**] [**Hospital 93**] MEDICAL CONDITION: 87 year old woman s/p AVR REASON FOR THIS EXAMINATION: eval for pleural effusions s/p AVR Provisional Findings Impression: DMFj WED [**2176-7-24**] 11:32 AM PFI: Unchanged bilateral pleural effusions with associated atelectasis. No new consolidation. Preliminary Report !! PFI !! PFI: Unchanged bilateral pleural effusions with associated atelectasis. No new consolidation. DR. [**First Name (STitle) 2618**] [**Doctor Last Name **] DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**] PFI entered: WED [**2176-7-24**] 11:32 AM [**Known lastname **],[**Known firstname 26**] [**Medical Record Number 104553**] F 87 [**2088-12-29**] Radiology Report MR [**Name13 (STitle) **] W &W/O CONTRAST Study Date of [**2176-7-21**] 10:10 AM [**Last Name (LF) **],[**First Name3 (LF) **] CSURG CSRU [**2176-7-21**] 10:10 AM MR [**Name13 (STitle) **] W &W/O CONTRAST Clip # [**Clip Number (Radiology) 104554**] Reason: r/o embolus Contrast: MAGNEVIST Amt: 13 [**Hospital 93**] MEDICAL CONDITION: 87 year old woman s/p avr REASON FOR THIS EXAMINATION: r/o embolus CONTRAINDICATIONS FOR IV CONTRAST: None. Final Report INDICATION: Status post aortic valve replacement, now with right arm and leg weakness. Evaluate for an embolus. COMPARISON: No previous studies. TECHNIQUE: Sagittal T1-weighted, T2-weighted, and STIR images of the thoracic spine, with axial T2-weighted images. Following intravenous gadolinium administration, sagittal T1-weighted images were repeated. FINDINGS: There are mild compression deformities of T12 and L1 vertebral bodies, without evidence of bone marrow edema to suggest acuity. There is no significant associated retropulsion. Alignment is preserved. High signal in the T12/L1 disc is likely related to degeneration. The spinal cord is normal in morphology and signal intensity, without evidence of an infarction. Theconus terminates at T12/L1. There is no spinal canal stenosis. There are at least moderate bilateral pleural effusions, incompletely evaluated. There is questionable caliceal fullness versus parapelvic cysts in the left kidney, incompletely evaluated. IMPRESSION: 1. Unremarkable appearance of the thoracic spinal cord without evidence of an infarction. 2. Mild compression deformities of T12 and L1 vertebral bodies, which appear to be chronic. 3. At least moderate bilateral pleural effusions, incompletely evaluated. 4. Caliceal fullness versus parapelvic cysts in the left kidney, incompletely evaluated. Renal ultrasound is suggested, if clinically indicated. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 95**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 96**] proved: SUN [**2176-7-21**] 3:39 PM [**Known lastname **],[**Known firstname 26**] [**Medical Record Number 104553**] F 87 [**2088-12-29**] Radiology Report MR HEAD W/O CONTRAST Study Date of [**2176-7-21**] 10:10 AM [**Last Name (LF) **],[**First Name3 (LF) **] CSURG CSRU [**2176-7-21**] 10:10 AM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # [**Clip Number (Radiology) 104555**] Reason: r/o cva [**Hospital 93**] MEDICAL CONDITION: 87 year old woman s/p avr REASON FOR THIS EXAMINATION: r/o cva CONTRAINDICATIONS FOR IV CONTRAST: None. Wet Read: PXDb SUN [**2176-7-21**] 1:36 PM Bilateral Microvascular embolic acute infarcts. No focal vascular occlusion, stenosis or aneurysm, however MRA is limited by motion degradation. DW [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], PA for Cardiac Surgery, at 1:20 PM. ([**First Name8 (NamePattern2) 30217**] [**Doctor Last Name **] [**Numeric Identifier 83113**]) Final Report INDICATION: Status post aortic valve replacement with right arm and leg weakness. CoMPARISON: Non-contrast head CT dated [**2176-7-19**] TECHNIQUE: Sagittal T1-weighted and axial T2-weighted, FLAIR, gradient echo, and diffusion-weighted images of the head were obtained. Three-dimensional time-of-flight MRA of the head was obtained. FINDINGS: There are multiple small (3-4 mm) foci of slow diffusion in the [**Doctor Last Name 352**] and white matter of the frontal, parietal, posterior temporal, and occipital lobes, as well as two foci in the right cerebellar hemisphere. They demonstrate low signal on the ADC map and high signal on FLAIR images, consistent with acute infarctions which are less than 10 days old. There are additional small hyperintensities in the supratentorial white matter and pons on T2-weighted and FLAIR images, likely representing mild to moderate chronic small vessel ischemic disease in a patient of this age. The ventricles and sulci are normal in size and configuration for age. HEAD MRA: The study is slightly limited by motion artifact. Flow is visualized in the intracranial internal carotid and vertebral arteries, and their major branches. Apparent diminished signal in the short horizontal segment of the left vertebral artery is likely artifactual. Otherwise, no hemodynamically significant stenoses are seen. There is no evidence of ananeurysm. IMPRESSION: 1. Multiple small acute infarctions (less than 10 days old) involving the anterior and posterior circulation territories bilaterally, highly suggestive of embolic etiology, particularly given the history of aortic valve replacement. 2. Unremarkable head MRA. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 35563**] DR. [**First Name11 (Name Pattern1) 95**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 96**] Approved: SUN [**2176-7-21**] 3:37 PM [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname 26**] [**Hospital1 18**] [**Numeric Identifier 104556**] (Complete) Done [**2176-7-17**] at 11:14:03 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] [**Street Address(2) 15115**] [**Location (un) 15116**], [**Numeric Identifier 15117**] Status: Inpatient DOB: [**2088-12-29**] Age (years): 87 F Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: avr ICD-9 Codes: 402.90, 786.05, 786.51, 799.02, 440.0, 424.1, 424.0 Test Information Date/Time: [**2176-7-17**] at 11:14 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2009AW1-: Machine: aw000 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Inferolateral Thickness: *1.6 cm 0.6 - 1.1 cm Left Ventricle - Ejection Fraction: 55% to 60% >= 55% Aorta - Descending Thoracic: 2.3 cm <= 2.5 cm Aortic Valve - Peak Gradient: *66 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 36 mm Hg Aortic Valve - LVOT diam: 2.0 cm Aortic Valve - Valve Area: *0.6 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. LEFT VENTRICLE: Overall normal LVEF (>55%). RIGHT VENTRICLE: Mild global RV free wall hypokinesis. AORTA: Normal ascending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Critical AS (area <0.8cm2). Mild to moderate ([**12-29**]+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Conclusions Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is normal (LVEF>55%). with mild global free wall hypokinesis. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Mild to moderate ([**12-29**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: The patient is AV paced, on low dose phenylephrine. There is a prosthetic aortic valve with no leak and no AI. Residual mean gradient is 15. Good biventricular systolic fxn. Trace MR. Aorta intact. Other parameters as pre-bypass. 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) **] [**2176-7-17**] 13:01 Brief Hospital Course: This patient was admitted and underwent aortic valve replacement with a 21mm St. [**Male First Name (un) 923**] Epic Porcine valve. The cross clamp time was 77 minutes and the total bypass time was 92 minutes. She was given Kefzol for her perioperative antibiotics. She tolerated the procedure well and was transferred to the CVIVU on Neosynephrine and Propofol. She received 3 units of PRBC on the post op night and was extubated on POD 1. She remained stable, was neurologically intact. On the morning of POD 1 she was noted to have weakness of the right extremeties. She required phenylephrine for low SVR and her extremeties moved, albeit with proximal motor weakness and a noted Rt facial droop.. A MRI of the head revealed evidence of acute Rt cerebral diffuse embolic infacts. her neuro exam waxed and waned. PT worked with her for mobility, strength and rehabilitation. She weaned from pressors and her strength returned. diuresis was begun, beta blockade resumed and ACE inhibition resumed for BP control as well as after load reduction for her cardiovascular profile. Her wounds were healing well, her CTs and pacing wires had been removed according to protocol. She was alert and oriented, but overall weak. She was moving all extremeties, the left side being stronger than the right. She had a urinary tract infection with pseudomonas aeruginosa for which Cipro was given. Arrangements were made for rehabilitation placement for further recovery prior to eventual discharge home. Medications on Admission: Diltiaem SR 240 daily HCTZ 25 daily Lisinopril 20 daily Iron 325 daily Oxybutynin 5 daily Simvastatin 20 daily Aspirin 325 daily Calcium Carbonate/Vit D 600/400 1 tab [**Hospital1 **] Benadryl/Tylenol 500/25 Qhs Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. 4. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for secretions. 8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain for 4 weeks. 10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every six (6) hours as needed for fever or pain. 11. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. 12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 2 weeks. 13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 15. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: diffuse right cerebral perioperative embolic strokes Aortic stenosis regurgitation s/p Aortic valve replacement Hypertension Hyperlipidemia Paroxysmal atrial fibrillation Gastroesophageal reflux disease s/p fundoplication Chronic renal insufficiency Chronic anemia Left rotator cuff tear Compression fractures of the spine S/P multiple breast cyst removal s/p Right rotator cuff repair S/P bilateral total knee replacements S/P subtotal gastrectomy in [**2125**] S/P Bilateral hammertoe surgery s/p bilateral carpal tunnel repair s/p Cholecystectomy s/p total abdominal Hysterectomy and salpingo-oophorectomy s/p Appendectomy Arthritis Tonsillectomy S/P umbilical hernia repair urinary tract infection Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] take all medications as directed Followup Instructions: Dr [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])- Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 10769**] after discharge from rehab Dr [**Last Name (STitle) 696**] in [**1-30**] weeks - [**Telephone/Fax (1) 62**] Please call for appointments [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2176-7-30**]

[ "403.90", "424.1", "427.31", "599.0", "272.4", "530.81", "585.9", "997.02", "285.21", "041.7", "434.11" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.21" ]

icd9pcs

[ [ [] ] ]

15967, 16014

12780, 14284

236, 376

16760, 16767

3047, 3597

17311, 17741

2303, 2331

14546, 15944

6777, 6803

16035, 16739

14310, 14523

16791, 17288

2346, 3028

181, 198

6835, 12757

404, 1407

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66,130

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31423+57744

Discharge summary

report+addendum

Admission Date: [**2136-3-8**] Discharge Date: [**2136-3-9**] Date of Birth: [**2108-10-26**] Sex: M Service: EMERGENCY Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 2565**] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 27 yoM w/ h/o bipolar disorder presenting with mania and delerium sent in from his psychiatrist's office. The patient is currently providing an unreliable history however per his brother in law and his sister the patient has had recent poor adherence to his medications and is has had erratic bizarre behavior x 3 months. Since then he has stopped taking his meds, per his sister he seems like he was "on speed" and never sleeps. The patient was evaluated by psychiatry in the ER who thought the patient had delerious or psychotic mania and had some catatonic features such as echolalia. He has hallucinations as well. Given delerium (not oriented to place or time) he was admitted to medicine service to rule out toxic metabolic cause prior to psychiatric inpt admission. . In the ED, initial VS: T 100.3 HR 127 BP 152/97 RR 18 O2 sat: 100% RA. In the ER he rec'd valium 10mg IV and 2mg IV ativan x 4 doses. He also was combative in the ER and jumped out of bed, ran into the hallway and attempted to grab a nurse by the neck. Due to low grade temp there was a plan for LP but given his combativeness was unable, so he was given vanc/ceftriaxone and acyclovir. Prior to his transfer to the floor his VS were: HR 92 BP 119/57 RR 14 O2 sat: 97% on RA. . Currently the patient has complaints of low back pain x 7 days, no other complaints. He is asking for food from legal sea foods and occasionally yells non-sense phrases out but during other times is sleeping heavily. He is unable to provide adequate history. Past Medical History: PSYCHIATRIC HISTORY (INCLUDE PRIOR HOSPITALIZATIONS, OUTPATIENT TREATMENTS, MEDICATION/ECT HISTORY, RESPONSE TO TREATMENT, HISTORY OF HOMICIDAL/SUICIDAL/ASSAULTIVE BEHAVIOR): -[**First Name3 (LF) 8372**]: diagnosed in teens, "major downturn in college," has been stabilized on Lithium in the past -ADHD -No previous psychiatric hospitalizations -No previous SA . PAST MEDICAL HISTORY (INCLUDE HISTORY OF HEAD TRAUMA, SEIZURES, OR OTHER NEUROLOGIC ILLNESS): -s/p assault in HS (?skull fracture) -severed ulnar nerve s/p repair Social History: (per OMR) Lives alone. Is a 2nd year law student at NE. Likes to go to bars, frequent barfights. Had 1 arrest for assaultive behavior while at U Mich [**Hospital1 69333**]. Had 1 arrest for assault within the past year (case dismissed after community service). No history of physical or sexual abuse. H/o cocaine, heroin (per family no known h/o IVDU) and ETOH abuse. Family History: (per OMR) 2 brothers: both with [**Name (NI) 8372**], 1 with schizophrenia. Father: depression. Paternal aunt: depression s/p ECT. Physical Exam: Vitals - T: 98.9 BP: 106/63 HR: 66 RR: 15 02 sat: 94% RA GENERAL: sleeping, AOx1 (person), thinks he is at the [**Hospital1 112**] and thinks it is [**2108-3-10**]. He is unaware of why he is in the hospital. HEENT: OP clear, JVP 8cm CARDIAC: RRR, no m/r/g LUNG: CTAB ABDOMEN: BS+, soft, NT, ND, no masses or organomegaly EXT: WWP, no c/c/e NEURO: somnolent, occasionally yells out phrases that are non-sense, answers questions appropriately sometimes, AOx1, occasional agitation. PERRL (3mm --> 2mm). able to follow commands, [**4-25**] grip stregnth bilaterally, [**4-25**] LE stregnth. no spinous process tenderness. no myoclonus. unable to cooperate with rest of neuro exam. DERM: flush, bilateral hand abrasions with dorsal surface erythema- blanching, blanching erythema of the knees bilaterally Pertinent Results: [**2136-3-8**] 04:00AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2136-3-8**] 04:00AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013 [**2136-3-8**] 04:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2136-3-8**] 04:00AM URINE RBC-0-2 WBC-0 BACTERIA-RARE YEAST-NONE EPI-0 [**2136-3-7**] 08:51PM LACTATE-1.0 [**2136-3-7**] 08:45PM GLUCOSE-163* UREA N-19 CREAT-1.1 SODIUM-137 POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-26 ANION GAP-14 [**2136-3-7**] 08:45PM ALT(SGPT)-46* AST(SGOT)-56* LD(LDH)-220 CK(CPK)-864* ALK PHOS-66 TOT BILI-0.5 [**2136-3-7**] 08:45PM LIPASE-36 [**2136-3-7**] 08:45PM ALBUMIN-4.6 CALCIUM-9.3 PHOSPHATE-2.5* MAGNESIUM-2.1 [**2136-3-7**] 08:45PM TSH-1.7 [**2136-3-7**] 08:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2136-3-7**] 08:45PM WBC-8.0 RBC-4.77 HGB-14.3 HCT-41.1 MCV-86 MCH-29.9 MCHC-34.7 RDW-12.0 [**2136-3-7**] 08:45PM NEUTS-71.1* LYMPHS-21.6 MONOS-5.0 EOS-1.5 BASOS-0.8 [**2136-3-7**] 08:45PM PLT COUNT-278 . [**2136-3-7**] Hand A&P: No acute fracture, dislocation, or foreign body of the left or right hand. . [**2136-3-7**] CXR: No acute intrathoracic abnormality . [**2136-3-8**] Head CT: No acute intracranial hemorrhage or edema. Brief Hospital Course: The patient is a 27 yoM w/ h/o bipolar disorder presenting with mania and delerium. . # Altered mental status: Patient was not oriented on presentation and was very aggressive. He became oriented to person and place over the first 12 hours but his alertness has waxed and waned with the the administration of sedating medications. Patient remained significantly agitated and aggressive. Due to his aggression and attempted assault of hospital staff he was maintained in four point restraints. Initial disorientation was concerning for delirium. Patient's subsequent infectious and metabolic work up was negative. Head CT was also negative for evidence of brain trauma. His serum and urine toxicology screens were negative making acute intoxication less likely. He was monitored closely for evidence of withdrawal. Patient's disorientation most likely represented psychosis related to his underlying psychiatric illness. Family reports recent history of mania in the setting of not adhering to his bipolar medication regimen. Psychiatry was consulted. Per their recommendations he was started on zyprexa, cogentin, and haldol. His home psychiatric medications of ambien, lexapro and seroquel were held. He required several boluses of haldol for extreme agitation. He was medically cleared and discharged for further psychiatric treatment to an inpatient psychiatric facility. . # Fever: Low grade temp of 100.6 on admission with normal WBC count and normal differential. Etiology unclear likely secondary to agitation or intoxication as his infectious work up remained negative and temperatures returned to [**Location 213**]. Due to erythema of bilateral hands with several small abrasions he was started on clindamycin for possible cellulitis. After 24 hours erythema resolved and showed no evidence of active infection. Antibiotics were discontinued. . # Chronic back pain: Per patient and family, he does not use IV drugs making osteomyelitis less likely and does not need to be worked up immediately. . # Mild transaminse elevation: Unclear baseline, reports of increased etoh use in the last week. Recommend out patient work up including hepatitis serologies. . # CODE: FULL # CONTACT: Mother # ICU CONSENT: Signed # DISPO: Psychiatric inpatient facility ([**Hospital1 **] 4) Medications on Admission: Seroquel Ambien Lexapro Discharge Medications: 1. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 2. Benztropine 2 mg/2 mL Solution Sig: One (1) mg Injection [**Hospital1 **] (2 times a day) as needed for when he receives haldol. 3. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet, Rapid Dissolve PO BID (2 times a day). 4. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) mg Injection IV DRIP (via continous IV drip): 1 mg per hour. 5. Multivitamin injection/thiamine 100 mg IV once per day (banana bag)particularly while not taking PO Discharge Disposition: Extended Care Discharge Diagnosis: Bipolar Disorder with acute mania Psychosis NOS Discharge Condition: Hemodynamically stable, altered alertness, oriented to person and place. Discharge Instructions: You presented to the Emergency Department with extreme agitation and confusion. Because of your aggressive behavior you required significant sedation and the decision was made to monitor you in the ICU. During your ICU admission you were evaluated for underlying illness and infection to account for your altered mental status. No underlying infection or metabolic abnormality was identified. The psychiatry team was consulted and they recommended admission to a psychiatric facility for further management of your symptoms and titration of medications. Followup Instructions: Please follow up with your primary care provider within two weeks of discharge to have your liver function monitored. Name: [**Known lastname 12251**],[**Known firstname **] Unit No: [**Numeric Identifier 12252**] Admission Date: [**2136-3-8**] Discharge Date: [**2136-3-9**] Date of Birth: [**2108-10-26**] Sex: M Service: EMERGENCY Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 11940**] Addendum: # Question of hand cellulitis given bilateral hand erythema and several abrasions. Erythema was likely secondary to patient's struggle against restraints as the erythema resolved with sedation. He was treated with clindaymycin for 36 hours and then discontinued as no active sign of infection. Recommend close monitoring of hands and abrasions. Would restart a 7 day course of clindamycin should patient develop signs of infection. # Etoh abuse: Per patient and family he has been binge drinking recently in the setting of his manic symptoms, but they deny any history of etoh dependence or withdrawal symptoms so unlikely to have withdrawal and low risk for Wernicke's. However, would continue to monitor withdrawal and provide daily banana bags with thiamine particulary if patient remains too sedated/agitated to tolerate po diet. Discharge Disposition: Extended Care [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11942**] MD [**MD Number(2) 11943**] Completed by:[**2136-3-9**]

[ "682.4", "724.2", "298.9", "296.04" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10263, 10436

5209, 5305

318, 325

8228, 8303

3839, 5133

8909, 10240

2852, 2987

7575, 8098

8157, 8207

7527, 7552

8327, 8886

3002, 3820

257, 280

353, 1898

5142, 5186

5320, 7501

1920, 2448

2464, 2836