ChanBeDu/relevant_section_length · Datasets at Hugging Face

2,800

167,093

48082+48083

Discharge summary

report+report

Admission Date: [**2132-5-16**] Discharge Date: [**2132-6-2**] Service: [**Last Name (un) **] [**Doctor First Name 147**] HISTORY OF PRESENT ILLNESS: This is a 78 year old male with a complex past medical history notable for non-small cell lung cancer, who was admitted to [**Hospital1 190**] Thoracic Surgery Service on [**2132-5-16**], for preoperative evaluation for a planned mediastinoscopy with a right upper lobe resection scheduled for [**2132-5-19**]. The patient initially presented to his primary care provider in [**2132-3-1**] with a two week history of hemoptysis. Evaluation chest CT scan demonstrated a 3.2 centimeters right upper lobe mass and a 2 centimeter pre-carinal lymph node. Subsequent needle biopsy was notable for non-small cell lung cancer. A PET scan conducted [**2132-5-1**], demonstrated right sided primary lung cancer with activity in the right hilum, and no apparently involvement of other organs. The patient was subsequently referred to Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**] for evaluation and thereafter scheduled for a mediastinoscopy with a right upper lobe resection on [**2132-5-19**]. The patient was subsequently admitted on [**2132-5-16**], for preoperative heparinization given a past history of chronic atrial fibrillation and a mechanical mitral valve. PAST MEDICAL HISTORY: 1. Hypertension. 2. Chronic atrial fibrillation. 3. Peripheral vascular disease. 4. Status post mechanical mitral valve replacement in [**2115**]. 5. Hyperlipidemia. 6. Diet controlled diabetes mellitus. 7. Anemia. 8. Status post left inguinal hernia repair. 9. Osteomyelitis. 10. Osteoarthritis. 11. Questionable seizure disorder. MEDICATIONS AT HOME: 1. Coumadin 5 mg p.o. q. day. 2. Digoxin 215 micrograms p.o. q. day. 3. Dilantin 100 mg p.o. q. day. 4. Toprol XL 50 mg p.o. q. day. 5. Zestril 5 mg p.o. q. day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Works as a school crossing guard. Has a greater than 40 pack year tobacco history. Denies any extensive history of alcohol or drug use. HOSPITAL COURSE: On [**2132-5-16**], the patient was admitted to the Thoracic Surgery Service under the direction of Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**] for preoperative heparinization. The patient was begun on a heparin drip at a rate of 1000 cc. per hour for a target PTT of 60 to 80. The patient was successfully anti-coagulated without complication through [**2132-5-19**], at which point he underwent a mediastinoscopy with a right upper lobe resection. The patient tolerated the procedure well and required one unit of fresh frozen plasma and three units of packed red blood cells interoperatively. The patient was subsequently successfully extubated in the Operating Room and transferred to the Recovery Room for further evaluation and management. On postoperative check, the patient was noted to be afebrile and stable with a 91% oxygen saturation on a 40% face mask and a postoperative hematocrit of 32.2. A right sided chest tube was noted to be in place with evidence of a small leak and moderate drainage to low continuous wall suction. The patient was subsequently cleared for transfer to the floor and was admitted to the Thoracic Surgery Service under the direction of Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**]. Postoperative pain control was provided via PCA. While on the floor, the patient had a protracted clinical course, but was nonetheless noted to gradually progress well clinically. Secondary to a persistently coarse respiratory examination, the patient underwent bronchoscopy on [**2132-5-21**], which demonstrated old obstructing blood clots with a greater preponderance in the right side versus the left side. The patient was subsequently suctioned clear of all such blood clots and was noted to have a clean and intact right upper lobe operative site. The patient was evaluated by Physical Therapy who continued to follow the patient for the duration of his stay and recommended to patient to [**Hospital 3058**] rehabilitation following resolution of his acute medical issues. The patient was restarted on his Coumadin therapy but was shortly thereafter noted to be supra-therapeutic with an INR of 3.1. The patient's Coumadin was subsequently discontinued pending resolution of his super-therapeutic status and further investigation as to the etiology of his hyper-sensitivity. Following identification of his super-therapeutic status, the patient was again noted to have transient worsening of his respiratory examination, instigating a repeat bronchoscopy on [**2132-5-23**]. Repeat bronchoscopy demonstrated a complete obstruction of the right main stem, right middle lobe and right lower lobe bronchi with blood clots and thick secretions, which were all subsequently removed with suction. In addition, marked extrinsic compression of the right middle lobe and right lower lobe was noted. The patient was thereafter begun on aggressive chest Physical Therapy and an aspiration work-up was begun. Serial video swallow studies were thereafter obtained, which initially demonstrated total intolerance of thin liquids and marginal tolerance of soft solids and nectar thickened liquids. Given these results, as well as the patient's apparent propensity for hyper-sensitivity to Coumadin therapy, it was thought that the patient was a significant risk for malnutrition and he was subsequently fitted with a Dobbhoff feeding tube for direct gastric feeding. The patient remained n.p.o. and on tube feeds through postoperative day number eight, during which time he was noted to exhibit improved clinical status. The patient was restarted on his Coumadin therapy and was subsequently gradually titrated to a target INR of 2.5. Repeat chest CT scan demonstrated improved aeration within portion of the right middle and right lower lobes. The patient's chest tube was subsequently removed without complications and the patient demonstrated a continued adequate oxygen saturation on minimal supplemental O2 therapy. Repeat video swallow and barium swallow studies conducted on [**5-30**], demonstrated persistent but decreased aspiration of plain liquids and adequate tolerance of soft solids and nectar thickened liquids. In addition, the patient was noted to demonstrate significant esophageal spasm with associated reflux of swallowed contents to the pyriform sinus. Despite these findings, it was thought that the patient would benefit from a feeding trial and he was subsequently re-instituted on soft solid diet and thickened nectar liquids with Boost supplements on [**5-30**]. The patient was thereafter noted to be tolerant of this modified diet and his tube feeds were entirely discontinued. The patient was thereafter noted to progress well clinically through postoperative day number 14, [**2132-6-2**], at which point he was cleared for discharge to an extended care facility for further evaluation and management, and was provided instructions for follow-up. DISPOSITION: The patient is to be discharged to an extended care facility with instructions for follow-up. CONDITION ON DISCHARGE: Stable. DISCHARGE MEDICATIONS: 1. Digoxin 250 micrograms p.o. q. day. 2. Colace 100 mg p.o. twice a day. 3. Dilantin 100 mg p.o. q. day. 4. Lopressor XL 15 mg p.o. q. day. 5. Dilaudid 2 to 4 mg p.o. q. four to six hours p.r.n. for pain. 6. Levofloxacin 500 mg p.o. q. day times seven days. 7. Coumadin dosage to be titrated by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for a target INR of 2.5 to 3.0. DISCHARGE INSTRUCTIONS: 1. The patient is to maintain his incisions clean and dry at all times. 2. The patient may shower but to pat-dry incisions afterwards; no bathing or swimming until further notice. 3. The patient is to consume a soft solid, thickened liquids only diet, with Boost pudding supplement with each meal. 4. Physical Therapy for daily strength, balance and chest therapy. 5. Daily wound checks [**Hospital1 **]-weekly peripheral PT/INR draws on Mondays and Thursdays beginning [**2132-6-5**]; the results are to be reported to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for titration of Coumadin dose for target INR of 2.5 to 3.0. 6. Additional follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] as needed; the patient is to call [**Telephone/Fax (1) 16315**], to schedule an appointment. 7. The patient is to follow-up with Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**] in ten to 14 days following discharge; the patient is to call [**Telephone/Fax (1) 170**], to schedule an appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**] Dictated By:[**Last Name (NamePattern1) 1053**] MEDQUIST36 D: [**2132-5-31**] 18:08 T: [**2132-5-31**] 18:16 JOB#: [**Job Number 101399**] Admission Date: [**2132-5-16**] Discharge Date: [**2132-6-2**] Service: [**Last Name (un) **] [**Doctor First Name 147**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**] Dictated By:[**Last Name (NamePattern1) 1053**] MEDQUIST36 D: [**2132-5-31**] 18:08 T: [**2132-5-31**] 18:15 JOB#: [**Job Number 101399**]

[ "997.3", "780.39", "998.11", "492.8", "V43.3", "401.9", "427.31", "162.3", "443.9" ]

icd9cm

[ [ [] ] ]

[ "96.6", "33.22", "32.4", "33.24", "34.21", "34.22" ]

icd9pcs

[ [ [] ] ]

7275, 7681

2125, 7217

7705, 9485

1742, 1949

164, 1357

1379, 1721

1967, 2106

7243, 7252

30,887

134,444

9621

Discharge summary

report

Admission Date: [**2147-2-9**] Discharge Date: [**2147-2-24**] Date of Birth: [**2091-8-27**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 668**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Paracentesis x 2 Thoracentesis RIJ central venous line placement Hemodialysis catheter placement Hemodialysis History of Present Illness: Mr. [**Known lastname 32595**] is a 55 yo male with EtOH cirrhosis (hx of SBP and hepatic encephalopathy), DM who presented to Dr.[**Name (NI) 948**] office today for a regular appointment. There, he was noted to have a systolic BP in the 60s and reported lightheadedness for the past 2-3 days. He was sent to the emergency department, where his initial BP was 90/48. He reports one week of LH that he describes as discoordination/stumbling as well as fogginess like he has when becoming encephalopathic. He also has had decreased PO liquid intake and decreased UOP. He denies F/C, abd pain, changes in stool, BRBPR, melena, dysuria. He does report productive cough x 1.5 weeks and a sick contact in his wife. [**Name (NI) **] was recently admitted at [**Hospital3 **] for 5 days for RLE cellulitis in which he was d/c's one week ago and finished a course of keflex 2 days ago. He was recetnly of his lasix dose during that stay [**1-16**] increased creatinine, but it was restarted upon his discharge. His home dose of aldactone was stopped 1.5 weeks ago. He has had no other changes in his medications and ocntinues to take his lactulolse, titrated to [**4-19**] BMs daily. He had a 7L by para yesterday at [**Hospital3 3583**] (no cell count in their system), 10L last week. . In the ED, he recieved a 500cc bolus with improvement in his BP to 101/59. His CXR showed worsening L pleural effusion and he was given vanc/ceftaz. A paracentesis was not performed reportedly because of concern about his platelets being 21 and INR 1.8. He was afebrile, HR in the 60s, and satting 99% on RA. Past Medical History: # EtOH induced cirrhosis - Portal hypertension - Grade I esophageal varices - Diuretic refractory ascites. - On [**Hospital3 **] list after a recent 40lb weight loss - Multiple admissions to [**Hospital3 3583**] and [**Hospital1 18**] for hepatic encephalopathy - s/p TIPS [**2137**] with frequent revisions [**11/2145**] and then closure in [**4-/2146**] secondary to hepatic encephalopathy # Pancytopenia -Chronic from underlying liver disease -Baseline HCT in mid 20s -Baseline platelets in 20-40 # CKD with baseline Cr 1.0 # DM2, insulin dependent # s/p cholecystectomy for porcelain gallbladder in [**10/2145**] # Carcinoid tumor in gastric fundus # OSA (doesn't use his home BiPAP) # Squamous cell skin ca on left shoulder # Morbid Obesity # Chronic Venous Stasis Social History: Lives with his wife. Denies recent tobacco use, 8py h/o smoking, quit age 26. H/o alcohol abuse, quit ~[**2134**]. Remote marijuana/cocaine use in the 60s-70s, no IVDU. Unemployed at present. He previously worked as the director of food & beverage services on a cruiseline in the Hawaiian islands. Family History: Mother died at age 56 of a CVA. Father died at age 84 Alzheimer's. Sister with type II diabetes, seizures. Brother with heart disease. Another brother is healthy. Physical Exam: VS - T 96 BP 96/50 P 59 R Sat 99% on RA. GENERAL - Middle-aged male sitting in bed in NAD HEENT - sclerae anicteric, MMD NECK - supple, no thyromegaly, no JVD LUNGS - breathing comfortably. decreased BS on left. Mild rhonchi on right. HEART - RRR, no MRG ABDOMEN - normoactive BS, grossly distended, not tense. mild TTP RUQ, no TTP elsewhere. RUQ healed surgical scar present, umbilical hernia present EXTREMITIES - 1+ LE edema present b/l with venous stasis changes in his lower legs. Skin break in RLE, covered with clear dressing, no signs of infection. NEUO/PSYCH - alert and oriented x 3, very slight asterixis present. Strength 5/5 throughout. Sensation to light touch intact except decreased in toes bilaterally. CN 2-12 intact. Brief Hospital Course: MEDICINE Course: 55 yo with EtOH cirrhosis admitted for hypotension who was found to have ESBL Ecoli PNA and new ARF believed to be 2/2 HRS now on HD but may also have a component of ATN from hypotension. He was transferred off of Medicine for a liver [**Year (4 digits) **]. . #. Cirrhosis: Chronic issue, followed by Dr. [**Last Name (STitle) 497**]. Due to past etOH abuse. Sober for many years. Complicated by HRS. Encephalopathy was managed with high doses of lactulose and rifamixin. Definitively treated with liver [**Last Name (STitle) **] (see Surgery course). . #. Paroxysmal atrial fibrillation: Pt developed PAF this admission with rapid ventricular response. He has converted back into sinus each time spontaneously. Once his BP was somewhat unstable for SBPs around 80. He has known atrial dilation and is likely sensitive to hypervolemia stretching his atria and causing Afib. Started on metoprolol with good effect. . #. Hepatic encephalopathy: Worsened in the context of infection early in the admission. Improved with management of his PNA and high doses of lactulose + rifaximin 600 mg PO BID. . #. Renal failure: Concern for HRS with worsening creatinine despite IVF and albumin. Given his hypotension early in the admission in the context of spesis, there may be a component of ATN which may be recoverable. Renal u/s WNL. Nephrology involved and patient had tunneled SC right side placed [**2147-2-13**], started HD [**2147-2-13**]. . #. Ecoli/Klebsiella Pneumonia/RLE cellulitis: Growing Ecoli and Klebsiella both sensitive to meropenem from sputum. BCx and ascites Cx are negative. Treated with meropenem for known Ecoli and Klebsiella PNA. Plan for total of 14 days of treatment to be completed on [**2147-2-24**], but transferred to surgery prior to that time. Repeat PA and LAT CXR with improving edema and no signs of focal infiltrate prior to surgery. . #. Pancytopenia: chronic, thought [**1-16**] hepatic dysfunction. Transfuse for PLU < 10 or active bleeding. Transfuse for HCT < 21 or active bleeding. . #. DM2: Chronic issue. On ISS + glargine. . MICU Course: 1) Hypotension: Patient presented with hypotension with systolic BP's in 60's while sleeping. He reported some lightheadedness, but was mentating throughout. He initially received significant fluid resuscitation, albumin, and blood products with refractory blood pressure. He was never febrile or tachycardic, and WBC was initially at baseline ~2,000. Nonetheless, infectious work-up was pursued with a diagnostic paracentesis performed at time of admission to the ICU. Peritoneal fluid showed only 56 WBC's and culture was negative. He was started empirically on Levofloxacin for empiric coverage of a community-acquire pneumonia. On the day following admission, a diagnostic thoracentesis of his left pleural effusion was performed, with removal of 1 liter serosanguinous transudative fluid. Gram stain was negative and cultures were without growth. Due to persistently low BP's, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim test was performed to rule out adrenal insufficiency with appropriate result 11.7 -> 19.7. His home dose of Nadolol was held. TTE revealed dilated atria but preserved systolic function. A central line was placed and CVP measured at 33, following fluid resuscitation. BP's remained low for ~24 hours in the ICU, and antibiotic coverage was subsequently broadened to Vancomycin, Meropenem, and Levofloxacin. Sputum culture eventually grew an ESBL e.coli and pan-sensitive klebsiella organism. Vancomycin was discontinued, and patient was continued on Meropenem. - CMV viral load pending 2) Acute renal failure: On [**2-9**], patient was noted to have decreased urine output in the setting of hypotension. He voided 400 cc in the morning and subsequently did not void for ~24 hours. Bladder scan revealed urinary retention. Foley placement attempt was unsuccessful and Urology was called. Renal [**Month/Year (2) 950**] without evidence of hydronephrosis or post-obstructive pathology. Per Liver consult recommendations, patieht was started on standing albumin, midodrine, and octreotide for presumed hepatorenal syndrome. Bladder pressures were measured at ~30. Renal was subsequently consulted for his acute renal failure. On [**2-13**] a hemodialysis catheter was placed by IR, and HD was initiated without incident. Sevelamer was initiated for hyperphosphatemia. 3) Cirrhosis: Patient has known alcoholic cirrhosis, currently on [**Month/Day (2) 1326**] list. MELD score elevated to 35 on this admission. He was continued on Rifaximin and Lactulose. 4) Coagulopathy: He required multiple transfusions of platelets and FFP in effort to modify his coagulopathy for invasive procedures, including CVL placement, paracentesis, HD line placement, and thoracentesis. Patient is known to be guiac-positive. He was transfusion dependent for duration of ICU stay but without overt evidence of bleeding. 5) DM2: Patient had episodes of borderline hypoglycemia in the setting of ARF. His home dose of NPH was discontinued, and he was continued on sliding scale insulin. 6) Pleural effusion: s/p dignostic thoracentesis on [**2-10**] with removal of 1 liter serosanguinous fluid, consistent with transudate. Cultures NGTD. SURGICAL COURSE: Mr. [**Known lastname 32595**] [**Last Name (Titles) 1834**] an orthotopic liver [**Last Name (Titles) **] on [**2147-2-21**]. Please see Dr.[**Name (NI) 670**] op note for further detail. The operation was notable for a 15L blood loss, and he received approximately 64 pRBCs, 54 FFP, 13 platelets, 7 cryoprecipitate, and 1 Factor VII. His abdomen was left abdomen and transferred to the ICU in critical condition on pressors. On POD 1 he was taken back to the OR for a washout and closure of his abdomen. After his abdomen was closed, he remained critically ill with pressor requirements. On POD [**12-16**] his LFTs and INR rose, presenting a picture concerning for impending liver failure. A bedside [**Month/Day (2) 950**] failed to demonstrate portal flow. At this point, the patient had acute desaturation, became hypotensive, and had no breath sounds on his right side. He was urgently decompressed with a 16gauge angiocatheter needle -- a formal 28Fr chest tube was then inserted at the bedside. His oxygenation and pressures improved after these interventions. He then returned to the OR and [**Month/Day (2) 1834**] an exlap, portal vein and hepatic artery thrombectomies. A frozen section demonstrated ischemia but no hepatic necrosis. Please see Dr. [**Name (NI) 32606**] operative note for further detail. Again, he returned to the ICU in critical condition, on multiple pressors. On POD [**1-15**], he required multiple pressors to maintain his blood pressures. He also became increasingly acidemic. Given the large amount of blood products he had received, there was concern for citrate toxicity. His ionized calcium levels were persistently below 1.0, and his pressures transiently improved with calcium supplementation. By the morning of POD [**2-13**], he continued to have multiple pressor requirements. A repeat [**Month/Day (2) 950**] was unable to demonstrate hepatic artery flow. Given this complication, there were extensive discussions with the family about the patient's prognosis, and they chose to make him comfort measures only. He expired on [**2147-2-24**]. Medications on Admission: lasix 120mg qday (off for 5 days, restarted one week ago) aldactone 50mg (stopped 1.5 weeks ago) rifaximin 600 [**Hospital1 **] cipro 200 qday protonix 40mg qday nadolol 20mg qday lactulose ~ 45ml - titrate to [**4-19**] BMs insuline NPH 75qAM and 70qPM humalogue SSI QID acidophilus keflex QID (finished 5 days ago Discharge Disposition: Expired Facility: [**Hospital1 18**] Discharge Diagnosis: s/p OLT [**2-21**] Acute renal failure Pneumonia Hypotension Pleural effusion Ascites Pancytopenia Coagulopathy Cirrhosis Discharge Condition: Expired

[ "997.79", "E878.0", "327.23", "998.11", "459.81", "303.93", "572.3", "511.9", "482.82", "585.9", "250.00", "285.1", "456.21", "286.9", "276.1", "789.59", "278.01", "584.5", "427.31", "571.2", "572.4", "V58.67", "568.0", "453.9", "284.1", "572.2" ]

icd9cm

[ [ [] ] ]

[ "96.71", "38.95", "54.91", "51.36", "50.12", "00.93", "50.4", "38.07", "96.6", "39.95", "34.91", "54.12", "54.59", "38.93", "38.06", "50.59" ]

icd9pcs

[ [ [] ] ]

11940, 11979

4144, 11574

324, 435

12144, 12154

3193, 3357

12000, 12123

11600, 11917

3372, 4121

273, 286

463, 2068

2090, 2862

2878, 3177

54,381

131,708

5616+55686

Discharge summary

report+addendum

Admission Date: [**2130-6-27**] Discharge Date: [**2130-7-1**] Date of Birth: [**2071-3-7**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: flank pain Major Surgical or Invasive Procedure: none. History of Present Illness: 59 yo w/ hx of hepatitis C (neg VL), psoriatic arthritis, DM, HTN, depression, hx of etoh abuse (4yrs sober) and CKD stage III (per notes), who presented to the ED with c/o of b/l flank pain. Pt. reports that over the past few months he has felt more fatiuge that usual. He has lost 12lbs during that time but states that it was intentional. Over the past week, he developed bilateral flank pain, dull, gradual, w/o radiation. He was seen at NWH on [**7-12**] where he was admitted, was treated for pain and discharged home (per pt.). He apparently had CT abdomen that may have shown a liver mass. Since leaving NWH, he continued to feel malaised, developed SOB on exertion and while laying flat, had had decreased PO intake and feeling of being generally weak. He noted loose stools over the past 4 days. He reports that his roommate noted that his abdomen is larger, however, he has not noted this himself. After being at home in above state, . In the ED, initial vs were: T97.1F P83 BP115/86 R28 96%O2 sat. He underwent an abdominal US, which showed an echogenic liver without discrete mass on US and MPV, LPV and RPV thrombosis with small amount of ascites. With NG lavage, was noted to have a small amount of red blood in NS fluid after removal of ~1L of meds and food. Rectal exam was notable for BRBPR/hemorrhoids. Heparin gtt was held given concern for GIB and Protonix gtt was started. He received 15g of kyaxylate PO for hyperkalemia, which was suctioned w/ NG lavage. Paracentesis revealed 900 WBCs w/ 51% PMNs and ~ 14.5K RBCs. He was given Zosyn IV for suspected SBP. His tachypnea persisted, as did o2 requirement, thus was transferred to MICU. . On the floor, VS were 95.5F, 116/63, 87, 18, 94% on NRB. He was diaphoretic and taking rapid, shallow breaths. He felt mildly SOB, but had no other complaints. Past Medical History: psoriatic arthritis diabetes smoking hep c with undetectable viral load hypertension ADD depression h/o etoh abuse, sober for 3 years chronic renal insufficiency Social History: Lives with friend in [**Name (NI) **] alone. former brick layer and construction worker. - Tobacco: 1ppd x 40+ years - Alcohol: last 4 yrs ago. - Illicits: marijuana occasionally, denies IVDU. Family History: Mother committed suicide, ETOH abuse. Sister with severe depression. Father died in 60's of unknown cause. No FHx of cancer. No blood clotting d/os as far as he knows. Physical Exam: General: Alert, oriented, dyspneic and diaphoretic. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP 9, no LAD Lungs: decreased breath sounds throughout, no crackles/wheezes. CV: Regular rate and rhythm, normal S1 + S2, [**1-28**] SM at RUSB to neck, no gallops. Abdomen: distended, NT, tympanitic in midline, bowel sounds present, no rebound tenderness or guarding. Liver 7cm below costal margin. GU: foley Ext: cool, well perfused, 2+ pulses, no clubbing, cyanosis or edema NEURO: oriented, alert, attentive, intact language and praxis. Full strength in UEs and LEs. Toes down, normal tone. Pertinent Results: [**2130-6-27**] 11:23PM GLUCOSE-109* UREA N-102* CREAT-4.1* SODIUM-134 POTASSIUM-6.5* CHLORIDE-101 TOTAL CO2-10* ANION GAP-30* [**2130-6-27**] 11:23PM CALCIUM-8.9 PHOSPHATE-9.5*# MAGNESIUM-3.1* [**2130-6-27**] 11:23PM WBC-7.3 RBC-4.88 HGB-14.3 HCT-44.5 MCV-91 MCH-29.3 MCHC-32.1 RDW-15.6* [**2130-6-27**] 11:23PM PLT COUNT-191 [**2130-6-27**] 11:23PM PT-14.7* PTT-27.3 INR(PT)-1.3* [**2130-6-27**] 07:55PM ASCITES TOT PROT-1.4 GLUCOSE-130 LD(LDH)-320 ALBUMIN-0.8 [**2130-6-27**] 07:55PM ASCITES WBC-900* RBC-[**Numeric Identifier 22536**]* POLYS-51* LYMPHS-12* MONOS-34* MESOTHELI-3* [**2130-6-27**] 06:59PM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.022 [**2130-6-27**] 06:59PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-150 GLUCOSE-NEG KETONE-TR BILIRUBIN-MOD UROBILNGN-1 PH-6.5 LEUK-NEG [**2130-6-27**] 06:59PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [**2130-6-27**] 06:59PM URINE AMORPH-MOD [**2130-6-27**] 04:30PM GLUCOSE-142* UREA N-95* CREAT-3.6*# SODIUM-133 POTASSIUM-5.8* CHLORIDE-95* TOTAL CO2-16* ANION GAP-28* [**2130-6-27**] 04:30PM estGFR-Using this [**2130-6-27**] 04:30PM ALT(SGPT)-149* AST(SGOT)-271* ALK PHOS-376* TOT BILI-4.6* [**2130-6-27**] 04:30PM LIPASE-22 [**2130-6-27**] 04:30PM ALBUMIN-3.7 [**2130-6-27**] 04:30PM WBC-6.2 RBC-5.05 HGB-14.8 HCT-45.5 MCV-90 MCH-29.2 MCHC-32.4 RDW-15.6* [**2130-6-27**] 04:30PM NEUTS-83.5* LYMPHS-10.1* MONOS-4.5 EOS-1.6 BASOS-0.3 [**2130-6-27**] 04:30PM PLT COUNT-200 [**2130-6-27**] 04:30PM PT-14.1* PTT-28.0 INR(PT)-1.2* Brief Hospital Course: 59 year old with a history of hepatitis C (neg viral load), psoriatic arthritis, Diabetes Mellitus, hypertension, depression, history of etoh abuse (4 years sober) and chronic kidney disease stage III, who presented to the ED with complaints of bilateral flank pain. He was found to have portal vein thrombosis, bloody nasogastric lavage, bright red blood per rectum, tachypnea and repiratory distress. . # Portal Vein Thrombosis (main, left, right): Given the patient's history of a lung mass on CT at an outside hospital, malignancy was initially of great concern although hypercoaguable diseases, pancreatitis, and cirrhosis were also considered. The patient was started on a heparin drip on HD 2 after an endoscopy confirmed no active bleeding. A hypercoaguability panel was deferred to a later date as the patient was already started on heparin. A hepatitis panel and PSA were negative or within normal limits. An HCV viral load was pending at the time of death. A CEA was elevated concerning for malignancy. . # Acute Renal Failure / Chronic Kidney. The patient's acute renal failure was likely oliguric ATN with a FeNa of 1.7, The etiology may have been due to pre-renal ATN from intravascular depletion and underperfusion of the kidney. The patient was initially given an albumin load and started on a lasix drip. The lasix drip was switched to lasix boluses becuase the patient's BUN was increasing. Initially the patient's creatinine stabilized but did not decrease as would have been expected in ATN. The patient was in metabolic acidosis, with elevated K+. The patient was given kayexalate, bicarbonate and lasix with some improvement in his potassium. Extensive discussions with the patient revealed that he did not wish for invasive interventions, hemodialysis, to improve metabolic status. Afternoon labs on HD3 revealed elevated potassium and worsening creatinine. The patient was given an 80mg bolus of lasix with low urine output. The patient persistently refused kayexalate. An EKG demonstrated no change, no evidence of high k+. . # Metablic Acidosis, Respiratory acidosis: The patient presented with uncompensated mild lactic acidosis with concommitant respiratory acidosis. The patient's metabolic acidosis initially improved with albumin and lasix. On HD 3, afternoon labs revealed worsening renal function. The patient did not respond with adequate urine output to an 80 mg lasix bolus. The patient developed agitation in the afternoon which was thought to be secondary to receiving ativan and morphine for a CT scan as the onset coincided. The patient was given his celexa in the evening and was noted to calm down. He was called by nursing becuase of episodes of diaphoresis and agitation upon awakening that disappeared upon sleeping. An EKG revealed no evidence of acute MI or elevated k+. The patient was evaluated, vital signs were normal, (RR, HR and BP within normal limits) and stable and the patient was afebrile and continued to refuse medical care. In the evening it was decided to draw blood cultures, change his foley, send a urine culture and check his electrolytes. At this time, the patient developed deep breathing and worsening diaphoresis. Repeat labs and an ABG revealed marked lactic acidosis with a pH of 7.1. The patient developed hypotension to systolic 40s and became transiently unresponsive. 5L of normal saline were administered with levophed for pressure support. Bicarbonate and Narcan were also given and antibiotic therapy was extended to vancomycin and cefepime. Pressures returned and the patient was initially stabiliized and levophed was weaned off. Kayexalate per rectum was administered to the patient, stimulating another bradycardic hypotensive event. The patient was supported maximally with levophed and phenylephrine drips. Bicarbonate was again administered. A central line was placed in the right femoral artery for central access. The patient developed bradycardia and ventricular fibrillation before passing. Per the patient's wishes he was not intubated. . # Malignancy: A CT from [**Location (un) 745**] [**Location (un) 3678**] showed potential 15mm lesion in R lobe of liver; 10mm lesion in L lobe of liver. The patient presented with a normal AFP (1.4) but high levels of CEA (228), concerning for colon CA, cholangio CA, pancreatic CA, gastric CA, lung CA, medullary thyroid. However, CEA can also be raised in cirrhosis or pancreatitis. A CT chest abdomen and pelvis was performed without contrast (the patient has renal failure) on HD 3 to evaluate interval change of prior masses and evaluation of possible new masses. Preliminary read of the CT showed masses in the liver, lungs and mediastinum. Palliative care and the [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) **] Diabetes doctor [**First Name (Titles) **] [**Last Name (Titles) 4221**] to discuss the patient's stated wish to not pursue invasive treatment measures. The patient expressed wishes to not have dialysis, chemotherapy or non-curative surgery. . # Hypoxemia. The patient??????s hypoxemia is likely multifactorial: likely a combination of volume overload, pulmonary vascular shunting from liver thrombi, restrictive due to increased intraabdominal pressure w/ ascites, restrictive due to obesity, underlying pulmonary disease from chronic smoking. As hypoxia worsened over the patient's first night, there was concern for a PE, given patient's hypercoagulable condition. The patient was being treated for portal venous thrombosis with heparin drip, which is the treatment for PE. A TTE revealed no evidence of transpulmonary shunting or PFO or ASD. There was mild left vetricular hypertrophy, a bicuspid valve and moderate pulmonary hypertension noted. . # Spontaneous Bowel Perforation: A diagnostic paracentesis was postive for SBP although the patient demonstrated no clinical signs of encephalopathy or fever. The patient was started on ceftriaxone and an albumin challenge for HD 1 and 3. . #. Diabetes: PO diabetic drugs were held. Blood sugars were covered Humulin 15U HS and insulin sliding scale. . # Anxiety / pain: The patient's anxiety and pain were treated with IV morphine and ativan. The patients gabapentin and buspar were started when the patient was cleared for diet . # HTN. The patient's antihypertensive medications were held as he was normotensive on admission. . # Bloody NG lavage at end of procedure. Etiology unclear, at first there was concern for varcieal bleeding. The patient was initially treated with IV ppi and octreotide. Endoscopy revealed no variceal bleeding and octreotide was discontined and ppi was changed to PO. . # Bright Red Blood per Rectum: Likely due to external hemorrhoids. Hcts were monitored. Medications on Admission: Nizoral 2 % 1 per day Dextroamphetamine Sulfate 10 Mg 1 po qid Humulin N 100/ml as directed, up to 15 units daily Hydrochlorothiazide 25 Mg take 1 tablet (25MG) by ORAL route every day Celexa 20 Mg UNKNOWN TAKE ONE TABLET 1 TIME PER DAY Neurontin 600 Mg UNKNOWN 1 [**Hospital1 **] and 2 qhs Buspar 30 Mg 1 po bid Doxazosin Mesylate 2 Mg 1 tab in a [**12-24**] a day Simvastatin 40 Mg take 1 tablet (40MG) by ORAL HS Lorazepam 1 Mg [**12-24**] to 1 [**Hospital1 **] prn Metformin Hcl 500 Mg two pills twice a day Lisinopril 40 Mg take 2 tablet (80MG) by ORAL route every day Glipizide 10 Mg twice daily Norvasc 10 Mg 1 time per day Viagra 100 Mg as needed Ultram 50mg as needed Vitamin B-1 100 Mg Folic Acid 1mg once a day Discharge Disposition: Expired Discharge Diagnosis: Acute Renal Failure. Portal Venous Thrombosis. Discharge Condition: Patient expired. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 3775**] Admission Date: [**2130-6-27**] Discharge Date: [**2130-7-1**] Date of Birth: [**2071-3-7**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 3776**] Addendum: In the Brief Hospital Course: # Spontaneous Bowel Perforation should read # Spontaneous Bacterial Peritonitis Discharge Disposition: Expired [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 593**] [**Name8 (MD) 304**] MD [**MD Number(1) 594**] Completed by:[**2130-7-5**]

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icd9cm

[ [ [] ] ]

[ "38.93", "54.91", "45.13" ]

icd9pcs

[ [ [] ] ]

13302, 13481

13198, 13279

332, 339

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Discharge summary

report+addendum

Admission Date: [**2106-12-19**] Discharge Date: [**2106-12-30**] Date of Birth: [**2044-7-5**] Sex: M Service: MEDICINE Allergies: Aspirin Attending:[**First Name3 (LF) 8104**] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: None History of Present Illness: 62 yo male with hx of ?Crohns, hypertension, ?seizure d/o tranfered from [**Hospital3 **] s/p intubation for b/l pneumonia. Patient apparently with 3-4 days of fever and cough. Per EMTs he had a chest cold with non-productive cough without CP or SOB. He was seen by his PCP [**Last Name (NamePattern4) **] 3 days PTA and took cold medication without relief. In the field he was not in respiratory distress. BP 170/88, HR 100. His RR was 16 and 96%/RA. He was then evaluated in the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] where his VS were: 102.8, 124, 168/80, 40, 81%/RA at 1230pm. CXR reported to have b/l pneumonia. EKG showed sinus tachycardia with ?TWI though difficult to assess. He was intubated and given Levaquin and Ceftriaxone. Per their record, he received seasonal influenza vaccine. On arrival to [**Hospital1 **] his VS were: T100 (rectal), 86 113/59, 22, 97% on vent. ABG on AC, TV 550, Rate 14, Fi02 100, PEEP 5 was: 7.32/41/294 at 1700. Urine and blood cultures were sent. A CTA torso was done and showed small right-sided subsegmental PEs. NGT was placed and patient was given Ceftriaxone 1 gram IV and 3 L of IVF. He was sedated on Midazolam and Fentanyl. A Heparin drip was started. Received ceftriaxone in [**Hospital1 18**] ED and received levofloxacin in [**Hospital1 **]. VS on transfer to the ICU were: HR 60, BP 93/51, RR 15, O2Sat 100% (CMV TV 550, f 14, PEEP 5, FiO2 100%). On review of records, notable for SBPs to 80s in ED. so versed was decreased and fentanyl stopped. REVIEW OF SYSTEMS: unable to attain due to intubation Past Medical History: 1. Unknown psychiatric disorder 2. Seizures 3. HTN 4. HLD 5. Crohn's Disease 6. S/p partial right colectomy [**2089**] 7. S/p partial small bowel resection PCP is [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Name (STitle) **] [**Telephone/Fax (1) 49340**] Social History: No etoh or drugs, or current smoking per ED record at [**Hospital1 **] Family History: NC Physical Exam: VITALS: 96.4 (axillary) HR: 70 BP: 108/60 oxygen sat: 98% GENERAL: intubated HEENT: Normocephalic, atraumatic. No conjunctival pallor. +scleral edema/erythema. pupils small and sluggish but equally reactive. No JVD. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**], though difficult assessment due to lung sounds LUNGS: rhonchorous with good air movement b/l ABDOMEN: Decreased BS. Soft, distended. NT. No HSM EXTREMITIES: Trace edema b/l, 2+ dorsalis pedis/ posterior tibial pulses. Warm SKIN: No rashes/lesions, ecchymoses. NEURO: not following commands or opening eyes to voice Pertinent Results: OSH Labs: Trop .02 @1230 , Valproic acid 58, ABG on AC 550/12/90% at 1325: 7.26/54/170 7.0>11.1/32.2<119, MCV 89 N84.5, L8.8, M5.5, E0.9, B0.4 PT 15.2, PTT 29.0, INR 1.3 . 141/3.1/112/21/15/0.9<135 lactate 1.2 CK 946, MB 4, Trop <.01 ALT 55, AST 34 AP 74, TB 0.4 Lip 15 UA: >50 RBC, 0-2 WBC, mod bact, neg nitrite, 25 protein, 15 ketone, 0-2 epi Colonoscopy [**10/2103**]: Findings c/w Crohn's disease, mild ulceration at anastomotic site Admission Labs: [**2106-12-19**] 03:35PM WBC-7.0 RBC-3.61* HGB-11.1* HCT-32.2* MCV-89 MCH-30.6 MCHC-34.4 RDW-13.5 [**2106-12-19**] 03:35PM PLT COUNT-119* [**2106-12-19**] 03:35PM PT-15.2* PTT-29.0 INR(PT)-1.3* [**2106-12-19**] 03:35PM UREA N-15 CREAT-0.9 SODIUM-142 POTASSIUM-3.1* CHLORIDE-111* TOTAL CO2-20* ANION GAP-14 [**2106-12-19**] 03:35PM ALT(SGPT)-55* AST(SGOT)-34 CK(CPK)-946* ALK PHOS-74 TOT BILI-0.4 [**2106-12-19**] 03:35PM LIPASE-15 Cultures **FINAL REPORT [**2106-12-24**]** FECAL CULTURE (Final [**2106-12-24**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2106-12-24**]): NO CAMPYLOBACTER FOUND. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2106-12-22**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). [**2106-12-24**] SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-Non reactive **FINAL REPORT [**2106-12-24**]** GRAM STAIN (Final [**2106-12-22**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2106-12-24**]): NO GROWTH. **FINAL REPORT [**2106-12-27**]** Blood Culture, Routine (Final [**2106-12-27**]): NO GROWTH. **FINAL REPORT [**2106-12-26**]** Blood Culture, Routine (Final [**2106-12-26**]): NO GROWTH. **FINAL REPORT [**2106-12-22**]** DIRECT INFLUENZA A ANTIGEN TEST (Final [**2106-12-22**]): REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] AT 1017 [**12-20**]. REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 83727**] [**2106-12-22**] AT 1530. POSITIVE FOR INFLUENZA A VIRAL ANTIGEN. Positive for Swine-like Influenza A (H1N1) virus by RT-PCR at State Lab. DIRECT INFLUENZA B ANTIGEN TEST (Final [**2106-12-20**]): Negative for Influenza B. **FINAL REPORT [**2106-12-25**]** Blood Culture, Routine (Final [**2106-12-25**]): NO GROWTH. **FINAL REPORT [**2106-12-25**]** Blood Culture, Routine (Final [**2106-12-25**]): NO GROWTH. CT abd/pelvis with contrast [**12-20**] 1. Progression of bibasilar atelectasis and consolidation consistent with pneumonia. The known pulmonary emboli which were demonstrated previously were not examined on this abdomen and pelvis CT. 2. Interval increase in gallbladder distention and new pericholecystic fluid. The findings are potentially concerning for acute cholecystitis; clinical correlation is recommended. This could be further assessed with ultrasound and/or HIDA scan. TTE [**2106-12-20**] The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Doppler parameters are most consistent with normal left ventricular diastolic function. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild to moderate pulmonary artery systolic hypertension. There is no pericardial effusion. CTA torso [**12-19**] CT CHEST: There are filling defects within the right subsegmental arteries (3, 14 and 3, 26) supplying the anterior and posterior segments. In addition, filling defects involving the right middle lobe subsegmental branches (3, 47) are also identified. There are possible left upper lobe subgmental pulmonary emboli (3,24). There are bilateral lower lobe consolidations with air bronchograms (3, 57). While this may represent atelectasis as it is enhancing, underlying infection cannot be excluded given the presence of air bronchograms. There are multiple mediastinal and left hilar lymph nodes. For example, at example, there is a left hilar lymph node measuring 1.3 x 1.5 cm (3, 43). A prevascular lymph node measures 0.7 x 2.3 cm (3, 27). There is no axillary lymphadenopathy identified. There is no pleural effusion. Very trace pericardial fluid vs thickening is noted. There is no evidence of aortic dissection. No pneumothorax is seen. Gynecomastia is noted. CT OF THE ABDOMEN: The spleen, liver, gallbladder, pancreas, adrenal glands and kidneys are unremarkable. There is mild amount of perinephric fat stranding, bilaterally, nonspecific. Multiple small, subcentimeter retroperitoneal lymph nodes are noted. Small bowel loops are collapsed. There is no free fluid or free air. CT OF THE PELVIS: The rectum, sigmoid colon are unremarkable and contains large amount of stool and air. A Foley catheter is identified within the bladder. There is no pelvic or inguinal lymphadenopathy. BONE WINDOWS: There are no suspicious lytic or sclerotic lesions identified. Final Report REASON FOR EXAMINATION: Evaluation of NG tube placement. Portable AP chest radiograph was compared to prior study obtained at 06:46 a.m., the same day. The NG tube tip is in the stomach, in unchanged position. Cardiomediastinal silhouette is stable. There is significant interval improvement in pulmonary edema that is almost completely resolved. The right lower lobe atelectasis is currently more obvious than on the prior study since it is not obscured by the pulmonary edema. Bilateral retrocardiac atelectasis is present as well as bilateral pleural effusions. IMPRESSION: 1. Small right-sided subsegmental pulmonary emboli as described above. Possible left upper lobe subgmental pulmonary emboli. No evidence of right heart strain. 2. Bilateral lower lobe atelectasis; underlying infection not excluded. 3. Mediastinal lymphadenopathy. 4. No acute intra-abdominal pathology noted. [**2106-12-19**] EKG Normal sinus rhythm, rate 71. There is no diagnostic abnormality. No previous tracing available for comparison. Compared to the previous tracing the sinus rate has increased from 70 to 98 and there are minor anterolateral repolarization changes of non-specific chararacter. [**2106-12-20**] Cardiology ECHO Conclusions The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Doppler parameters are most consistent with normal left ventricular diastolic function. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild to moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Labs at Discharge: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2106-12-30**] 06:10AM 11.5* 2.92* 8.9* 27.0* 92 30.5 33.1 13.1 429 [**2106-12-29**] 05:31AM 9.9 3.13* 9.3* 29.1* 93 29.7 31.9 13.1 405 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [**2106-12-30**] 06:10AM 429 [**2106-12-30**] 06:10AM 32.2* 42.1* 3.2* [**2106-12-29**] 05:31AM 405 [**2106-12-29**] 05:31AM 21.5* 37.3* 2.0* Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2106-12-30**] 06:10AM 137* 16 0.7 140 3.8 107 25 12 [**2106-12-29**] 05:31AM 136* 14 0.7 141 3.6 107 23 15 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2106-12-29**] 05:31AM 8.8 3.2 1.9 Brief Hospital Course: ASSESSMENT AND PLAN: 62 yo male with hx of Crohns, hypertension, transferred from [**Hospital3 **] after an episode of respiratory distress and intubation. #. Hypoxic Respiratory Failure: He was transferred intubated due to respiratory failure. He was found to have influenza A, subsequently diagnosed as H1N1. He was treated with 150mg [**Hospital1 **] dosing of Tamiflu. He continued to be febrile for the first week of admission. He was also found to have a small right-sided subsegmental pulmonary emboli and possible left upper lobe subsegmental pulmonary emboli. He was started on a heparin gtt for anticoagulation and had a lower extremity ultrasound negative for DVT. There was also evidence of pneumonia on chest CT and he was treated for CAP with Levofloxacin/Ceftriaxone (day 1 [**12-19**]). Ceftriaxone was stopped on [**12-22**] due to negative culture data and he completed 5 days of Levofloxacin. A bronchoscopy was done on [**12-24**] which showed no evidence of malignancy (given enlarged lyumph nodes on CT scan of the chest). Cefepime/Vancomycin were started on [**12-25**] for continued fevers and possible Ventilator Associated Pneumonia. This was continued for a planned 7 day course. Patient was followed by the infectious disease team. He was extubated on [**12-27**] without complication but continued to require supplemental oxygen and nebulizer treatments. The last dose of Tamiflu was on [**12-28**] to complete a 10 day course. #Pulmonary embolism: For his pulmonary embolism, Mr. [**Known lastname 30683**] was initially on a Heparin drip which was transitioned to Lovenox with a bridge to Coumadin. Towards the end of his ICU course, Mr. [**Known lastname 30683**] self-diuresed with mild assistance with Lasix. His respiratory status remained stable on the floor. Lovenox was discontinued on day of discharge. #, Diastolic Heart Failure: Nl systolic function on echocardiogram. Lasix iv bid. #. Oropharyngeal bleed: On night of admission, patient developed gross blood from his oropharynx. His Hct remained stable and ENT evaluated patient and placed an OG tube. The bleeding was observed and felt to be secondary to trauma to the posterior pharynx from intubation. The bleeding resolved. #. Mental Status Changes: Patient would become aggitated unless not completely sedated during his intubation period. There was concern of his mental status, however post-extubation he was noted to be slow, but improving greatly by his brother. There were no concerning focal deficits to warrant further work-up. An RPR had been negative. He had continued improvement of his mental status on the floor. He was alert, oriented, attentive, with fluent and coherent speech. He did have mild cognitive impairments likely due to residual sedative effects and prolonged ICU stay. #. Elevated CKs: Patient had elevated CKs to 1000s during first days of admission. They downtrended and returned to [**Location 213**] levels. #. Bradycardia: Patient had episode of HRs to 40s with attempted insertion of NG tube. Tube was immediately withdrawn and HR increased to high 60s. This did not reoccur during admission. #. Crohn's Disease: No active issues during this admission, and given healthy weight, felt that was not malabsorbing to the point that parenteral premavir was needed. #. Seizure disorder/Depression: Patient was maintained on his home medications. CODE STATUS: Full code EMERGENCY CONTACT: [**Name (NI) **] brother, [**Name (NI) **] [**Name (NI) 30683**] [**Telephone/Fax (1) 83728**], cell [**Telephone/Fax (1) 83729**]; sister, [**Name (NI) 5731**] [**Name (NI) 83730**] [**Telephone/Fax (1) 83731**] CVS: [**Location (un) 5110**] on [**Location (un) **]. [**Telephone/Fax (1) 83732**] Medications on Admission: [**First Name8 (NamePattern2) **] [**Hospital1 **]: Divalproex sodium (Depakote) 125 mg [**Hospital1 **] Folic Acid-B2-B6 daily Escitalopram (Lexapro) 5 mg daily Cholestyramine (Questran) 4 GM Powd Olanzapine (Zyprexa) 2.5mg Oxcarbazepine (Trileptal) 150mg Zonisamide (Zonegram) 25mg [**First Name8 (NamePattern2) **] [**Location (un) 5110**] CVS: Folic Acid 1mg daily Zyprexa 20mg daily Furosemide 20mg daily Oxcarbazepine 900mg QHS Lexapro 10mg daily bromoline eye drops Zonisamide 300mg QHS Depakote 500mg ER daily Per family: Divalproex 500mg [**Hospital1 **] Zonegram 300mg QHS Oxcarbazapine 900mg QHS Lexapro 10mg daily Zyprexa 20mg QHS Per neurologist: Divalproex ER 500mg [**Hospital1 **] Zonisamide 300mg QHS Oxcarbazepine 900mg QHS Lexapro 20mg daily Lasix 10mg daily B12 injection every 2 months Zyprexa 20mg daily Questran 4g daily Centrum MVI daily Folate 1mg daily Discharge Disposition: Extended Care Facility: [**Hospital1 **] Discharge Diagnosis: 1) Influenza 2) Respiratory failure 3) Pulmonary Embolism 4) Decompensated Diastolic Heart Failure 5) Ventilator Associated Pneumonia Discharge Condition: Mental Status:Clear and coherent, though with some memory impairment/confusion, but attentive and interactive Level of Consciousness:Alert and interactive Activity Status:Out of Bed with assistance to chair or wheelchair Discharge Instructions: You were admitted with respiratory failure likely due to influenza pneumonitis. You were also noted to have pulmonary emboli of unclear etiology and stated on anticoagulation. You also have fluid overload. Your course was also possibly complicated by pneumonia. Followup Instructions: You will be given instructions on your follow-up appointments when you are discharged from rehabilitation. Name: [**Known lastname 13308**],[**Known firstname 63**] Unit No: [**Numeric Identifier 13309**] Admission Date: [**2106-12-19**] Discharge Date: [**2106-12-30**] Date of Birth: [**2044-7-5**] Sex: M Service: MEDICINE Allergies: Aspirin Attending:[**First Name3 (LF) 5698**] Addendum: See attached addendum Brief Hospital Course: He will need outpatient testing to determine possible etiologies of pulmonary emboli. Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 2. Oxcarbazepine 600 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 3. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-8**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Divalproex 500 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a day). 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed for constipation. 9. Zonisamide 100 mg Capsule Sig: Three (3) Capsule PO HS (at bedtime). 10. Olanzapine 10 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze, sob. 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 15. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 16. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous twice a day for 3 days: last dose 12/27. 17. Cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection Q8H (every 8 hours) for 3 days: last dose 12/27. 18. Furosemide 20 mg IV BID Discharge Disposition: Extended Care Facility: [**Hospital1 **] Discharge Diagnosis: 1) Influenza 2) Respiratory failure 3) Pulmonary Embolism 4) Decompensated Diastolic Heart Failure 5) Ventilator Associated Pneumonia Discharge Condition: Mental Status:Clear and coherent, though with some memory impairment/confusion, but attentive and interactive Level of Consciousness:Alert and interactive Activity Status:Out of Bed with assistance to chair or wheelchair Discharge Instructions: You were admitted with respiratory failure likely due to influenza pneumonitis. You were also noted to have pulmonary emboli of unclear etiology and stated on anticoagulation. You also have fluid overload. Your course was also possibly complicated by pneumonia. You will need to have further testing to determine why you have blood clots in your lung. Followup Instructions: You will be given instructions on your follow-up appointments when you are discharged from rehabilitation. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5700**] MD [**MD Number(2) 5701**] Completed by:[**2106-12-30**]

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icd9cm

[ [ [] ] ]

[ "96.07", "96.72", "31.42", "38.91", "38.93", "96.6" ]

icd9pcs

[ [ [] ] ]

19138, 19181

17349, 17436

290, 296

19359, 19359

2996, 3443

19982, 20249

2319, 2323

17459, 19115

19202, 19338

15192, 16075

19606, 19959

2338, 2977

1882, 1918

230, 252

10652, 11394

324, 1863

3460, 10633

19373, 19582

1940, 2215

2231, 2303

515

184,373

16520+16521+16522

Discharge summary

report+report+report

Admission Date: [**2162-6-12**] Discharge Date: Date of Birth: [**2094-6-13**] Sex: M Service: CCU CHIEF COMPLAINT: Transferred to [**Hospital6 649**] for workup of right-sided heart failure and evaluation for possible mitral valve replacement. HISTORY OF THE PRESENT ILLNESS: This is a 67-year-old male with an extensive cardiac history including CABG times three, mitral valve repair in [**2159**], ejection fraction 30-40%, [**2-1**]+ MR, [**3-2**]+ TR, dilated right and left atria and right ventricle, history of V tach arrest, now status post AICD placement, history of sick sinus syndrome, now status post pacer placement, pulmonary hypertension, systemic hypertension, chronic atrial fibrillation, and chronic renal failure, who presented to [**Hospital 1474**] Hospital on [**2162-6-8**] complaining of nausea, vomiting, and increasing abdominal girth. He was found to be hypotensive (questionable) presumably by overdiuresis and was treated with IV fluids, packed red blood cells and was briefly on pressors. A CT of the abdomen showed abdominal ascites with pooling of IV contrast in the right heart and IVC. The patient was then transferred to the [**Hospital6 256**], as noted above. Workup of liver etiology of ascites has been negative. Paracentesis here withdrew 750 cc of transudative fluid. Cardiac Surgery consult was placed to evaluate the patient for a possible mitral valve replacement. The patient was seen by the Dental Service and was cleared for surgery by them. A TTE and a TEE were performed. The TTE was performed on [**2162-6-14**] and was mostly consistent with the TEE findings as will be described below except that the mitral regurgitation was qualified as 3+ and the tricuspid regurgitation was 4+. The TEE was performed on [**2162-6-15**] and showed a markedly dilated right atrium, dilated right ventricle, [**12-31**]+ MR, 2+ TR, markedly dilated left atrium, severely depressed left ventricular function, and a well-seated mitral valve ring. As part of the preoperative workup, the patient was sent to undergo cardiac catheterization. During that cardiac catheterization the patient was found to have elevated bilateral filling pressures. Measurements were taken pre and post milrinone with the following results listed respectively: Cardiac output 3.88, 4.31; cardiac index 1.77 and 1.9; pulmonary capillary wedge pressures 33 and 28; pulmonary artery pressure 60/32 and 50/25; right atrial pressure 25 and 21; left ventricular ejection fraction was found to be 37% with 4+ MR. The patient's only patent graft was found to be his LIMA to LAD and he also had a patent left main stent which is supplying his left circumflex. Consequently, he was transferred from the Catheterization Laboratory to the CCU to undergo milrinone therapy and aggressive diuresis to optimize him for any surgery that might take place. At the time of this dictation, Surgery evaluation is still ongoing and the final treatment option for this patient has not been decided upon. PAST MEDICAL HISTORY: 1. Coronary artery bypass graft (CABG) in [**2141**], [**2146**], and [**2159**]. 2. Cardiac catheterization in [**11-30**], during which the patient's left main underwent rotational atherectomy and PTCA with stent placement, slowly with evidence of competitive flow, midvessel, after takeoff. 3. Status post mitral valve repair in [**2159**]. 4. Pacer placement in [**2161-4-29**]. 5. AICD placement in [**2162-4-29**] for a V tach arrest which was DC cardioverted to sinus rhythm during an admission for CHF exacerbation and hemoptysis. The pacer placement was for sick sinus syndrome. 6. Chronic atrial fibrillation, ejection fraction 25-40%. 7. Pulmonary hypertension. 8. Systemic hypertension. 9. Hypercholesterolemia. 10. Chronic renal failure with a baseline creatinine of 1.3. 11. Gout. 12. Hemoptysis. 13. GERD. 14. Status post appendectomy. 15. Status post right neck mass excision. 16. Status post herniorrhaphy. 17. Iron-deficiency anemia. ADMISSION MEDICATIONS: 1. Lopressor 12.5 b.i.d. 2. Plavix 75 q.d. 3. Lipitor 10 q.d. 4. Imdur 30 q.d. 5. Hydralazine 10 t.i.d. 6. Aldactone 25 b.i.d. 7. Coumadin 2.5 q.h.s. 8. Prevacid 30 q.d. 9. Folic acid one q.d. 10. Albuterol, Atrovent, and Flovent inhalers. 11. Lexapro 10 q.d. 12. Colchicine. 13. Lasix 120 p.o. q.d. 14. Zaroxolyn 2.5 q.d. MEDICATIONS ON TRANSFER FROM THE MEDICINE FLOOR TO THE CCU: 1. Captopril 12.5 t.i.d. 2. Aspirin 81. 3. Lopressor 12.5 b.i.d. 4. Lipitor. 5. Zaroxolyn 2.5 q.d. 6. Ibuprofen. 7. Colchicine. 8. Tums. 9. Albuterol. 10. Atrovent. 11. Fluticasone. 12. Lexapro. 13. Folate. 14. Protonix. ALLERGIES: Quinidine causes a rash. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 97.6, pulse 66, V paced, blood pressure 103/61, respiratory rate 15, oxygen saturation 91% on 2 liters, pulmonary artery pressure 52/27 with a mean of 36, cardiac output 4.1, cardiac index 1.2. No focal neurological deficits. Alert and oriented times three. Heart: Regular heart rate. No rubs or gallops. A positive IV/VI holosystolic mitral regurgitation murmur. Extremities: Marked lower extremity edema. Neck: Positive JVD bilateral. Lungs: Lower one-third lung field crackles. Abdomen: Soft, nontender, nondistended. HEENT: No icterus. No pallor. Mucous membranes moist. Right femoral vein cordis with Swan in place. Right femoral arterial line. PERTINENT DATA ON TRANSFER TO CCU: Hematocrit 33.3, INR 1.6, creatinine 1.2. HOSPITAL COURSE: In addition to the above described in the history of the present illness, it should be noted that on a CAT scan performed at an outside hospital there is evidently a small mass on one of the patient's kidneys which will need further evaluation after the patient's acute episodes are resolved. After transfer to the CCU, the patient was maintained on a milrinone drip and was started on a Lasix drip. Over the first two days, he diuresed 8 liters of fluid with improvement in his cardiac index and his pulmonary artery pressures. He was continued on his beta blocker, ACE inhibitor, Aldactone, Zaroxolyn. His Plavix and Coumadin were held in anticipation of surgery and heparin was not started as the patient was maintaining an INR of 1.6 to 1.8 on his own. A Swan-Ganz was eventually re-sited to the right IJ to allow the patient more mobility. His right femoral arterial line was also re-sited to his right radial artery for the same reason. The rest of this hospital course and discharge status, medications, and diagnoses will be addended by the next intern coming on service. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5214**] Dictated By:[**Last Name (NamePattern1) 2582**] MEDQUIST36 D: [**2162-6-20**] 12:20 T: [**2162-6-20**] 08:47 JOB#: [**Job Number 46926**] Admission Date: [**2162-6-12**] Discharge Date: [**2162-7-5**] Date of Birth: [**2094-6-13**] Sex: M Service: CARDIOTHORACIC CHIEF COMPLAINT: Mr. [**Known lastname 1968**] is a 68-year-old male who was admitted in mid-[**Month (only) **], with a complaint of abdominal discomfort, to the medical service. HISTORY OF PRESENT ILLNESS: A 68-year-old man with a history of CAD, status post CABG, with a history of congestive heart failure and also mitral valve repair, as well as ICD placement, presented to outside hospital prior to transfer to [**Hospital1 **]-[**Hospital1 **] [**First Name (Titles) 151**] [**Last Name (Titles) **], vomiting, hypertension, and new onset ascites. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 415**] MEDQUIST36 D: [**2162-7-5**] 12:30 T: [**2162-7-5**] 11:31 JOB#: [**Job Number 46927**] Admission Date: [**2162-6-12**] Discharge Date: [**2162-7-5**] Date of Birth: [**2094-6-13**] Sex: M Service: CARDIOTHORACIC HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old man with a long cardiac history which includes coronary artery bypass grafting in [**2141**], [**2146**] and [**2159**], associated with congestive heart failure and an EF of 25-30%. He has also had a mitral valve replacement in the past, as well as an AICD placement in [**Month (only) 116**] of this year. He presented to the [**Hospital 1474**] Hospital with complaint of [**Hospital **] and vomiting, as well as increased abdominal girth. He was found to be hypotensive and was admitted to their ICU briefly requiring pressors. An echo at the [**Hospital 1474**] Hospital showed an EF of 40% with PA systolic pressures of 25-30, severe MR [**First Name (Titles) **] [**Last Name (Titles) **], as well as hypokinesis of the inferior posterior walls, as well as hypokinesis of the apical septum. The patient was transferred to [**Hospital Ward Name 26168**] [**First Name (Titles) **] [**Last Name (Titles) **] to discuss treatment of his ascites and possibly redo mitral valve. PAST MEDICAL HISTORY: 1) Significant for, as stated previously, CABG in [**2141**], [**2146**] and [**2159**], with a LIMA to the LAD and saphenous vein graft to the PDA in [**2146**], and a radial graft to the LIMA to the PDA in [**2159**]. 2) Congestive heart failure with an EF of 25-30%, with ischemic cardiomyopathy. 3) Status post mitral valve repair. 4) Chronic atrial fibrillation. 5) Sick sinus syndrome, status post pacer in [**2161-4-29**]. 6) A V-tach arrest at the time of admission for his sick sinus syndrome. 7) Pulmonary hypertension. 8) Hypertension. 9) Chronic renal insufficiency. 10) GERD. 11) Hypercholesterolemia. 12) Gout. 13) Bronchitis associated with hemoptysis. 14) Iron deficiency anemia. PAST SURGICAL HISTORY: 1) Significant for coronary artery bypass grafting x 3. 2) Mitral valve replacement x 1. 3) Appendectomy. 4) Right neck mass excision. 5) Hernia repair. MEDS AT ADMISSION: 1) lasix 120 qd, 2) Zaroxolyn 2.5 prn with weight gain, 3) aspirin 325 qd, 4) Lopressor 12.5 [**Hospital1 **], 5) Plavix 75 qd, 6) Prevacid 30 qd, 7) folic acid 1 qd, 8) Lipitor 10 qd, 9) Imdur 30 qd, 10) hydralazine 10 tid, 11) aldactone 25 [**Hospital1 **], 12) Lexapro 10 qd, 13) albuterol prn, 14) Atrovent prn, 15) Flovent [**Hospital1 **], 16) Coumadin 2.5--last taken [**2162-6-7**]. ALLERGIES: Quinidine which causes a rash. SOCIAL HISTORY: Lives with his wife in [**Name (NI) 39908**], [**State 350**]. Occasional alcohol. No history of alcohol abuse. Denies tobacco use. PHYSICAL EXAM AT TIME OF ADMISSION: Vital signs - temperature 97.4, heart rate 55, blood pressure 129/77, respiratory rate 24, O2 sat 99% on room air. General - pleasant man, sitting upright, speaking in full sentences, in no acute distress. Skin - no jaundice or rashes. HEENT - anicteric, noninjected. Pupils equally round and reactive to light. Extraocular movements intact. Mucous membranes moist. OP clear. Neck - JVD at angle of jaw, no bruits. no lymphadenopathy. Heart - irregularly irregular, III/VI holosystolic murmur throughout. Respiratory - a few vesicular breath sound at bases, otherwise clear. Abdomen was distended, nontender, soft, with shifting dullness to percussion, but no fluid wave transmission, no hepatosplenomegaly, positive bowel sounds. Extremities - 3+ pitting edema bilaterally up to the knees. Neuro - cranial nerves II through XII grossly intact, no focal deficits. LAB DATA: White count 6.4, hematocrit 34.9, platelets 160, PT 18.5, PTT 39.8, INR 2.3, sodium 138, potassium 4.3, chloride 100, CO2 28, BUN 25, creatinine 1.3, ALT 16, AST 68, LDH 994, alk phos 86, total bili 2.4, albumin 3.9. EKG was afib., paced irregularly with a rate of 63, with axis of -68??????, [**Street Address(2) 1766**] elevations in V3, and [**Street Address(2) 4793**] elevation in V2 through 4. HOSPITAL COURSE: The patient was treated by the medical service with consultation from heart failure service, as well as cardiology. The cardiac surgery service was consulted as well. The patient was diuresed over the first 10 days of his hospitalization. Following that period of time, the patient was evaluated for heart transplant, as it was felt that he may require an LVAT during his mitral valve replacement. On the [**6-25**], the patient was brought to the cardiac catheterization lab where an intra-aortic balloon pump was placed prior to his being transferred to the operating room for a redo mitral valve replacement. Please see the catheterization lab report for full details. In summary, he had an intra-aortic balloon pump placed prior to surgery. He was then brought directly to the surgical suite, at which time he underwent redo mitral valve replacement with a #27 mosaic porcine valve via a right thoracotomy. The patient tolerated the operation and was transferred from the operating room to the Cardiothoracic Intensive Care Unit. Please see the OR report for full details and summary. The patient was transferred, after redo MVR, with a mean arterial pressure of 82. He was V-paced at a rate of 80. His IV medications included amiodarone at 2 mg/min, epinephrine at 0.03 mcg/kg/min, milrinone at 0.5 mcg/kg/min, Levophed at 0.15 mcg/kg/min, and propofol at 10 mcg/kg/min. In the immediate postoperative period, the electrophysiology service was consulted regarding ventricular ectopy. At that time, his internal pacer was increased to a rate of 90 in an attempt to control his ventricular ectopy. The patient did well in the immediate postoperative period. During the first 24 hours, epinephrine was weaned to off, and his amiodarone was decreased to 1 mg/min. On the morning of postoperative day #1, the intra-aortic balloon pump was weaned and ultimately discontinued. During that period, the patient remained hemodynamically stable. Neurologically, the patient's sedation was weaned to a point that he was able to move all four extremities and nod appropriately following a quick neuro assessment. The patient was resedated therefore requiring continued ventilatory support. Following removal of the intra-aortic balloon pump, the patient's Levophed was weaned to off, and on postoperative day #2, the propofol was discontinued, thereby allowing us to wean the patient from the ventilator. The patient was successfully extubated on postoperative day #2. Over the next several days, the patient was slowly weaned from his milrinone infusion. On postoperative day #5, the milrinone was successfully discontinued. Following the successful discontinuation of the IV milrinone infusion, the patient was transferred to Far-2 for continued postoperative care and cardiac rehabilitation. The patient remained on Far-2 for an additional three days, during which time his activity level was increased with the assistance of the physical therapist and the nursing staff. On postoperative day #10, it was decided that the patient was stable and ready to be discharged to home with the assistance of visiting nurses. DISCHARGE PHYSICAL EXAM: Vital signs - temperature 98, heart rate 70, V-paced, blood pressure 100/52, respiratory rate 20, O2 sat 95% on room air, weight preoperatively 102 kg, and at discharge 97.3 kg. Alert and oriented x 3. Moves all extremities. Follows commands. Respiratory - breath sounds diminished at the bases, otherwise clear to auscultation. Cardiac - regular rhythm, S1, S2. Right thoracotomy incision with staples, no erythema. Abdomen was soft, nontender, positive distention, and positive bowel sounds. Extremities were warm and well-perfused with 3-4+ edema bilaterally. LAB DATA: Hematocrit 29.3, PT 14.7, INR 1.4, potassium 3.9, BUN 21, creatinine 1.3. DISCHARGE MEDICATIONS: 1) carvedilol 3.125 mg [**Hospital1 **], 2) aldactone 12.5 mg qd, 3) enalapril 5 mg [**Hospital1 **], 4) amiodarone 400 mg [**Hospital1 **] x 1 week, then 400 mg qd x 1 week, then 200 mg qd for 1 month, 5) lasix 80 mg [**Hospital1 **], 6) potassium chloride 20 mEq qd, 7) enteric-coated aspirin 325 mg qd, 8) senna 2 tablets [**Hospital1 **], 9) percocet 5/325, 1-2 tabs, q 6 h prn, 10) resume Prevacid 30 mg qd. DISCHARGE DIAGNOSES: 1) Status post redo mitral valve replacement with a #27 mosaic porcine valve via a right thoracotomy. 2) Status post coronary artery bypass grafting x 3, [**2141**], [**2146**], [**2159**]. 3) Congestive heart failure. 4) Chronic atrial fibrillation. 5) Sick sinus syndrome and ventricular tachycardic arrest. 6) Status post AICD permanent pacemaker placement. 7) Pulmonary hypertension. 8) Hypertension. 9) Chronic renal insufficiency. 10) Gastroesophageal reflux disease. 11) Hypercholesterolemia. 12) Gout. 13) Bronchitis associated with hemoptysis. 14) Iron deficiency anemia. 15) Status post appendectomy. 16) Status post right neck mass excision. 17) Status post hernia repair. CONDITION AT DISCHARGE: Good. FO[**Last Name (STitle) **]P: 1) He is to have follow-up with Dr. [**Last Name (Prefixes) **] in [**3-2**] weeks. 2) Follow-up with Dr. [**Last Name (STitle) **] from the heart failure service on [**7-22**] at 1:00 pm. 3) Follow-up with Dr. [**Last Name (STitle) **], his primary care provider, [**Last Name (NamePattern4) **] 1 month. 4) He is also to have follow-up in the wound clinic in 1 week. DI[**Last Name (STitle) 408**]E INSTRUCTIONS: The patient is also to have a potassium, BUN and creatinine checked by the visiting nurses with results called-in to Dr. [**Last Name (STitle) **] [**Last Name (Prefixes) 2546**] office on Thursday, [**7-8**]. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 415**] MEDQUIST36 D: [**2162-7-5**] 12:30 T: [**2162-7-5**] 11:31 JOB#: [**Telephone/Fax (2) 46928**]

[ "424.0", "414.02", "428.0", "424.2", "414.01", "V45.82", "403.91", "789.5", "427.31" ]

icd9cm

[ [ [] ] ]

[ "88.53", "39.61", "38.93", "88.56", "54.91", "37.23", "37.61", "35.23", "89.68", "97.44" ]

icd9pcs

[ [ [] ] ]

16155, 16864

15719, 16133

11876, 15012

4040, 4724

9763, 10377

16879, 17802

7028, 7192

7992, 9008

4739, 5514

9031, 9739

10394, 11858

15038, 15695

26,139

175,355

10418

Discharge summary

report

Admission Date: [**2132-10-30**] Discharge Date: [**2132-11-23**] Date of Birth: [**2061-9-24**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Oxacillin / Heparin Agents Attending:[**First Name3 (LF) 826**] Chief Complaint: line sepsis Major Surgical or Invasive Procedure: hemodialysis hemodialysis catheter replacement mechanical ventilation transesophageal echocardiogram midline placement History of Present Illness: Mr. [**Known lastname 4154**] is a 71 year old man with PMH significant for ESRD on HD and endocarditis who was admitted to [**Hospital3 105**] on [**2132-9-12**] with respiratory failure and endocarditis following a hospitalization at [**Hospital1 18**] for MRSA septic shock. He had been recovering there until day of arrival, when he was found to have a fever of 101.0. He was found to be growing VRE and was started on linezolid on day of admission. It is not clear if this was from a surveillance culture or if he had been spiking fevers prior to day of arrival. While at [**Hospital1 **], vanco had been dosed by level throughout his course, with the last level 30 on [**10-28**]. Of note, he was dialyzed today through the tunnelled catheter that was placed in his groin in [**10-9**] by IR. At baseline, the patient is oriented x [**11-24**] with periods of confusion. He was transferred to this facility for change of HD access. Past Medical History: 1. ESRD on HD, anuric, M, W, F tunneled catheter 2. Atrial Fib/DDD pacer [**6-27**] interrogation 3. CAD s/p stent mild 40% prox LAD on cath '[**27**]. Echo showed EF > 60% on [**10-27**], mod pulm HTN, no significant valve dz. Normal MIBI in [**10-26**]. 4. hypothyroid 5. PEG 6. h/o LUE DVT (on coumadin) 7. HTN 8. ? HIT 9. Left total knee replacement [**2123**] 10. multiple line infections 11. h/o presumable MRSA endocarditis and sepsis [**9-27**] (could not be confirmed with TTE) TEE not perfomred as pt has esophageal narrowing on EGD in past. 12. Anemia of chronic disease (on Epo) 13. Vented since [**5-27**] line sepsis, MRSA PNA, recurrent [**2132-7-1**] 14. history of TB as a child and now with negative PPD 15. DM (?) 16. VRE in urine in [**6-27**] Social History: Retired dentist, was living in [**Location (un) **] with wife, kids, and [**Name2 (NI) 7337**], denies etoh/tob. Family History: Both parents died in 90's, healthy. Physical Exam: T 99.7 HR 69 BP 198/92 RR 30 93% vent: 550 x 12 40% PEEP 5 Gen: agitated, HEENT: MMM, pupils reactive Neck: trach in place, no LAD, bilateral 4-6 cm area of nontender edema over shoulders Cor: RRR 1/VI systolic murmur best heard over LLSB Pulm: CTAB no crackles Abd: obese, well healed surgical incisions, NTND + BS no hepatosplenomegaly Ext: WWP, DP/PT/Radial pulses 2+, no splinter hemorrhages, osler nodes Neuro: hand grip [**3-27**] otherwise patient did not comply with exam, + asterixis, could not evaluate cranial nerves although palate elevated symmetrically. Pertinent Results: Admission: [**2132-10-29**] 10:20PM BLOOD WBC-10.8 RBC-3.13* Hgb-9.1* Hct-27.6* MCV-88 MCH-28.9 MCHC-32.8 RDW-18.9* Plt Ct-186 [**2132-10-29**] 10:20PM BLOOD Neuts-90.6* Bands-0 Lymphs-5.1* Monos-3.8 Eos-0.4 Baso-0.2 [**2132-10-29**] 10:20PM BLOOD PT-17.1* PTT-28.0 INR(PT)-2.0 [**2132-10-29**] 10:20PM BLOOD Glucose-49* UreaN-34* Creat-2.2* Na-140 K-5.5* Cl-107 HCO3-27 AnGap-12 [**2132-10-29**] 10:20PM BLOOD ALT-44* AST-79* AlkPhos-471* TotBili-0.4 [**2132-10-29**] 10:20PM BLOOD Calcium-8.6 Phos-1.6* Mg-2.2 [**2132-10-30**] 09:34AM BLOOD Type-ART pO2-114* pCO2-35 pH-7.47* calHCO3-26 Base XS-1 [**2132-10-29**] 10:53PM BLOOD Lactate-1.7 [**2132-11-23**]: [**2132-11-23**] 04:33AM BLOOD WBC-14.7* RBC-3.68* Hgb-10.5* Hct-33.8* MCV-92 MCH-28.6 MCHC-31.1 RDW-18.4* Plt Ct-105* [**2132-11-23**] 04:33AM BLOOD Glucose-68* UreaN-40* Creat-3.1* Na-139 K-4.8 Cl-107 HCO3-24 AnGap-13 [**2132-11-23**] 04:33AM BLOOD Calcium-9.5 Phos-3.4# Mg-2.5 [**2132-11-22**] 11:46AM BLOOD Type-ART Temp-38.4 Rates-20/2 Tidal V-500 PEEP-10 FiO2-80 pO2-78* pCO2-55* pH-7.23* calHCO3-24 Base XS--5 AADO2-440 REQ O2-75 Intubat-INTUBATED Vent-CONTROLLED CT head [**10-29**]: No evidence of hemorrhage or infarction. Evidence of chronic ischemia and right maxillary sinus and bilateral mastoid opacification, unchanged since [**2132-6-11**]. CXR [**10-29**]: Bilateral multifocal pneumonia, and/or a moderate degree of congestive failure. ECHO [**10-31**]: 1. The left atrium is mildly dilated. The left atrium is elongated. The right atrium is moderately dilated. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3.Right ventricular chamber size is normal. Right ventricular systolic function is normal. There is an echogenic density in the right ventricle consistent with a pacemaker lead. 4.The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. 5.The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Physiologic mitral regurgitation is seen (within normal limits). 6.There is moderate pulmonary artery systolic hypertension. 7.There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2132-9-1**], no change. IMPRESSION: No echocardiographic evidence of endocarditis. PICC placement [**11-7**]: 1. Successful placement of a 21 cm, single lumen [**Last Name (un) **] midline catheter with tip in the left subclavian vein, ready for use. 2. Venogram demonstrates stenosis at the junction of the left subclavian and brachiocephalic veins. TEE [**11-7**]: Conclusions: Despite multiple attempts, the TEE probe could not be passed into the esophagus. At baseline, the patient was hypotensive, on vasopressors, with difficult intravenous access, therefore deeper sedation was deemed unsafe from the hemodynamic standpoint. TEE was therefore aborted. CXR [**11-14**]: No significant interval change in the appearance of the right mid lung infiltrate, pulmonary vascular congestion, and pleural effusion since the prior study. CXR [**11-18**]: Increased pulmonary edema compared to [**2132-11-18**] with unchanged probable multifocal pneumonia. Brief Hospital Course: Assessment: 71yo man with ESRD on HD< CAD s/p PCI, paroxysmal afib s/p PPM, ?HIT, recurrent line bacteremia, ventilator-dependent since [**5-27**], admitted with VRE line bacteremia and pseudomonas multifocal pneumonia, progressively deteriorated without alternative options for treatment, until goals of care were made to be comfort measures only. Hospital course is discussed below by problem: 1. Line sepsis: He was found to have VRE from his hemodialysis catheter. This was removed and replaced twice. In addition, he was treated with many antibiotics, including (at the end of his hospitalization) daptomycin, colistin, metronidazole, and ambisome. His lines continued to be infected. The idea of treating him with an "antibiotic lock" using ambisome, daptomycin, and argatroban in a heplock was considered, but no studies of safety and efficacy had been done investigating this method. The ID team was following his care closely throughout the hospitalization. 2. Hypotension: The patient was found to be recurrently hypotensive. This was most likely secondary to sepsis, as he had both a line infection and a pneumonia that could not be treated effectively. In addition, he became hypotensive with increases in PEEP and with hemodialysis. He was initially treated with small fluid boluses, changes in ventilator settings, and adjustments to hemodialysis, but eventually had to be placed on levophed. This medication, however, was not enough to maintain his blood pressure, and it was discontinued when the patient was made CMO. He did not have any available access to start another pressor. 3. Respiratory failure: This was thought to be secondary to either septic emboli from his line, pneumonia, or ARDS (from sepsis or volume overload). Volume overload was considered less likely as his respiratory status worsened after being dialyzed. Despite aggressive antibiotic treatment, including courses of linezolid, daptomycin, levofloxacin, cefepime, meropenem, colistin, and flagyl, the patient continued to decline, until his ventilator settings were difficult to manage in conjunction with his hypotension and desaturations. When the goals of care were changed to comfort measures only, the patient was taken off the ventilator. 4. Atrial fibrillation: The patient had several episodes of paroxysmal atrial fibrillation with rates in the 150s. These resolved quickly, once with the administration of po amiodarone (likely not causal given the route of administration). The patient was maintained on po amiodarone as well. He could not be given a beta blocker or calcium channel blocker due to his hypotension. 5. ESRD on HD: During the hospitalization, the renal service was closely following and administering hemodialysis when appropriate. This was stopped when it was no longer feasible given his hypotension and lack of access. 6. Leukocytosis: As above, this was likely secondary to infection. A TEE was recommended by the ID service but was unable to be performed due to the patient's agitation without sedation and hypotension with sedation. 7. Glucose control: He was maintained in the hospital on lantus while his tube feeds were running and a sliding scale of insulin for tighter blood sugar control. 8. Elevated INR: He was noted to have an elevated INR, temporally related to coumadin, which resolved s/p FFP, and vitamin K. 9. Access: His hemodialysis catheter and midline were both replaced, but there were no alternative ways of managing the HD catheter infection. He was getting levophed through his midline, but did not have any way to get better access. He had no good indication for central line attempts, as they would likely be unsuccessful and would cause more harm than benefit. His family decided to make the goals of care comfort measures only and all additional treatment measures were withdrawn. Medications on Admission: citalopram 30 Q48, linezolid 600 Q12, haloperidol 2 mg Q 8 PRN, lorazepam 0.25 mg Q 8, acetominophen 650 Q6 PRN, alteplase 2 mg IV 3 x week, bisacodyl 10 mg PR Q12 PRN, insulin regular Q12, hydroxyzine 25 mg Q8, nepro strength 50 ml/hr, epo 15,000 units 3 x week, percocet Q 6 PRN, lansoprazole 30 QD, iron 300 mg QD, b12 1000 mcg QD, amio 200 mg QD, senna 1 tab Q12, metoprolol 25 Q12, docusate 100 mg Q12, ipratrop/albuterol 4 puffs Q4 PRN. Discharge Medications: N/A Discharge Disposition: Extended Care Discharge Diagnosis: Sepsis Pseudomonal pneumonia Vancomycin resistent enterococcal line infection Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A

[ "518.82", "V66.7", "482.1", "286.9", "112.5", "285.29", "427.31", "519.1", "038.8", "996.62", "276.0", "995.92", "585.6", "244.9", "401.9", "V46.11" ]

icd9cm

[ [ [] ] ]

[ "99.07", "96.72", "96.6", "99.04", "38.95", "38.93", "39.95" ]

icd9pcs

[ [ [] ] ]

10687, 10702

6324, 10166

323, 443

10823, 10832

2986, 6301

10884, 10890

2345, 2382

10659, 10664

10723, 10802

10192, 10636

10856, 10861

2397, 2967

272, 285

471, 1410

1432, 2198

2214, 2329

68,785

170,496

38875

Discharge summary

report

Admission Date: [**2113-3-6**] Discharge Date: [**2113-3-21**] Date of Birth: [**2077-9-13**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 78**] Chief Complaint: R Frontal Headache Major Surgical or Invasive Procedure: PCOM aneurysm coiling [**2113-3-6**] History of Present Illness: 35 year old male who was having sex with his wife when he began to experience sudden onset of severe headache followed by seizure like activity. He ran to the bathroom falling twice. He was diaphoretic and vomiting as well. He presented to [**Hospital3 **] Hospital with complaints of [**10-15**] frontal headache. His GCS was 15 upon arrival to the OSH, with pupils 4mm and reactive bilaterally and no motor deficits were noted. The patient continually complained of nausea and was vomiting. A noncontrast head CT was obtained which showed a right subarachnoid hemorrhage suspect for a leaking aneurysm within the circle of [**Location (un) **] per report. He was subsequently intubated in the setting of bleed and decompensating neurologic status. During the intubation he had an episode of bradycardia to 26 which responded to atropine with good effect. He was transferred to [**Hospital1 18**] for further management Past Medical History: Per report none Social History: Per report denies alcohol, tobacco Family History: unknown Physical Exam: On Admission: O: T: BP: 117/69 HR:54 R: 16 O2Sats:100% Gen: intubated, sedated. WD/WN HEENT: Pupils: 2mm NR EOMs unable to assess Neuro: +cough, +corneals Mental status: sedated, sticks out tongue to command, no commands otherwise. Orientation: unable to assess Language: intubated Cranial Nerves: I: Not tested II: Pupils 2mm bilaterally and nonreactive. III-XII: unable to assess Motor: localizes to sternal rub briskly with bilateral upper extremities, withdraws to noxious bilateral lowers. purposely going for tube when turning to change sheets. Sensation: unable to assess Toes downgoing bilaterally Coordination: unable to assess On Discharge: Awake and alert to person place and time, Pupils equal and reactive to light 6mm to 4mm, extraocular movements full, face symmetric, tongue midline, no pronator drift, strength full in all extremities. Pertinent Results: CTA HEAD W&W/O C & RECONS [**2113-3-6**] A 7-mm aneurysm at the origin of right PCOM is the likely culprit of subarachnoid hemorrhage layering along the tentorium and sylvian fissures bilaterally. No significant mass effect or midline shift. Cerebral Angiogram [**2113-3-14**] 1. Status post coiling of a right posterior communicating artery, with no evidence of residual filling of the aneurysm. 2. Moderate degrees of vasospasm predominantly in the right circulation involving the right internal carotid artery, right middle cerebral artery and right anterior cerebral artery, with mild improvement after intra-arterial verapamil administration. CT Head [**2113-3-19**] Progressive decrease in the amount of subarachnoid hemorrhage, with small amount of bifrontal subarachnoid hemorrhage persisting. Brief Hospital Course: 35 y/o Male presented to [**Hospital3 **] hospital after experiencing a severe headache while having sex with his wife followed by an onset of seizure like activity. He also presented with n/v, but remained nonfocal. Head CT showed a SAH, patient was intubated and transferred to [**Hospital1 18**] for further neurosurgical workup. Upon arrival to [**Hospital1 18**], a head CTA was performed and a PCOMM aneurysm was found. On [**2-/2032**], patient had an angiogram to coil his PCOMM aneurysm. He was placed on aspirin and nimodipine. His exam s/p angiogram was nonfocal other than a slight right nasolabial flattening. On [**3-8**], patient remains nonfocal, but complains of a [**7-15**] headache that was somewhat relieved with pain medication. He remained stable without issue. CTA/P was performed routinely on [**2113-3-9**]. On [**3-10**] he remained stable in the ICU with his headache still persisting. On [**3-12**] his headache was reported as [**8-15**] and his mental status would wax and wane. He was placed on Neo-Synephrine in order to maintain his blood pressure and with pressures in the 180's to 200's systolic his mental status improved. On [**3-13**] vasopressors were stopped and his mental status again began to decline. Pressors were restarted and with his systolic pressure in the 180's to 200's again his mental status improved. A cerebral angiogram was done which showed moderate to severe vasospasm. At that time he received verapamil x 2. On [**3-16**] he had another CTA which showed improved spasm and his Neo-Synephrine was discontinued. On [**3-17**] his exam was nonfocal and he had a bowel movement which he had yet to have during this hospitalization. He was transferred to the floor on [**3-18**] and his dilantin was stopped. His nimodipine was continued and his exam remained nonfocal. A Head CT on the 13th also showed no change. On [**3-19**] he had an episode of emesis overnight with specks of blood per the patient. Protonix and Maalox were added in order to treat his gastritis. On [**3-20**] he was cleared for PT, he was deemed fit for discharge and a prescription for his Nimodipine was secured at a pharmacy near his home. Medications on Admission: None Discharge Medications: 1. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO every four (4) hours for 7 days: do not stop taking this medication before the full course is complete. Disp:*84 Capsule(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 5. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**1-7**] Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 7. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for for GI distress. 8. Dexamethasone 1 mg Tablet Sig: Two (2) Tablet PO every six (6) hours for 2 days: then 1 tablet PO q6hours x 4 days, then 1 tablet PO BID x 4 days, then 1 tab PO daily x 2 days, and then off. Disp:*42 Tablet(s)* Refills:*0* 9. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain: Take only for breakthrough pain or severe headache. Disp:*13 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: SAH PCom aneurysm coiling 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. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs. ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal). ?????? You may resume sexual activity. ?????? 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 call the office to be seen by Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) **] to be seen in 4 weeks. You will need an MRA of the brain, Dr [**First Name (STitle) **] Protocol on that same day. Completed by:[**2113-3-20**]

[ "430", "435.9", "564.09", "787.91", "784.0", "535.50" ]

icd9cm

[ [ [] ] ]

[ "39.72", "88.41", "38.93", "96.71" ]

icd9pcs

[ [ [] ] ]

6796, 6802

3183, 5374

335, 374

6872, 6872

2353, 3160

8954, 9197

1438, 1447

5429, 6773

6823, 6851

5400, 5406

7020, 8012

8038, 8931

1462, 1462

2130, 2334

277, 297

402, 1331

1772, 2116

1477, 1628

6887, 6996

1353, 1370

1386, 1422

19,375

119,260

6231

Discharge summary

report

Admission Date: [**2103-10-13**] Discharge Date: [**2103-10-29**] Service: MEDICINE Allergies: Penicillins / Motrin / Vioxx / Colchicine / Optiray 320 / Iodine Containing Agents Classifier Attending:[**Doctor Last Name 10493**] Chief Complaint: abd pain Major Surgical or Invasive Procedure: Hemicolectomy with diverting colostomy [**10-15**] History of Present Illness: 84 y/o woman with multiple medical problems including HTN, CAD, Diastolic Dysfunction, and chronic pain [**3-17**] multiple issues presents to the medical service with LLQ abdominal pain. She visited the emergency department yesterday and was discahrged after an evaluation was performeed. A CT scan did not identify a likely etiology of her LLQ pain. Abdominal plain films demonstrated no air-fluid levels, no free air. She was discharged from the emergency room at that time. She called her physicians, however, later in the day with continued symptoms of LLQ pain, nausea and diarrhea x 1, and she returned to the ER. . Labs at that time were notable for a WBC of 12.8. She did spike a temperature to 101.3 and was started empirically on Cipro and Flagyl for presumed diverticulitis. Due to a history of encarcerated hernia, her [**Month/Day (2) 3390**] wanted surgery to consult on the patient. Surgery recommended serial abdominal exams and to rescan in 48 hours if she is not improved. . She was seen by her [**Month/Day (2) 3390**] [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] in the ED, who agreed with continued conservative management with IVF, bowel rest, and antibiotics. . Past Medical History: # Cor pulmonale - Echo [**7-20**]: LV EF 65%, 1+ TR, PA systolic # HTN # CAD - cath in [**9-17**] w/ 50% stenosis in LAD # Atypical Chest Pain # Hypercholesterolemia # OSA (does not use CPAP) # HTN # DJD, OA # Spinal Stenosis # Cervical Spondylosis # diverticulosis with numerous previous episodes of diverticulitis # hx of strangulated hernia - s/p partial bowel resection # s/p CCY # h/o recurrent LE cellulitis # Gout # PE ([**2-17**]) - was on coumadin # Hemorrhoids - internal and external - documented via colonscopy in [**2099**] # Benign colonic admenoma [**2099**] # Neuropathy (w/ postural lightheadedness) # Glaucoma # Endometrial mass, not undergone further work-up yet # Polymyalgia Rheumatica # NIDDM Social History: Widowed, lives alone in [**Location (un) 2312**] though daughter and 2 grandchildren live downstairs. Daughter takes care of patient, including doing her shopping. Patient also has VNA once a week, a health aide 3 times/week (helps with showering), PT 2 times/week, and a housekeeper once every 2 weeks. Denies EtOH, tobacco, IVDU. Family History: Father, brother died of [**Location (un) 499**] cancer Mother died breast cancer [**Name (NI) **] (both) have prostate cancer MGM, Mother, and brother all had DM No fam hx of CAD, MI, strokes, or blood clots Physical Exam: Vitals: 100.6 120/46 80 26 96%2L Gen: ill appearing, uncomfortable HEENT: PERRL, EOMI. MMM. Conjunctiva well pigmented. Neck: Supple, without adenopathy or JVD. No tenderness with palpation. Chest: CTAB anterior and alterally Cor: Normal S1, S2. RRR. No murmurs appreciated. Abdomen: Soft, some moderate distention. Marked tenderness to palpation in LLQ. She tolerates my hand there with pressure after some time, howeger, and has no rebound. Extremity: Warm, edema bialterally, erythema and warms as well. 1+ DP pulses bilat. . Pertinent Results: Admission labs: . [**2103-10-13**] 06:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011 [**2103-10-13**] 06:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2103-10-13**] 06:20PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 [**2103-10-13**] 05:06PM LACTATE-1.7 [**2103-10-13**] 02:00PM GLUCOSE-137* UREA N-16 CREAT-1.1 SODIUM-140 POTASSIUM-3.5 CHLORIDE-97 TOTAL CO2-32 ANION GAP-15 [**2103-10-13**] 02:00PM ALT(SGPT)-18 AST(SGOT)-21 ALK PHOS-181* TOT BILI-0.8 [**2103-10-13**] 02:00PM LIPASE-36 [**2103-10-13**] 02:00PM ALBUMIN-3.9 CALCIUM-9.3 PHOSPHATE-3.8 MAGNESIUM-2.1 [**2103-10-13**] 02:00PM WBC-12.8* RBC-4.20 HGB-11.0* HCT-33.8* MCV-81* MCH-26.2* MCHC-32.6 RDW-14.9 [**2103-10-13**] 02:00PM NEUTS-83.0* LYMPHS-13.6* MONOS-3.0 EOS-0.2 BASOS-0.1 [**2103-10-13**] 02:00PM PLT COUNT-331 [**2103-10-12**] 09:55PM GLUCOSE-194* UREA N-19 CREAT-1.0 SODIUM-141 POTASSIUM-3.7 CHLORIDE-99 TOTAL CO2-32 ANION GAP-14 [**2103-10-12**] 09:55PM proBNP-508 [**2103-10-12**] 09:55PM WBC-10.8 RBC-4.09* HGB-10.5* HCT-33.2* MCV-81* MCH-25.8* MCHC-31.8 RDW-15.8* [**2103-10-12**] 09:55PM NEUTS-75.2* LYMPHS-20.9 MONOS-3.3 EOS-0.2 BASOS-0.4 . Microbiology: [**2103-10-13**] Blood cx: No growth [**2103-10-21**] Blood cx: No growth [**2103-10-16**] MRSA screening: No MRSA isolated [**2103-10-21**] Urine cx: contamination . Imaging: . [**2103-10-12**] CXR: No acute cardiopulmonary process identified. . [**10-12**] Bilateral LE Ultrasound: No evidence of lower extremity DVT bilaterally. . [**2103-10-13**] CT Abd and pelvis w/o contrast: 1. Colonic diverticulosis but no evidence of acute diverticulitis. 2. Unchanged prominence of the extra- and intra-hepatic biliary tree in this patient status post cholecystectomy. Stable hyperdense exophytic right renal lesion, incompletely characterized without contrast. If not further worked up, this can be attempted to be better defined with a dedicated MRI or ultrasound. 3. Unchanged appearance of suspicious endometrial lesion better described on previous vaginal ultrasound and continues to be suspicious for underlying malignancy. 4. Mild tree in [**Male First Name (un) 239**] opacities in the right lower lobe representing an infectious bronchiolitis. . [**2103-10-13**] AXR: No free intraperitoneal air. Nonspecific bowel gas pattern, without evidence for obstruction. . [**2103-10-14**] RUQ US: 1. No evidence of choledocholithiasis in the visualized portion of the common bile duct; however, most distal aspect is not visualized. 2. Chronic biliary ductal dilatation. . [**2103-10-14**] CT abd and pelvis w/o contrast: 1. Interval development of acute diverticulitis with perforation in the mid descending [**Month/Day/Year 499**] and intra-abdominal free air. 2. No fluid collection or abscess. 3. Unchanged prominence of the extra and intrahepatic biliary system. 4. Stable hyperdense exophytic left renal lesion, for which workup was previously recommended. 5. Unchanged appearance of suspicious endometrial lesion for which workup was previously recommended. These findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (medicine) and Dr. [**Last Name (STitle) **] (surgery) early morning [**2103-10-15**]. . [**2103-10-16**] CXR: In comparison with study of [**10-15**], some atelectatic changes persist at the bases. No evidence of acute focal pneumonia. The various tubes remain in place. Free air cannot be identified or unequivocally excluded on this image. This would require CT or a lateral view. . [**2103-10-17**] CXR: In comparison with study of [**10-16**], there is slightly more prominence of opacification at the bases consistent with some combination of atelectasis and effusion. Tubes remain in place. . [**2103-10-21**] CXR: Worsening volume loss and consolidation/effusion in the left lower lobe. . [**2103-10-24**] Bilateral LE Ultrasound: No evidence of right or left lower extremity DVT Brief Hospital Course: #) Diverticulitis with perforation: Pt was admitted for severe LLQ abdominal pain associated with nausea, vomiting and diarrhea. Pt underwent a series of imaging that initially revealed no etiology for her symptoms. She was started on ciprofloxacin and flagyl for suspected diverticulitis. With persistence of symptoms over the first 48 hours of admission, repeat imaging was performed. The repeat CT scan of abdomen and pelvis performed on [**2103-10-15**] revealed perforated diverticulitis. Pt was taken to the operating room where a hemicolectomy with diverting colostomy was performed without complication. Pt was transferred to the ICU after the surgery where she remained intubated until [**2103-10-17**] when she was safely extubated and placed on supplemental oxygen. Pt was stable and transferred to the floor on [**2103-10-18**]. . She completed her course of antibiotics. She was easily weaned off of her supplemental oxygen. Her diet was slowly advanced to regular diet which she tolerated well. She was seen by physical therapy and should continue physical therapy as an outpatient until she reaches her baseline mobility. Her pain was well controlled on a regimen of tylenol and percocet. She was followed by the surgery team who monitored her ostomy output and instructed her to return to clinic on [**2103-11-1**] for follow up and removal of her staples. . 3) DMt2: Patient is on glipizide 2.5mg po bid at home. On admission she was switched to sliding scale insulin. Despite surgery and perforated diverticulitis glucose was well controlled. Because pt's po intake is not at baseline she is being discharged on sliding scale insulin and qid fsbs. It is recommended that once her diet and glucose levels are stable that she be restarted on her home medication. . #) Atypical Chest Pain: Pt had one episode of chest pain during admission she states that this is a regular occurence for her. She has had extensive cardiac work up prior to this admission. EKGs were performed that showed no ischemic changes. She was given sublingual nitroglycerin and pain resolved. Please continue to provide nitroglycerin in pain recurs. Pt does not require monitoring of cardiac enzymes unless there are significant EKG changes. . #) Bilateral Leg pain: Initially described as lateral calf pain that improves with elevation of her legs. Tylenol and oxycodone were administered but provided minimal relief. Due to her immobility there was concern for presence of lower extremity DVT (though unlikely to occur bilaterally and simultaneously while on subcutaneous heparin prophyllaxis). Lower extremity ultrasound was performed on [**10-24**] and revealed no evidence of DVT. The following night pain recurred with more characteristics of neuropathic pain (burning sensation, sensitive to light touch). Pt was restarted on her gabapentin 300mg [**Hospital1 **] that had been held since her surgery. At time of discharge, pt reports that pain has resolved since restarting gabapentin on [**2103-10-25**]. . #) Chronic diastolic CHF: stable; Pt did develop diffuse edema and crackles at the bases of her lungs. Fluid retention thought to be largely due to third spacing from surgery and the large quantities of fluid administered in the setting of perforated diverticulitis. Lasix was held on admission and was started at low dose after her surgery. At time of discharge pt was diuresing well on lasix 80mg po daily. If pt develops difficulty breathing or increased crackles on exam please consider increasing her lasix to her home dose of lasix 80mg po tid. Recommend monitoring blood pressure an urine output while adjusting lasix dose. Please consider adding an ACEI in the following weeks if blood pressure permits. . #) CAD: stable; patient continued on metoprolol and aspirin during her admission. . #) HTN: controlled and stable; patient continued on metoprolol and decreased dose of lasix during admission. Please consider adding an ACEI in the following weeks if blood pressure permits. . # Polymyalgia rheumatica: Stable; Pt was switched to IV hydrocoritsone perioperatively. On transfer to the floor pt was restarted on equivalent dose of prednisone 5mg po daily. . #) Code status: DNR DNI confirmed w patient. . #) Contact: [**Name (NI) **] [**Last Name (NamePattern1) **] [**Name (NI) 24258**]: [**Telephone/Fax (1) 24259**] Medications on Admission: Latanoprost 0.005 % one gtt qhs Atorvastatin 40 mg qhs Omeprazole 20 mg daily Prednisone 5 mg daily Calcium Carbonate (Tums) 500mg po TID Docusate Sodium 100mg po bid Senna 8.6mg po daily prn constipation Potassium Chloride 10meq tablet Cholecalciferol 400 units daily Oxycodone-Acetaminophen 5-325 mg [**2-14**] q6H Gabapentin 300 mg [**Hospital1 **] Aspirin EC 81 mg daily Metoprolol Succinate 25 mg daily Furosemide 80mg [**Hospital1 **] Nitroglycerin 0.4mg SL prn Glipizide 2.5mg po bid Gabapentin 300mg po bid Discharge Medications: 1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 2. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H PRN (): Please do not exceed 4 grams of acetaminophen per day. 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed: Please do not exceed 4 grams of acetaminophen per day. 12. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: 1-2 tablets Sublingual once a day as needed for chest pain. 13. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO three times a day. 14. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day. 15. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Primary: Perforated diverticulitis Secondary: Noninsulin dependent diabetes mellitis type 2 controlled hypertension Coronary artery disease chronic diastolic congestive heart failure PMR Discharge Condition: Stable; pt does not require supplemental oxygen; pt is tolerating regular diet and po medications; pt is currently unable to ambulate due to deconditioning. Discharge Instructions: You were admitted to the hospital for severe abdominal pain. After being started on antibiotics and undergoing several imaging studies you were found to have perforated diverticulitis. You immediately underwent surgery in which the affected portion of your [**Location (un) 499**] was removed and a colostomy was placed without complications. You recovered well from the surgery. At the time of discharge you were tolerating a regular diet and no longer needed supplemental oxygen. The physical therapist worked with you and recommend continuing physical therapy after leaving the hospital. You were followed by the surgery team for the remainder of your hospitalization and will follow up with them as an outpatient. . The following changes were made to your medications: 1) Your glipizide was stopped while in the hosptial. You are on sliding scale insulin to maintain you blood sugars. Once your diet is stable and your glucose is stable you can discontinue the insulin and resume your glipizide. Please discuss with your physician before making any changes. 2) Your furosemide dose was decreased to 80mg po daily. Once you have adequate po intake you can increase your furosemide to your home dose. Please discuss with your physician before making any changes. 3) Your bowel regimen of senna and colace was discontinued. . Please continue taking all other medications as previously prescribed. . Please notify your physician or return to the emergency room if you experience severe abdominal pain, significantly decreased ostomy output, vomiting, fever, difficulty breathing, increased chest pain or any other symptom that is concerning to you. Followup Instructions: Please follow up with your surgeon Dr. [**Last Name (STitle) **] on [**11-1**] at 9:15am at [**Street Address(2) 1126**]. Phone [**Telephone/Fax (1) 8792**]. . Please see your primary care physician within one week of discharge. . Provider: [**Name Initial (NameIs) 11595**] (RHEUM LMOB) [**Doctor Last Name 11596**] Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2103-11-15**] 12:30 . Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 1401**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2104-1-24**] 10:40 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]

[ "V12.51", "272.0", "428.32", "V58.61", "725", "403.90", "518.81", "414.01", "585.9", "327.23", "274.9", "250.00", "276.51", "562.11", "569.5", "413.9", "416.9", "428.0", "496" ]

icd9cm

[ [ [] ] ]

[ "45.75", "46.11", "96.71" ]

icd9pcs

[ [ [] ] ]

13900, 13970

7559, 11918

313, 366

14201, 14360

3519, 3519

16064, 16725

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11944, 12460

14384, 16041

2969, 3500

265, 275

394, 1640

3535, 7536

1662, 2378

2394, 2728

12,795

187,660

1876

Discharge summary

report

Admission Date: [**2140-11-7**] Discharge Date: [**2140-11-18**] Service: MEDICINE Allergies: Naprosyn / Metoprolol / Nsaids / Verapamil / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 7055**] Chief Complaint: Chest pain; shortness of breath. Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: Ms. [**Known lastname 3142**] is an 85 year-old woman with a history of severe 2-vessel CAD, congestive heart failure and restrictive lung disease who presents with chest pain and shortness of breath. Initially presented to an OSH on the evening prior to transfer where she was noted to be short of breath with clear lungs. CK was checked and negative with a troponin of 0.14 and BNP of 246. Second troponin noted to be elevated (6.91) and her O2 sat decreased to 88% on RA. Lovenox and aspirin was given, along with IV diltiazem for a HR in the 120s. For possible COPD exacerbation, she was also given nebs and solumedrol. Upon presentation to our ED, vitals showed T 98.6, HR 90, BP 108/44, RR 20 and 88% on room air with increase to 94% on 3 liters. Plavix 600mg, lasix 40mg IV were given and she was taken to the cath lab. Review of systems: unable to obtain given intubation. Past Medical History: 1. CARDIAC RISK FACTORS: (+) Diabetes (?) Dyslipidemia (?) Hypertension . 2. CARDIAC HISTORY: -PERCUTANEOUS CORONARY INTERVENTIONS: --[**1-12**]: LAD mid 80% (TAXUS STENTED); LCX 90% origin lesion (CYPHER STENTED), 70% in the upper pole of a large OM1 (POBA) as well as a 90% more distal lesion in a OM1 subbranch -PACING/ICD: None -CABG: None -CHF, diastolic ([**9-14**]) . 3. OTHER PAST MEDICAL HISTORY: - Peripheral [**Month/Year (2) 1106**] disease s/p R popliteal-DP bypass - History of GI bleed in [**7-13**], negative EGD and colonoscopy in [**7-/2138**] - COPD: mild restrictive ventilatory defect - Osteoarthritis - Chronic venous insufficiency - Chronic kidney disease - IBS - Hypothyroidism - Chronic UTI's - Chronic diarrhea - History of uterine cancer s/p TAHBSO - History of breast cancer s/p lumpectomy - History of Appendectomy (remote) - History of Cholecystectomy (remote) Social History: -Tobacco history: Yes. Quit smoking: >20 years ago -ETOH: Denies -Illicit drugs: Denies -Currently resides at [**Hospital 38**] Rehab. Family History: Mother died in 60's w/CAD. Physical Exam: VS: T= BP=127/59 HR=90 RR=14 (AC) O2 sat=100% on 1.0 FiO2; down to 93% on .50 FiO2 GENERAL: Intubated. Awake and interactive. Uncomfortable when changing right groin dressing. HEENT: NCAT. Sclera anicteric. Right surgical pupil; left 3mm-->2mm, Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with difficult to interpret JVP. CARDIAC: RR, normal S1, S2 though distant. No clear murmurs. No S3 or S4. LUNGS: Course breath sounds with mild expiratory wheeze. ABDOMEN: Soft, NTND. Obese. No HSM or tenderness. EXTREMITIES: 1+ lower extremity edema. Prior medial scar noted on right. Venous stasis changes noted. Pulses were dopplerable. Pertinent Results: [**2140-11-7**] 09:04AM GLUCOSE-245* LACTATE-1.2 NA+-139 K+-4.4 CL--98* TCO2-27 [**2140-11-7**] 09:00AM CK(CPK)-153* [**2140-11-7**] 09:00AM cTropnT-0.38* [**2140-11-7**] 09:00AM CK-MB-10 MB INDX-6.5* [**2140-11-7**] 09:00AM WBC-12.8* RBC-3.85* HGB-11.8* HCT-33.6* MCV-87 MCH-30.6 MCHC-35.0 RDW-15.1 [**2140-11-7**] 09:00AM NEUTS-92.4* LYMPHS-6.9* MONOS-0.6* EOS-0 BASOS-0.1 [**2140-11-7**] 09:00AM PLT COUNT-244 [**2140-11-7**] 09:00AM PT-13.6* PTT-34.3 INR(PT)-1.2* [**2140-11-7**] 10:53AM TYPE-ART O2 FLOW-6 PO2-53* PCO2-43 PH-7.38 TOTAL CO2-26 BASE XS-0 INTUBATED-NOT INTUBA COMMENTS-MASK [**2140-11-7**] 11:48AM ALBUMIN-3.7 [**2140-11-7**] 11:48AM CK-MB-10 MB INDX-7.1* cTropnT-0.31* [**2140-11-7**] 11:48AM ALT(SGPT)-19 CK(CPK)-141* ALK PHOS-102 AMYLASE-20 TOT BILI-0.6 DIR BILI-0.2 INDIR BIL-0.4 [**2140-11-7**] 12:39PM GLUCOSE-297* LACTATE-1.1 NA+-138 K+-4.3 CL--98* [**2140-11-7**] 08:28PM CK-MB-14* MB INDX-9.3* cTropnT-0.66* [**2140-11-7**] 04:44PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG Discharge labs: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2140-11-18**] 06:00AM 5.9 3.27* 10.1* 29.4* 90 31.0 34.4 14.8 328 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 [**2140-11-18**] 06:00AM 160* 49* 1.5* 138 4.2 100 31 CHEMISTRY TotProt Calcium Phos Mg [**2140-11-18**] 06:00AM 9.1 3.5 1.9 [**2140-11-10**] 12:30 pm URINE Site: CLEAN CATCH **FINAL REPORT [**2140-11-12**]** URINE CULTURE (Final [**2140-11-12**]): ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ <=1 S STUDIES: EKG ([**2140-11-6**]): Sinus tach at 111. 1mm ST-elevations in II/F and lateral ST-depressions. Inferior q-waves (?old). Anterior q-waves (old). EKG #2 ([**2140-11-7**]): Sinus at 92. 1st degree AV block. ST-elevations less pronounced. . 2D-ECHOCARDIOGRAM ([**2140-9-7**]): - left atrium is elongated; estimated right atrial pressure is 0-5 mmHg - mild symmetric LVH with normal cavity size (due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded) - LVEF>55% - Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg); transmitral Doppler and tissue velocity imaging are consistent with Grade II (moderate) LV diastolic dysfunction - RV chamber size and free wall motion are normal - AV leaflets are mildly thickened; no AS; trace AR - MV leaflets are mildly thickened; [**12-9**]+ MR - TV mildly thickened - Moderate pulmonary artery systolic hypertension . CARDIAC CATH ([**2140-11-7**]): 1- Selective coronary angiography of this right-dominant system demonstrated severe three-vessel CAD. Thewhole coronary system was mildly calcified. The LMCA had no angiographically-apparent disease. The LAD had 90% diffuse lesion at the previous PCI site. The LCX proximal stent was patent and the the OM1 (POBA [**2136**]) was 100% occluded. The RCA was a dominant vessel and totally occluded proximally (known) after the AM1 takeoff. The distal RPDA supplied the inferior wall and received faint collaterals from the LAD septal. Most of these collaterals arose from the diseased mid LAD segment (also the site of previous PCI). 2- Limited resting hemodynamic assessment revealed mildly elevated arterial pressure (145/75 mmHg). 3- Successful POBA of the mid LAD at teh site of previous PCI with marked improvement in flow to the distal LAD and more robust septal collaterals to the distal RPDA. 4- Unsuccessful attempt to recanalize totally occluded OM1 proximally. 5- Successful deployment of an angioseal device to the RCFA. 6- Successful endotracheal intubation by the end of the case for worsened pulmonary edema. TTE ([**2140-11-7**]): The left atrium and right atrium are normal in cavity size. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with severe hypokinesis of the inferior wall and distal half of the anterior septum. The remaining segments contract normally (LVEF = 40 %). 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. Mild to moderate ([**12-9**]+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Renal US ([**2140-11-10**]): 1. No hydronephrosis. 2. Very limited Doppler study due to technical factors which demonstrates bilateral arterial and venous blood flow. No further Doppler characterization can be made. CXR ([**2140-11-12**]): The PICC line is unchanged. Calcified pleural plaques are unchanged. There is bilateral lower lobe volume loss but no definite infiltrate. No significant change compared to prior. Brief Hospital Course: # ST ELEVATION MI The patient was transferred after having an ST-Elevation MI in the inferior distribution and 3-vessel disease on cardaic catheterization. Druing catheterization she had a POBA to the mid LAD. She was referred to cardiothoracic surgery for possible CABG but was felt not to be a surgical candidate. She was continued on her aspirin, carvedilol, simvastatin and started on Plavix. She should continue to take these medications. She experienced no episodes of chest pain after the catheterization or for the remainder of her hospital stay. # CONGESTIVE HEART FAILURE This patient was felt to be in acute diastolic heart failure on admission. She was given IV lasix on admission. She required intubation on [**2140-11-7**] for hypoxemic respiratory failure due to her pulmonary edema. She was extubated on [**2140-11-9**] after her oxygenation improved and she was diuresed with IV Lasix. Her respiratory status continued to improve. She had a TTE here showing an EF of 40% and mild to moderate regional left ventricular systolic dysfunction with severe hypokinesis of the inferior wall and distal half of the anterior septum. She had some fluid retention with oliguric renal failure but did not require re-intubation and her oxygen was able to be weaned off with further diuresis. The patient was continued on carvedilol. She was not started on an acei or [**Last Name (un) **] due to her family's wishes given a history of hypotension while on lisinopril. # CHRONIC KIDNEY DISEASE/ACUTE RENAL FAILURE: The patient has a baseline creatitine of 1.2 to 1.5. Her creatinine was below her baseline at the time of presentation at 1.1. After her cardiac catheterization her creatinine began to rise and rose above her baseline on day 4. The renal team evaluated her and felt her ARF was consistent with ATN secondary to dye. Her creatitine peaked at 4.2 on day 7 of hospitalization. Given her acute renal faliure her medications were renally adjusted and nephrotoxic medications were held. A renal US showed no evidence of hydronephrosis. A lasix drip was initally tried when she became oliguric, but did not aide in increasing her urine output. After her peak at 4.2 she began to quickly drop her creatitine and soon her urine output increased. By discharge her creatinine was back to its baseline of 1.5. # PULM: The patient was intubated in the cath lab given decreasing sats and pO2. PFTs more consistent with restriction than with COPD, likely due to her body habitus. She is on advair and albuterol as an outpatient. She was quickly extubated a few days after admission, however she required 5-6L of oxygen for many days given her oliguric acute renal failure and volume overload due to pulmonary edema. Once extubated he was continued on advair and albuterol prn as well as atrovent prn. As her renal failure resolved and she began to make more urine she was able to be weaned off oxygen. She was sating in the mid 90s on RA the day of discharge. # URINARY TRACT INFECTION: The patient developed a urine culture which grew out enterococcus. She was initally treated with ceftriaxone while the urine culture was pending, but then switched to amoxicillin. However she continued to have fevers so she was broadened to amoxicillin-clavulonic acid for a 5 day course. This was finished and her fevers resolved. She was placed on bactrim 1 ss tab daily for UTI ppx given her history of chronic UTIs. # BACK PAIN: The patient has chronic back pain at home and continued to have pain while she was hospitalized. She had been on 10 mg of oxycodone every 8 hours prior to admission. This was modified many times, especially when she was delirious during the middle of her stay, however by time of discharge she was on a stable regimen of 5 mg of oxycodone every 4 hours standing and 5 mg of oxycodone every 4 hours prn. She was also given 1 gm of tylenol every 6 hours. PT worked with the patient to mobilize her out of bed as staying in bed was likely worsening her back pain. # DELIRIUM: The patient had several episodes of delirium, especially at night. She responded well to 5 mg po of zyprexa. By time of discharge she was alert and oriented without an episode of delirium for 3 days without requiring medications. The delirium was thought to be due to her age, the opiods she was being treated with for he back pain, and disorientation after changing rooms. # RHYTHM: The patient maintained sinus rhythm during her hospitalization and was monitored on telemetry. # DIABETES: The patient was continued on her home NPH with sliding scale insulin coverage. Her glyburide was held while she was hospitalized, but restarted on discharge. # HYPOTHYROIDISM: The patient was continued on levothyroxine. # ANEMIA: The patient has anemia at basliene with Hct previously ranging from the high 20's to low 30's. Likely related to anemia of chronic kidney disease. She did not require transfusion while hospitalized here. Her Hct was stable at 29.4 on discharge. Medications on Admission: 1. Carvedilol 25 mg [**Hospital1 **] 2. Imdur 60 mg daily 3. Bumex 3 mg daily 4. Spironolactone 25 mg daily 4. Simvastatin 80 mg daily 5. NPH 22 units QAM 6. Glyburide 10 mg daily 7. Levothyroxine 50 mcg daily 8. Albuterol 90 mcg/Actuation 2 puff Q6H PRN 9. Advair Diskus 250-50 2 inhalations [**Hospital1 **] 10. Fluticasone 50 mcg nasal 11. Dicyclomine 10 mg [**Hospital1 **] 12. Esomeprazole 40 mg [**Hospital1 **] 13. Allopurinil 200 mg daily 14. Colchicine 0.6 mg daily 15. Oxycodone 10 mg Q8H PRN 16. Lorazepam 0.5 mg QHS PRN 15. Lidocaine 5 % 12 hours on, 12 hours off 16. Gabapentin 300 mg QAM and 600 mg QPM 17. Bisacodyl 10 mg daily 18. Lactulose PRN 19. Vitamin C 1,000 mg daily 20. Vitamin B daily . Cipro 250 mg [**Hospital1 **] Fluconazole 150 mg daily Discharge Medications: 1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QAM (once a day (in the morning)). 2. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12 hours on and 12 hours off. 4. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) inj Injection TID (3 times a day). 7. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty Two (22) units Subcutaneous qam. 8. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Esomeprazole Magnesium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: Two (2) puffs Inhalation [**Hospital1 **] (2 times a day). 12. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Bumetanide 2 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 16. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a day. 17. Imdur 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 18. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO once a day. 19. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Inhalation every six (6) hours as needed for shortness of breath or wheezing. 20. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO once a day. 21. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day. 22. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 23. Lactulose 10 gram/15 mL Solution Sig: 15-30 mL PO every six (6) hours as needed for constipation. 24. Vitamin C 1,000 mg Tablet Sig: One (1) Tablet PO once a day. 25. Vitamin B Complex Capsule Sig: One (1) Capsule PO once a day. 26. Dicyclomine 10 mg Capsule Sig: One (1) Capsule PO twice a day. 27. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 28. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours). 29. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 30. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every eight (8) hours. 31. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for omentum fold rash. 32. Miralax 17 gram (100 %) Powder in Packet Sig: Seventeen (17) gram PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Primary - ST elevation myocardial infarction Acute renal failure Urinary tract infection Secondary - Chronic diastolic congestive heart failure Diabetes Chronic kidney disease Hypothyroidism Chronic back pain Discharge Condition: Stable Discharge Instructions: You were transferred to this hospital due to an acute heart attack for treatment. You underwent cardiac catheterization and had angioplasty (breakage the blockage in the artery) to a blocked artery. After the catheterization your kidney function worsened likely due to the dye used during the catheterization. Your creatitine has decreased to its baseline. You developed a urinary tract infection and were treated with antibiotics. As you have chronic urinary tract infections you will need to be on antibiotics for prevention. Medication changes: 1. You were started on 325 mg of aspirin daily. 2. You were started on plavix 75 mg daily. 3. You were started on bactrim single strength 1 tab daily for urinary tract prophylaxis. 4. Your oxycodone was changed to 5 mg every 4 hours with another 5 mg every 4 hours as needed for pain. 5. For additional control of you pain you have been getting 1000 mg of tylenol every 8 hours. 6. Miconazole powder is being applied to a fungal infection on the skin of your stomach. 7. Given constipation with the oxycodone you were started on miralax daily. Otherwise continue your outpatient medications as prescribed. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 2 L Go to the emergency room or call your primary doctor if you experience chest pain, shortness of breath, dizziness, blood in your stool, or black stool. Followup Instructions: An appointment was made for you to follow up with a nurse practioner in your primary doctor's office: Provider: [**First Name11 (Name Pattern1) 2482**] [**Last Name (NamePattern4) 10466**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**] Date/Time:[**2140-11-23**] 9:00 An appointment was made for you to follow up with your cardiologist: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2141-1-26**] 10:00 Please keep your previously scheduled appointment: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], M.D. Date/Time:[**2141-2-23**] 12:00 It is important you keep these appointments. If you cannot make one of them, please call and reschedule. Completed by:[**2140-11-18**]

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187,535

8966

Discharge summary

report

Admission Date: [**2138-8-16**] Discharge Date: [**2138-8-26**] Date of Birth: [**2053-12-3**] Sex: F Service: MEDICINE Allergies: Verapamil / Iodine-Iodine Containing / Zoloft / Atenolol / Toprol XL / Norvasc / Pindolol / Zestril / Clonidine / Keflex / Meclizine / Wellbutrin / Penicillins / Erythromycin Base / Avelox Attending:[**First Name3 (LF) 1711**] Chief Complaint: A-Fib with RVR Major Surgical or Invasive Procedure: Transesophageal ECHO and cardioversion History of Present Illness: 84 y/o woman with a history of paroxysmal atrial fibrillation who is here for afib with RVR. The patient has recently had multiple hospitalizations, one for the same complaint and another for a complaint of chronic dyspnea and lightheadedness. She has had multiple cardioversions, the most recent on [**2138-6-18**] during which she was also loaded on amiodarone and started on pradaxa. Both of these medications had since been stopped due to side effects and ecchymoses. . Her most recent hospitalization was seven days ago when she underwent an extensive workup for her dyspnea, however investigations including spirometry, persantine MIBI and echocardiogram were all unrevealing for a cause of her symptoms. . This morning the patient reports waking up feeling dyspnea and chest pressure; she checked her heart rate and found it to be in the 140s, and on the advice of her telehealth team came in to be evaluated. Her [**Doctor Last Name **] of hearts monitor at the time showed sinus rhythm followed by APCs with a 5 beat run of NSVT, then atrial fibrillation. . In the ED, she was started on a nitroglycerin and heparin drip. Her blood pressure proved to be labile and dropped from the 110s systolic to the 80s. Cardiology was consulted who recommended metoprolol 2.5mg IV which had some mild effect on her rate. Her chest pressure resolved and the nitroglycerin drip was stopped. . On review of systems, she reports intermittent dizziness and dyspnea on exertion at home. She has no history of stroke or TIA. No history of recent weight change or edema. No palpitations, syncope or presyncope. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: +Hypertension 2. CARDIAC HISTORY: - Diastolic congestive heart failure - Atrial fibrillation s/p cardioversionx5 3. OTHER PAST MEDICAL HISTORY: - COPD - Obstructive sleep-disordered breathing, mild - not on CPAP - Diverticulosis - Benign paroxysmal positional vertigo - Anxiety - Anemia - MSSA sepsis in [**2134-7-18**] - Pneumonia (~[**2132**]) - Hx of C. diff Social History: Occupation: Recently retired entrepreneur (used to own a secretarial/graphics/design company). Drugs: Denies. Tobacco: Quit smoking 16 years ago with 80 pack-year history. Alcohol: Social. Other: Lives alone; completes all ADLs, walks with a cane on left at baseline. Family History: - Father died of myocardial infarction in his 40s. - Mother died of congestive heart failure at 88. - Otherwise, no family history of arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION EXAM General: No acute distress, alert and oriented x3 [**Year (4 digits) 4459**]: No conjunctival pallor, pupils equal round and reactive. No scleral icterus Neck: JVP at 5cm at 45 degrees. Negative hepatojugular reflexes. Normal A and V waves. CV: Irregularly irregular, no murmurs, rubs, gallops. Abdomen: Soft, Non-tender, non-distended. Extremites: No edema. Well perfused, capillary refill <1 sec. Pulses: 2+ radial, 1+ distal. . DISCHARGE EXAM Pertinent Results: ADMISSION LABS [**2138-8-16**] 11:53PM PT-16.9* PTT-150* INR(PT)-1.5* [**2138-8-16**] 06:25PM cTropnT-<0.01 [**2138-8-16**] 11:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-TR [**2138-8-16**] 11:30AM CK-MB-3 cTropnT-<0.01 proBNP-1521* [**2138-8-16**] 11:30AM WBC-9.4 RBC-4.40 HGB-13.6 HCT-39.0 MCV-89 MCH-30.8 MCHC-34.8 RDW-13.6 [**2138-8-16**] 11:30AM NEUTS-74.9* LYMPHS-17.5* MONOS-5.2 EOS-1.5 BASOS-0.9 DISCHARGE LABS PERTINENT STUDIES EKG [**2138-8-20**] Atrial fibrillation with rapid ventricular response. Diffuse low voltage. Compared to the previous tracing of [**2138-8-19**] the ventricular response has slowed. Otherwise, no diagnostic interim change. CXR ([**2138-8-16**]): No acute cardiopulmonary process CXR ([**2138-8-20**]): As compared to the previous radiograph, there is no relevant change. Borderline size of the cardiac silhouette with mild tortuosity of the thoracic aorta. No pleural effusion. No pulmonary edema. No hilar or mediastinal abnormalities. Brief Hospital Course: 84 y/o woman with history of diastolic CHF and paroxysmal atrial fibrillation who presents with chest discomfort, dyspnea and atrial fibrillation with RVR. ACTIVE DIAGNOSES: # AFIB WITH RVR: Patient was recently taken off her amiodarone secondary to side effects and has an enlarged left atrium. She likely has paroxysmal atrial fibrillation. After discussion about side effects and benefits of treatment, patient opted to restart amiodarone. She was loaded with 200mg TID. She was rate controlled with metoprolol 25mg po BID and anticoagulated with heparin bridge and warfarin 3mg po daily. Metoprolol was discontinued prior to cardioversion. Patient was cardioverted on HD8. It was felt that her amiodarone level at this time was adequate to increase the likelihood the patient would remain in sinus rhythm after cardioversion. At the time of discharge, patient's INR was 2.6. Patient will have an INR machine delivered to her home and will be instructed on how to use it. She is aware that her goal INR is 2.0-3.0. # DYSPNEA: Unclear etiology; patient is s/p extensive workup without clear etiology. She does report feeling her symptoms more acutely as she falls asleep and when she wakes up, so it is possibly related to her sleep-disordered breathing. Not hypoxic during SOB episodes. Reviewed OMR notes and found an issue with LH and dizziness with Ipratroprium and Spiriva in the past, but these symptoms seemed to persist after stopping the medicine. [**Month/Day/Year 1570**]'s reviewed with team. During admission the patient did have intermittent shortness of breath with some wheezing. Chest xray was unconcerning for pneumonia, white blood cell count was within normal range and the patient was afebrile throughout admission. Dyspnea likely related to both her atrial fibrillation and COPD. For her COPD she was given Atrovent nebulizer treatments and started on Spiriva. CHRONIC ISSUES: # dCHF: No evidence of acute CHF exacerbation. She was continued on her home lasix. # ANXIETY: Home alprazolam was continued. SW also asked to evaluate and recommended outpatient counseling. TRANSITIONAL ISSES: -Patient maintained full code status throughout hospitalization -Continue amiodarone 200mg po BID, with monitoring of PFTs, TFTs, and LFTs -Continue coumadin with INR monitoring (goal 2.0-3.0) -Follow up with outpatient cardiologist Dr. [**Last Name (STitle) **] Medications on Admission: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. alprazolam 0.25 mg Tablet Sig: 0.5 Tablet PO QHS (once a day (at bedtime)) as needed for anxiety/insomnia. 4. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Discharge Medications: 1. Outpatient Lab Work Please check Chem-7, INR on [**2138-8-28**] with results to Dr. [**Last Name (STitle) **] at Phone: [**Telephone/Fax (1) 62**] 2. fingerstick INR Please use fingerstick INR machine to monitor INR thanks 3. furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:*45 Tablet(s)* Refills:*2* 4. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 6. ipratropium bromide 0.02 % Solution Sig: One (1) vial Inhalation Q6H (every 6 hours) as needed for wheezing. 7. Xopenex 1.25 mg/3 mL Solution for Nebulization Sig: One (1) vial Inhalation every four (4) hours as needed for shortness of breath or wheezing. 8. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Ten (10) ML PO five times a day as needed for cough. 9. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 10. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Take twice daily for one week, then decrease to once daily. Disp:*60 Tablet(s)* Refills:*2* 11. warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. Tessalon Perle 100 mg Capsule Sig: One (1) Capsule PO three times a day as needed for cough. Disp:*90 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Atrial Fibrillation with rapid ventricular response. Chronic Diastolic congestive heart failure chronic obstructive pulmonary disease Obstructive sleep apnea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had a rapid heart rate with the atrial fibrillation and needed to restart amiodarone and undergo another cardioversion. You will need to continue to take the amiodarone to keep you in a regular rhythm. Your shortness of breath with walking seems to be better and the wheezing and cough has been stable with the addition of spiriva. You were restarted on coumadin and arrangements were made for a INR machine to be delivered to your house and training will be provided. Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. Your furosemide was increased to 60 mg daily on [**8-26**] and your weight at discharge is 157 pounds on our scale. You can talk to Dr. [**Last Name (STitle) **] about adjusting your furosemide according to your weight at home. . If you have a coughing or wheezing spell at home, please try a nebulizer with the ipratroprium and Xopenex. If that does not help completly, you can take robitussin cough syrup with dextromethoraphan every 4 hours. You may also try ice chips or tessilon perles as needed. If you have chest pain from the coughing that is only when you cough or take a deep breath, use a warm pack for local relief and take tylenol every 6 hours. If you are dizzy or lightheaded at home, please change position slowly and do not stand or sit up quickly. You can check your blood pressure at home but continue to take your medicine unless your top blood pressure number is less than 90. Please also talk to Dr. [**Last Name (STitle) 4507**] about undergoing another sleep study and getting a new CPAP machine. It is important to treat your sleep apnea to help your medical issues. . We made the following changes to your medicines: 1. Discontinue aspirin 2. Increase furosemide to 60 mg daily 3. STart Spiriva to treat your wheezing and breathing 4. Start amiodarone to keep you in a regular heart rhythm 5. Start warfarin to prevent a stroke. Your goal INR is between 2.0 and 3.0. 6. STart robitussin cough syrup and tesselon perles for your cough Followup Instructions: Primary Care: Department: Primary Care Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**] When: Wednesday [**2138-9-17**] at 11:30 AM Location: MEDICAL CARE AFFILIATES Address: [**Location (un) 31127**], [**Location (un) **],[**Numeric Identifier 31128**] Phone: [**Telephone/Fax (1) 31124**] . Cardiology: Department: CARDIAC SERVICES When: MONDAY [**2138-9-8**] at 3:00 PM With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES Specialty: Electrophysiology When: WEDNESDAY [**2138-10-8**] at 9:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Pulmonology: Department: [**Hospital Ward Name 1570**] When: MONDAY [**2138-9-15**] at 2:00 PM Department: PULMONARY FUNCTION LAB When: MONDAY [**2138-9-15**] at 1:40 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 When: MONDAY [**2138-9-15**] at 2:00 PM With: DR. [**First Name8 (NamePattern2) 3688**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "428.0", "327.23", "300.00", "V58.69", "786.59", "428.32", "496", "401.9", "427.31", "429.3" ]

icd9cm

[ [ [] ] ]

[ "88.72", "99.62" ]

icd9pcs

[ [ [] ] ]

8929, 8986

4675, 4832

464, 505

9188, 9188

3594, 4652

11427, 13074

2878, 3096

7514, 8906

9007, 9167

7092, 7491

9339, 11404

3111, 3575

2247, 2326

410, 426

533, 2144

9203, 9315

2357, 2576

6588, 7066

4850, 6572

2188, 2227

2592, 2862

14,267

137,454

22876

Discharge summary

report

Admission Date: [**2134-2-26**] Discharge Date: [**2134-3-31**] Date of Birth: [**2063-3-2**] Sex: F Service: CARDIOTHORACIC Allergies: Strawberry / Penicillins / Iodine; Iodine Containing Attending:[**First Name3 (LF) 14964**] Chief Complaint: Myocardial Infarction Major Surgical or Invasive Procedure: [**2134-2-26**] Cardiac Catheterization [**2134-3-5**] Surgical extraction of teeth 5, 6, 8, and 11. [**2134-3-8**] CABGx3 (LIMA->LAD, SVG->OM, SVG->rPLV) [**2134-3-8**] Cardiac Catheterization [**2134-3-8**] Revision of left internal mammary artery graft [**2134-3-20**] Placement of right internal Jugular perma catheter [**2134-3-30**] Exploratory Laparotomy, subtotal colectomy History of Present Illness: Ms. [**Known lastname 59148**] is a 70 year old female admitted to [**Hospital **] Hospital for chest pain. She ruled in for a myocardial infarction by enzymes with a troponin of 0.21. Her hospital course was complicataed by pulmonary edema on [**2134-2-17**] for which she was intubated. She was also found to be quite anemic requiring 6 units of blood total. Ceftriaxone was started for pneumonia. A cardiac catheterization was significant for an 80% stenosed right coronary artery, mild circumflex disease and questionable left main disease. She was subsequently transferred to the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for percutaneous coronary intervention and further management. Past Medical History: Coronary Artery Disease Atrial Fibrillation End Stage Renal Disease Tachy-Brady syndrome s/p Pacemaker Hypercholesterolemia Gastroesophageal reflux disease Left breast resection Gastrointestinal bleed Hypertension Hiatal Hernia Status post surgery for diverticulitis Past appendectomy and cholecystectomy Past ceserean section Retroperitoneal Bleed Cerebrovascular accident Mesenteric Ischemia Social History: Quit smoking in [**2120**]. No alcohol use. Retired bank teller. Physical Exam: GEN: Plae elderly female in no acute distress VS: 132/73 76 AF 98% 2 liters of O2 HEENT: PERRL, EOMI, Anicteric, dry mucosa NECK: Supple, no lymphadenopathy LUNGS: Clear HEART: Irregularly irregular, distant heart sounds ABD: Soft, nontender, nondistended, normal active bowel sounds EXT: 1+ doraslis pedis pulses bilaterally. NEURO: Cranial nerves grossly intact, Slight confusion. Pertinent Results: [**2134-2-26**] 05:00PM GLUCOSE-106* UREA N-102* CREAT-7.8* SODIUM-133 POTASSIUM-3.8 CHLORIDE-96 TOTAL CO2-17* ANION GAP-24* [**2134-2-26**] 05:00PM WBC-20.1* RBC-3.56* HGB-10.4* HCT-30.6* MCV-86 MCH-29.3 MCHC-34.0 RDW-14.8 [**2134-2-26**] 06:10PM ALT(SGPT)-6 AST(SGOT)-14 ALK PHOS-102 AMYLASE-318* TOT BILI-0.4 [**2134-3-30**] 10:38PM BLOOD WBC-19.1* RBC-2.26*# Hgb-6.6*# Hct-21.2*# MCV-94 MCH-29.2 MCHC-31.1 RDW-18.4* Plt Ct-102*# [**2134-3-30**] 10:38PM BLOOD UreaN-71* Creat-2.6* Na-139 K-4.0 Cl-101 HCO3-21* AnGap-21* [**2134-3-30**] 10:38PM BLOOD ALT-206* AST-117* LD(LDH)-566* AlkPhos-122* Amylase-196* [**2134-3-30**] 11:01PM BLOOD Glucose-85 Lactate-8.1* K-4.2 [**2134-2-26**] EKG Atrial fibrillation. Left ventricular hypertrophy with ST-T wave changs. No previous tracing available for comparison. [**2134-2-26**] Cardiac Catheterization Selective coronary angiography of this right dominant system demonstrated significant disease in the LMCA. The short LMCA had an ostial and proximal 80% lesion which resulted in pressure damping using a 5 French catheter. The LAD had mild luminal irregularities without angiographically apparent, flow-limiting disease. The LCx had a 60% lesion in the OM1 branch and mild disease in the OM2. The RCA was not selectively engaged but had a known 50% diffuse proximal segment and a focal 80% midvessel lesion. [**2134-3-1**] Carotid duplex ultrasound Plaque formation seen at the bilateral carotid bifurcations, associated with a 60-69% stenosis in the right internal carotid artery and a less than 40% stenosis in the left internal carotid artery. [**2134-3-1**] ECHO Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild pulmonary artery systolic hypertension. Mild mitral regurgitation. [**2134-3-2**] CXR Cardiomegaly [**2134-3-4**] Successful exchange of nonfunctioning right IJ hemodialysis catheter for a new 19-cm catheter-tip tunneled hemodialysis catheter with tip in right atrium. Line is ready for use. [**2134-3-8**] Cardiac Catheterization 1. Severe native three vessel coronary artery disease. 2. LIMA with 90% narrowing in the mid vessel consistent with a kink. 3. Severely elevated right sided filling pressures. 4. Moderate pulmonary arterial hypertension. 5. Severely elevated left sided filling pressures. 6. Successful placement of drug-eluting stents in RCA [**2134-3-11**] Head CT Multiple foci of decreased attenuation involving both the [**Doctor Last Name 352**] and white matter in the parietooccipital regions bilaterally, which likely represent infarcts. Given the lack of a specific vascular distribution and the multiplicity of these, this likely is an embolic phenomenon. No intracranial hemorrhage. [**2134-3-17**] PICC Placement [**2134-3-23**] Abdomen CT scan Extensive atheromatous disease involving the aorta as well as the visceral arteries. Probable hepatic and splenic infarcts. Probable colitis distal colon. Correlate clinically and with endoscopy if indicated. Discussed with Dr [**First Name (STitle) **] of referring team. There are patchy-ground glass changes within the entire lungs, which findings should be correlated with other parameters of failure. Airways appear patent. Incidental small tracheal diverticulum was seen. [**2134-3-26**] Ultrasound 1) Normal Doppler evaluation of the portal veins, hepatic veins, and hepatic arteries. Given these findings and the subsegmental appearance of the hepatic infarct, an embolic etiology may be considered. 2) Ill-defined hypoechoic region in the right lobe/dome of the liver, corresponding to the area of suspected hepatic infarct. 3) Spleen not able to be imaged due to obscuring gas from the coexisting pneumothorax. [**2134-3-29**] ECHO 1. The left atrium is normal in size. The right atrium is moderately dilated. 2.There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. 5.The mitral valve leaflets are mildly thickened. 6.There is a small posterior ( to the right atrium) pericardial effusion. There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. 7. There is an echogenic density in the right ventricle consistent with a pacer wire. Brief Hospital Course: Ms. [**Known lastname 59148**] was admitted to the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**] [**Last Name (NamePattern1) **] Medical Center on [**2134-2-26**] for further management of her cardiac disease. She underwent a cardiac catheterization which revealed left main and 2 vessel disease. After her cardiac catheterization she developed right lower quadrant pain. A CT scan was performed which revealed a moderate to large retroperitoneal bleed in her pelvis extending to the right kidney. As her vitals signs and hematocrit were stable, careful observation was performed. The renal staff was consulted for assistance with her end stage renal disease necessitating hemodialysis. Hemodialysis was resumed per her schedule. Given the severity of her coronary disease, the cardiac surgical service was consulted for surgical revascularization. Ms. [**Known lastname 59148**] was worked-up in the usual preoperative manner. She was transfused for anemia. Ceftriaxone and clindamycin were continued for pneumonia and an elevated white blood cell count. A carotid duplex ultrasound was performed which revealed moderate right and minimal left internal carotid artery stenosis. A dental consult was obtained which revealed several diseased teeth in need of extraction. On [**2134-3-5**], 4 teeth were successfully extracted without complication. On [**2134-3-8**], Ms. [**Known lastname 59148**] was taken to the operating room where she underwent coronary artery bypass grafting to three vessels. Postoperatively she was taken to the cardiac surgical intensive care unit for monitoring. She developed ischemic changes on her EKG and was taken to the cardiac catheterization lab where a kink was seen in her left internal mammary artery graft to her left anterior descending artery. Stenting was also performed to her right coronary artery. She was thus returned to the operating room where she underwent a revision of her left internal mammary artery graft. Postoperatively she was returned to the cardiac surgical intensive care unit for monitoring. Hemodialysis was resumed as per preop. On postoperative day one, her permanent pacemaker was interrogated by the electrophysiology service. Plavix was started for anticoagulation for her stents. As she had some clotting of her hemodialysis line, a new one was inserted over a wire. On [**2134-3-11**], Ms. [**Known lastname 59148**] became less responsive with right upper extremity weakness and a stroke service consult was obtained. A head CT was performed which showed multiple infarcts in the parietooccipital regions bilaterally. Heparin as a bridge to Coumadin was started for anticoagulation and her blood pressures were maintained higher. The occupational and physical therapy services were consulted for assistance with her care. Tube feeds were started for nutritional support. Diflucan and Levaquin were started for a urinary tract infection. On [**2134-3-15**], Ms. [**Known lastname 59148**] was extubated. She was able to follow commands and move all four extremities although her right upper extremity remained weaker. Seroquel was used for occasional agitation. On postoperative day nine, Ms. [**Known lastname 59148**] had a increase in her white blood cell count and pan cultures were sent. A PICC line was placed for intravenous access. The transplant service was consulted for evaluation for placement of a fistula versus a tunnelled catheter, however elected to wait until her culture data returned. Vancomycin was started as her catheter tip revealed staph on culture. A right internal jugular perma cath was placed for hemodialysis. On [**2134-3-22**], Ms. [**Known lastname 59148**] became more lethargic and hypotensive requiring Neo-Synephrine. An infectious disease consult was obtained who recommended an chest/abdominal CT scan to rule out infection. Antibiotics were continued. On [**2134-3-23**], a chest and abdominal CT was performed which revealed extensive atheromatous disease involving the aorta as well as the visceral arteries, probable hepatic and splenic infarcts and probable colitis in the distal colon. A blood culture grew gram positive cocci and broad spectrum antibiotics were started. Ms. [**Known lastname 59148**] was reintubated and a transesophageal echocardiogram was performed which showed diffuse, complex atheroma of the thoracic aorta and thrombus versus vegetation associated with indwelling catheter. No valvular vegetations were seen. Her PICC line was changed. The general surgery service was consulted to assist in her care. On [**2134-3-25**], Ms. [**Known lastname 59148**] had rapid deterioration in her blood pressure. A chest x-ray revealed a tension pneumothorax which was treated with a chest tube with improvement in her vital signs. Total parental nutrition was started for nutritional support to rest her bowels. Her liver enzymes continued to trend upwards and a right upper quadrant ultrasound was performed. This revealed an ill-defined hypoechoic region in the right lobe/dome of the liver, corresponding to the area of suspected hepatic infarct. No cholelithiasis was observed. Her lipase became elevated suggesting pancreatitis. Ms. [**Known lastname 59148**] remained on blood pressure support. She became febrile despite antibiotic treatment. A repeat CT scan of her abdomen revealed no significant change when compared to the prior study. The appendix was not definitely visualized. The intrapelvic loops of small bowel were unremarkable. There was a small amount of free fluid in the pelvis. Again noted is probable thickening of the rectosigmoid wall and there was interval increase in the anasarca. The general surgery service took Ms. [**Known lastname 59148**] to the operating room where she underwent a laparotomy. She was found to have extensive ischemia of the small and large bowel and during resection became hemodynamically unstable and needed to be rushed back to cardiac intensive care unit for monitoring. Per her families request, support was withdrawn and Ms. [**Known lastname 59148**] [**Last Name (Titles) **] on [**2134-3-30**] at 2:15 AM. Medications on Admission: Protonix 40mg daily Ceftriaxone Atenolol 50mg Daily Lasix 120 twice daily Reglan 5mg three times daily Epogen Plavix Aspirin Discharge Medications: None Discharge Disposition: [**Date Range **] Discharge Diagnosis: Death Discharge Condition: Pt [**Date Range **] on [**2134-3-30**] 0220 Completed by:[**2134-4-21**]

[ "285.9", "482.41", "410.71", "403.91", "584.9", "434.11", "557.0", "996.03", "997.1", "445.81", "599.0", "E878.2", "038.9", "V09.81", "521.09", "410.91", "414.01", "568.0", "512.1", "427.1", "535.51", "427.31", "998.11", "428.0", "995.92", "998.2" ]

icd9cm

[ [ [] ] ]

[ "39.95", "88.56", "36.05", "96.04", "38.91", "37.22", "99.04", "45.73", "88.72", "36.07", "23.19", "39.61", "00.14", "96.6", "34.04", "37.23", "38.95", "36.15", "96.72", "54.59", "88.55", "36.12" ]

icd9pcs

[ [ [] ] ]

13359, 13378

7033, 13155

341, 724

13427, 13502

2475, 7010

13330, 13336

13399, 13406

13181, 13307

2070, 2456

280, 303

752, 1556

1578, 1973

1989, 2055

15,876

119,894

26578

Discharge summary

report

Admission Date: [**2136-3-29**] Discharge Date: [**2136-4-3**] Date of Birth: [**2064-2-7**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 297**] Chief Complaint: Hyperkalemia and aspiration pna resulting in respiratory failure Major Surgical or Invasive Procedure: Central line placement. History of Present Illness: Mrs [**Known lastname **] is a 72 yo woman c PMH significant for T2 DM, HTN, CRF. Pt was brought last night to [**First Name8 (NamePattern2) **] [**Location (un) 620**] after c/o abdominal pain since yesterday afternoon. She apparently c/o nausea and vomiting. She has not had a BM for 1 week. Denied CP or SOB. At [**Location (un) 620**] found to have elevated K of 7.2. Pt was given Kayexelate 30 g po after which she had an episode of coffe ground emesis 100 cc. Pt was given another dose of Kayexelate after which she vomited 200 cc of yellow bile. Altogether she received CaCl 2 amps, Phenergan 12.5, Zofran 4 once, Kayexelate 30 x 2, NaHco3 1 amp, insulin 10 U, NS x [**2130**] . Her SpO2 begun to drop from 96 % on admission to 88% on NRB (4 am)VS 170/60 HR 66 At 445 she was sedated (rocuronium, Etomidate, ) and intubated. She was transfered to our MICU. In [**Hospital1 18**] [**Name (NI) **] pt on CMV RR 13 TV 550 PEEP Labs c lactate of 5.3. K 6.9 Metabolic acisosis c gap of 20. She was given NS 2 lt ,Lasix 20 IV , Insulin 10 U , Nacoh3 , Ca gluc , Levaqun and Flagyl. She was transferred to MICU. Past Medical History: HTN CHF T2 DM Social History: not avail on admission Family History: not avail on admission Physical Exam: PE VS: 99.3 HR 63 BP 146 66 SpO2 99% MV Gen: Elderly female intubated HEENT: Dry mucous membranes, PERRL Chest: CTAB, no crackles CVR: RRR, nl s1, s2. no r/m/g Abdomen: soft, obese, ND, NABS Ext: No edema Pertinent Results: [**2136-3-29**] 06:10AM WBC-15.0* RBC-3.73* HGB-11.7* HCT-34.6* MCV-93 MCH-31.3 MCHC-33.7 RDW-13.5 [**2136-3-29**] 06:10AM NEUTS-76* BANDS-15* LYMPHS-2* MONOS-7 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2136-3-29**] 06:10AM GLUCOSE-268* UREA N-76* CREAT-2.2* SODIUM-139 POTASSIUM-6.8* CHLORIDE-108 TOTAL CO2-19* ANION GAP-19 [**2136-3-29**] 06:17AM LACTATE-5.2* K+-6.9* [**2136-3-29**] 08:52AM LACTATE-6.4* K+-6.3* [**2136-3-29**] 06:10AM CK(CPK)-31 [**2136-3-29**] 06:10AM CK-MB-NotDone . [**4-2**] Echo: Mild symmetric left ventricular hypertrophy with mildly reduced left ventricular systolic function. Mild mitral regurgitation. Mildly dilated ascending aorta. . [**4-2**] CXR - Dense bilateral perihilar consolidation which progressed from [**3-29**] through [**4-1**] is now joined by moderate pulmonary edema worsened since [**3-31**], accompanied by increasing moderate bilateral pleural effusion. Mediastinal contour indicates elevated central venous pressure. Lung volumes are quite low exaggerating heart size which is probably top normal and only slightly enlarged. No pneumothorax. Tip of the left subclavian line projects over the junction of the brachiocephalic veins. No indication of pneumothorax. Colonic distention seen in the splenic flexure is unchanged over the past several days. Brief Hospital Course: A/P: 72 yo woman c T2 DM, HTN, admitted c elevated BS up to 400, metabolic acidosis c hyperkalemia , renal failure, UTI and respiratory failure most likely d/2 aspiration and heart failure. . #Respiratory failure- Patient was intubated at OSH after witnessed aspiration event after receiving kayexelate. She remained intubated after transfer initially and was slowly weaned off the ventilator. Once her metabolic status was improved, she was extubated. Post extubation she continued to have high oxygen requirement with one or two episodes of desaturation. CXR was consistent with volume overload and she was given lasix for diuresis. She diuresed well with IV lasix and her O2 requirement improved. She was also treated with levoflox for aspiration Pneumonia. . # Hyperkalemia - at OSH, patient was given Calcium gluconate, bicarb. Renal was consulted on transfer to ICU. They recommended IVF and lasix, along with calcium, bacarbinate,insulin, glucose, albuterol and kayexalate. Her potassium steadily improved and by the following day she was hypokalemic. It was unclear why patient was hyperkalemic, not clearly medication related. She had elevated blood sugars on admission and acute renal insufficiency. . # Renal failure- Initially her renal function improved with aggressive iv fluids and then tapered off. She was diresed and her renal function improved to 1.7 on day of discharge. Prior to discharge she was started on Losartan. Her potassium and renal function should be monitored closely. . # CHF- Initially given concern for infection and elevated lactate she received aggresive IV fluids. After high O2 requirements post extubation she was given lasix for diuresis. Her oxygen saturation improved drastically. Echo was done which showed EF 40-45%. She was also restarted on her [**Last Name (un) **] and hydral/imdur were added for afterload reduction. Aspirin was continued. Her creatinine and potassium should be monitored daily. . # UTI - Urine with GPC, She received a 7 day course of Vancomycin. . # T2DM - Cont SSI. She should be restarted on her PO diabetic regimen after discharge. # FEN - Patient received tube feeds while she was intubated. Post extubation she underwent a Speech and Swallow evaluation given her history of aspiration pneumonia. Her swallow eval was ok and her diet was advance to po diet. Medications on Admission: ASA 325 Glipizide 10 po qd Norvasc 10 qd Atenolol 50 qd Synthroid Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED): Regular Insulin Sliding Scale Glucose Value 0-50 mg/dL -> please give 4 oz. Juice and [**Location (un) **] crackers; 51-150 mg/dL - 0 Units of Regular Insulin; 151-200 mg/dL - 2 Units of Regular Insulin; 201-250 mg/dL - 4 Units of Regular Insulin; 251-300 mg/dL - 6 Units of Regular Insulin; 301-350 mg/dL - 8 Units of Regular Insulin; 351-400 mg/dL - 10 Units of Regular Insulin; Sugars>400 Notify M.D. . 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 4. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 5. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for low Fe. 8. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Hydralazine 10 mg Tablet Sig: Three (3) Tablet PO Q6H (every 6 hours). 10. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 13. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day for 1 days. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at [**Hospital6 1109**] - [**Location (un) 1110**] Discharge Diagnosis: Hyperkalemia Acute Renal failure Congestive Heart Failure Type 2 diabetes Hypertension Discharge Condition: Good Discharge Instructions: Please continue to take all your medications as directed and follow up with all your appointments appropriately. Followup Instructions: Please follow up with your PCP [**Last Name (NamePattern4) **] [**1-23**] weeks after discharge from the Rehab facility. Completed by:[**2136-4-3**]

[ "V58.67", "276.2", "428.0", "584.9", "250.00", "518.81", "276.7", "585.9", "507.0", "401.9", "599.0" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

7200, 7345

3219, 5577

343, 368

7476, 7483

1875, 3196

7645, 7796

1606, 1630

5693, 7177

7366, 7455

5603, 5670

7507, 7622

1645, 1856

239, 305

396, 1513

1535, 1550

1566, 1590

31,131

180,982

49754

Discharge summary

report

Admission Date: [**2107-3-29**] Discharge Date: [**2107-3-30**] Date of Birth: [**2052-4-12**] Sex: F Service: MEDICINE Allergies: Dilantin / Erythromycin Base Attending:[**First Name3 (LF) 1711**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: 54F with CAD s/p CABG (LIMA-LAD atretic, SVG-PDA occluded, SVG-OM patent per last cath in [**12-11**], s/p 15 stents), breast cancer s/p mastectomy and chemotherapy, current smoker, presenting with exacerbation of chronic chest pain. She usually has angina which which is [**2109-3-7**] and resolves with nitroglycerin. It is brought on by exertion such as cleaning, but also can occur at rest. This morning her pain was [**6-14**] which was of the same quality but did not resolve with nitroglycerin. She presented to [**Hospital3 **] ED where she did not have ECG changes or positive biomarkers. She was hypotensive to SBP of 60 and was given 1L NS and started on dopamine. Of note patient reports baseline SBP is in 80s and at times requires fluid boluses as an outpatient for poor PO intake with chemo. Given significant cardiac history, she was transferred to [**Hospital1 18**] and brought to the cath lab. Cardiac cath showed stable configuration of the native and bypass vessels, with no new lesions. She denies positional and/or pleuritic component to the pain. She does feel that it has improved somewhat post-procedure. Of note, patient had a screening colonoscopy in [**2106-12-4**] which found a colonic polyp but no intervention undertaken at that time. She was scheduled for repeat colonscopy today. She was taking lactulose for prep and was having significant clear diarrhea from it. She currently reports feeling very dehydrated. She reports generally poor PO intake which she attributes to chemotherapy for breast cancer. For most of her life patient has been very constipated and prior to 4 months ago was on multiple laxatives. 4 months ago she developed diarrhea and stopped the laxatives without improvement. She was seen at an OSH for this diarrhea and was told it was likely viral and that it would resolve with conservative measures. She has previously had problems with GI bleeding (red blood in toilet bowl), most recently 1 month ago, but not recently. At [**Hospital3 4107**] rectal exam performed but guaiac status not documented. At times she has required transfusions and was told by her cardiologist that she should not let her hematocrit go below 30%. Past Medical History: Cardiac Risk Factors: - Diabetes, + Dyslipidemia, - Hypertension . Cardiac History: CABG in [**2095**] with LIMA-LAD (atretic), SVG-PDA (occluded), SVG-OM patent per last cath in [**12-11**], s/p 15 stents . Percutaneous coronary intervention, (multiple but anatomy unavailable at present) . Pacemaker/ICD placed: none . PMH: 1. Breast cancer diagnosed [**5-11**], tx'ed with chemotherapy and radiation. Patient does not report being told that she had metastatic disease. 2. CAD s/p CABG 3. ?seizure disorder 4. ?multiple sclerosis (per last [**Hospital1 18**] note). 5. h/o peptic ulcer 6. Chronic neck and back pain from herniated discs Social History: Social history is significant for the presence of current tobacco use - previously 5ppd ([**8-14**]) years ago - now less but patient cannot quantify. There is no history of alcohol abuse. Family History: There is significant family history of premature coronary artery disease or sudden death in multiple family members Physical Exam: VS: T 96.6, BP 98/52 on 5.0 mcg/kg/min of dopamine, HR 63, RR 23, O2 100% on 3L NC Gen: WDWN middle aged female in NAD, resp or otherwise. Pale-appearing. Oriented x3. Mood, affect appropriate. At times inattentive, falls asleep. Smells of cigarette smoke. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Mucous membranes dry. Neck: Supple with nondistended JVP CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. III/VI systolic murmur at the base. no radiation to carotids. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi anteriorly. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; Left: Carotid 2+ without bruit; Femoral 2+ without bruit; Pertinent Results: Cardiac cath [**2107-3-29**]: 1. Coronary angiography of this right dominant system revealed no new critical coronary disease. The LMCA had no obstructive coronary disease. The LAD had minimal coronary disease. The LCX had diffuse disease with a 70% stenosis in OM1 with stenosis in a small distal part of the vessel. The RCA was non-selectively engaged and confirmed to be totally occlusive proximally. The SVG-OM was patent. The SVG-RPDA was known to be totally occluded and therefore not engaged. The LIMA-LAD was also known to be atretic and therefore not engaged as well. 2. Resting hemodynamics revealed low systemic arterial pressure with an SBP of 67 mm Hg off of dopamine with IV fluids wide open. Dopamine IV gtt was increased to 10 mcg/kg/min with an SBP of 86 mm Hg. 3. Left ventriculography was deferred. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Patent SVG-OM. CTA chest [**2107-3-29**] 1. No evidence of pulmonary embolism. 2. Patchy airspace disease at both lung bases posteriorly (left greater than right). An element of aspiration in posterior lobes cannot be excluded. 3. Moderate-sized hiatal hernia. 4. 2 mm right middle lobe pulmonary nodule. If clinically indicated, a 6 to 12 month follow up may be obtained to evaluate for stability. ECHO [**2107-3-30**] The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) There is no ventricular septal defect. The right ventricular cavity is mildly dilated with normal free wall contractility. There is abnormal diastolic septal motion/position consistent with post-op state however early right ventricular volume overload cannot be excluded (clip [**Clip Number (Radiology) **]). 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. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. LABS [**2107-3-30**] 02:46AM BLOOD Triglyc-97 HDL-33 CHOL/HD-6.0 LDLcalc-145* [**2107-3-30**] 02:46AM BLOOD %HbA1c-5.3 [**2107-3-30**] 02:46AM BLOOD WBC-8.5 RBC-3.20* Hgb-10.3* Hct-29.8* MCV-93 MCH-32.2* MCHC-34.6 RDW-13.2 Plt Ct-265 [**2107-3-30**] 02:46AM BLOOD PT-13.3 PTT-24.9 INR(PT)-1.1 [**2107-3-30**] 02:46AM BLOOD Plt Ct-265 [**2107-3-30**] 02:46AM BLOOD Glucose-108* UreaN-7 Creat-0.5 Na-143 K-3.7 Cl-114* HCO3-19* AnGap-14 [**2107-3-30**] 02:46AM BLOOD CK(CPK)-27 [**2107-3-29**] 04:20PM BLOOD ALT-15 AST-18 CK(CPK)-32 AlkPhos-103 [**2107-3-29**] 04:20PM BLOOD cTropnT-<0.01 [**2107-3-30**] 02:46AM BLOOD CK-MB-NotDone cTropnT-<0.01 Brief Hospital Course: ASSESSMENT AND PLAN, TO BE REVIEWED AND DISCUSSED IN MULTIDISCIPLINARY ROUNDS: 54F with significant CAD s/p CABG with multiple failed grafts and stenting, poor historian/possible med-seeking behavior, presenting with anginal chest pain and found to have no new lesions on cardiac cath. CAD: Patient was taken to cath lab because history suggestive of unstable angina given her significant history and symptoms similar to known angina. Cardiac cath did not demonstrate any significant new lesions. Patient was weaned off her dopamine drip on the day after her catherization. Her blood pressure was systolic 80s. Patient was discharged on her home toprol XL at 12.5mg daily, Imdur 60mg daily, lisinopril 20mg daily with strict instructions to be checking her blood pressure at home and to hold these medications if her systolic blood pressure was less than 100. Her ECHO was repeated and showed EF>55 and abnormal diastolic septal motion/position consistent with post-op state however early right ventricular volume overload cannot be excluded. She was discharged with close follow up with her cardiologist to readdress her medications and smoking cessation. In terms of risk factors, Hb A1C was 5.3, LDL 145, HDL 33. Patient discharged on her normal ASA and statin. Chest pain: Likely due to her know chronic stable angiina. Patient ruled out for ACS by cardiac cath, PE by negative CTA of chest, and no indications of pericarditis by EKG and ECHO. Repeat ECHO showed preserved EF and no gross wall motion abnormalitis. Can reassess the abnormal diastolic septal motion if indicated. Hypotension: Patient's blood pressure runs a the low-end of normal (in 80s) so initial drop was probably less-concerning. It does not seem that she was adequately volume resuscitated and by history and physical she is likely volume depleted, and likely chronic. She was initially started on a dopamine gtt but weaned off overnight and maintaining her pressures, SBP 80s. She was afebrile, normal WBC, no indication of sepsis. She was discharged with SBP 80s, and patient knows to continue holding her BP medications for any hypotension. She notes she is feeling well and is aware of her baseline hypotension. Rhythm: NSR, no apparent arrhythmias presently continue to monitor on telemetry. Breast Cancer: Patient continued on Arimadex. No active issues but chemotherapy treatment may be contributing to patient's poor PO intake. Chronic neck and back pain She was initially several doses of dilaudid based on patient's account of home medications. However, dilaudid was discontinued once medications were verified with [**Hospital1 112**] cardiologist, and patient continued on her home dosing of MScontin, MSIR. Medications on Admission: Imdur 60mg daily Lisinopril 20mg daily ASA 325mg daily Tegretol 200mg [**Hospital1 **] Plavix 75mg daily Lipitor 80mg daily Celexa 40mg [**Hospital1 **] Metoprolol 12.5mg daily Diazepam 10mg daily MS contin 15mg [**Hospital1 **] MSIR 15mg q8h Arimadex 1mg daily Zofran 4mg TID Trazadone 200mg qHS Advair Discus 50/100 1 puff [**Hospital1 **] Combivent 2 puffs qid albuterol nebulizer q4h PRN shortness of breath. Advil liquigels 2 tabs PRN Maalox [**1-5**] tabls PRN Benadryl prn itch Colace nitroglycerin spray PRN (generally [**1-5**] sprays daily) Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 4. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 5. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 6. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 7. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily (). 11. Diazepam 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 12. Trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 13. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily): Hold for systolic blood pressure under 100. 14. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold for systolic blood pressure under 100. 15. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily): Hold for systolic blood pressure under 100. 16. Celexa 40 mg Tablet Sig: One (1) Tablet PO once a day. 17. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 18. Lactulose 20 gram Packet Sig: Three (3) PO twice a day. 19. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime. 20. GlycoLax 17 gram (100 %) Powder in Packet Sig: One (1) PO twice a day. 21. Tigan 300 mg Capsule Oral 22. Nitrolingual 0.4 mg/Dose Spray, Non-Aerosol Sig: [**1-5**] Translingual once a day. Discharge Disposition: Home With Service Facility: Old Colony Elder Services Discharge Diagnosis: Final diagnosis: Chronic stable angina without acute coronary syndrome Secondary diagnosis: Hypotension Coronary artery disease Hypertension Discharge Condition: Stable Discharge Instructions: You were admitted for worsening of your chronic chest pain. You were evaluated by cardiac catheterization which showed no changes. You also had an echocardiogram of your heart which showed good heart function. Please monitor your groin site after your cardiac catheterization. Please call your physician if you notice any blood collection at the site, pain at the site, or numbness or tingling in your toes. We did not make any changes to your medications but it is very important that you take all your prescribed medications, especially your daily plavix, and your blood pressure medications with holding parameters. Do not take the following medications if your systolic blood pressure is less than 100: - imdur - metoprolol - lisinopril Please follow up with your physician [**Name Initial (PRE) 176**] 1-2 weeks of discharge from the hospital. Please keep your scheduled cardiology appointment. Please call your physician or return to the hospital immediately if you experience any lightheadedness, weakness, chest pain, shortness of breath, or feeling that you are about to pass out. Please also call your physician if you have low blood pressures and are needing to hold your blood pressure medications. Followup Instructions: Please follow up with your physician [**Name Initial (PRE) 176**] 1-2 weeks of discharge from the hospital. Please keep your scheduled cardiology appointment.

[ "250.00", "401.9", "211.3", "413.9", "276.51", "724.5", "338.29", "723.1", "414.01", "414.02", "174.8", "305.1" ]

icd9cm

[ [ [] ] ]

[ "88.56", "37.22" ]

icd9pcs

[ [ [] ] ]

12787, 12843

7502, 10208

300, 325

13029, 13038

4616, 5435

14301, 14463

3451, 3568

10809, 12764

12864, 12864

10234, 10786

12881, 12936

13062, 14278

3583, 4597

250, 262

353, 2564

12957, 13008

2586, 3228

3244, 3435

21,307

172,217

4793

Discharge summary

report

Admission Date: [**2128-1-29**] Discharge Date: [**2128-2-3**] Service: HISTORY OF THE PRESENT ILLNESS: The patient is an 82-year-old woman with multiple medical problems, doing well, until after dialysis on[**2128-1-29**], when she had an acute onset of left lower quadrant pain, which was extremely sharp. The patient had no nausea, vomiting, fever or chills. The pain is episodic. The patient had periods of minimal pain. Colostomy has gas and stool the bag. PAST MEDICAL HISTORY: 1. Coronary artery disease/MI. 2. Congestive heart failure. 3. Chronic obstructive pulmonary disease. 4. End-stage renal disease. 5. Hypertension. 6. Noninsulin dependent diabetes mellitus. 7. Asthma. 8. Colon cancer. 9. Osteoporosis. 10. Peripheral vascular disease. 11. Peptic ulcer disease. 12. Nephrolithiasis. 13. History of gallstones. 14. History of UTIs. PAST SURGICAL HISTORY: 1. Colectomy/sigmoid colostomy. 2. Coronary artery bypass graft. 3. Total abdominal hysterectomy, bilateral oophorectomy. 4. Appendectomy. 5. Right A-V fistula. 6. Right A-V thrombectomy times three. 7. Femoral-popliteal in [**2121**], right lower extremity. 8. Subtotal gastrectomy, status post gastric cancer. MEDICATIONS: 1. Zestril 10 mg PO q.d. 2. Lasix 20 mg PO q.d. 3. Coumadin 1 mg PO q.d. 4. Pravachol 10 mg PO q.d. 5. Lopressor 25 mg PO b.i.d. 6. Imdur 90 mg PO q.d. 7. Sodium bicarbonate 650 mg t.i.d. 8. Quinine 325 mg PO q.d. 9. Nitroglycerin 0.4 mg PO p.r.n. 10. Glyburide 2.5 mg, ?????? tablet PO q.d. 11. Meclizine. 12. Flovent. 13. Albuterol 2 puffs inhaled q.i.d. 14. Atrovent 2 puffs inhaled q.i.d. ALLERGIES: The patient is allergic to SULFA, PENICILLIN, AND CODEINE. PHYSICAL EXAMINATION: Examination revealed the following: Pulse 74, blood pressure 192/93, 12, 99% on three liters nasal cannula. GENERAL: The patient is alert and oriented times three, mild distress, but distractible. HEENT: pupils. equal, round, and reactive to light, nonicteric. CHEST: Midline sternal scar, decreased breath sounds bilaterally. CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: Flat, positive bowel sounds, left lower quadrant tenderness, heme-negative. No mass in the rectal vault. EXTREMITIES: Normal. Stoma is pink. LABORATORY DATA: Laboratory data revealed the following: White count 4.5, hematocrit 33.6, platelet count 122. Chem 7 140, 3.2, 94, 28, 73. 2.9, 370. The EKG showed normal sinus rhythm with ST depressions in the anterolateral leads. Chest x-ray showed flat diaphragm, surgical clips, and sternal wires. No free air. No pneumothorax. The CT scan showed portal venous air in the IMV, thickened colon proximal to the stoma, free fluid, fat stranding, no clear peritonitis, minimal flow through SMA and celiac. On [**2128-1-29**], the patient was taken to the operating room for an exploratory laparotomy with resection of the ischemic colon and ileal descending colon anastomosis with formation of ileostomy and ileostomy. The patient did well postoperatively, and she was transferred to the Intensive Care Unit, intubated. Upon entrance to the SICU, the patient's ABG was 7.37, 39, 259, 23 on 600 by 10 SIMV. Regarding the Infectious Disease Department, the patient was given Vancomycin and Ceftriaxone, as well as Flagyl preoperatively. The patient was on subcutaneous heparin for DVT prophylaxis and Zantac also for prophylaxis. On postoperative day #1, the patient continued to do well. A vent wean was begun. The patient was on CPAP 5/5 with ABG of 7.29, 45, 179, and 23. The patient received hemodialysis on postoperative day #1. On postoperative day #2, the patient was extubated. The Foley was removed. The patient remained NPO. On postoperative day #3, the patient remained in the SICU. The patient was given sips by mouth. The patient tolerated this well and the patient's diet was advanced as tolerated. On postoperative day #4, the patient was transferred to the floor for further care. The patient's femoral line was removed, as well as the patient's A line. The patient received hemodialysis on postoperative day #4 at 2.5 kilograms removed during hemodialysis. On postoperative day #5, the patient continued to do well, and the patient was tolerating a regular diet. The patient returned to hemodialysis for further fluid removal. On postoperative day #4, the Department of Physical Therapy also saw the patient and agreed that rehabilitation would be the best option for this patient. On postoperative day #5, the patient was screened for rehabilitation. The biliary medicine team was consulted on postoperative day #5 regarding choledocholithiasis. Recommendation was not to do anything at this time, do the anticoagulation of the patient, as well as her poor status. If at some point, the wish was to reverse the patient's anticoagulation, they could perform a sphincterotomy, but they were concerned about the use of general anesthesia. The is pending discharge on postoperative day #5 to rehabilitation. DISCHARGE STATUS: Good. FINAL DIAGNOSIS: Status post left colectomy and ileostomy for ischemic colon. DISCHARGE MEDICATIONS: 1. Zestril 10 mg PO q.d. 2. Lasix 20 mg PO q.d. 3. Pravachol 10 mg PO q.d. 4. Sodium bicarbonate 650 mg PO t.i.d. 5. Albuterol 2 puffs q 6.h. p.r.n. 6. Atrovent 2 puffs inhaled q.i.d. 7. Glyburide 3.75 mg PO q.d. 8. Vancomycin ....................hemodialysis. 9. Combivent nebulizers q.4h.p.r.n. 10. Flovent metered dose inhaler two puffs b.i.d. 11. Tylenol 650 mg PO q.4 to 6h.p.r.n. 12. Sliding scale regular insulin. 13. Lopressor 25 mg PO b.i.d. 14. Imdur 90 mg PO q.d. 15. Zantac 150 mg PO q.d. 16. Amphojel 30 cc t.i.d. 17. Treatment for stoma care. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-205 Dictated By:[**Last Name (NamePattern1) 6067**] MEDQUIST36 D: [**2128-2-3**] 09:37 T: [**2128-2-3**] 09:52 JOB#: [**Job Number 20091**]

[ "403.91", "250.40", "440.20", "496", "428.0", "414.01", "V45.81", "557.0" ]

icd9cm

[ [ [] ] ]

[ "39.95", "46.52", "45.79", "46.94", "46.21" ]

icd9pcs

[ [ [] ] ]

5139, 5939

5054, 5116

896, 1705

1728, 5036

500, 873

28,634

153,972

23587

Discharge summary

report

Admission Date: [**2103-12-5**] Discharge Date: [**2103-12-7**] Date of Birth: [**2036-12-28**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 398**] Chief Complaint: cardiac arrest Major Surgical or Invasive Procedure: Defibrillation and Bag-Valve Mask ventilation History of Present Illness: 66 W with pmhx of met leiomyosarcoma on experimental therapy of a TKI inhibitor ARQ 171 C2D8, was in clinic, received decadron/pepcid then ARQ 171 and subsequently became unresponsive. Her husband was at her side and noted increasing auditory respiration, and she became less responsive. He noted this was [**6-21**] minute prior to completion of infusion of chemo. He alerted the nurses, whoc found her in cardiac arrest and defibrillated her x1 within minutes. Her rhythm converted to sinus tachycardia, with stable BP, and o2 sat. She did not require intubation, stat abg 7.37/34/205 on a NRB. . In the [**Hospital Unit Name 153**], on review of systems, she states she has a recent sore throat the morning of admission, and her husband has had a cold. Otherwise, no f/c, nausea/vomitting, headache, cp. . Regarding her leiomyosarcoma: Presented with vaginal bleeding and had a D and C; She then had a TAH/BSO in [**2101-4-12**] - the pathology showed a leiomyosarcoma 7.5 cm in dimension with 10 mitosis per 10 high-powered field. On [**2102-8-1**] she had a right lower lobe wedge resection for metastatic leiomyosarcoma. She has had 2 admits due to chemo related side effect - 1. fever and neutropenia [**2103-3-13**] and discharged on [**2103-3-17**]; #2 C.Difficile Colitis admit on [**2103-4-12**] and discharge [**2103-4-17**]. Past Medical History: PMH: -Leiomyosarcoma, uterine origin -HTN -Bladder diverticulum Social History: She is accompanied by her husband of 47 years, who is himself starting treatment for CLL. She lives in [**Hospital1 1474**]. She never smoked. She was a receptionist at a community bank in [**Hospital1 1474**]. No alcohol. No IV drugs. She has two grown daughters and four grandkids. Family History: father with prostate CA Physical Exam: Admission Physical VS 97.3 101/53 89 10 96% 3L GEN: NAD, AAO, appropriate HEENT: PERRL, EOMI OP Clear, Mass on right parotid area, dry mm CV: RRR no mrg CHEST: fine crackle at L base , good air movement ABd + BS, soft nt/nd, enlarged firm liver, EXT: no c/c/ 1+ pitting edema b/l Neuro: aaox3, no focal deficits, grossly intact Discharge Physical VS T98.7 BP 112/82 P 98 SAO2 985 RA GEN: NAD HEENT: right neck mass, no pharyngeal erythema or purulence CV: RRR, no MRG, nl S1/S2 Chest: CTAB, good air movement, firm nodular left breast ABD: soft, NT, mildly distended, firm/nodular liver Ext: 2+ pittind edema (unchanged from passed weeks) Neuro: AAOx3, approprieat, no focal deficits Pertinent Results: CXR: Left pleural effusion with adjacent relaxation atelectasis. Early developing pneumonia in this region cannot be entirely excluded. There is mild volume overload. Repeat radiography following appropriate diuresis may be of benefit to assess for this possible underlying infection. . Echo: 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 number of aortic valve leaflets cannot be determined. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is borderline pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. . EKG pre ekg qt 434, after code, qt 458, also TWI V1V4 EKC [**12-6**]: sinus tachycardia, QTc 468 EKG [**12-7**]: sinus tachycardia, QTc 448 . [**2103-12-5**] 11:02PM LACTATE-8.4* pH 7.37/34/205 . Electroyltes [**2103-12-5**] 11:10AM BLOOD WBC-10.9 RBC-3.11* Hgb-11.1* Hct-34.0* MCV-109* MCH-35.8* MCHC-32.7 RDW-17.3* Plt Ct-175 [**2103-12-5**] 11:10AM BLOOD Calcium-7.7* Phos-3.1 Mg-2.1 [**2103-12-7**] 06:07AM BLOOD WBC-10.4 RBC-3.01* Hgb-11.0* Hct-33.5* MCV-112* MCH-36.7* MCHC-32.9 RDW-18.9* Plt Ct-165 [**2103-12-5**] 11:10AM BLOOD Glucose-75 UreaN-21* Creat-0.6 Na-142 K-4.2 Cl-101 HCO3-21* AnGap-24* [**2103-12-6**] 05:56AM BLOOD Glucose-68* UreaN-21* Creat-0.5 Na-141 K-4.3 Cl-102 HCO3-24 AnGap-19 [**2103-12-7**] 06:07AM BLOOD Glucose-65* UreaN-23* Creat-0.6 Na-142 K-4.0 Cl-102 HCO3-21* AnGap-23* [**2103-12-7**] 06:07AM BLOOD Calcium-8.1* Phos-3.1 Mg-2.4 . Cardiac Enzymes [**2103-12-5**] 02:10PM BLOOD CK-MB-4 cTropnT-<0.01 [**2103-12-5**] 10:48PM BLOOD CK-MB-4 cTropnT-<0.01 [**2103-12-6**] 05:56AM BLOOD CK-MB-4 cTropnT-<0.01 Brief Hospital Course: The patient presented to the 7 [**Hospital Ward Name 1826**] outpatient Hem/[**Hospital **] clinic for treatment of metastatic leiomyosarcoma. She received Decadron and Pepcid pretreament and then ARQ 171. Her husband then found her unresponsive and called nursing staff. She was found to be pulseless and was immediately defibrillated. A code was called. She responded to one shock with restoration of NSR, BP and SA02 - BP 100's/70's, SaO2 96-99% on oxygen. She did not require intubation but was briefly mask ventilated. She received 2g Mag given the the prolongation of QTc from 438 to 458 after ARQ 171 administration, but no other intravenous medication. She was admitted to the ICU. . In the ICU, she was placed on telemetry and given fluids given SBP's in 90's, with improvement of her BP. Her lisinopril was held. An ABG showed no acidemia. However, she did have a gap acidosis with bicarbonate compensation. There was no evidence of renal failure, uremia, dka, or history of ASA ingenstion to account for acidosis. Her lactate was high - likely lactate B due to malignancy, which may have accounted for her acid-base status. Her CXR showed no new findings, no pneumothorax, no widened mediastinum, no dilated heart. Her cardiac enzymes where flat. An echo was performed to look for an arrthymogenic metastasis; although it was a poor study, no wall-motion abnormalities suggestive of a metastasis where found. A PE was thought to be unlikely as she would have to have had a massive PE with RV dysfunction (not seen on EKG) and would not have recovered so quickly or had normal O2 saturations. She received serial EKG's showing initially prolonging QTc 438 (prior to arrest)-458 (at arrest)-468 (next day) which then decreased to 448 on day of discharge. Cardiology was consulted and were able to trace her arrhythmias around the time of arrest. Per discussion with cardiology, they noted PVC's after administraion of ARQ 171, then QT prolongation and then an R-on-T followed by assytole. Based on these findings, it was thought that ARQ 171 most likely caused Torsades and cardiac arrest. She was not placed on any medication as her long QT was resolving and as the inciting [**Doctor Last Name 360**] was removed. She remained asymptomatic the rest of her hospital course without chest pain, SOB, diaphoresis or palpatations. She was discharged with close cardiology follow up. Medications on Admission: Compazine 10 mg PRN Decadron 10 mg IV needed prior to infusion of ARQ to 20 mg orally as needed prior to infusion Anzemet 100 mg PRN prior to infusion lisinopril 5 mg daily oxycodone 5 mg at bedtime p.r.n. Centrum Silver stool softener Discharge Medications: 1. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. Discharge Disposition: Home Discharge Diagnosis: Cardiac Arrest Leiomyosarcoma Discharge Condition: improved, stable Discharge Instructions: You were diagnosed with cardiac arrest. We believe that you experienced cardiac arrest because of an abnormal rhythm called long QT that occured because of the chemotherapy [**Doctor Last Name 360**] ARQ 171. Your QT interval is no longer prolonged at this time. However, you will need to have the QT interval monitored closely. Followup Instructions: Please call your oncologist for a follow up appointment Provider: [**Name Initial (NameIs) 455**] 1-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F Date/Time:[**2103-12-12**] 11:00 . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2103-12-11**] 1:00 at [**Hospital1 **], [**Hospital Ward Name 516**] [**Location (un) 8661**] 7

[ "596.3", "401.9", "518.0", "288.60", "E933.1", "276.6", "427.5", "V10.42", "427.69", "197.0", "276.2" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7624, 7630

4840, 7233

330, 378

7704, 7723

2904, 4817

8100, 8503

2156, 2181

7520, 7601

7651, 7683

7259, 7497

7747, 8077

2196, 2885

276, 292

406, 1746

1768, 1833

1849, 2140

28,389

139,931

51844

Discharge summary

report

Admission Date: [**2152-9-15**] Discharge Date: [**2152-9-25**] Date of Birth: [**2104-11-22**] Sex: F Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 668**] Chief Complaint: Abdominal pain x 1 week Major Surgical or Invasive Procedure: [**9-15**] Angiography: SMA stent (for aortic dissection) [**9-18**]: Right hemi-colectomy (5cm) and long Hartmann's for dead nonperforated bowel History of Present Illness: This is a 47 y/o F who presented to an outside hospital with complaints of sharp and crampy colicky abdominal pain. She denies nausea/vomiting. She does have flatus, but no BM for days at initial presentation. Last BM yesterday. She was discharged home yesterday, but presented to [**Hospital1 18**] ED with the same complaints. She presented because her pain never resolved. A CT scan at the OSH was normal by report (no images available). Past Medical History: HTN GERD Umbilical surgery (infant) Social History: She admits to tobacco (only 1 cig/day), denies EtOH, denies IVDU, denies illicit drugs. Family History: HTN, DM Type II Physical Exam: On Admission: Temp 98.4, HR 90, BP 248/119, RR 18, O2 sat 99% RA GEN: obese, in mild distress CV: RRR, no m/r/g Lungs: CTA B/L ABD: + BS, soft, obese, LLQ mild pain, mild tenderness, obese EXT: warm feet, no edema, palp. pulses throughout NEURO: fully intact On Discharge: Temp 99.9, HR 81, BP 136/84, RR 16, O2 sat 95% on room air Gen: no acute distress, alert and oriented CV: RRR, no murmurs, gallops or rubs Pulm: clear bilaterally Abd: soft, obese, nontender, nondistended, incision clean and without erythema Ext: warm, no edema, 2+ pulses Pertinent Results: [**2152-9-15**] 09:03PM TYPE-ART PO2-167* PCO2-36 PH-7.43 TOTAL CO2-25 BASE XS-0 [**2152-9-15**] 09:03PM GLUCOSE-89 K+-3.2* [**2152-9-15**] 09:03PM freeCa-1.03* [**2152-9-15**] 08:02PM GLUCOSE-100 UREA N-11 CREAT-0.7 SODIUM-134 POTASSIUM-4.0 CHLORIDE-99 TOTAL CO2-26 ANION GAP-13 [**2152-9-15**] 08:02PM CALCIUM-9.1 PHOSPHATE-4.1 MAGNESIUM-2.0 [**2152-9-15**] 08:02PM WBC-8.9 RBC-4.07* HGB-11.8* HCT-35.0* MCV-86 MCH-29.0 MCHC-33.8 RDW-13.9 [**2152-9-15**] 08:02PM PLT COUNT-672* [**2152-9-15**] 08:02PM PT-13.1 PTT-26.6 INR(PT)-1.1 [**2152-9-15**] 08:20AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-POS amphetmn-NEG mthdone-NEG [**2152-9-15**] 08:20AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014 [**2152-9-15**] 08:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2152-9-15**] 08:20AM URINE RBC-0 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 RADS [**9-15**]: CT OF THE ABDOMEN WITH IV CONTRAST: Beginning at the most superior [**Last Name (LF) 107369**], [**First Name3 (LF) **] aortic dissection is visualized. The superior extent of it is not visualized. Along the visualized superior portion, the false lumen is thrombosed, but more inferiorly, at the level of the diaphragmatic hiatus, both lumens are opacified. A defect is visualized within the dissection flap slightly more distally, allowing for communication of each lumen. The origin of the celiac axis is narrow and arises from the false lumen. The dissection extends into the proximal portion of the superior mesenteric artery, with a thrombus along the leading edge of the false lumen terminating 2 cm beyond the take-off. Along its proximal portion, there is associated narrowing of the true lumen, but distally the mesenteric branches appear normally opacified. The right renal artery arises from the true lumen, the left renal artery from the false lumen. Both kidneys enhance symmetrically. CT OF THE PELVIS WITH IV CONTRAST: The inferior mesenteric artery also arises from the false lumen. Its origin shows marked wall thickening. Although its major distal branches appear opacified, the presence of nonocclusive thrombus along the origin of the artery is suspected to account for this appearance. More distally, the false lumen extends into the proximal left common iliac artery, where the dissection terminates. The distal portions of each common iliac artery are supplied by the true lumen. The bladder, uterus are within normal limits. The rectum is largely obscured by streak artifact from retained barium from an earlier study. There is no ascites. BONE WINDOWS: There are no suspicious lytic or blastic lesions. IMPRESSION: Incompletely visualized acute thoracic aortic dissection involving the entire abdominal aorta. Multiple visceral branches arise from the false lumen. The dissection extends into the proximal superior mesenteric artery, where its leading edge is thrombosed. Nonocclusive thrombosis of the proximal inferior mesenteric artery is also suspected. [**9-18**]: CT ABDOMEN WITH AND WITHOUT INTRAVENOUS CONTRAST: 1. Grossly abnormal/edematous transverse colon and hepatic flexure as described above, the differential would include ischemia/infarction, less likely possibilities would be infection. 2. Patent superior mesenteric artery stent with flow seen proximal, within and distal to the stent. 3. Stable aortic dissection extending into the left common iliac artery. [**9-21**] Renal U/S IMPRESSION: 1. Blood flow to both kidneys with normal resistive indices demonstrated within the renal parenchyma. 2. Suggestion of turbulence within the main right renal artery, albeit with good distal flow, that raises the possibility of a dissection within the right main renal artery. CARDS [**9-15**] ECHO: The left atrium is normal in size. There is severe symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is hyperdynamic (LVEF>75%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no left ventricular outflow obstruction at rest or with Valsalva. The thoracic aorta is not well seen. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. IMPRESSION: Suboptimal image quality. Severe symmetric left ventricular hypertrophy with normal cavity size and excellent biventricular systolic function. In the absence of a history of hypertension, these findings are c/w non-obstructive hypertrophic cardiomyopathy. PATH [**9-19**] Right colon, colectomy: 1. Extensive mucosal and submucosal necrosis consistent with ischemic injury. 2. Resection margins free of necrosis. MICRO [**9-16**] Urine: No growth [**9-16**] blood: No growth [**9-20**] Urine: No growth [**9-20**] Blood: Pending Brief Hospital Course: The patient was admitted to the vascular service under Dr. [**Last Name (STitle) **]. The patient was transferred to the CVICU and emsolol and nitroprusside drips were started. Repeat CT Scan showed a type B aortic dissection from just distal to the aortic arch to the L iliac, with dissection of the R renal artery and SMA (with a stenosing clot). The patient was brought to angiography and the SMA was stented. Transplant surgery was consulted for questionable mesenteric ischemia. The patient was ruled out for an MI and had good blood pressure control on nitroglycerin gtt. The patient was tranferred to the VICU on HD2. On HD2 and HD3, the patient's abdominal pain continued. On HD4, she began developing worsening right lower quadrant abdominal pain and had an elevated white count of 13,000. She underwent a CT scan that demonstrated extensive thickening of the wall of the hepatic flexure and the proximal transverse colon along with diffuse edema and mesenteric stranding. The patient was brought to the OR on the evening of HD4 for exploratory laparotomy. A 10-12 cm section of infarcted ascending colon was found and resected. A long Hartmann's pouch was created with a colostomy. The patient was transferred from the OR to the PACU in stable condition. The patient was brought back to the VICU for further cardiac monitoring and was transferred to the hepatobiliary service for post-operative care. Cardiology was consulted for blood pressure control. The patient was started on labetolol 300 TID and lisinopril 20 daily with a SBP goal of less than 120. On the evening of post-op day 3/early POD4, the patient had decreased urine output that resolved with LR fluid boluses. A renal ultrsound demonstrated turbulence within the main right renal artery but with good distal flow. The patient increased her PO intake and urine output stabilized. On POD4, the patient began to have an increase in ostomy output. Diet was advanced from clears to regular. The patient was started on PO pain medication. Immodium was started on POD6 to control the ostomy output. On POD6 she passed her physical therapy evaluation. On POD7 her staples were removed and steri-strips applied. She is discharged in good condition, tolerating a regular diet, and has good pain control. Medications on Admission: 1. HCTZ 25mg daily 2. Ranitidine 150mg daily 3. Percocet prn Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Nicardipine 20 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). Disp:*60 Capsule(s)* Refills:*2* 4. Labetalol 100 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. 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* 7. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO TID (3 times a day). Disp:*90 Wafer(s)* Refills:*2* 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain: Take colace with Percocet to prevent constipation. Disp:*40 Tablet(s)* Refills:*0* 9. Loperamide 2 mg Capsule Sig: One (1) Capsule PO DAILY (Daily): Hold if ostomy output stops or is sluggish. Disp:*30 Capsule(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Aortic dissection Ischemic ascending colon Discharge Condition: Good Discharge Instructions: Please call your doctor for: - fever greater than 101 - persistent nausea or vomiting - inability to eat or drink - increasing redness, swelling, warmth, or foul smelling drainage from your wound - abdominal pain not controlled by pain medications - increased or decreased output from ostomy - any other concerns you may have Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], within one week of your discharge. It is important that you keep your systolic blood pressure at 120 to prevent further damage to your aorta. You will be taking 2mg immodium for ostomy output. If there is low or no ostomy output, stop taking the immodium. Call Dr. [**Name (NI) 32606**] office with questions conerning ostomy output. Please take all medications as prescribed. Followup Instructions: Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2152-10-24**] 10:00 (Patient needs to be NPO 3 hours prior to CTA) Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2152-10-24**] 11:15 Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Call ([**Telephone/Fax (1) 10248**] for an appointment. Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in one week. Call ([**Telephone/Fax (1) 107370**] for an appointment.

[ "443.29", "530.81", "443.23", "441.03", "557.0", "401.9", "425.4" ]

icd9cm

[ [ [] ] ]

[ "46.11", "00.45", "00.40", "88.47", "88.42", "39.90", "45.73", "45.93", "39.50" ]

icd9pcs

[ [ [] ] ]

10542, 10600

6939, 9230

295, 444

10687, 10694

1700, 6916

11543, 12139

1100, 1117

9341, 10519

10621, 10666

9256, 9318

10718, 11520

1132, 1132

1406, 1681

232, 257

472, 920

1146, 1392

942, 979

995, 1084

27,987

186,627

32249+57791

Discharge summary

report+addendum

Admission Date: [**2168-10-18**] Discharge Date: [**2168-10-24**] Date of Birth: [**2090-8-19**] Sex: M Service: CARDIOTHORACIC Allergies: Ativan / Morphine / Percocet Attending:[**First Name3 (LF) 1267**] Chief Complaint: Jaw pain with mild dyspnea on exertions Major Surgical or Invasive Procedure: [**10-18**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to LPDA) History of Present Illness: 78 y/o male who was admitted to OSH with NQW MI and pneumonia in [**9-28**]. He was given antibiotics and then underwent ETT which was positive. Had a cardiac cath which revealed multiple vessel disease. Past Medical History: Coronary Artery Disease s/p Stent to LCX and LAD [**2164**], Hypertension, Hyperlipidemia, Diabetes Mellitus, Stroke, COPD, Pneumonia [**9-28**], GI Bleed, Depression, s/p hernia repair, s/p back surgery, s/p cholecystectomy Social History: Retired. Quit smoking in [**2166**] after 1ppd x 50 years. Denies ETOH. Family History: NC Physical Exam: VS: 86 16 167/68 Gen: WDWN male in NAD Skin: W/D intact HEENT: EOMI, PERRL Pertinent Results: Echo [**10-18**]: 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. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). Post CPB: Preserved biventricular function. Normal valve structure and function [**2168-10-23**] 07:50AM BLOOD WBC-10.7 RBC-3.27* Hgb-10.1* Hct-30.2* MCV-92 MCH-30.9 MCHC-33.4 RDW-13.5 Plt Ct-298# [**2168-10-23**] 07:50AM BLOOD Plt Ct-298# [**2168-10-23**] 07:50AM BLOOD PT-13.3 INR(PT)-1.1 [**2168-10-24**] 07:15AM BLOOD Glucose-141* UreaN-12 Creat-0.9 Na-147* K-3.5 Cl-108 HCO3-30 AnGap-13 CHEST (PA & LAT) [**2168-10-23**] 8:26 AM CHEST (PA & LAT) Reason: evalu for pleural effusions [**Hospital 93**] MEDICAL CONDITION: 78 year old man s/p CABGx4 REASON FOR THIS EXAMINATION: evalu for pleural effusions CHEST TWO VIEWS AT [**2168-10-23**] AT 08:27 CLINICAL INFORMATION: Evaluate pleural effusion status post CABG. FINDINGS: COMPARISON STUDY: [**2168-10-20**]. Since the prior study, there is decreased opacification of the right lung base, with clearing of the patchy opacities seen on the prior study. There is continued mild blunting of the right costophrenic angle consistent with a small right-sided pleural effusion. In addition, there may be a very mild degree of right lower lobe atelectasis. The left lung is clear. The cardiomediastinal silhouette is unremarkable. IMPRESSION: Interval clearing of right lower lobe with residual small right pleural effusion and very mild right basilar atelectasis. Brief Hospital Course: Mr. [**Known lastname 20825**] was a same day admit after undergoing pre-op work-up as an outpatient. On day of admission he was brought to the operating room where he underwent a coronary artery bypass graft x 4. Please see operative report for details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Later on op day he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one he was started on beta blockers and diuretics and gently diuresed towards his pre-op weight. Later on post-op day one he was transferred to the SDU for further care. On post-op day two his chest tubes and epicardial pacing wires were removed. On post-op day three he had bouts of rapid atrial fibrillation and Amiodarone was started and pt. received Lopressor and Magnesium boluses. He converted to NSR. He was ready for discharge on POD #5. Medications on Admission: Metformin 500mg [**Hospital1 **], Simvastatin 20mg qd, Macrobid 100mg qd x 14d, Lexapro 10mg qd, Aggrenox 20-25mg [**Hospital1 **], Imdur 30mg qd, Lopressor 25mg [**Hospital1 **], Lisinopril 10mg qd, Lantus 10units at bedtime, Advair, Albuterol Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*1* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 5. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 6. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 7. Lexapro 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day for 1 weeks: 400 mg daily x 1 week, then decrease to 200 mg daily ongoing until dc'd by cardiologist . Disp:*40 Tablet(s)* Refills:*0* 9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 10. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous once a day. Disp:*QS 1 month* Refills:*0* 11. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 1 weeks. Disp:*14 Tablet(s)* Refills:*0* 12. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO BID (2 times a day) for 1 weeks. Disp:*14 Packet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 PMH: Stent to LCX and LAD [**2164**], Hypertension, Hyperlipidemia, Diabetes Mellitus, Stroke, COPD, Pneumonia [**9-28**], GI Bleed, Depression, s/p hernia repair, s/p back surgery, s/p cholecystectomy Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks Dr. [**Last Name (STitle) 5310**] in [**12-26**] weeks Dr. [**Last Name (STitle) 75396**] in [**11-24**] weeks Completed by:[**2168-10-24**] Name: [**Known lastname 3471**],[**Known firstname 33**] E Unit No: [**Numeric Identifier 12377**] Admission Date: [**2168-10-18**] Discharge Date: [**2168-10-24**] Date of Birth: [**2090-8-19**] Sex: M Service: CARDIOTHORACIC Allergies: Ativan / Morphine / Percocet Attending:[**First Name3 (LF) 4551**] Addendum: Mr. [**Known lastname **] was evaluated by PT and felt not to be safe to go home due to heavy use of his arms while ambulating with a walker. This was discussed with the patient and his wife. [**Name (NI) 12378**] refused rehab stay. Wife said she will help him w/ambulation. [**Hospital 12379**] rehab was advised, but they both refused. Discharge Disposition: Home With Service Facility: [**Hospital3 413**] VNA [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 358**] MD [**MD Number(1) 359**] Completed by:[**2168-10-24**]

[ "401.9", "272.4", "427.31", "E878.2", "496", "414.01", "276.50", "997.1", "250.00", "410.72" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

7706, 7916

3273, 4173

337, 434

6269, 6275

1134, 1924

6786, 7683

1020, 1024

4468, 5889

2453, 2480

5984, 6248

4199, 4445

6299, 6763

1039, 1115

258, 299

2509, 3250

462, 667

689, 915

931, 1004

1934, 2416

2,135

156,848

12744

Discharge summary

report

Admission Date: [**2191-2-3**] Discharge Date: [**2191-2-11**] Date of Birth: [**2118-8-9**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 759**] Chief Complaint: cc:[**CC Contact Info **] Major Surgical or Invasive Procedure: ERCP w/ removal of CBD stent and sphincterotomy intubation for hypoxia and ICU admission History of Present Illness: 72 yo male with multiple sclerosis on chronic steroids admitted for elective CBD stent removal [**2191-2-2**], developed mild bleeding post-sphincerotomy and now had episode of hypotension (sbp 70s) in the setting of a 7 point hct drop (although his hct may have been slightly hemoconcentrated on admission). Initially presented [**11-13**] with ascending cholangitis that required abx and CBD stent placement. He has been doing well since that admission. His hct in [**11-13**] was in low 30s, however, today was 37.2 prior to procedure. During the ERCP he had an episode of desaturation to 70s. His old stent was removed, he underwent a sphincterotomy and placement of a new stent. He received flumazenil and naloxone after he became hypoxic. His oxygen sats have been normal since then on 2liters NC. At 3:30am he developed acute onset sbp in 70s and ST to 140s that responded to a few hundred cc of IVFs. He had an og lavage that showed cherry cola colored fluid that did not clear after 1200cc. After OGT removed, had 100cc emesis. Concern was for upper gi bleed and airway protection so he was transferred to the ICU for closer monitoring. Past Medical History: # Multiple sclerosis: symptoms for one year (LE weakness), diagnosed a few months ago, had bx of spinal cord as per pt, on prednisone and hypdrocortisone. # COPD: Has been on inhalers for a few years, never been intubated for or treated for COPD flare. Never had PFTs. Not on home o2. # "neurogenic bladder" by records but symptoms seem more consistent with BPH- dribbling and difficulty initiating urination # [**Month/Day (1) **] cancer: s/o resection 10 years ago, no adjunctive treatment # osteomyelitis of left hip as child- left with difficulty walking for life but did not need cane . PSHx: CCY [**Month/Day (1) **] resection resection of benign RUL tumor Appy Right knee repair Hernia repair x2 Social History: SHx: Married. Tobacco- 1pack per day for 60 years, quit 1.5 years ago No etoh. Uses a walker to walk but rarely walks outside of home. Family History: Mother: [**Name (NI) **] ca Physical Exam: PE: NAD. Alert and oriented. Perrl. Neck supple. tachy s1/s2 cta, no wheezes abd soft, mildly distended, +bs, mildly distended no peripheral edema, lateral deviation of toes +DP pulses b/l Pertinent Results: 137/4.4/101/29/33/0.5/93, ag 7 alt-11, ast-15, ap-33, tb-0.6, [**Doctor First Name **]-35, lip-43 7/37.2/216, 75%pmn hct 37.2-->30.4 after 11 hours . EKG: sinus tachycardia @100bpm, nl axis, nl intervals . CXR:enlargement of pulm knob, clear lung fields, left cp angle cut- off but clear on 1am x-ray [**2191-2-3**] 01:20PM BLOOD WBC-7.0 RBC-4.12* Hgb-12.5* Hct-37.2* MCV-90 MCH-30.3 MCHC-33.6 RDW-15.5 Plt Ct-216 [**2191-2-4**] 04:58PM BLOOD WBC-14.1*# RBC-4.99 Hgb-15.1 Hct-43.5 MCV-87 MCH-30.3 MCHC-34.7 RDW-14.5 Plt Ct-77*# [**2191-2-4**] 08:36PM BLOOD WBC-16.3* RBC-4.68 Hgb-14.4 Hct-40.6 MCV-87 MCH-30.7 MCHC-35.4* RDW-15.4 Plt Ct-80* [**2191-2-11**] 07:00AM BLOOD WBC-7.0 RBC-4.28* Hgb-13.0* Hct-38.1* MCV-89 MCH-30.3 MCHC-34.0 RDW-14.4 Plt Ct-192 [**2191-2-3**] 01:20PM BLOOD UreaN-18 Creat-0.6 [**2191-2-4**] 12:03AM BLOOD Glucose-93 UreaN-33* Creat-0.5 Na-137 K-4.4 Cl-101 HCO3-29 AnGap-11 [**2191-2-11**] 07:00AM BLOOD Glucose-108* UreaN-9 Creat-0.6 Na-143 K-3.8 Cl-102 HCO3-33* AnGap-12 [**2191-2-3**] 01:20PM BLOOD ALT-13 AST-39 AlkPhos-41 TotBili-0.4 [**2191-2-5**] 06:04AM BLOOD ALT-16 AST-65* AlkPhos-40 Amylase-24 TotBili-2.6* [**2191-2-6**] 06:17AM BLOOD ALT-20 AST-45* AlkPhos-35* Amylase-31 TotBili-1.7* [**2191-2-9**] 05:45AM BLOOD TSH-2.1 Brief Hospital Course: 72 yo male with hx of MS, ascending cholangitis, s/p cholecystectomy, COPD and RUL resection for benign mass who presented for outpatient elective removal of CBD stent complicated by hypoxia and bleeding after sphincterotomy. Hypotension/GI bleed - Hypotension was secondary to significant GI bleed. Pt received 10 units pRBCs, 3 units FFP, and IVF for a total of 13L fluid resuscitation. GI performed EGD which showed old blood but no active bleeding site. He had been started on stress dose steroids on floor given chronic steroid use and probable baseline adrenal insufficiency. This was continued initially but once stable, was quickly tapered to home dose. He then received IV lasix for diuresis given volume load during resucitation. His Hct remained stable, and he did not require any further transfusions - the source of his GI bleed remained unclear. Tachycardia/afib - Pt with episode of atrial fibrillation on telemetry on [**2-6**]. Initially unclear if it was tachycardia causing hypotension or vice versa. However, he had 5L UOP for the day, looked dry on exam, and so he was given IVF first with immediate improvement of BP to 110s/70s, HR slowed initially to 110s-130s, then converted to sinus rhythm after an addition 500cc bolus. This was most likely caused by hypovolemia. He was hydrated and lytes were repleted, and he remained in sinus rhythm. Continued treatment for underlying infection as below. Ventilatory support - Pt was intubated given hypotension and respiratory distress. He received fluid resuscitation as described above and once stable, was extubated after SBT and rsbi of 30. Unclear cause of hypoxia although hypervolemia due to fluid resuscitation was on the differential. Pt was breathing comfortably on RA at time of discharge. PNA - Pt with likely pneumonia given RUL opacity on exam. Sputum grew pseudomonas; pt clinically stable. He was given empiric treatment with vanco and zosyn for 7 days, with subsequent decrease in sputum production and resolution of leukocytosis. Biliary stent - LFT's stabilized. Not thought to have biliary source for sepsis. Will need repeat ERCP at some point as outpatient for removal of stent. Tolerating PO at time of discharge. COPD - On inhalers while intubated and changed over to nebs after extubation. Held albuterol given tachycardia. He was also given steroids for MS [**First Name (Titles) **] [**Last Name (Titles) **] adrenal insufficiency. thrombocytopenia - DIC labs wnl, concern for HIT so avoided all heparin products. HIT ab was sent which was found to be negative. MS - Pt is bedbound given acute illness. He was given a steroid taper and arranged for outpatient services. PPx - He was given PPI, bowel regimen, and pneumoboots for prophylaxis. Code status - full Medications on Admission: Meds on admission: Prednisone 15mg po daily fludrocrtisone 0.1mg [**Hospital1 **] ativan Metoprolol 25mg [**Hospital1 **]---??? asa 325mg daily prevacid 30mg daily advair 250/50- one puff [**Hospital1 **] Spiriva- two puffs daily caclium and vitamin D daily Citalopram 20 mg daily KCL 40meq daily Discharge Medications: 1. 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* 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 6. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation Q4H (every 4 hours). Disp:*1 bottle* Refills:*2* 8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. 10. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Location (un) **] vna Discharge Diagnosis: s/p ERCP w/ post-sphincterotomy bleed hypoxia s/p intubation thrombocytopenia pneumonia multiple sclerosis COPD Discharge Condition: stable, breathing comfortably on room air w/ stable Hct Discharge Instructions: Please go to the ED or call your physician if you have nausea, vomiting, increased abdominal pain, change in your skin color, diarrhea or constipation, shortness of breath, chest pain, dizziness, fever, chills or any other symptoms that are concerning to you. . Take your medications as directed. Please do not take aspirin at this time. Followup Instructions: Please call Dr.[**Name (NI) 39323**] office [**Telephone/Fax (1) 2360**] to schedule a repeat ERCP in the next month. . Make sure to follow up with your primary care physician in the next few weeks. Completed by:[**2191-6-21**]

[ "518.81", "785.59", "492.8", "276.2", "E878.8", "340", "V58.65", "285.1", "427.31", "287.4", "482.1", "998.11" ]

icd9cm

[ [ [] ] ]

[ "99.07", "51.85", "96.04", "97.55", "51.87", "99.04", "96.71", "45.13" ]

icd9pcs

[ [ [] ] ]

8191, 8246

4053, 6831

337, 428

8402, 8460

2767, 4030

8847, 9077

2511, 2541

7179, 8168

8267, 8381

6857, 6862

8484, 8824

2556, 2748

273, 299

456, 1614

6876, 7156

1636, 2342

2358, 2495

26,162

153,433

11511

Discharge summary

report

Admission Date: [**2102-12-22**] Discharge Date: [**2102-12-29**] Date of Birth: [**2032-3-7**] Sex: F Service: Surgery. CHIEF COMPLAINT: Discharge from surgical wound. HISTORY OF PRESENT ILLNESS: The patient was hospitalized from [**2102-12-6**] until [**2102-12-11**]. She underwent at that time bilateral distal external iliac and common femoral artery endarterectomies with patch angioplasties. She tolerated the procedure well. Her hospital course was unremarkable except for a draining lymphocele. The patient was without constitutional symptoms. The wound was without erythema. She was discharged in stable condition with [**Hospital6 1587**] to follow-up with wound care. She was followed up a week from post discharge and the skin clips were removed. There was no incident of infection present at that time. She now presents to our Emergency Room with increasing drainage from her left groin wound. The patient noted bleeding from the groin wound the day that she was seen in the Emergency Room. The patient is now admitted for further evaluation and treatment. ALLERGIES: No known drug allergies. PAST MEDICAL HISTORY: 1. Significant for diabetes mellitus. 2. Hypertension. 3. Tobacco use. 4. She does admit to claudication prior to surgery earlier this month. PREVIOUS SURGICAL HISTORY: 1. Cholecystectomy. 2. Tonsillectomy. 3. The patient has known renal artery stenosis on the right of 80% and is followed by her primary care physician at home. PHYSICAL EXAMINATION: Physical examination in the Emergency Room: Vital signs 99.6 F.; blood pressure 168/95; pulse 68; respiratory rate 18. General appearance is an obese elderly white female sitting in bed. Her HEENT examination was unremarkable. There is no lymphadenopathy. Chest is clear to auscultation bilaterally. She has a regular rate and rhythm with a III/VI systolic ejection murmur at the left lower sternal border which radiates to the aorta. The abdomen is obese with multiple areas of ecchymosis and is nontender. There is no flank tenderness. There is no spinal tenderness. Both lower extremities were with edema, pitting up to the knee. The calves are tense with mild tenderness on palpation. The left thigh is tender on palpation. The left incision in the groin is dehisced and draining. Neurological examination was unremarkable. LABORATORY: Admitting labs included a CBC with a white blood cell count of 8,900, hematocrit of 32.5, platelets 243,000, BUN 17, creatinine 0.9, potassium 4.1, PT and INR were normal. HOSPITAL COURSE: The patient, on admission, was urgently taken to the Operating Room on [**2102-12-22**], and underwent a left groin exploration with a left external iliac to SFA bypass graft with 8 mm ringed [**Doctor Last Name 4726**]-Tex. The left common iliac was ligated and the wound was debrided with removal of the patch. The patient tolerated the procedure well and was transferred to the Surgical Intensive Care Unit for continued monitoring and care. The patient was afebrile and hemodynamically stable. She lost about 1600 cc of blood. The patient was transfused. Incisions were clean, dry and intact. She had a palpable dorsalis pedis and bilaterally. She was continued NPO; intravenous fluids were continued. Infectious Disease was consulted regarding antibiotic choice and length of therapy. Ultrasound showed a low attenuation and fluid collection seen in both groins, but bilaterally these were about 7.2 cm on the right and 6 cm on the left. There was no flow seen in either of these collections. They recommended Zosyn and Vancomycin at this time until cultures showed definitive organisms. Her white count was elevated on postoperative day two to 18,100 from 13,100. Hematocrit remained stable at 28.8. Her coagulation studies remained normal. Incisions showed a serous drainage and the left groin was with serous foul smelling drainage. On postoperative day three, the patient remained afebrile. White count defervesced to 11,400. Hematocrit was 26.2. The remaining examination was unremarkable. She was transfused one unit of packed red blood cells for a hematocrit of 26.2. She remained in the Medical Intensive Care Unit. On postoperative day four, overnight events were none. There was no nausea or vomiting; some diarrhea and she remained afebrile. She continued on her Zosyn and Vancomycin. Wound dressings were normal saline, wet-to-dry. Her diet was advanced and ambulation was begun. Physical Therapy was requested to see the patient. She was transferred to the Regular Nursing Floor. Infectious Disease followed the patient during her perioperative period and prior to discharge. C. difficile cultures were sent for the diarrhea which both were negative. Her wound cultures grew Methicillin sensitive Staphylococcus aureus, sensitive to penicillin and amoxicillin. Physical Therapy saw the patient. She required full assist for ambulation. They felt that she would be a candidate for rehabilitation. Case management began screening. Final recommendations of Infectious Disease were that the organisms were Gram positive cocci, sparse growth, suggesting alpha Strep, sparse growth of diphthoids to colony morphology, Staphylococcus aureus, rare growth, Staphylococcus was sensitive to Clinoidally and Erythromycin, Gentamycin, Lobaplatin and Oxicillin. It was penicillin resistant. There was E. coli which was sensitive to Ampicillin, Gentamicin, Pentacillin, Lobaplatin, Piptaz, Tobramycin, Bactrim. Anaerobic cultures grew bacteria of Phrugellis, sparse growth, beta lactamase positive. Recommendations were to continue the Zosyn until just before discharge, then begin the patient on Lobaplatin just before discharge, then begin the patient on Lobaplatin 500 mg q. day and Flagyl 500 mg three times a day. This is for an indefinite period of time until the wound is completely dry and non-draining. The patient was discharged in stable condition to a rehabilitation. Wound Care is dry sterile 4 by 4 packing with ABD dressings which should be done under sterile technique. She will follow-up with Dr. [**Last Name (STitle) **] in two weeks. The wound was without erythema. It is deep. The base is clean with beginning granulation tissue. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg q. day. 2. Flagyl 500 mg three times a day. 3. Lobaplatin 500 mg q. day. 4. Lasix 50 mg q. day. 5. Zantac 150 mg twice a day. 6. Atrovent inhaler puffs two four times a day. 7. Lasix 40 mg twice a day. 8. Atenolol 50 mg twice a day; hold for systolic blood pressure less than 100, heart rate less than 50. 9. Captopril 100 mg three times a day; hold for systolic blood pressure of less than 100. 10. Percocet tablets one to two q. four hours p.r.n. for pain. 11. Clonidine 0.1 mg p.o. three times a day. DISCHARGE DIAGNOSES: 1. Wound dehiscence with graft rupture, status post exploration ilial-femoral bypass with [**Doctor Last Name 4726**]-Tex and wound debridement. 2. Hypertension, controlled. 3. Renal artery stenosis, stable. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**] Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2102-12-29**] 14:27 T: [**2102-12-29**] 20:11 JOB#: [**Job Number **]

[ "401.9", "998.11", "440.1", "496", "996.62", "998.3", "443.9", "250.00" ]

icd9cm

[ [ [] ] ]

[ "39.49", "39.31" ]

icd9pcs

[ [ [] ] ]

6873, 7363

6309, 6852

2587, 6286

1540, 2569

161, 193

222, 1145

1167, 1517

17,606

140,086

14729

Discharge summary

report

Admission Date: [**2179-9-7**] Discharge Date: [**2179-10-19**] Date of Birth: [**2138-7-9**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 301**] Chief Complaint: The patient was admitted to [**Hospital1 18**] on [**9-7**] for an elective revision of his prior gastric bypass secondary to persistent weight gain following his initial surgery that was likely caused by a gastro-gastric fistula. (His prior surgery was first complicated by a leak requiring return to the OR for leak repair, which was then complicated by a second leak causing an intra-abdominal abscess.) Major Surgical or Invasive Procedure: [**9-6**] revison of gastric bypass, partial gastrectomy, LOA, G tube placement [**9-8**] gastric perforation repair, placement gastrostomy tube, fibrin glue/reinforcement History of Present Illness: The patient has a history of morbid obesity s/p gastric bypass in [**2172**] complicated by a leak necessitating return to the OR for repair, which was then complicated by a second leak that eventually led to an intraabdominal abscess that was treated with antibiotics and via JP drain placement. The patient has had persistent weight gain over the past few years, although he was not following the post bypass diet per report. He was also noted to have anemia and underwent an EGD and colonoscopy; the latter was normal but the EGD showed a patent gastro-gastric fistula. The fistula is thought to be contributing to his weight gain. For this reason, along with the anemia, the patient was admitted to [**Hospital1 18**] on [**9-7**] for revision of his gastric bypass and repair of the gastro-gastric fistula. Past Medical History: PMx: back pain/DJD, dyslipidemia and hypoglycemia, morbid obesity PSx: [**2173-9-21**] open gastric bypass c/b ileus and leak s/p exploratory laparotomy, [**Location (un) 1661**]-[**Location (un) 1662**] drain placement, revision of his gastrojejunostomy, and gastrostomy tube placement c/b persistent gastrojejunal leak with intraabdominal abscess formation s/p drainage via gastric JP drain and abx therapy Social History: Married, has children Family History: Noncontributory Physical Exam: His blood pressure was 127/81, pulse 80, respirations 12 and O2 saturation 97% on room air. On physical examination [**Known firstname **] was casually dressed, healthy appearing and in no distress. His skin was warm, dry with no rashes, occasional skin tags otherwise no lesions. Sclerae were anicteric, conjunctiva clear, pupils were equal round and reactive to light, fundi were normal, mucous membranes were moist, tongue was paint and the oropharynx was without exudates or hyperemia. Trachea was in the midline and the neck was supple with full range of motion, no adenopathy, thyromegaly or carotid bruits. Chest was symmetric and the lungs were clear to auscultation bilaterally with good air movement. Cardiac exam was regular rate and rhythm with normal S1 and S2, no murmurs, rubs or gallops. The abdomen was soft, non-tender, non-distended with normal bowel sounds activity, no appreciable masses and there was a well-healed midline vertical incision scar with no hernias. There was no spinal tenderness or flank pain. Lower extremities were without edema, venous insufficiency or clubbing. There was no evidence of joint swelling or inflammation of the joints. There were no focal neurological deficits and his gait was normal. Pertinent Results: [**2179-9-7**] 05:29PM BLOOD WBC-24.3*# RBC-4.88 Hgb-12.4* Hct-38.8* MCV-80* MCH-25.5* MCHC-32.0 RDW-15.9* Plt Ct-381 [**2179-9-17**] 04:23AM BLOOD WBC-25.0* RBC-3.60* Hgb-9.5* Hct-29.4* MCV-82 MCH-26.3* MCHC-32.2 RDW-16.1* Plt Ct-520* [**2179-9-22**] 04:14AM BLOOD WBC-13.2* RBC-3.34* Hgb-9.0* Hct-26.8* MCV-80* MCH-27.1 MCHC-33.7 RDW-16.4* Plt Ct-722* [**2179-10-7**] 07:24AM BLOOD WBC-4.5 RBC-3.49* Hgb-9.2* Hct-27.8* MCV-80* MCH-26.3* MCHC-32.9 RDW-14.6 Plt Ct-296 [**2179-9-9**] 01:55AM BLOOD Neuts-91.5* Lymphs-5.5* Monos-3.0 Eos-0 Baso-0.1 [**2179-9-13**] 09:25PM BLOOD Neuts-80.6* Lymphs-10.9* Monos-6.7 Eos-1.2 Baso-0.6 [**2179-9-20**] 08:36AM BLOOD Neuts-78.0* Lymphs-14.6* Monos-5.4 Eos-1.6 Baso-0.3 [**2179-9-7**] 10:24PM BLOOD Glucose-156* UreaN-10 Creat-0.9 Na-139 K-4.5 Cl-105 HCO3-24 AnGap-15 [**2179-9-11**] 10:30AM BLOOD Glucose-107* UreaN-11 Creat-0.6 Na-139 K-3.5 Cl-106 HCO3-25 AnGap-12 [**2179-10-11**] 04:26AM BLOOD Glucose-90 UreaN-17 Creat-0.5 Na-138 K-4.0 Cl-105 HCO3-27 AnGap-10 [**2179-9-7**] 10:24PM BLOOD CK(CPK)-637* [**2179-9-8**] 03:10PM BLOOD CK(CPK)-1372* [**2179-9-13**] 09:25PM BLOOD CK(CPK)-455* [**2179-9-22**] 04:14AM BLOOD ALT-30 AST-23 AlkPhos-86 Amylase-121* TotBili-0.8 [**2179-9-7**] 10:24PM BLOOD Calcium-8.5 Phos-3.4 Mg-1.5* [**2179-9-10**] 04:46AM BLOOD Albumin-2.5* Calcium-7.6* Phos-1.4* Mg-1.8 [**2179-9-17**] 04:23AM BLOOD Albumin-2.2* Calcium-7.4* Phos-3.6 Mg-1.8 [**2179-10-1**] 04:41AM BLOOD Albumin-2.7* Calcium-8.2* Phos-4.3 Mg-1.8 Iron-14* [**2179-10-12**] 02:13AM BLOOD Albumin-3.0* Calcium-8.3* Phos-4.3 Mg-1.8 Iron-13* [**2179-9-14**] 06:45AM BLOOD calTIBC-229* Ferritn-134 TRF-176* [**2179-9-28**] 05:42AM BLOOD calTIBC-241* VitB12-649 Ferritn-82 TRF-185* [**2179-10-12**] 02:13AM BLOOD calTIBC-309 Ferritn-36 TRF-238 Brief Hospital Course: OPERATIONS DURING ADMISSION [**9-7**]: Revision of Roux-en-Y gastric bypass, Partial gastrectomy, Placement of gastrostomy tube, Adhesiolysis, Incisional hernia repair [**9-9**]: Repair of gastric perforation, Gastrostomy tube, Application of fibrin glue [**9-13**]: Exploratory Laparotomy with repair of leak, drainage of intraabdominal abscess, closure [**9-13**]: Intraoperative endoscopy for peritonitis and gastric perforation. Other procedures: Placement of CVL, Epidural placement CONSULTATIONS DURING ADMISSION Infectious Disease General Surgery, Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **] [**Name5 (PTitle) **] Surgery, Dr [**Last Name (STitle) **] 1. Revision of gastric bypass and repair of gastro-gastric fistula: The patient was admitted to [**Hospital1 18**] on [**9-7**] for revision of his gastric bypass and repair of the gastro-gastric fistula. He went to the OR on [**9-7**] and underwent revison of gastric bypass, partial gastrectomy, LOA, and G tube placement with three JP drains in place. The patient was found to have extensive adhesions requiring lengthy lysis. Intraoperative methylene blue placement down NGT did not reveal any gastric leak. 2. Intraabdominal leak: Postoperatively his methylene blue repeat test down the NGT was again negative. Since the operation, however, the patient was persistently tachycardic to the 120s unrelieved by changing his epidural and multiple pain medications titrations by Pain Medicine. On [**9-8**] throughout the day he remained in sinus tachycardia and was noted to have increasing oxygen requirements. The patient was also febrile, pan cultures were negative, though CXR revealed LLL basilar opacity (unchanged). The patient was continued on unasyn. A repeat methylene blue test was positive. 3. Repair of gastric perforation, Gastrostomy tube, Application of fibrin glue: Given the leak findings, on [**9-8**] the patient was taken emergently to the operating room for gastric perforation repair, placement gastrostomy tube, and fibrin glue/reinforcement. The patient tolerated the procedure well, was extubated, and brought to the PACU in stable condition. Postoperatively the patient did well. He was started on TPN through CVL, and then on G-tube feeds on [**9-13**]. His NGT was removed. His pain was well controlled on an epidural of bupivicaine and clonidine, which was discontinued on [**9-13**]. He ambulated and was having bowel movements. He did continue to have temperatures at night to 101.6 but his blood and urine culture workup was negative. His CXR continued to show a LLL basilar opacity. He was continued on unasyn. 3. Fever and Tachycardia: On POD [**5-27**], the patient was noted to develop sudden tachycardia without any change in symptoms. ECG, cardiac enzymes, blood and urine cultures were negative; CXR unchanged. He was placed on telemetry. A repeat methylene blue test was negative for a leak. The day's events were noteable for starting G tube feeds and discontinuing the epidural. He was taken to the operating room on [**9-14**] for tachycardia, fever, and leukocytosis to a peak of 25.5. 4. Exploratory Laparotomy revealing persistent leak and intraabdominal abscess: Intraoperatively the patient had gross pus (>400cc) oozing from his abdomen, primarily from the left upper quadrant. Following drainage of the abscess, Dr [**Last Name (STitle) **] was consulted to perform an intraoperative endoscopy, which revealed a retrocolic gastric leak via bubble test. Given the deep location of the leak, Dr. [**Last Name (STitle) **] of general surgery was consulted for repair of the leak. The leak was repaired, the patient had 3 JP drains placed in addition to the prior G-tube. He was started on zosyn postoperatively and the unasyn discontinued. He remained tachycardic and febrile, however, with his WBC continuing to rise to 25.5. On [**9-16**] vancomycin and fluconazole were added in addition to the zosyn. His signs of infection failed to resolve, however, and so on [**9-17**] infectious disease was consulted. Intraoperative swab cultures grew 4+ PMNs, 2+ GPCs in pairs and clusters, and 2+ GNR,with cultures showing Hafnia alvei resistant to Unasyn, intermediate to Zosyn, and Klebsiella pneumoniae. For this reason ID recommended that the zosyn, vancomycin, and fluconazole be discontinued, and the patient was started on meropenem on [**9-17**] with a resultant defeversence and decline in his leukocytosis. For nutrition, given the persistent leak, the patient was made NPO, the G tube feedings discontinued with the surgery, and he remained on TPN. His JP drain 2 was placed on high suction and continued to put out high volumes of pus. JP 3 and the G tube were alternated on suction. JP 1 was pulled approximately one week after the surgery. By [**9-27**] the patient's fevers had defervesced and his tachycardia improved. His urine output remained profused throughout. 5. RLE DVT: On [**2179-9-24**] the patient was out of bed and ambulated with physical therapy when he noted pain behind his right knee. Though he had been maintained on venodynes and SQ heparin for DVT prophylaxis, ultrasound of right lower extremity performed revealed a thrombus within the right gastrocnemius vein. [**Date Range **] surgery consult was called, and they recommended anticoagulation with heparin. A repeat RLE ultrasound on [**9-27**] revealed interval resolution of the thrombus. Heparin drip continued for several weeks and then discontinued as recommended by [**Month/Year (2) 1106**]. 6. Persistent Leak: On [**9-26**] the patient underwent a repeat methylene blue test that revealed leakage into the peritoneum. With the thought that the JP drains, being on high suction may be preventing healing of a persistent leak, both JP 2 and JP3 were pulled back approximately one inch on [**9-27**]. On [**10-3**], the patient underwent a repeat methylene blue test. This continues to show a leak into the peritoneum. Will continue present course and repeat methylene blue in one week. Infectious disease had recommended changing meropeneum to cipro until all drains are out. On [**2179-10-6**] CT Scan performed. No evidence of contrast leakage or obstruction from the portion of stomach that contains the G tube. On [**2179-10-10**] Methylene blue was injected into G-tube with no appearance of leak from drains. G-tube feedings begun at 10cc/hr and advanced 10cc q 6 hours at 1/2 strength to 100cc with low residuals. On [**2179-10-12**] Upper Gi study done showing leak at GJ site. Meropeneum discontinued and cipro po started until last JP discontinued. [**2179-10-17**] tube feedings increased to full strength at 100 cc/hr. TPN discontinued. [**2179-10-18**] Dilaudid pca discontinued and dilaudid po given. Tube feedings cycled from 1800 to noon. Discharge planning instituted. [**2179-10-19**] Patient will be discharged today. He will go home on full strength tube feedings. Cycled from 1800 until 10am with 8 hours of free time daily. He will have a VNA to teach regarding tube feedings and monitor wound. His return to see Dr. [**Last Name (STitle) **] is in one week. Medications on Admission: Sucralfate 1 g tablet 4 times a day for her heartburn/peptic ulcer disease prophylaxis; Prilosec 20 mg daily for reflux; multivitamin daily, magnesium/zinc capsules daily, iron 600 mg daily, folic acid 0.8-mg tablet daily, vitamin B12 1000 mcg tablets sublingually daily and vitamin D in the form of calcium citrate twice daily Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*2* 2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): please crush. Disp:*60 Tablet(s)* Refills:*3* 3. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q2H (every 2 hours) as needed for pain: Please crush and try to wean as tolerated. Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Home [**Hospital 43333**] Hospice and Community Discharge Diagnosis: 1. Gastrogastric fistula. 2. Obesity. 3. Incisional hernia. Discharge Condition: Stable Discharge Instructions: You are being discharged on medications to treat the pain from your operation. These medications will make you drowsy and impair your ability to drive a motor vehicle or operate machinery safely. You MUST refrain from such activities while taking these medications. Please call your doctor or return to the emergency room if you have any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. Activity: No heavy lifting of items [**10-6**] pounds for 6 weeks. You may resume moderate exercise at your discretion, no abdominal exercises. Wound Care: no tub baths or swimming. If there is clear drainage from your incisions, cover with clean, dry gauze. You may place drain sponges around your g-tube and JP drain. You may place a dry gauze on the upper portion of your abdominal incision. Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: Dr. [**First Name (STitle) **] (for Dr. [**Last Name (STitle) **] On [**10-27**] at 11:15 in the [**Hospital 1560**] clinic. [**Hospital Ward Name 23**] [**Location (un) 470**]. Completed by:[**2179-10-19**]

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icd9cm

[ [ [] ] ]

[ "54.59", "96.6", "44.69", "44.61", "43.89", "45.13", "43.19", "99.04", "53.51", "38.93", "99.15" ]

icd9pcs

[ [ [] ] ]

13298, 13376

5333, 12500

720, 895

13480, 13489

3529, 5310

15095, 15305

2227, 2244

12878, 13275

13397, 13459

12526, 12855

13513, 14712

2259, 3510

273, 682

14724, 15072

923, 1740

1762, 2172

2188, 2211

75,764

118,325

42257

Discharge summary

report

Admission Date: [**2125-12-3**] Discharge Date: [**2125-12-5**] Service: NEUROLOGY Allergies: Hydromorphone / Meperidine / propoxyphene / Percodan / Diphenhydramine / aspirin Attending:[**First Name3 (LF) 618**] Chief Complaint: Speech disturbance Major Surgical or Invasive Procedure: none History of Present Illness: The pt is a 89 year-old woman with a history of prior right frontal IPH, HTN, HLD and hypothyroidism who is blind and dependent on a cochlear implant for hearing, who presents with acute onset confusion and aphasia. Reportedly she lives in an [**Hospital3 400**] facility, and she was having breakfast with another resident, and it was noted that she began to develop garbled slurred speech. She was taken to [**Hospital6 2561**], where on arrival she was noted to have a blood pressure of 207/75. She was given 10mg of labetalol, and underwent a NCHCT which showed a 1.4x1.7cm left posterior temporo-occipital lobe hemorrhage. She was then transferred to [**Hospital1 18**] for further evaluation. She has a history of a prior right frontal hemorrhage earlier this year, which was thought to be secondary to a combination of amyloid angiopathy and and hypertension or just hypertension. At baseline she reportedly is quite calm, and able to converse well using the cochlear implant. She reportedly can make out faces if they are well lit and close to her right eye. According to her health aid who currently accompanies her, she lives [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1820**] [**Last Name (NamePattern1) **] in [**Hospital1 8**]. Past Medical History: - Prior right frontal IPH - HTN - HLD - Hypothyroidism - Deaf - dependent on cochlear implant - Legally blind - no vision out of left eye, only slight vision out of right eye. Social History: Lives in [**Hospital3 **]. Mobilises with cane and at times walker Registered deaf and blind Has aids who help during the week but these have been stopped due to insurance problems Baseline able to speak coherently Family History: Unknown Physical Exam: Admission Physical Exam: Vitals: T: 97.9 P: 79 R: 18 BP: 167/65 SaO2: 99% on RA General: Awake, cooperative, agitated. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Shouts out 'I can't...I can't...hurt...' Attempted to place cochlear implant in place, which prompted her to start screaming, waving arms and batting at head. Despite additional attempts at adjustment, unable to successfully communicate using it. -Cranial Nerves: Left cornea cloudy, does not blink to threat or appear to be able to track with the right eye. Right surgical pupil. Very slight flattening of the right NL fold. Tongue protrudes midline. -Motor/Sensory: Lifts all extremities antigravity, making purposeful movements with arms, pulling at lines. Withdraws legs purposefully from tickle. -DTRs: [**Name2 (NI) **] moving all extremities and does not relax well to assess reflexes. Plantar response was withdrawal bilaterally. Physical exam at discharge: Neuro: Calm, speaks in clear and coherent sentences when she can understand you. Moving all extremities purposefully. Left cornea opacified, tracking on right. No facial asymmetry. Must talk in calm normal voice. Pertinent Results: Laboratory results: Admission labs: [**2125-12-3**] 05:48PM BLOOD WBC-6.8 RBC-4.53 Hgb-12.1 Hct-38.1 MCV-84 MCH-26.8* MCHC-31.9 RDW-20.2* Plt Ct-454* [**2125-12-3**] 05:48PM BLOOD Neuts-80.9* Lymphs-10.8* Monos-6.3 Eos-1.7 Baso-0.4 [**2125-12-3**] 05:48PM BLOOD Glucose-126* UreaN-9 Creat-0.5 Na-130* K-4.1 Cl-94* HCO3-20* AnGap-20 [**2125-12-4**] 05:27AM BLOOD ALT-19 AST-33 AlkPhos-89 TotBili-0.3 [**2125-12-4**] 05:27AM BLOOD Albumin-4.1 Calcium-9.1 Phos-3.9 Mg-1.8 . Other pertinent labs [**2125-12-4**] 05:27AM BLOOD Osmolal-269* . Urine: [**2125-12-3**] 05:48PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006 [**2125-12-3**] 05:48PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [**2125-12-4**] 10:46AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009 [**2125-12-4**] 10:46AM URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR [**2125-12-4**] 10:46AM URINE RBC-22* WBC-4 Bacteri-NONE Yeast-NONE Epi-0 [**2125-12-4**] 10:46AM URINE Mucous-RARE . Microbiology: [**2125-12-3**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] - No growth to date [**2125-12-3**] URINE URINE CULTURE-No growth [**2125-12-3**] BLOOD CULTURE Blood Culture, Routine-PENDING - no growth to date . Radiology: [**2125-12-3**]: OSH CT scan shows 1.4x1.7cm left posterior temporo-occipital lobe hemorrhage without significant edema or [**Last Name (un) **] effect. Diffuse atrophy present. . [**2125-12-5**]: Non-contrast Head CT: 1. Left posterior temporo-occipital lobe hemorrhage essentially unchanged over 46 hours. The relative stability of this hemorrhage, as well as its associated edema, raises the possibility of an underlying structural abnormality such as a mass, although there is no surrounding edema. 2. Global atrophy, predominantly central and preferentially involving the temporal lobes, raising the possibility of underlying Alzheimer disease and possible associated CAA, with "lobar hemorrhage." . EEG: Preliminary read: diffusely slow 7 Hz. no sleep. no epileptiform activity. no focal slowing. Brief Hospital Course: 89 year-old woman with a history of HTN, HLD and prior right frontal hemorrhage, who is legally deaf and blind, dependent on a cochlear implant, presented with garbled non-sensical speech, found to have a new small 1.4x1.7cm left occipital lobe hemorrhage without significant edema or mas effect and cortical atrophy at OSH with marked HTN to SBP 200s. BP was controlled with IV labetalol at OSH and patient was transitioned to a labetalol infusion and admitted to the neuro ICI on [**12-3**]. Labetalol infusion was stopped on [**12-4**] due to SBP in 90s which stabilised. She continued to be very agitated and complained of significant back pain s/p fall on [**11-28**] and seemed to have expressive aphasia. Given her previous hemorrhage, the aetiology was felt likely due to a combination of hypertension and amyloid angiopathy. Has hyponatremia 130 which appears chronic and not in keeping with SIADH. Her sodium improved to 134 prior to discharge. Patient was deemed appropriate for transfer out of the ICU as she had remained clinically stable and no longer required IV anti-hypertensives and was transferred to the neurology floor on [**2125-12-5**]. Repeat Head CT on [**2125-12-5**] showed improvement in bleed size. Given the consideration that seizures may be causing her speech problems, she had an EEG which showed diffuse slowing consistent with age but no epileptiform activity or focal slowing. A swallow evaluation showed no signs of aspiration or dysphagia. Physical therapy evaluated the patient and found her to have very unsteady ambulation with a cane. They recommended outpatient PT and recommended her for discharge only with 24 hour supervision. The patient's daughter ensured us that she would have 24 hour supervision with the help of personal care aids who could also help with exercises. Medications on Admission: - Alendronate 70mg weekly - Diltiazem 30mg [**Hospital1 **] - Lovastatin 10mg qd - Lisinopril 10mg [**Hospital1 **] - Sertraline 100mg daily - MVI - Calcium and vitamin D - Dorzolamide 2% drops 1 drop [**Hospital1 **] - Timolol 0.5% 1 drop [**Hospital1 **] - Lumigan 0.03% drops [**Hospital1 **] - Prednisolone acetate 1% drops [**Hospital1 **] - Alphagan 0.1% drops [**Hospital1 **] - Levothyroxine 25mcg qd - Ferrex 150mg cap qd Discharge Medications: 1. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 3. alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every Sunday). 4. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 5. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 6. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 7. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. lovastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: intraparenchymal hemorrhage - left occipital lobe Discharge Condition: Mental Status: Confused - always. (Primarily due to sensory deficits) Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Neuro: Mental status exam severely limited by blindness and deafness (small improvement with cochlear device). Patient able to speak in clear coherent fluent sentences. Moves all extremities spontaneously and equally. Discharge Instructions: You were admitted to the hospital for difficulties with language and confusion. Your brain imaging showed a small bleed in the left occipitial lobe, likely related to a similar cause as the bleed you had previously, high blood pressure and amyloid. A repeat head CT showed the bleed to be resolving. A preliminary EEG read showed no sign of seizure activity. The physical therapy team evaluated and found you to go home with 24 hour supervision. Given that your daughter has agreed to 24 hour supervision, we are sending you home with home PT and VNA services. No changes have been made to your medications. Followup Instructions: Please call registration to update your information: [**Telephone/Fax (1) 10676**] Please follow up in [**Hospital 878**] clinic with Dr. [**Last Name (STitle) **] in the [**Hospital1 18**] [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Building: Tuesday [**2-5**] at 2:30pm Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2126-2-5**] 2:30 [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

[ "V49.85", "V45.89", "431", "401.9", "564.1", "389.9", "276.1", "437.9", "365.9", "369.10", "277.39", "733.00", "285.9", "369.4", "300.4", "365.70", "V49.86" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9217, 9275

5827, 7651

307, 314

9369, 9369

3646, 3666

10430, 10965

2053, 2062

8132, 9194

9296, 9348

7677, 8109

9798, 10407

2902, 3397

2102, 2621

3411, 3627

249, 269

342, 1606

5216, 5804

3682, 5207

9384, 9774

1628, 1805

1821, 2037

28,681

102,724

32867

Discharge summary

report

Admission Date: [**2184-8-2**] Discharge Date: [**2184-8-13**] Date of Birth: [**2130-1-22**] Sex: F Service: MEDICINE Allergies: Morphine And Related / Levaquin Attending:[**First Name3 (LF) 3276**] Chief Complaint: fevers Major Surgical or Invasive Procedure: Thoracocentesis History of Present Illness: Patient is a 54 year-old female with a history of pulmonary embolism, chronic left-sided pleural effusion, and Non-small cell lung CA on seliciclib chemotherapy who presents with fevers. Patient is s/p several regimens of chemotherapy and XRT, as well as rigid bronchoscopy and laser treatment for obstructive bronchial lesion, currently on seliciclib received 3rd cycle on [**2184-7-29**]. She was recently discharged from the hospital on [**2184-7-15**] with a newly diagnosed right-sided pulmonary embolism, as well as a post-obstructive pneumonia, for which she received azithromycin x 5 days and cefpodoxime x 14 days. The patient's fevers have not improved on either regimen. Past Medical History: Past Medical History: #. Non-small cell lung CA diagnosed [**10/2183**] from bronchoscopic biopsy of left-upper lobe mass at [**Hospital3 417**] Hospital with PET CT showing uptake in mediastinal lymph nodes and left adrenal, S/P rigid bronchoscopy and laser treatment and stenting in [**11/2183**] at [**Hospital1 18**], cisplatin and XRT from [**Month (only) 404**]-[**Month (only) 956**] [**2183**], XRT to 4th left rib in [**2184-2-28**], pemetrexed therapy in [**2184-3-30**], Taxotere therapy in [**2184-4-29**], CT in [**2184-5-30**] with disease progression, enrolled in clinical trial for seliciclib in [**2184-6-29**] #. Pulmonary embolism diagnosed in [**2184-6-29**], started on enoxaparin #. Left-sided pleural effusions, unsusccessful thoracentesis on [**2184-7-13**], repeat on [**2184-8-3**]. #. GERD #. Hypothyroidism PAST SURGICAL HISTORY: 1. Cholecystectomy [**2169**]. 2. Total abdominal hysterectomy for uterine fibroids [**2164**]. 3. Partial thyroidectomy in [**2164**] for further evaluation of a nodule. . PAST ONCOLOGIC HISTORY: history of meningioma resected in [**2181**]; developed a chronic cough in the beginning of 11/[**2182**]. On [**2183-11-16**] she developed hemoptysis which prompted her to present to [**Hospital 76515**] Hospital in [**Hospital1 1474**]. A mass was seen in her left upper lobe on chest x-ray. She underwent bronchoscopy on [**2183-11-19**] with pathology consistent with nonsmall cell lung cancer, most likely adenocarcinoma. IH was positive for TTF-1 and CK7, negative for CK20. A PET-CT on [**2183-11-29**], reportedly showed uptake in the left lung, mediastinal lymph nodes, and left adrenal gland. Head MRI was negative. She had a bronchoscopy on [**2183-12-19**] at which time a stent was placed in the left mainstem bronchus. She underwent repeat bronchoscopy and endobronchial ultrasound on [**2184-1-1**]. A level 7 and a level 4 node were biopsied by FNA. The cytology from these was negative. She started radiation therapy on [**2184-1-6**]. Social History: She lives with her partner. She smoked for 30 years x 1.5 packs per day, quit seven years ago. She denies alcohol use. Family History: Father - prostate cancer. No other family history of cancers Physical Exam: GEN: Well-appearing, well-nourished, no acute distress HEENT: NCAT, EOMI, PERRL, sclera anicteric, MMM, OP with white plaques at interface of gums and buccal mucosa bilat. NECK: No JVD, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: dullness to percussion and decreased breath sounds on left, crackles at right base. ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [**2184-8-1**] 10:00PM WBC-23.4* RBC-3.32* HGB-8.3* HCT-26.2* MCV-79* MCH-24.9* MCHC-31.5 RDW-19.5* [**2184-8-1**] 10:00PM NEUTS-93.6* BANDS-0 LYMPHS-2.6* MONOS-3.5 EOS-0.1 BASOS-0.1 [**2184-8-1**] 10:00PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-OCCASIONAL [**2184-8-1**] 10:00PM GLUCOSE-127* UREA N-27* CREAT-1.4* SODIUM-131* POTASSIUM-4.2 CHLORIDE-89* TOTAL CO2-30 ANION GAP-16 . . STUDIES: [**2184-8-2**] - CT TORSO FINDINGS: . CT OF THE CHEST WITH IV CONTRAST: Hyponehancement of left lingula and left lower lobe conistent with Pnuemonia is noted. There is a large plueral effusion filling the whole of the left hemithorax with complete collapse of the left lung. The large necrotic tumor in the left lower lung has increased in size since the last examination . Multiple bilateral new axillary lymph nodes are seen with the biggest measuring 13 x 4 in the right axillary region (series 3, image 15). A new prevascular lymph node is seen abutting between the left subclavian vein and left subclavian artery measuring 25 x 20 mm (series 3, image 14), which was not seen in the previous examinations. There aorticopulmonary node seen in the previous examination appears stable. The local tumor infiltration involving the mid portion of the left rib has increased in size with greater associated rib destruction (series 3, image 22). In addition, the left plueral tumor deep in the posterior sulcus along the spine has also increased in size. In the right lung, innumerable new pulmonary metastases along with interval increase in previous lesions, measuring up to 13 mm and are more extensive in the right middle lobe. . CT OF THE ABDOMEN WITH IV CONTRAST: New hypodense lesions are noted in the liver, most likely metastases. The patient is status post cholecystectomy. The intra- and extra-hepatic biliary duct dilatation is unchanged. Bilateral adrenal masses seen on the previous examination have increased in size. In addition, multiple retroperitoneal and mesenteric lymph nodes are noted which are new, with the left paraaortic lymph node measuring up to 21 x 35 mm, (series 3, image 75). Enhancing foci in the left psoas and right paraspinal seen on [**2176-6-15**] have also increased in size. A new metastatic focus is seen in the posterior subcutaneous tissue at the level of L3. . CT OF THE PELVIS WITH IV CONTRAST: Heterogeneously enhancing foci in the right iliacus, right gluteus, and the left quadriceps are persistent and have increased in size. Increase in interval pelvic lymphadenopathy is seen with the biggest lymph node measuring 19 x 24 along the left pelvic wall, series 3, image 104. . BONE WINDOWS: Interval increase in the destructive left fourth rib lesion is noted.In addition, new metastatic bony lesions are seen in vertebrae T4- T5. . Multiplanar reformats were essential in delineating the findings described above. . IMPRESSION: 1. Post-obstructive multilobar left lung pneumonia. 2. Marked progression of metastatic disease with increase in size of previous metastes, and development of innumerable multiple new metastases, more prominently in the right lung. 3. Increase in left pleural effusion filling the whole of left hemithorax causing collapse of the left lung. . . [**2184-8-3**] - PLEURAL FLUID: Gram stain negative, no growth on culture. . . [**2184-8-5**] - CXR IMPRESSION: 1. Worsening confluent opacity in the right mid-lung zone is concerning for superimposed pneumonia. 2. Probable increasing left pleural effusion and unchanged collapse of the left lung. . . [**2184-8-5**] - CXR IMPRESSION: 1. Rapidly progressive airspace process in the right mid-lung and base, which, in clinical context, may represent noncardiogenic pulmonary edema related to the apparent clinical transfusion reaction. Progressive pneumonic consolidation (including endobronchial spread of infection) and alveolar hemorrhage are additional concerns. Progression of known pulmonary metastases is most unlikely given the rapidity of change. 2. Complete opacification of the left hemithorax, reflecting a combination of obstructing [**Location (un) 21851**], lung collapse and effusion. . . TRANSFUSION REACTION WORKUP DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Ms. [**Known lastname 76514**] experienced a 3 degree F temperature increase, chills, a significant drop in her O2 saturation from 90-94% to 81%, and wheezing following transfusion of 40 cc's of ABO/Rh compatible leukoreduced, irradiated RBC's. Her O2 saturation improved to 97% when switched from 6L nasal cannula to non-rebreather mask. Response to Lasix per the clinical team was minimal (300cc diuresis). Post-transfusion CXR showed possible non-cardiogenic edema in right lung (left lung collapse unchanged). . There was no evidence of hemolysis in the post-transfusion sample (DAT negative, clear yellow serum). Possible explanations for this constellation of symptoms include TRALI (Transfusion-Related Acute Lung Injury), fluid-overload (TACO), allergy, or symptoms due to her underlying medical condition (pneumonia, pleural effusion, metastasis). The presence of fever, minimal response to diuresis, and noncardiogenic pulmonary edema on CXR are suspicious for TRALI. Blood samples will be sent to the Red Cross for work-up of this possible TRALI reaction and reported in an addendum. TRALI reactions are thought to be related to the donor product and would require no change in transfusion practice for this patient. . Transfusion associated circulatory overload (TACO) is less likely given the small volume of RBCs transfused (40cc), and lack of significant response to Lasix per the clinical team. The post-transfusion NTProBNP did rise in this patient, however the increase is difficult to interpret in this setting. An allergic transfusion reaction is also less likely in this patient given the absence of additional typical allergic symptoms. Ms. [**Known lastname 76520**] symptoms could also be due to her underlying pulmonary infections, lung collapse, and cancer. . No changes in transfusion practices are recommended at this time in this patient. Additional American Red Cross test results will be reported in an addendum. Brief Hospital Course: 54 year old female with NSCLC on palliative chemotherapy admitted [**2184-8-2**] with fevers. She had been treated for post obstructive pneumonia with 2 courses of antibiotics as an outpatient with no relief of her fevers. She continued to have fever to 102. After admission, a CT scan was preformed which showed worsening left sided pleural effusion. She underwent thoracentesis, without positive cultures, and was cultured many times for recurrent/daily fevers. The pleural fluid and blood cultures remain negative. It was thought that her fevers were likely related to her tumor/possible necrotic tissue in the lung. Her antibiotic coverage was switched to Augmentin and with the plan of being discharged on a ten day course. On [**2184-8-5**], Ms. [**Known lastname 76514**] was receiving a blood transfusion for anemia, and had an acute hypoxic reaction with heart rates to the 150s. She was transferred to the [**Hospital Unit Name 153**] and her oxygen requirement was weaned down to 4-5L at transfer. Her antibiotic coverage was broadened to Zosyn on the day of [**Hospital Unit Name 153**] transfer, and the patient has continued on Zosyn since this time. In the ICU, the patient's decompensation was though to be associated with TRALI, although other possibilities such as volume overload, were considered. The patient was diuresed with Furosemide. PE was unlikely given that the patient was on therapeutic enoxaparin. Exacerbation of post-osbtructive pneuomonia was also considered and the patient was continued on Zosyn. Vancomycin was added to her regimen. The patient's condition improved in the ICU and he was transfered back to the floor. Upon return to the floor the patient remained stable. She complained of chest pressure and an subsequent ECG was noted to show ST elevations in V1 and V2. Cardiac enzymes were negative. The patient was started on ASA and her enoxoparin was continued. The patient's pain was controlled on oxycodone. The did not have any more chest pain following this episode. The patient continued to have intermittent febrile episodes. This was thought to be realted to her tumor or secondary to lung infection. Given persistence of symptoms despite several courses of antibiotics, it was less likely that this represents an infectious source. Zosyn was continued. Fevers were controlled with ibuprofen as needed. The patient's hematocrit continued to decrease during her stay with a nadir of 20.7. ASA and lovenox were held and the HCT improved. During the duration of admission the patinent and her partner, who is her health care proxy, were [**Name2 (NI) 76521**] what the appropriate goals of care would be. They decided that a outpatient hospice program would be the best way to proceed at this time. Medications on Admission: #. Benzonatate #. Albuterol q6H PRN #. Enoxaparin 80mg q12H #. Lacutlose 30mL q8H:PRN #. Levothyroxine 150mcg daily #. Lorazepam 0.5mg q4H PRN #. Ondansetron 8mg PO or IV q8H PRN #. Oxycodone SR 60mg QAM, 80mg qPM #. Ranitidine 150mg daily #. Tiotropium 18mcg daily #. docusate 100mg [**Hospital1 **] #. MVI daily #. Senna #. Hydromorphone 2-4mg PO q3-4H PRN #. Fluticasone-salmeterol 250/50 [**Hospital1 **] #. Glyburide 2.5mg daily Discharge Disposition: Home With Service Facility: Old [**Hospital **] Hospice Discharge Diagnosis: Fever Post-obstructive PNA Transfusion reaction NSCLC Discharge Condition: Comfortable Discharge Instructions: You were admitted with fever which was atributed to a multifactorial process including a pneumonia and tumor related changes in your lungs. With these in mind you were started on antibiotic therapy. Also, during your stay you were noted to have a worsening anemia which necessitated transfusion of blood cells. During this process, you had a rare reaction that resulted in problems with your blood oxygenation. We imediately stopped the transfusion and trasnfered you to the intensive care unit for observation. There you remained stable and then transfered back to the oncology [**Hospital1 **]. You remained stable for the remainder of your hispitalization. Followup Instructions: Home with hospice [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**] Completed by:[**2184-8-13**]

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icd9cm

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29524

Discharge summary

report

Admission Date: [**2153-9-16**] Discharge Date: [**2153-9-22**] Date of Birth: [**2126-3-10**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1**] Chief Complaint: Rectal bleeding Major Surgical or Invasive Procedure: [**2153-9-17**]: Exploratory laparotomy, on-table enteroscopy, resection of ileocolonic anastomosis and repeat ileocolostomy History of Present Illness: Ms. [**Known lastname 11287**] is a 27 year-old surgical resident with Crohn's disease, status post ileocecectomy in [**3-31**], who presented to [**Hospital1 18**] with recurrent rectal bleeding. She reports recurrent lower gastrointestinal bleeding for the past 5 months. Prior to admission, she felt well until she noted some abdominal cramping, which was followed by a large, dark red, bloody bowel movement. She then felt woozy and apparently syncopized according to a friend. Following presentation in the [**Hospital1 18**] ED, she had a second moderate-sized bloody bowel movement. She reported crampy abdominal pain. No hematemasis. No NSAIDs or aspirin use. She has had multiple episodes of bright red blood per rectum since surgery. Prior colonoscopies have revealed bleeding at the anastamotic site. On [**2153-9-16**], she was admitted for surgical management on the Crimson surgical service with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Past Medical History: Past Medical History: Crohn's disease: Symptoms started ~5 years ago, diagnosis made 3 years ago at which time she presented with diarrhea and abdominal pain and was found to have a diseased terminal ileum. She was treated with steroids and 6-MP. She was then treated with Pentasa but this was stopped after it was thought to be unsuccessful. She had flare in [**12-31**] (severely edematous terminal ileum) and [**1-31**]. Past Surgical History: [**3-31**] Ileocecectomy Social History: She is single. She is currently a PGY-2 general surgery resident at [**Hospital1 18**]. She denies tobacco, alcohol, and recreational drug use. Family History: Twin Sister with [**Name (NI) 4522**] Father with hypertension Physical Exam: In Emergency Dept: Vitals: T-96.3, HR-108, BP-127/76, RR-18, O2 sat-100% on RA Constitutional: A/Ox3 HEENT: EOMI, PERRL, mucous membranes dry Pulm: CTAB Cardiac: slightly tachycardic, RR Abd: slight tenderness below umbilicus. No rebound, non-distened. +BS Rectal: stool guaiac positive Skin: Warm. Pale. No C/C/E Pertinent Results: [**2153-9-15**] 10:50PM PT-13.4* PTT-26.2 INR(PT)-1.2* [**2153-9-15**] 10:50PM PLT COUNT-340 [**2153-9-15**] 10:50PM WBC-11.0# RBC-3.10* HGB-9.6* HCT-27.6* MCV-89# MCH-30.9 MCHC-34.7 RDW-13.9 [**2153-9-15**] 10:50PM CALCIUM-8.7 PHOSPHATE-4.0 MAGNESIUM-1.9 [**2153-9-15**] 10:50PM GLUCOSE-100 UREA N-19 CREAT-0.7 SODIUM-140 POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-24 [**2153-9-16**]: Colonoscopy An ulcer was found in the ileo-colonic anastamosis. Some oozing was noted and 5 clips were placed with good hemostasis. [**2153-9-17**]: Pathology (RESECTION OF ILEOCOLONIC ANASTOMOSIS) I. Ileocolonic anastomosis, resection (A-I): 1. Superficial ulcer ileum just proximal to healed ileocolic anastomosis. 2. The rest of the small intestinal and colonic mucosa is normal. 3. No granulomas or dysplasia. II. Fragments of ileum and colon: Within normal limits. Brief Hospital Course: Following presentation in the emergency department, she was admitted to the surgical ICU and closely monitored. Serial hemocrits were obtained, and she received 2U pRBCs for hemocrit of 23.5, down from 27.6 on admission. Hemocrit rose to 30.7 post-transfusion. Per GI recommendation, she was underwent bowel prep with magnesium citrate for colonscopy scheduled the following morning. Colonoscopy found an ulcer in the ileo-colonic anastamosis. Some oozing was noted and 5 clips were placed with good hemostasis. Following the scope, she had another red bloody bowel movement. Due to persistent bleeding, a decision was made to proceed with exploratory laparotomy in the operating room. On [**2153-9-17**], she underwent an exploratory laparotomy, on-table enteroscopy, resection of ileocolonic anastomosis, and repeat ileocolostomy. She tolerated the procedure well with no complications. She was observed routinely in the PACU post-op and transferred to [**Hospital Ward Name 2982**] for routine post-operative care. . Neuro: Her pain was managed with a Dilaudid PCA and [**Doctor Last Name 3389**] Bupivicaine pump. On POD#2, the [**Doctor Last Name 3389**] pump was removed due to persistent leaking. As her bowel function returned to baseline, she was transitioned to oral Percocet with adequate relief. She was discharged home with Vicodin for 2 weeks. . GI: Operative wound dressings were removed on POD#2 and her midline incision was kept open-to-air with steri-strips in place. The site drained serous fluid for the first few days post-op which was likely related to the [**Doctor Last Name 3389**] Bupivicaine pump. Her abdomen remained slightly distended with minimal bowels sounds for the few days post-op. Her bowel function resumed slowly, and she reported passing flatus on POD#3. She reported passing some bloody clots per rectum post-operatively. . Nutrition: Her diet was advanced slowly from sips to regular due to persistent nausea. Her nausea was well-managed with IV Zofran and occasional Compazine. By POD#6, she tolerated a regular diet, and denied nausea and vomiting. . GU/Renal: Her foley was removed on POD#3. She voided adequate amounts without difficulty. . HEME: Her hemocrit dropped to 23.5 following admit and she received blood as described above. Post-operatively she remained hemodynamically stable and no further blood transfusions were needed. Medications on Admission: mercaptopurine 50 daily prednisone 5 [**Hospital1 **] protonix 40 daily mesalamine 1200 qid ambien 10 qhs prn ativan 0.5 prn Discharge Medications: 1. Mercaptopurine 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation for 1 months. Disp:*60 Capsule(s)* Refills:*0* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Mesalamine 1.2 g Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO four times a day. 5. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. 6. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for anxiety. 7. Prednisone 5 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: ileo-colonic anastamosis ulcer post-op ileus . Secondary: Chron's Disease Discharge Condition: Stable Tolerating a regular diet Adequate pain control with oral medication 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. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting 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 or progressively worsening despite taking the prescribed pain medication. * 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. Incision Care: *You may shower. Pat incision dry. *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. Followup Instructions: 1. Please call Dr.[**Name (NI) 10946**] office ([**Telephone/Fax (1) 9011**] for a follow-up appointment in [**1-27**] weeks.

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icd9cm

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[ "46.94", "45.62", "45.43", "45.11" ]

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27532

Discharge summary

report

Admission Date: [**2184-10-18**] Discharge Date: [**2184-10-23**] Date of Birth: [**2132-9-17**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 943**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: none History of Present Illness: 52 y/o M with cryptogenic cirrhosis, varices, who presents from outside hospital with GI bleed. He presented to OSH one day prior to admission after having melena and hematemesis at home. Reports throwing up both bright red blood and clots. In addition, he reported increasing abdominal girth over last several months. Denied chest pain, palpitaions. +Lightheadedness. . At the OSH, found to have hct of 35.1, INR 1.8. Given Vitamin K, FFP, PPI and Octreotide 50mcg bolus, followed by octreotide drip. EGD was performed [**10-17**] which revealed no active bleeding or red whale marks. Grade II-III esophogeal varices were seen, in addition to esophogeal erosions. There was no gastric varices and no blood seen in stomach. He was continued on IV PPI and IV octreotide. However, the following morning [**10-18**], he vomited moderate amount of emesis with approximately 50% clotted blood. At that time, hgb checked, found to be 11. Repeat EGD was performed on [**2184-10-18**], with banding of 3 varices. Transferred to [**Hospital1 18**] for further management. . On arrival here, complains of mild abdominal pains secondary to distension. Denies chest pains, SOB. Passed one melanotic BM. No further hematemesis Past Medical History: # cryptogenic cirrhosis- initial onset of cholestatic hepatitis after having a cholecystectomy; has undergone numerous investigations, including cross-sectional imaging, liver biopsy and ERCP on two occasions. A complete serological evaluation has not shown any cause for his liver cirrhosis. He has had two normal ERCPs performed at an outside institution. His liver biopsies here have shown features consistent with large bile duct obstruction # h/o arterial portal venous fistulae: noted within his right lobe of his liver s/p embolization # jaundice at the age of 4 # DM II- insulin requiring w/ peripheral neuropathy, retinopathy # GERD # CAD- 3 MI's in past, w/ 2 angioplasties, no stents Social History: He stopped drinking alcohol two years ago. Prior to that, he reports occasional ETOH use. 30+ pack year smoking history. Still actively smoking 1ppd Family History: No family history of liver disease. He has no history of blood transfusion or intravenous drugs. He did snort cocaine periodically during his 20's. He has never been a blood donor, does not have any tattoos and never served in the military Physical Exam: vitals- afebrile, VSS gen- well appearing, jaundiced, NAD heent- EOMI. + scleral icterus. mucous membranes dry pulm- bibasilar rales. no ronchi or wheezes cv- RRR. no m/r/g abd- soft, distended, non-tender. + dull flanks. liver edge palpable 1 cm below RCM. ext- no c/c/e skin- small spiders on anterior chest wall. + palmar erythema b/l neuro- alert and oriented x 3, conversating appropriately. no asterixis. motor strength 5/5 b/l Pertinent Results: ADMIT LABS: ========== [**2184-10-18**] 10:18PM WBC-4.8 RBC-3.02* HGB-10.1* HCT-30.1* MCV-100* MCH-33.5* MCHC-33.6 RDW-17.5* . LIVER U/S [**2184-10-19**]: ================ Again noted is a small liver with nodular contour and echotexture consistent with cirrhosis. There is a slightly increased amount of ascites perihepatically and throughout the abdomen. The left main and right hepatic veins are patent demonstrating normal flow and waveforms. The left and right hepatic arteries are patent demonstrating normal waveforms and flow. There is reversal flow of the main, left, and right portal vein, which appears new compared to prior study consistent with worsening portal hypertension. The spleen is enlarged at the upper limits of normal. There is no evidence of fistula formation. IMPRESSION: 1. Reversal of flow of the portal venous system, which appears new compared to prior study from [**2184-9-9**] and [**2184-8-8**]. No evidence of thrombosis or fistula formation. 2. Ascites Previous Studies: . ECHO [**2184-10-8**]- Left Atrium - Long Axis Dimension: *4.4 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 5.0 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 4.1 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: *5.7 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 40% (nl >=55%) Aorta - Valve Level: 3.6 cm (nl <= 3.6 cm) Aorta - Ascending: 3.4 cm (nl <= 3.4 cm) Aorta - Arch: 2.6 cm (nl <= 3.0 cm) Aortic Valve - Peak Velocity: 1.2 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: 226 msec TR Gradient (+ RA = PASP): *20 to 32 mm Hg (nl <= 25 mm Hg) . Conclusions: 1. The left atrium is mildly dilated. 2. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is moderately depressed. Inferior akinesis with apical and distal septal hypokinesis are present. 3. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. 4. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. . ERCP [**2184-9-14**]: 12 ERCP images were obtained by Dr. [**Last Name (STitle) 6745**]. Cholangiogram shows normal intra- and extra-hepatic ducts without evidence of dilatation or stricture. No intraluminal filling defects are identified. Cholecystectomy clips and vascular coils are noted . Liver Bx Path [**2184-8-24**]: . Right liver lobe, needle core biopsy (A): 1. Marked bile duct proliferation with associated neutrophils and cholestasis, see note. 2. Mild lobular predominately mononuclear all inflammation with scattered neutrophils. 3. Trichrome stains shows increased portal and bridging fibrosis and incomplete nodule formation (Stage 3). 4. Iron stain shows minimal iron deposits in hepatocytes. . II. Left liver lobe, needle core biopsy (B): . 1. Marked bile duct proliferation with associated neutrophils and cholestasis, see note. 2. Mild lobular predominately mononuclear all inflammation with scattered neutrophils. 3. Trichrome stain shows cirrhosis. 4. Iron stain shows minimal iron deposits in hepatocytes. . Note: The features are most suggestive of a chronic obstructive process (biliary type cirrhosis). . Abd U/S [**10-18**]- bilateral hydronephrosis. Decreased renal function with poor response to lasix. Brief Hospital Course: 52 y/o M w/ cryptogenic cirrhosis, GI bleed [**3-11**] varices s/p banding at OSH . # GI bleed: s/p variceal banding at OSH. Continued initially on IV pantoprazole, octreotide drip. Remained hemodynamically stable with stable hematocrit overnight. Hematocrit subsequently drifted down to 23. Still with some melena, however no further hemoptysis or bright red blood per rectum. Recieved 2units packed red blood cells and hematocrit subsequently stabilized . # Cirrhosis: Unclear etiology. Followed by Dr. [**Last Name (STitle) 497**]. Complicated by esophogeal varices, mild portal gastropathy. No evidence of encephalopathy. Evidence of ascites on exam. Liver u/s with dopplers demonstrated no evidence of thrombosis or fistula. There was noted reversal of flow and ascites. Diagnostic paracentesis was performed, and was negative for SBP. Plan for transplant eval per hepatology. Was discharged on spironolactone 50 mg PO qd, ursodiol 300 mg PO bid. . # DMII: continued on lantus. SSI. diabetic diet. neurontin for neuropathic pain . # CAD: chest pain free. EKG with no acute ST changes. no aspirin given GI bleed. no statin given cirrhosis. On cholestyramine for lipids. Added simvastatin 10 mg PO qd. . # CHF: recent ECHO [**2184-10-8**] shows depressed EF of 40%. Monitored I's/O's. Given lasix with blood transfusion. . # Psych: Continued on sertraline Medications on Admission: Lantus 45 units daily Neurontin 800 mg [**Hospital1 **] Sertraline 50 mg per day Octreotide 50mcg/hr Ursodiol 300mg/day Folic Acid 1mg/day Creon 2 caps QID Cholestyramine 1packet [**Hospital1 **] Pantoprazole 40mg IV BID Spironolactone 50mg per day . Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 4. Cholestyramine-Sucrose 4 g Packet Sig: One (1) Packet PO BID (2 times a day). Disp:*60 Packet(s)* Refills:*2* 5. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO QIDWMHS (4 times a day (with meals and at bedtime)). 6. Pregabalin 75 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 7. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). Disp:*30 Patch 24HR(s)* Refills:*2* 8. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a day. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Insulin Glargine 100 unit/mL Solution Sig: Forty Five (45) Units Subcutaneous once a day: Please take as prescribed. 12. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 13. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Upper GI bleed. Discharge Condition: Stable, ambulatory, afebrile Discharge Instructions: Please return to the hospital if you experience abdominal pain, fevers, bleeding, chest pain or shortness of breath. . Please take all your medications as prescribed. Followup Instructions: You have an appointment for upper endoscopy with Dr. [**Last Name (STitle) 497**] on Thursday, [**10-28**] at 2 p.m. Please arrive at 1 p.m. Please do not eat or drink after midnight on the night before the procedure. Dr.[**Name (NI) 948**] office will call you with any further instructions.

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icd9cm

[ [ [] ] ]

[ "54.91", "99.04" ]

icd9pcs

[ [ [] ] ]

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6719, 8079

325, 331

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359, 1575

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28,984

198,557

32259

Discharge summary

report

Admission Date: [**2174-12-3**] Discharge Date: [**2174-12-6**] Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2724**] Chief Complaint: [**Age over 90 **] y/o male who presented to an outside hospital following an unwitnessed fall. Major Surgical or Invasive Procedure: NONE History of Present Illness: [**Age over 90 **] y/o male who presented to an outside hospital following an unwitnessed fall. He tripped while walking, and struck his head on a post. He denies loss of consciousness, and beyond posterior neck pain, only noted a laceration on his forehead. Because of neck pain, a cervical spine CT was obtained at the OSH which revealed degenerative changes in the odontoid process and a nondisplaced fracture along the anterior border of the dens. He was neurologically intact and transferred to [**Hospital1 18**] for neurosurgical evaluation. Past Medical History: hypertension CAD renal cancer spinal stenosis nephrectomy angioplasty Social History: denies tobacco, EtOH, or IVDA Family Hx:noncontributory Family History: noncontributory Physical Exam: PHYSICAL EXAM on admission. Gen: WD/WN, comfortable, NAD. HEENT: Pupils: [**3-18**] bilaterally EOMs intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T FE FF IP Q AT [**Last Name (un) 938**] G Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. no pronator drift Propioception intact Toes downgoing bilaterally Rectal exam normal sphincter control Pertinent Results: [**2174-12-6**] 07:20AM BLOOD WBC-12.4* RBC-3.62* Hgb-11.1* Hct-34.8* MCV-96 MCH-30.6 MCHC-31.8 RDW-15.5 Plt Ct-336 [**2174-12-5**] 07:00AM BLOOD WBC-12.0* RBC-3.56* Hgb-11.0* Hct-34.6* MCV-97 MCH-30.9 MCHC-31.7 RDW-15.6* Plt Ct-295 [**2174-12-4**] 03:10AM BLOOD WBC-11.0 RBC-3.70* Hgb-11.8* Hct-36.3* MCV-98 MCH-31.9 MCHC-32.5 RDW-15.9* Plt Ct-343 [**2174-12-3**] 07:20AM BLOOD WBC-10.7 RBC-3.90* Hgb-12.2* Hct-37.9* MCV-97 MCH-31.2 MCHC-32.1 RDW-16.1* Plt Ct-396 [**2174-12-2**] 11:35PM BLOOD WBC-14.2* RBC-3.82* Hgb-12.0* Hct-36.3* MCV-95 MCH-31.3 MCHC-33.0 RDW-16.0* Plt Ct-377 [**2174-12-3**] 07:20AM BLOOD Neuts-82.6* Lymphs-11.9* Monos-4.6 Eos-0.6 Baso-0.3 [**2174-12-2**] 11:35PM BLOOD Neuts-77.9* Lymphs-17.4* Monos-4.1 Eos-0.4 Baso-0.1 [**2174-12-6**] 07:20AM BLOOD Plt Ct-336 [**2174-12-5**] 07:00AM BLOOD Plt Ct-295 [**2174-12-6**] 07:20AM BLOOD Glucose-93 UreaN-43* Creat-2.4* Na-143 K-4.3 Cl-110* HCO3-22 AnGap-15 [**2174-12-6**] 07:20AM BLOOD Glucose-93 UreaN-43* Creat-2.4* Na-143 K-4.3 Cl-110* HCO3-22 AnGap-15 [**2174-12-5**] 07:15PM BLOOD K-5.0 [**2174-12-5**] 07:00AM BLOOD Glucose-102 UreaN-41* Creat-2.2* Na-142 K-5.5* Cl-111* HCO3-20* AnGap-17 [**2174-12-2**] 11:35PM BLOOD CK(CPK)-292* [**2174-12-2**] 11:35PM BLOOD cTropnT-0.01 [**2174-12-2**] 11:35PM BLOOD CK-MB-7 [**2174-12-6**] 07:20AM BLOOD TotProt-5.7* [**2174-12-6**] 07:20AM BLOOD TotProt-5.7* Calcium-8.5 Phos-3.8 Mg-1.8 MR CERVICAL SPINE [**2174-12-3**] IMPRESSION: 1. Findings at C5-6 indicate acute extension injury and disruption of the anterior longitudinal ligament with mild prevertebral hematoma or edema. 2. Probable post-traumatic changes to the left lateral mass of C1, correlation with cervical spine CT for better bony details recommended. 3. Deformity of the odontoid process which does not appear to be due to acute fracture but correlation with CT is recommended . Mild increased soft tissue changes are seen in the posterior soft tissues indicating trauma. 4. No evidence of high signal within the spinal cord to indicate acute trauma, cord contusion or cord edema, or evidence of intraspinal hematoma. Reason: left thumb AP/lat [**2174-12-5**] FINDINGS: There is a non-displaced fracture at the base of the first metacarpal. There are also moderate degenerative changes at the first MCP and IP joints. The fracture is age indeterminate. Brief Hospital Course: HPI: [**Age over 90 **] y/o male admitted from outside hospital after unwitnessed fall. He tripped while walking, and struck his head on a post. He denies loss of consciousness, and beyond posterior neck pain, only noted a laceration on his forehead. C spine MRI showed a nondisplaced odontoid fracture, and he was placed in a C -collar, which he should wear continuously until his follow up with Dr. [**Last Name (STitle) 548**] in 6 weeks. The patient was reporting Left thumb pain/swelling. the x ray shows a non-displaced fracture at the base of the first metacarpal, for which we recommend that he follows up with an orthopedic surgeon outpatient. [**12-5**] Mr. [**Known lastname **] K/BUN/Cr elevated, nephrology consult placed, aditional tests ordered by nephrology and determined that he has chronic renal failure, for which we recommend that he is followed up by outpatient nephrology. He will continue using Sodium bicarbonate 650mg [**Hospital1 **] until he sees his nephrologist. In addition, we recommend he follows up with his PCP. [**Name10 (NameIs) **] recommended diet is low postassium, he is tolerating diet well, and he is voiding without difficulties. Mr. [**Known lastname 951**] was seen by PT, and he will be d/c with home PT/OT/Nursing/ and home health aide, arranged by case manager. [**2174-12-6**] Mr. [**Known lastname **] exam is non-focal, and he is neurologically stable. Medications on Admission: aspirin plendil procrit FeSO4 epogen Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 4. Felodipine 2.5 mg Tablet Sustained Release 24 hr Sig: Eight (8) Tablet Sustained Release 24 hr PO DAILY (Daily). 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*30 Tablet(s)* Refills:*2* 6. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO twice a day: Please check with your nephrologist on the length of regimen. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: s/p fall with odontoid fracture and epidural hematoma Discharge Condition: Neurologically stable Discharge Instructions: ?????? Do not smoke ?????? Keep wound clean and dry / No tub baths or pools for two weeks from your date of surgery, you may shower. ?????? Keep collar on at all times ?????? No pulling up, lifting> 10 lbs., excessive bending or twisting ?????? Limit your use of stairs to 2-3 times per day ?????? Have a family member check your incision daily for signs of infection ?????? Take pain medication as instructed; you may find it best if taken in the a.m. when you wake for morning stiffness and before bed for sleeping discomfort ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc. unless directed by your doctor ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Clearance to drive and return to work will be addressed at your post-operative office visit Continue using a low potassium diet. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine ?????? Any weakness, numbness, tingling in your extremities ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F ?????? Any change in your bowel or bladder habits Followup Instructions: PLEASE RETURN TO THE OFFICE IN 10 DAYS FOR REMOVAL OF YOUR SUTURES (they may be removed by your PCP) PLEASE FOLLOW UP WITH YOUR PCP FOR CONTINUITY OF CARE. PLEASE FOLLOW UP WITH YOUR NEPHROLOGIST Please follow up with your pcp and outpatient orthopedist for your left thumb nondisplaced fracute follow up. CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR. [**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS. YOU WILL NEED XRAYS PRIOR TO YOUR APPOINMENT (AP & LAT) Completed by:[**2174-12-7**]

[ "585.9", "V10.52", "403.90", "E885.9", "815.01", "805.02" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6424, 6483

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362, 369

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1167, 1397

227, 324

397, 951

1412, 1796

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1061, 1119

58,574

196,994

41645

Discharge summary

report

Admission Date: [**2108-6-28**] Discharge Date: [**2108-6-29**] Date of Birth: [**2041-6-1**] Sex: F Service: MEDICINE Allergies: aspirin / moxifloxacin Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: ASA desensitization Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: 67yo F with h/o HTN, HL, R carotid stenosis, s/p recent echo revealing anterior ischemia presenting for ASA desensitization for cardiac catheterization. Patient has a h/o anaphylaxis with aspirin. She reports that she first developed symptoms in response to a midol, and developed hives, her throat closed and her tongue and lips swelled. Her symptoms resolved with benadryl. Several years later, she again tried half of a baby aspirin, and again developed similar symptoms, relieved again with benadryl. Patient reports that she had a recent carotid artery doppler which indicated 40-59% stenosis of the right carotid artery. Given her family history of CAD and patient's h/o HTN and recent fatigue with exercise, PCP ordered [**Name Initial (PRE) **] stress echocardiogram which indicated an anterior infarct. Patient was then referred for cardiac catheterization. Patient reports that she has never experienced frank chest pain or pressure. She endorses occasional chest "pinch" which last 5-10minutes and only occurs at rest. She plays tennis 4-5 times a week for 2 hours at a time. She has been feeling progressively more fatigued recently after completing her games, but denies shortness or breath, lightheadedness or chest pain while playing. Of note, patient completed 33 cycles of radiation therapy in [**2108-1-24**] for relapse of meningioma. On review of systems, she denies any prior history of stroke, TIA, pulmonary embolism, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. She denies abdominal pain, nausea/vomiting, diarrhea or constipation. She denies dysuria, hematuria, or urinary incontinence. 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: Hypertension, hyperlipidemia 2. CARDIAC HISTORY: - Stress echo indicating anterior ischemia 3. OTHER PAST MEDICAL HISTORY: - Asthma - h/o TB, untreated - relapse of meningioma, s/p resection [**4-/2105**], s/p 33 cycles radiation ending [**2108-1-26**] - Factor V Leiden - Glaucoma - Depression - mild-moderate right carotid artery stenosis - h/o DVT in left leg ([**2099**]) - s/p appendectomy [**2104**] - s/p tubal ligation ([**2065**]) Social History: Patient lives in [**Location 11252**], NH - Tobacco history: Quit 40 years ago, smoked for approximately 7 yrs - ETOH: [**11-28**] glasses of wine per day - Illicit drugs: Denies current or history of use. Family History: - Mother: Peripheral vascular disease, CAD, h/o TIAs, DM - Father: CAD h/o CABG, ALL Physical Exam: ADMISSION EXAM VS: T= 96.5 BP= 136/64 HR= 80 RR= 12 O2 sat= 99%RA GENERAL: Well appearing female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 3 cm. No carotid bruits CARDIAC: PMI located in 5th intercostal space, midclavicular line. RRR, normal S1, S2. Grade [**1-1**] holosystolic murmur best heard at apex, radiating to axilla. No rubs or gallops. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: Warm and well perfused without edema or cyanosis. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . DISCHARGE EXAM XXXXXXXXX Pertinent Results: Admission labs: WBC-4.0 RBC-3.98* HGB-12.7 HCT-36.0 MCV-91 PT-11.4 PTT-24.2 INR(PT)-0.9 GLUCOSE-191* UREA N-18 CREAT-1.0 SODIUM-133 POTASSIUM-3.5 CHLORIDE-96 TOTAL CO2-25 ANION GAP-16 ALT(SGPT)-19 AST(SGOT)-23 ALK PHOS-55 TOT BILI-0.3 Chol 222 HDL 117 LDL 96 TGs 43 Studies: Stress echocardiogram ([**2108-6-15**] at [**Location (un) 11252**] Cardiology): Questionable anterior septal ischemia, mild to moderate aortic insufficiency, aortic sclerosis without significant aortic stenosis, mild mitral insufficiency and tricuspid insufficiency, borderline pulmonary hypertension. Patient exercised for 10min, reached 11 METS, with no angina. . CXR ([**2108-6-28**]): No acute cardiopulmonary process. . ECG ([**2108-6-28**] on admission): Normal sinus rhythm, normal axis, normal intervals. P wave inversions in V1 concerning for left atrial enlargement. . Cardiac Catheterization: 1. Selective coronary angiography of this right dominant system demonstrated no angiographically flow limiting stenoses. The Left Main and LAD were normal. The mid LCX had a discrete 40% lesion. The RCA had mild diffuse non-obstructive disease. 2. Limited resting hemodynamics revealed a normal LVEDP and normal central aortic pressures. Brief Hospital Course: REASON FOR ADMISSION 67 yo F with HTN, HL, recent stress echo evidence of anterior iscemia and h/o anaphylaxis to ASA presenting for aspirin desensitization prior to cardiac catheterization. ACTIVE ISSUES # Aspirin allergy: Patient has a known history of angioedema with aspirin intake. Prior to cardiac catheterization, she was desensitized in case she required daily aspirin following this procedure. Aspirin desensitization protocol was followed. Patient received montelukast 1 hour prior to begining aspirin. One hour following the final aspirin dose, patient developed lip tingling and swelling and was given diphenhydramine 25mg x1 which resolved her symptoms. Symptoms did not return on HD1 and patient was discharged on aspirin 81mg po daily. Patient was encouraged to take diphenhydramine in the future if similar symptoms developed. # Abnormal stress echo: Patient has no history of chest pain with exercise or at rest. However, recent stress echo showed question of anterior septal ischemia. Patient has been on clopidogrel for carotid stenosis in the setting of an aspirin allergy. Catheterization on [**2108-6-29**] showed no significant stenosis or lesions. Patient was discharged on daily aspirin 81mg. Clopidogrel was discontinued. #Fatigue- Patient complains of new onset of fatigue, beginning at the end of her 2nd set of tennis. However, she is able to complete a third set. She denies chest pain, shortness of breath. Differential diagnosis includes coronary artery disease, effect of recent radiation, anemia, hypothyroidism, pulmonary disease (asthma, pulmonary hypertension). Hemoglobin was normal during recent outpatient labs. Patient has known asthma and recent echo did show mild pulmonary hypertension. # HTN: Blood pressure controlled at home with lisinopril-HCTZ. HCTZ was held prior to catheterization, and restarted after. BP was stable throughout admission. CHRONIC ISSUES #Asthma: She was continued on her home fluticasone and montelukast. Respiratory status was stable throughout admission. #Glaucoma: She was continued on her home alphagan, lumigan eye drops TRANSITIONAL ISSUES: 1. Follow-up with PCP regarding recent onset of increased fatigue. Medications on Admission: - Beclomethasone 42mcg INH two sprays to each nostril daily - Bimatoprost 0.01% 1 drop to each eye qHS - Brimonidine 0.1% drops to each eye [**Hospital1 **] - Clopidogrel 75mg po daily - Lisinopril-hydrochlorothiazide 10-12.5mg po daily - Montelukast 10mg po daily - Fluticasone 11mcg INH [**Hospital1 **] - Flaxseed 1 tbs po qAM - Myocalm 25mg-50mg-20mg-10mg 1tab qAM, 2tab po qPM - Cod liver oil 1 tbs po qAM - MVI 1tab po daily Discharge Medications: 1. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. beclomethasone dipropionate 40 mcg/Actuation Aerosol Sig: One (1) Inhalation 2 sprays to each nostril once daily (). 3. bimatoprost 0.01 % Drops Sig: One (1) drop Ophthalmic qHS (). 4. brimonidine 0.1 % Drops Sig: One (1) Ophthalmic [**Hospital1 **] (2 times a day). 5. fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation [**Hospital1 **] (2 times a day). 6. lisinopril-hydrochlorothiazide 10-12.5 mg Tablet Sig: One (1) Tablet PO once a day. 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. Disp:*30 Tablet, Chewable(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Aspirin allergy Secondary diagnosis: 1. Hypertension 2. Asthma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you during your recent admission to [**Hospital1 69**]. You were admitted for aspirin desensitization and cardiac catheterization. You were successfully desensitized to aspirin, and should take a baby aspirin every day. You no longer need to take clopidogrel. If you experience any lip swelling or rash or itching, take one benadryl 25 mg by mouth, as this relieved your symptoms while you were in the hospital. Your cardiac catheterization did not show any significant lesions in the arteries surrounding the heart. You can resume your normal activities. You should follow up with your primary care physician regarding your recent increase in fatigue. Followup Instructions: Department: Primary Care/ Cardiology Name: Dr. [**First Name8 (NamePattern2) **] [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 11250**] When: Dr. [**Last Name (STitle) 11250**] has walk in appointments for you to attend. You do not need to call or schedule an appointment. You need to be seen in the office 4-8 days after your hospital discharge. There are no walk in appointments Friday [**7-6**]. Please call the office if you have questions. Location: [**Location (un) **] CARDIOLOGY Address: [**Apartment Address(1) 64797**], GILFORD,[**Numeric Identifier 64798**] Phone: [**Telephone/Fax (1) 11254**]

[ "V17.3", "780.79", "401.9", "V15.82", "272.4", "V14.6", "433.10", "793.2", "V07.1" ]

icd9cm

[ [ [] ] ]

[ "88.53", "37.22", "88.56" ]

icd9pcs

[ [ [] ] ]

8776, 8782

5401, 7517

310, 335

8912, 8912

4149, 4149

9779, 10404

3040, 3129

8100, 8753

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4165, 5378

8823, 8840

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2320, 2374

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161,165

28483

Discharge summary

report

Admission Date: [**2159-9-29**] Discharge Date: [**2159-10-9**] Date of Birth: [**2159-8-23**] Sex: M Service: Neonatology HISTORY OF PRESENT ILLNESS: Infant was retro transferred from [**Hospital3 1810**] to [**Hospital3 **] on [**9-29**]. Prenatal history: Mother was a 36 year-old, Gravida III, Para II with prenatal fetal diagnosis of large fetal ascites at approximately 29 weeks. This ascites was associated with lung compression but no other signs of hydrops. Normal kidney and bladder by fetal ultrasound and fetal MRI. Evaluated by the [**Month (only) 65428**] with pediatric surgery, Dr. [**Last Name (STitle) 37080**]. Mother presented with spontaneous rupture of membranes on [**10-23**] and contractions requiring admission to the [**Hospital3 **]. She received betamethasone, intrapartum antibiotics and magnesium sulfate. Despite tocolysis, labor progressed and infant delivered by Cesarean section. DELIVERY COURSE AT [**Hospital3 **]: Infant born by Cesarean section at 30 weeks gestation; emerged with spontaneous cry but developed respiratory distress. Initial intubation attempts were unsuccessful with a 3.0 and a 2.5 ET tube, due to failure to advance beyond vocal cords. Intubated with a 2.0 ET tube. Infant noted to have transient bradycardia during intubation but otherwise heart rate was over 100. Apgars were 6 at 1 minute and 9 at 5 minutes. INITIAL COURSE AT THE [**Hospital3 **]: Birth weight was 2.24 kg. Head circumference 31 cm. Length 41 cm. UAC and peripheral IV placed. Remained n.p.o. during stay. GI: Diagnostic and therapeutic abdominal paracentesis performed on day of life 1 with removal of 150 cc of fluid (93% lymphocytes) after tapping both right and left abdominal sides, consistent with chyle. Infectious disease: Received 48 hours of Ampicillin and Gentamycin. Blood culture normal. Hematology: Received phototherapy for peak bilirubin of 8.6. Cardiovascular: Echo on [**8-24**] with a small patent ductus arteriosus with PFO right ventricular hypertension and mildly dilated right ventricle with decreased function. Normal left ventricular function. Rest of heart structurally normal. Respiratory: Status post 2 doses of Surfactant. Extubated day of life 3. Following extubation, slowly developed stridor and respiratory distress which did not improve with racemic epinephrine. Consultation recommended. Transferred to [**Hospital3 1810**] for further evaluation. HOSPITAL COURSE AT [**Hospital1 **]: [**Hospital1 **]: Bronchoscopy noted vocal cord granulomas; excision on [**8-31**] with reintubation until [**9-2**] when he was electively extubated to room air. No stridor post extubation. Flexible bronchoscopy on [**9-7**] without reaccumulation of granulomas. Respiratory: Extubated on [**9-2**]. Caffeine citrate discontinued on [**9-25**]. No spells, remains on room air. Fluids, electrolytes and nutrition/gastrointestinal: After PICC attempts were unsuccessful, right IJ was placed on [**8-31**] with tip in the SVC by fluoro. Abdominal ultrasound on [**8-28**] with ascites. Rest normal. He was started on Octreotide prior to initiation of feeds. Feedings were then initiated with Portagen on [**8-29**] and tolerated advancement to 100 cc/kg per day. Noted to have feeding intolerance with feedings over 100 cc/kg per day and thus feedings were kept at 100 cc/kg per day. Prilosec and Reglan started to increase gastric emptying with some improvement noted. Octreotide change to a continuous infusion on [**9-15**] with attempt to decrease chylous effusions. (No effect at 1 mcg/kg per hour and then increased to 2 mcg/kg per hour with some improvement). Two weeks prior to admission, improved ascites on [**9-12**]. Two days prior to transfer, noted to have emesis and increased abdominal girth and held feeding. Returned back to baseline. No further intolerance for the past 48 hours. Phosphorus and calcium supplements, due to limited amounts in Portagen. Had been on Phospho-Soda but this was discontinued on [**9-26**] due to elevated phosphorus of 9.3, showing some weight gain over the past week. Developed large bilateral inguinal hernias with ultrasound showing normal testes and epididymis. Neuro: Normal head ultrasound on [**9-24**]. Ophthalmology: Zone 2 immature bilaterally on [**9-21**]. Heme: Phototherapy discontinued on [**8-28**]. Status post packed red blood cell transfusion. Infectious disease: Sepsis evaluation. Vancomycin and Gentamycin x 48 hours. No growth in blood cultures. HOSPITAL COURSE: Respiratory: On re-admission to the [**Hospital3 **], infant has been stable in room air. Occasional desaturation episodes requiring blow-by oxygen. Plan to start Diuril to assess if diuresis would help ascites. Received one dose of Diuril and was made n.p.o. and has had no further dosing. Cardiovascular: Continued to have an audible murmur on admission. Cardiology was consulted. An echo was obtained on [**10-3**], revealing no patent ductus arteriosus. Collateral veins versus pulmonary veins. No further recommendations at this time. Fluids, electrolytes and nutrition: Received from [**Hospital3 18242**] on total fluids of 120 cc/kg/day; 100 kg/day of which was Portagen 26 calories with 6 calories of MCT oil, total 32 calories per ounce. Infant was made n.p.o. on [**10-2**] due to increasing abdominal girth greater than 40 cm. Attempt to refeed and once again abdominal girth increased. On [**10-6**] episode of bloody stool with no change in KUB compared to previous films. Sepsis evaluation performed, started on vanc and gent. Currently on total fluids of 120 Remains NPO on PN/IL. No stool since [**10-6**]. He is also receiving Octreotide. His admission weight was 2.790 kg. His discharge weight is 3285g. His dry weight calculation is currently is 3.0kg. Gastrointestinal: [**Known lastname 10733**] is being followed by the gastrointestinal team, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5749**] is the attending. He arrived from [**Hospital3 1810**] on Octreotide at 2 mcg/kg per hour via continuous infusion via Broviac. He is also receiving Reglan and Prilosec to help with the side effects of the Octreotide. Plan for abdominal MRI with anethesia today. Genitourinary: Continues to have bilateral inguinal hernias, large, being followed by surgery, awaiting repair. Most recent labs on [**10-7**] revealed a sodium of 138; potassium of 4.7; chloride 101; total C02 of 26; BUN 8; creatinine .2; albumin 3.1; ALT 19; AST 55; alkaline phosphatase 175. Hematology: Blood type A positive. Received packed red blood cells on [**10-3**] due to hematocrit of 26. Repeat hematocrit on [**10-6**] was 38.9. Infectious disease: CBC and blood culture obtained on [**10-6**]. Blood culture called back positive for gram positive cocci in clusters. Both Staph aureus, coag + and Staph epi, coag negative isolated. Repeat cultures sent on [**10-7**] via peripheral and central line site; both remain no growth to date. He is currently on Vancomycin 48 mg q. 8 hours, Gentamycin 13 mg q. 24. Vanco peak on [**10-8**] of 30. Gent levels due for today [**10-9**]. Neuro: Reported from [**Hospital3 1810**], head ultrasound is within normal limits. Sensory has not yet had hearing screen. Eyes examined were most recently examined on [**10-2**], revealing immature retinal zone 3 with recommended follow- up the week of [**10-22**]. Dr.[**First Name9 (NamePattern2) **] [**Name (STitle) **] was the attending who saw the infant. Psychosocial: The family is invested and involved in this infant's care and strong advocates for his needs. CONDITION AT DISCHARGE: Guarded. DISCHARGE DISPOSITION: To [**Hospital3 1810**]. NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 1743**] [**Last Name (NamePattern1) 56983**]. CARE RECOMMENDATIONS: Continue 120 cc/kg/day of parenteral nutrition. Continue Octreotide of 2 mcg/kg per hour. Continue antiobiotics. Abdominal MRI scheduled for today. MEDICATIONS: 1. Octreotide 2 mcg/kg/per hour continuous infusion. 2. Vancomycin 48 mg IV q8 3. Gentamicin 13 mg IV q24 4. Gentamicin Ophthalmic ribbon to both eyes q8 5. Sucrose 22% 1-2ml w pacifier q2 as needed 6. Remainder of meds currently on hold due to NPO status including: a. Omeprazole 12 mg po/pg daily b. Calcium Carbonate (elemental calcium) 120 mg po/pg q12 c. Metoclopromide 0.3 mg po/pg q8 d. Sodium Phosphate -- 62.5 mg phosphorus po/pg daily e. Diuril 15 mg po/pg q12 f. Vitamin E 20 units po/pg daily g. Ferrous sulfate (25 mg/ml) 0.3 ml po/pg daily h. Goldline infant multivitamins 1ml po/pg daily CAR SEAT POSITION SCREENING: Not applicable. STATE NEWBORN SCREENS: Not applicable. IMMUNIZATIONS RECEIVED: Mother awaiting 60 day vaccine for PediaRx. DISCHARGE DIAGNOSES: 1. Premature infant born at 30 weeks gestation, now 46 days old, corrected to 36 and [**3-30**]. 2. Chylous ascites 3. status post vocal cord granulomas 4. Bilateral inguinal hernias 5. Staph aureus and Staph epi bacteremia w/ episode of hematochezia on day of diagnosis [**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], MD [**MD Number(2) 56585**] Dictated By:[**Name (STitle) 69042**] MEDQUIST36 D: [**2159-10-8**] 01:00:41 T: [**2159-10-8**] 07:39:12 Job#: [**Job Number 69043**]

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icd9cm

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Discharge summary

report

Admission Date: [**2172-9-9**] Discharge Date: [**2172-9-12**] Date of Birth: [**2117-12-8**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 8388**] Chief Complaint: Hyponatremia Major Surgical or Invasive Procedure: None History of Present Illness: 54 year old female with h/o hep C cirrhosis with HCC s/p RFA and recent right PVT who presented after Cyberknife planning today with dizziness, altered mental status and hyponatremia. Patient was undergoing evaluation for [**First Name3 (LF) **] and was found to have initially a lesion in segment VI [**9-26**] that grew on repeat imaging [**4-3**]. She was treated with radiofrequency ablation; but a 1cm lesion near the dome of the liver could not be treated. Plan was for cyberknife therapy of this lesion. Patient arrived for treatment and planning appointment today for cyberknife. Per review of OMR note, she was A&Ox3, slow to respond and confused, as well as c/o dizziness and malaise. Labs were sent that showed: Na 120, K 5.1, Cr 2.2 (baseline 0.9-1), Ca [**72**].2, ALT 86, AP 154, Tbili 5.7, Alb 3.0, AST 189, Hct 33.5, Plt 71. She reports feeling dizzy for the few weeks. Also has had a few days of dark, tea-colored urine and decreased urine output. She has had poor po intake as well due to decreased appetite. Also reports mild confusion. Her sister reports that she has been losing weight quickly since being placed on diuretics. Her sister feels that she is melting away and reports that she has been slowly decompensating over the last several months. She also cites her chronic low back pain In the ED, initial vitals were 97.8 104 106/41 18 100%RA. Labs were notable for a Na of 120-->116, Creat 2.2-->2.0, Lactate 3.4-->2.6, Ca [**72**].2. Transfer vitals 98.2 96 109/50 18 100%RA. RUQ ultrasound showed patent portal vein but reversal of flow. She was noted to be jaundiced. Has 22g PIV right now. Review of systems: Negative for fever, chills, night sweats, chest pain, shortness of breath, abdominal pain, diarrhea or constipation. Does have occasional blood on toilet paper. Also with occasional nausea. Denies dysuria. Past Medical History: Hepatitis C Cirrhosis, not candidate for [**Year (2 digits) **] HCC - 2.8cm lesion in liver treated with RFA in [**6-27**], also with 1cm lesion near dome of liver that was not treated but had fiduciary placed. Repeat CT [**8-28**] showed tumor thrombus involving the anterior branch of the right and came off [**Month/Year (2) **] list. portal vein measuring 5.4 cm Lower back pain and sciatica Encephalopathy GERD Cystic complex adnexal mass, currently undergoing workup Polysubstance abuse and alcohol abuse. Esophageal Varices (EGD [**2170**] showed 4 cords of grade I-II varices) Anemia/thrombocytopenia Brain surgery in the distant past S/p Hysterectomy right salpingo-oophorectomy for cerivcal carcinoma in situ Social History: Currently unemployed. Has a long history of substance abuse including alcohol, cocaine. Currently smoking 1 pack per week. Last EtOH use one year ago per patient, 02/10 per review of OMR notes. Currently living with ex-husband who has alcohol abuse problem. Previously lived with sister but reports that she wasn't around enough so moved back in with her husband. Family History: Father had prostate cancer. Mother still living but battles with depression. Physical Exam: VS: 96.6 77 106/48 16 99%RA GEN: Awake, but slow to answer questions. Slightly sleepy but alert and oriented x 3. HEENT: PERRL, EOMI, sclera mildly icteric, MM dry, OP without lesions, no lymphadenopathy or thyromegaly. RESP: CTA b/l with good air movement throughout CV: RRR with II/VI systolic murmur at apex ABD: BS+, not tender or distended, mild splenomegaly, liver edge not palpable EXT: Trace to 1+ nonpitting edema in BLE L>R SKIN: Mild skin jaundice throughout NEURO: AAOx3 but slow flat affect. Cn II-XII intact. 4+/5 strength throughout. No sensory deficits to light touch appreciated. Pertinent Results: BLOOD . [**2172-9-9**] 01:50PM BLOOD WBC-7.5 RBC-3.06* Hgb-10.9* Hct-33.5* MCV-109* MCH-35.6* MCHC-32.6 RDW-15.9* Plt Ct-71* [**2172-9-11**] 06:45AM BLOOD WBC-4.7 RBC-2.51* Hgb-9.2* Hct-27.9* MCV-111* MCH-36.5* MCHC-32.8 RDW-16.8* Plt Ct-46* . [**2172-9-9**] 05:01PM BLOOD PT-19.1* PTT-34.0 INR(PT)-1.7* [**2172-9-11**] 06:45AM BLOOD PT-20.1* PTT-38.6* INR(PT)-1.8* . [**2172-9-9**] 01:50PM BLOOD Glucose-128* UreaN-35* Creat-2.2*# Na-120* K-5.1 Cl-85* HCO3-27 AnGap-13 [**2172-9-11**] 06:45AM BLOOD Glucose-141* UreaN-17 Creat-0.8 Na-127* K-4.5 Cl-101 HCO3-22 AnGap-9 . [**2172-9-9**] 01:50PM BLOOD ALT-86* AST-189* AlkPhos-154* TotBili-5.7* DirBili-2.0* IndBili-3.7 [**2172-9-11**] 06:45AM BLOOD ALT-71* AST-181* AlkPhos-154* TotBili-2.7* . [**2172-9-9**] 07:41PM BLOOD VitB12-1728* . [**2172-9-9**] 07:41PM BLOOD TSH-2.3 . [**2172-9-10**] 03:22AM BLOOD Cortsol-7.4 . [**2172-9-9**] 01:50PM BLOOD AFP-2.7 . MICRO: [**2172-9-9**] 11:35 pm URINE Source: CVS. **FINAL REPORT [**2172-9-11**]** URINE CULTURE (Final [**2172-9-11**]): PRESUMPTIVE GARDNERELLA VAGINALIS. >100,000 ORGANISMS/ML.. . IMAGING: Doppler U/S abd: IMPRESSION: Reversal of flow in the main, right and left portal veins. No evidence of portal vein thrombosis. Cholelithiasis without findings of cholecystitis. . Brief Hospital Course: 54 year old female with h/o hep C cirrhosis with HCC s/p RFA and recent right PVT who presented after Cyberknife planning today with dizziness, altered mental status and hyponatremia likely secondary to poor po intake in the setting of mild chronic hyponatremia from liver disease. . #. Hyponatremia: Was 116 initially with FENa 0.8% and improved to 123. She appeared hypovolemic on exam. Diuretics initially held. . #. Altered mental status: Likely from hyponatremia and mild hypercalcemia in the setting of profound depression. No e/o infection. No paracentesis done as no ascites evident, CXR normal, UA negative. TSH, B12, RPR all negative. . #. Acute renal failure: Likely due to dehydration, as it resolved with IVF. . #. Hepatitis C Cirrhosis: Complicated by known varices. LFTs, coags slightly worse than recent baseline on admission though no evidence of acute decompensation given lack of ascites and peripheral edema. Continued home lactulose, rifaximin, MVI, thiamine and folic acid. . #. Anemia and Thrombocytopenia: At baseline, no evidence of bleeding. . #. Code status: DNR/DNI, confirmed with sister and patient. Patient will be bridged to hospice care as an outpatient. . #. Bacterial vaginosis: Gardnerella vaginalis noted on urine culture. As asymptomatic and usually self-limited, no antibiotic treatment given. Medications on Admission: Lasix 60 mg po daily Aldactone 100mg po daily Vitamin D2 50,000 units qweek thursday Folic Acid 1mg po daily Lactulose 30ml po qid Lorazepam 0.5mg po qhs Methylphenidate 5mg po tid at 8am, noon, 4pm Omeprazole 20mg po daily Rifaximin 400mg po bid Acetaminophen 1000mg po bid Magnesium oxide 400mg po daily Multivitamin 1 tab po daily Thiamine 100mg po daily Discharge Medications: 1. Hospital bed Indication: Frequent position changes due to HCC 2. Commode 3 in 1 commode 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every 6 hours): Goal 3 to 4 bowel movements per day. 5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 6. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO twice a day. 9. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO twice a day. 10. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day. 11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 14. Outpatient Lab Work Please have sodium and creatinine rechecked with your VNA on Wednesday, [**2172-9-16**]. Have results faxed to Dr.[**Name (NI) 948**] office at [**Telephone/Fax (1) 4400**]. 15. Oxycodone 5 mg Capsule Sig: [**12-21**] Capsules PO every 4-6 hours as needed for pain. Disp:*60 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 5087**] VNA/Partners Discharge Diagnosis: Hyponatremia Acute kidney injury Decompensated hepatitis C / alcoholic cirrhosis Hepatocellular carcinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: You were admitted to [**Hospital1 69**] on [**2172-9-9**] from from the [**Hospital 35292**] clinic with increasing fatigue and dizziness. You were found have a low sodium, and were initially watched in the ICU. On [**2172-9-10**], you were transitioned to the medical floor. During the hospitalization, you requested measures to increase your comfort. On discharge, you have been set up for a bridge to hospice care. Medication changes include - Stopping Lasix - Stopping Aldactone Followup Instructions: Please have your sodium level checked with your VNA on [**2172-9-16**]. Results should be conveyed to Dr. [**Last Name (STitle) 497**] (fax [**Telephone/Fax (1) 4400**]). Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2172-9-23**] 3:00 Provider: [**Name10 (NameIs) 35354**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 5777**] Date/Time:[**2172-10-5**] 1:00

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icd9cm

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icd9pcs

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54676

Discharge summary

report

Admission Date: [**2149-8-6**] Discharge Date: [**2149-8-9**] Service: MEDICINE Allergies: indomethacin / Cefaclor / Ace Inhibitors Attending:[**First Name3 (LF) 2712**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: 1. Emergent left-sided craniotomy for decompression. 2. Right-sided burr hole evacuation x2. 3. Duraplasty (allograft). History of Present Illness: 88 year old male with a past medical history of TIA, hypertension, CHF, coronary artery disease, rheumatic fever, temporal arteritis, AAA status post repair, RCA stent, anemia, COPD who presented from an OSH with altered mental status and e/o a chronic subdural hematoma transferred to MICU for apnea. Nightfloat admission note as follows: OSH records not available on transfer. History provided by family as patient was altered. The patient fell approx four weeks ago at home under unclear circumstances. No changes until a day or two ago when the patient had confusion, gradually worsening. The family notes that he was repeating letters and also was picking at papers and putting them back down on his desk. Patient prior to this he was ambulatory with a cane. Now patient only wants to sit in bed and [**Doctor Last Name **]. No history of prior bleeds. No trauma today. No known anticoagulation. At OSH, the patient was also found to have a potential pneumonia and was started on levofloxacin. CT head demonstrated bilateral subdural hematoma with midline shift to the right by 1 cm (was evaluated by neurosurgery in our ED, although CDs do not come with the patient's chart). Keppra was given at OSH. On ROS, no fevers or chills, productive cough, no chest pain or shortness of breath, no neck pain, no abdominal pain, no rash, no focal numbness tingling or weakness, and no urinary symptoms. In the ED, initial VS were: 97.2 75 131/70 32 97% 4L CT and CTA from outside hospital reviewed with neurosurgery Neurosurgery consulted: pt is not currently an operative candidate for this subacute SDH. Suggest admit to medicine with q4hr neuro checks. Neurosurg will continue to follow. HCP confirms DNR/DNI status. Pt was given morphine, levofloxacin. Blood cultures were sent. Mental Status: awake, responding to questions with short answers. VS prior to transfer were: 97.0 80 154/75 16 100% On arrival to the floor, the patient was sitting on edge of bed with family at bedside. The patient was interactive with me, but inattentive and not oriented. Pt was supposed to go for burr hole [**2149-8-7**] but it was postponed bc he desatted. triggered for resp distress, CXR neg. Placed on O2 and remained on floor. Triggered again this AM for unresponsiveness. Went from being AAOxperson to nonverbal. ABG 7.48/32/84/25 prior to transfer. EKG unchanged. Stat head CT unchanged. Transferred for apnea. full set of labs obtained and were unchanged, including CBC, lytes, and CE. O2 gradually declining throughout day to 70s, pt placed on ventimask. Got 1.5mg morphine at 1pm. In the MICU VS HR 84, 140/81, 22, 96% face mask. Foley put out 900mL when placed. Cheynes-stoked breathing pattern. O2 desats mostly when patient apneic. Past Medical History: CHF AAA pacemaker/ICD MI [**2137**], [**2140**]: RCA stent knee replacements TIA Broken neck, not repaired Social History: patient lives with wife. was ambulatory before. no drugs, etoh or cigarettes. Family History: NC Physical Exam: 84, 140/81, 22, 96% face mask GENERAL: lying in bed, cachectic, intermittently agitated when hyperventilating and lying still when apneic HEENT: PERRL, MMM, EOMI, yellow crust over eyelids NECK: 4-5cm JVP LUNGS: CTAB HEART: RRR, normal S1 S2, 3/6 systolic murmur ABDOMEN: Soft, NABS, no organomegaly, TTP diffusely (prior to foley placement) EXTREMITIES: No c/c/e NEUROLOGIC: not answering questions but follows some commands (turns head, squeezes hands, wiggles toes. CN 2-12 appear grossly intact. moving all extremities. Pertinent Results: Admission Labs [**2149-8-6**] 10:22AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018 [**2149-8-6**] 10:22AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2149-8-6**] 10:22AM URINE RBC-40* WBC-13* BACTERIA-NONE YEAST-NONE EPI-0 [**2149-8-6**] 10:22AM URINE HYALINE-3* [**2149-8-6**] 10:22AM URINE MUCOUS-RARE [**2149-8-6**] 05:55AM GLUCOSE-115* UREA N-26* CREAT-1.5* SODIUM-143 POTASSIUM-3.7 CHLORIDE-111* TOTAL CO2-21* ANION GAP-15 [**2149-8-6**] 05:55AM ALT(SGPT)-23 AST(SGOT)-26 LD(LDH)-256* ALK PHOS-84 TOT BILI-0.6 [**2149-8-6**] 05:55AM ALBUMIN-3.1* CALCIUM-8.6 PHOSPHATE-2.9 MAGNESIUM-2.1 [**2149-8-6**] 05:55AM WBC-6.4 RBC-2.54* HGB-9.1* HCT-29.0* MCV-114* MCH-35.7* MCHC-31.3 RDW-15.9* [**2149-8-6**] 05:55AM PLT COUNT-86* [**2149-8-6**] 05:55AM PT-14.1* PTT-33.8 INR(PT)-1.3* [**2149-8-6**] 12:27AM LACTATE-1.4 [**2149-8-5**] 11:40PM GLUCOSE-96 UREA N-26* CREAT-1.6* SODIUM-141 POTASSIUM-3.4 CHLORIDE-108 TOTAL CO2-22 ANION GAP-14 [**2149-8-5**] 11:40PM estGFR-Using this [**2149-8-5**] 11:40PM NEUTS-85.4* LYMPHS-8.2* MONOS-4.6 EOS-1.5 BASOS-0.3 [**2149-8-5**] 11:40PM NEUTS-85.4* LYMPHS-8.2* MONOS-4.6 EOS-1.5 BASOS-0.3 [**2149-8-5**] 11:40PM PLT COUNT-87* [**2149-8-5**] 11:40PM PT-13.5* PTT-33.8 INR(PT)-1.3* [**2149-8-8**] 04:18AM BLOOD WBC-9.0 RBC-2.90* Hgb-10.5* Hct-32.6* MCV-112* MCH-36.2* MCHC-32.2 RDW-15.6* Plt Ct-70* [**2149-8-7**] 10:50AM BLOOD WBC-6.7 RBC-2.93* Hgb-10.7* Hct-33.3* MCV-114* MCH-36.6* MCHC-32.2 RDW-16.0* Plt Ct-81* [**2149-8-7**] 04:40AM BLOOD WBC-6.0 RBC-2.63* Hgb-9.4* Hct-29.8* MCV-113* MCH-35.6* MCHC-31.4 RDW-16.0* Plt Ct-84* [**2149-8-5**] 11:40PM BLOOD WBC-7.4 RBC-2.82* Hgb-10.1* Hct-31.8* MCV-112* MCH-35.7* MCHC-31.7 RDW-15.7* Plt Ct-87* [**2149-8-9**] 03:56AM BLOOD Neuts-83.3* Lymphs-8.0* Monos-6.9 Eos-1.7 Baso-0.1 [**2149-8-5**] 11:40PM BLOOD Neuts-85.4* Lymphs-8.2* Monos-4.6 Eos-1.5 Baso-0.3 [**2149-8-9**] 03:56AM BLOOD Plt Ct-68* [**2149-8-9**] 03:56AM BLOOD PT-14.0* PTT-31.5 INR(PT)-1.3* [**2149-8-8**] 01:51PM BLOOD Plt Ct-67* [**2149-8-8**] 01:51PM BLOOD PT-14.0* PTT-31.8 INR(PT)-1.3* [**2149-8-8**] 04:18AM BLOOD Plt Ct-70* [**2149-8-9**] 03:56AM BLOOD Glucose-92 UreaN-22* Creat-1.5* Na-140 K-3.6 Cl-106 HCO3-24 AnGap-14 [**2149-8-8**] 10:06PM BLOOD Glucose-146* UreaN-23* Creat-1.5* Na-145 K-3.8 Cl-108 HCO3-26 AnGap-15 [**2149-8-8**] 01:51PM BLOOD Glucose-117* UreaN-24* Creat-1.5* Na-147* K-4.7 Cl-111* HCO3-23 AnGap-18 [**2149-8-8**] 04:18AM BLOOD Glucose-94 UreaN-22* Creat-1.5* Na-144 K-3.9 Cl-108 HCO3-24 AnGap-16 [**2149-8-7**] 04:40AM BLOOD Glucose-94 UreaN-22* Creat-1.6* Na-146* K-3.6 Cl-110* HCO3-23 AnGap-17 [**2149-8-9**] 03:56AM BLOOD ALT-18 AST-41* LD(LDH)-282* AlkPhos-85 TotBili-0.5 [**2149-8-7**] 10:50AM BLOOD CK(CPK)-254 [**2149-8-6**] 05:55AM BLOOD ALT-23 AST-26 LD(LDH)-256* AlkPhos-84 TotBili-0.6 [**2149-8-8**] 04:18AM BLOOD CK-MB-8 cTropnT-0.05* [**2149-8-7**] 03:45PM BLOOD CK-MB-8 cTropnT-0.04* [**2149-8-7**] 10:50AM BLOOD CK-MB-8 cTropnT-0.04* [**2149-8-9**] 03:56AM BLOOD Albumin-3.3* Calcium-8.4 Phos-3.2 Mg-2.0 [**2149-8-8**] 10:06PM BLOOD Calcium-8.6 Phos-3.5# Mg-2.0 [**2149-8-8**] 01:51PM BLOOD Calcium-7.8* Phos-5.2*# Mg-2.1 [**2149-8-8**] 04:18AM BLOOD VitB12-1465* Folate-15.4 [**2149-8-8**] 10:30PM BLOOD Type-[**Last Name (un) **] pO2-46* pCO2-42 pH-7.41 calTCO2-28 Base XS-1 Comment-PERIPHERAL [**2149-8-8**] 02:08PM BLOOD Type-ART pO2-187* pCO2-39 pH-7.39 calTCO2-24 Base XS-0 [**2149-8-8**] 10:30PM BLOOD Lactate-1.6 [**2149-8-8**] 02:08PM BLOOD Lactate-1.2 [**2149-8-8**] 09:04AM BLOOD Glucose-93 Lactate-0.7 Na-142 K-4.1 Cl-110* [**2149-8-8**] 09:04AM BLOOD Hgb-8.6* calcHCT-26 [**2149-8-8**] 09:04AM BLOOD freeCa-1.08* Brief Hospital Course: 88 year old male with a past medical history of TIA, hypertension, CHF, coronary artery disease, rheumatic fever, temporal arteritis, AAA status post repair, RCA stent, anemia, COPD who presented from an OSH with altered mental status and found to have a bilateral subdural hematoma transferred to MICU for apnea/desats. # Apnea/desats:Apnea most likely secondary to elevated ICP from SDH as it was [**Last Name (un) 6055**] [**Doctor Last Name 6056**] pattern. The patient was not hypoxemic and had only mild pulm edema on CXR. Pt also had uncal herniation on CT which was evidence of high elevated ICP from the subdural. EKG unchanged. ABG stable and pt was neither hypoxic nor hypercarbic. The patient's clinical status throughout the day deteriorated. Neurosurg was following as well and was updated throughout the day about his clinical status.They concluded no further intervention could be undertaken. He was exhibiting [**Last Name (un) **] [**Doctor Last Name 6056**] breathing throughout the day which was being treated with Morphine bolus's for air hunger. He never followed commands and was barely responsive during this time. At approx. 6:45PM I met with the family including a son, daughter and wife and discussed how his breathing had became more agonal and he was looking more uncomfortable. It was decided then by the family and myself a morphine drip should be started for comfort. Approx. 15-20 minutes later the patient peacefully passed away with family at bedside. Time of death was 7:46 PM. Dilated fixed pupils, non reactive to light, no corneal reflex b/l. No breath sounds and no heart sounds, unresponsive. Chief cause of death is Hypoxemic respiratory failure caused by subdural hematoma. PCP not listed in our system, will attempt to obtain from family. Autopsy rejected by family (wife). Admitting office and medical examiner were contact[**Name (NI) **] and they will accept the case given surgery and trauma was involved in the case. The family were grateful for the care provided and had no further questions or concerns. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientFamily/Caregiver. 1. Furosemide 20 mg PO DAILY 2. Valsartan 40 mg PO DAILY 3. Atorvastatin 20 mg PO DAILY 4. Metoprolol Tartrate 25 mg PO BID 5. Terazosin 5 mg PO HS 6. Aspirin 81 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Acetaminophen 650 mg PO DAILY Discharge Medications: patient passed away Discharge Disposition: Expired Discharge Diagnosis: patient passed away Discharge Condition: patient passed away Discharge Instructions: patient passed away Followup Instructions: patient passed away

[ "V43.65", "V45.82", "V12.54", "V45.02", "496", "285.9", "398.90", "446.5", "432.1", "414.01", "V15.82", "518.81", "786.04", "401.9", "348.4", "V49.86" ]

icd9cm

[ [ [] ] ]

[ "02.12", "01.31" ]

icd9pcs

[ [ [] ] ]

10241, 10250

7732, 9794

269, 390

10313, 10334

3963, 7709

10402, 10424

3399, 3403

10197, 10218

10271, 10292

9820, 10174

10358, 10379

3418, 3944

207, 231

418, 2202

2217, 3158

3180, 3288

3304, 3383

20,132

170,645

51208

Discharge summary

report

Admission Date: [**2173-12-27**] Discharge Date: [**2173-12-31**] Date of Birth: [**2098-6-17**] Sex: F Service: MEDICINE Allergies: Ceclor / Vasotec / Talwin / Vioxx / Allopurinol And Derivatives / Lyrica Attending:[**First Name3 (LF) 602**] Chief Complaint: left ankle pain Major Surgical or Invasive Procedure: None this hospitalization History of Present Illness: This is a 75 year-old Female with a PMH significant for IgM MGUS, iron deficiency anemia, celiac disease, primary biliary cirrhosis, HTN, diastolic dsyfunction, OSA, depression and chronic venous insufficiency who recently presented to the [**Hospital1 18**] ED ([**2173-12-25**]) with concern for right lower extremity cellulitis and re-presented with right knee pain and hypotension. . She initially presented to the ED on [**2173-12-25**] with right foot pain and swelling with erythema without fevers or chills. She was prescribed Augmentin and Bactrim and discharged with close follow-up. She had been having mild shortness of breath with exertion and some URI symptoms with sore throat over several weeks, and was taking Cipro PO for this. On the evening of [**12-26**], she experienced a mechanical fall in the shower and from then on had right lateral knee pain. She has known osteoarthritis and the pain seemed similar. She returned to the ED on [**2173-12-27**] with 'knee buckling' and associated bilateral extremity pain. She also had some chest pain and resting dyspnea transiently. She had no joint pain or swelling; no erythema. In the ED, she had a temperature of 101.9F and was given 1 gram of IV Vancomycin. She was also transiently hypotensive to the 70-80s and received 1.5L NS x 1 with improvement to the 90s. She was transferred to the MICU - mentating well, with adequate urine output and without lightheadedness or dizziness. . Upon admission to the MICU, she required Levaphed gtt to maintain her systolic pressures and was having frequent ectopy on telemetry. She was volume resuscitated with adequate UOP. Her leukocytosis of 14.4 improved to normal with empiric IV Vancomycin and Zosyn. Of note, her ESR and CRP were elevated. Serial CXRs showed mild-to-moderate pulmonary edema and cardiomegaly. Bilateral knee radiographs showed no evidence of infection or joint effusion; and an attempt at right knee arthrocentesis resulted in a 'dry tap'. Her leg erythema did improve with empiric antibiotics. A 2D-Echo showed mild symmetric LV hypertrophy, preserved LVEF function of 55%, with a severe resting LV outflow tract obstruction. Overall, she improved with volume resuscitation in the setting of her LVOT obstruction noted on 2D-Echo; and she was weaned from pressor support. She did have some left conjunctival irritation, periobital swelling and photophobia develop on admission with a pruritic left eye. She denies visual acuity changes. . On arrival to the floor, the patient is breathing comfortably. She has no headache and vision changes. No chest pain or trouble breathing. Her left eye is pruritic and she has some photophobia. Past Medical History: PAST MEDICAL & SURGICAL HISTORY: 1. IgM Monoclonal gammopathy of unknown significance 2. Iron deficiency anemia 3. Celiac disease 4. Primary biliary cirrhosis 5. Hypertension 6. Obesity 7. Obstructive sleep apnea 8. History of depression 9. (?) Diabetes 10. Cervical stenosis 11. Lumbar spine, degenerative joint disease 12. Hyperparathyroidism 13. Vitamin D deficiency 14. h/o endometriosis 15. h/o colonic adenomas 16. Hemorrhoids 17. Osteoporosis 18. s/p appendectomy 19. Gout 20. Coronary artery disease (s/p LAD stenting in [**5-/2168**]) 21. Septal hypertrophy (s/p alcohol ablation [**5-/2168**]) 22. Diastolic dysfunction 23. Cholelithiasis 24. Allopurinol-induced vasculitis (?) 25. s/p shoulder surgery ([**2173-3-12**]) Social History: Lives in [**Location 3786**], MA. Lives alone with her cat. In the past, worked as an accountant. Divorced with one son. Quit smoking ten years ago (previously had 20-pack-year), no alcohol use; no recreational substance use. Family History: non-contributory. Physical Exam: ADMISSION EXAM: . VS: BP 80 / 50, temp 99, HR 80, RR 12, 100% RA Gen: Caucasian female in NAD Cardiac: Mild systolic murmur radiating to carotids, no extrasystolic heart sounds Pulm: clear bilaterally Abd: soft, NT, ND, normoactive bowel sounds Ext: blanching erythema noted in lower extremities up to the level of the calf, 1+ lower extremity edema, slightly warm bilaterally, normal range of motion . DISCHARGE EXAM: . VITALS: 98.9 98.2 63-81 89-148/41-89 16 96% RA I/Os: 530 | 870 Foley (LOS +2.8L) GENERAL: Appears in no acute distress. Alert and interactive, elderly female. HEENT: Normocephalic, atraumatic. EOMI. PERRL (4-2 mm). Left conjunctival irritation with normal pupillary response; mild left periorbital edema with mild erythema. Nares clear. Mucous membranes moist. NECK: supple without lymphadenopathy. JVD 2-3cm just above the clavicle at 90-degrees. CVS: Regular rate and rhythm, 2/6 systolic murmur at LLSB, no rubs or gallops. S1 and S2 normal. RESP: Decreased breath sounds at bases bilaterally with faint inspiratory crackles at right > left base. No wheezing, rhonchi. Stable inspiratory effort. ABD: soft, obese, non-tender, non-distended, with normoactive bowel sounds. No palpable masses or peritoneal signs. EXTR: no cyanosis, clubbing, 2+ peripheral pulses; right knee with vertical well-healed scar; bilateral knees with minimal swelling, no erythema or fullness; [**11-22**]+ pitting edema bilaterally to upper shins NEURO: CN II-XII intact throughout. Alert and oriented x 3. Strength 5/5 bilaterally, sensation grossly intact. Gait deferred. Pertinent Results: ADMISSION LABS: . [**2173-12-27**] 12:55PM BLOOD WBC-14.4* RBC-4.15* Hgb-11.7* Hct-34.3* MCV-83 MCH-28.2 MCHC-34.1 RDW-14.9 Plt Ct-311 [**2173-12-27**] 12:55PM BLOOD Neuts-92.4* Lymphs-3.7* Monos-2.9 Eos-0.3 Baso-0.6 [**2173-12-28**] 11:38AM BLOOD ESR-62* [**2173-12-27**] 12:55PM BLOOD Glucose-89 UreaN-36* Creat-1.8* Na-133 K-2.8* Cl-97 HCO3-17* AnGap-22* [**2173-12-27**] 12:55PM BLOOD ALT-33 AST-45* LD(LDH)-288* AlkPhos-97 TotBili-0.4 [**2173-12-27**] 12:55PM BLOOD Albumin-3.6 Calcium-8.4 Phos-4.2 Mg-1.7 [**2173-12-28**] 03:56AM BLOOD Cortsol-21.9* [**2173-12-28**] 03:56AM BLOOD CRP-179.5* [**2173-12-27**] 12:55PM BLOOD IgG-846 IgA-54* IgM-358* [**2173-12-27**] 09:06PM BLOOD Type-[**Last Name (un) **] Temp-36.9 pO2-77* pCO2-34* pH-7.35 calTCO2-20* Base XS--5 Intubat-NOT INTUBA Comment-GREEN TOP [**2173-12-27**] 09:06PM BLOOD Glucose-90 Lactate-1.3 K-3.0* [**2173-12-27**] 09:06PM BLOOD freeCa-1.05* . PERTINENT AND DISCHARGE LABS: . [**2173-12-31**] 07:55AM BLOOD WBC-8.2 RBC-4.00* Hgb-11.0* Hct-32.2* MCV-81*# MCH-27.5# MCHC-34.2 RDW-15.5 Plt Ct-341# [**2173-12-28**] 03:56AM BLOOD PT-17.7* PTT-29.5 INR(PT)-1.7* [**2173-12-28**] 11:38AM BLOOD ESR-62* [**2173-12-31**] 07:55AM BLOOD Glucose-94 UreaN-11 Creat-0.8 Na-141 K-3.8 Cl-109* HCO3-22 AnGap-14 [**2173-12-28**] 03:56AM BLOOD ALT-32 AST-47* LD(LDH)-148 AlkPhos-78 TotBili-0.4 [**2173-12-31**] 07:55AM BLOOD Calcium-9.2 Phos-2.8 Mg-2.1 [**2173-12-28**] 03:56AM BLOOD Cortsol-21.9* [**2173-12-28**] 03:56AM BLOOD CRP-179.5* [**2173-12-27**] 12:55PM BLOOD IgG-846 IgA-54* IgM-358* [**2173-12-31**] 07:55AM BLOOD Vanco-14.8 . URINALYSIS: clear, negative for LE, negative for Nitr, no protein . MICROBIOLOGY DATA: [**2173-12-27**] Blood cultures (x 2) - pending [**2173-12-27**] Urine culture - negative [**2173-12-27**] MRSA screen - negative [**2173-12-28**] Blood culture - pending . IMAGING: [**2173-12-27**] CHEST (PA & LAT) - Mild interstitial edema. Recommend post-diuresis films to exclude underlying subtle pneumonia. . [**2173-12-27**] TTE - The left atrium is dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP > 18mmHg). There is a severe resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (?#) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. Compared with the prior study (images reviewed) of [**2168-3-18**], tissue Doppler imaging now suggests increase left ventricular filling pressure. The left ventricular outflow gradient is similar. . [**2173-12-28**] KNEE (AP, LAT & OBLIQUE) - No radiographic evidence for infection in either the right or left knee. No joint effusion on either side. If there is an area of soft tissue swelling on physical exam that is concerning for infection, then further assessment with MRI, CT or ultrasound could be performed. Brief Hospital Course: 75F with a PMH significant IgM MGUS, iron deficiency anemia, celiac disease, primary biliary cirrhosis, hypertension, chronic diastolic heart failure, and chronic venous insufficiency who recently presented to the [**Hospital1 18**] ED ([**2173-12-25**]) with concern for right lower extremity cellulitis who was treated with PO antibiotics, and was re-admitted with probable sepsis ans septic shock. . #Probable sepsis and septic shock due to lower extremity cellulitis: Patient was admitted with a presumed lower extremity cellulitis after failing Bactrim and Augmentin PO associated with lower extremity swelling and erythema. She initially was in septic shock with hypotension requiring IVF and 24 hours of vasopressor support in the MICU. Her antibiotics were broadened to Vancomycin/Zosyn. Leukocytosis improved and swelling, erythema resolved. Knee radiographs were unrevealing. Right knee arthrocentesis was attempted and was "dry". Blood and urine cultures were negative. Although it was not completely clear if the cellulitis was the cause of hypotension, patient endorsed no other symptoms to suggest another source of dehydration or other infection. Therefore, patient was continued on a 7-day course of Vancomycin. . #Chronic diastolic heart failure/HYPERTROPHIC CARDIOMYOPATHY: Patient was found to have diastolic heart failure and had an echocardiogram which showed a resting LVOT gradient similar to previous. Given sepsis her BB/CCB/Lasix were intially held but BB and Verapamil were restarted prior to discharge. Lasix was held as patient was not volume overloaded and the patient was given instructions to discuss restarting of her Lasix at her PCP [**Name Initial (PRE) **] 3 days from discharge at which time her Lasix can likely be restarted. . # ACUTE RENAL INSUFFICIENCY - No prior documentation of chronic renal disease; baseline creatinine 0.8-1.0 per outpatient records. Admitted with hypotension and creatinine responded to volume resuscitation (admission creatinine 1.8). Likely pre-renal in the setting of volume depletion/infection. vs. decreased effective-circulating volume vs. poor forward flow in the setting of LVOT obstruction. Her creatinine improved and was 0.8 on discharge. . # LEFT EYE CONJUNCTIVAL INJECTION, IRRITATION - The pateint had acute onset of left eye irritation with conjunctival injection. Ophthalmology consulted and noted left epithelial tear. We treated with polysporin ointment Q4H and she will continue this for 7-days without follow-up. . # CORONARY ARTERY DISEASE - Patient presented with known CAD; last cardiac catheterization in [**10/2168**] (Dr. [**Last Name (STitle) **] showing a right dominant system with no angiographically significant CAD - the LMCA, LAD, LCX, and RCA were all patent with mild disease. LVEF 56%. She had undergone stenting of her LAD in [**5-/2168**] of a 70% mid-LAD lesion. She presented with non-specific chest complaints this admission, which resolved with IV fluid resuscitation. EKG remained reassuring. No cardiac biomarkers obtained. We continued Aspirin, Plavix and her statin medication. . # HYPERTENSION - Home regimen includes Atenolol and Verapamil. These were held given her recent hypotension concerns this admission. Atenolol 50 mg PO daily was resumed prior to discharge. Verapamil will be resumed as an outpatient. . # DEPRESSION - We continued Amitryptiline 50 mg PO QHS. . # GOUT - Exam findings not consistent with acute gout flare. We avoided Allopurinol given prior hypersensitivity syndrome (documented in records) and resumed her home colcichine dosing once her creatinine stabilized. . # IgM MONOCLONAL GAMMOPATHY OF UNDETERMINED SIGNIFICANCE - MICU checked immunoglobulin levels in the setting of suspected sepsis to see if she was a candidate for IVIG - this admission IgG 846, IgA 54, IgM 348 - similar to her prior values. She improved without need for IVIG therapy. . # CELIAC DISEASE - Patient was diagnosed 15-years ago and she has never been compliant with a glute-free diet. She has occasional flatulence without bloating or diarrhea. She has some resulting osteoporosis - on calcium and vitamin D supplementation. Last tTG was 61. Her most recent EGD was in [**2167**] and was consistent with celiac disease. Will need outpatient follow-up with her gastroenterologist. . # PRIMARY BILIARY CIRRHOSIS, COLONIC ADENOMAS - Diagnosed in [**2157**] in the setting of abnormal LFTs. Subsequent liver biopsy demonstrated PBC findings. Has been compliant with Actigal since that time. Supposed to have yearly AFPs and abdominal U/S for surveillance. AFP in [**4-/2173**] was normal and her U/S in [**12/2171**] was stable. She has no symptoms currently. In terms of her colonic adenomas, her last endoscopy in [**2170**] was stable; repeat to be performed in [**2175**]. LFTs: AST 47, ALT 32, T-bili 0.4 and normal Alk-phos this admission. We continued her home dosing of Ursodiol 900 mg PO QAM, 600 mg PO QHS. . TRANSITION OF CARE ISSUES: 1. In terms of her colonic adenomas, her last endoscopy in [**2170**] was stable - repeat to be performed in [**2175**]. 2. PICC line placed and patient will complete 7-day course of IV Vancomycin for right lower extremity cellulitis concerns. 3. Patient will return home with visiting nurse services and physical therapy. 4. Patient will continue polysporin eye drops to left eye for 7-days more. No ophthalmology follow-up required. 5. Patient will restart Verapamil on [**2174-1-1**] and her PCP will determine when she should restart her home Lasix dose. Medications on Admission: HOME MEDICATIONS (confirmed with patient) 1. Amitriptyline 40 mg PO daily 2. Atenolol 50 mg PO daily 3. Clopidogrel 75 mg PO daily 4. Colchicine 0.6 mg PO BID 5. Fexofenadine 180 mg PO daily 6. Furosemide 80 mg PO daily 7. Hydrocortisone 2.5% cream rectally applied [**Hospital1 **] 8. Ketoconazole 2% cream applied to skin daily 9. Lactulose 10 gram/15 mL [**11-22**] tablespoons by mouth Q6H PRN constipation 10. Nystatin 100,000 unit/mL susp - 5 cc by mouth swish and swallow PO QID 11. Nystatin 100,000 unit/gram powder applied to affected area PRN TID 12. Oxycodone 10 mg ER PO Q12 hours 13. Simvastatin 40 mg PO daily 14. Ursodiol 900 mg PO Q AM, 600 mg PO QPM 15. Verapamil 120 mg ER PO QHS 16. Zolpidem 10 mg PO QHS PRN insomnia 17. Aspirin 325 mg EC PO daily 18. Biotin 1 mg PO daily 19. Calcium carbonate (2 tabs) 600 mg (1500 mg) PO daily 20. Cholecalciferol-vitamin D3 - [**2161**] units PO daily 21. Cyanocobalamin-B12 (dosage uncertain) 22. Docusate sodium 200 mg PO daily 23. Multivitamin 1 tablet PO daily Discharge Medications: 1. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 24H (Every 24 Hours) for 7 days: started [**2173-12-27**], end [**2174-1-2**]. Disp:*5 doses* Refills:*0* 2. Outpatient Lab Work PICC line dressing change weekly and PRN with cap change. 3. amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO twice a day. 7. fexofenadine 180 mg Tablet Sig: One (1) Tablet PO once a day. 8. hydrocortisone 2.5 % Cream Sig: One (1) application Rectal twice a day. 9. ketoconazole 2 % Cream Sig: One (1) application Topical once a day as needed for rash. 10. lactulose 10 gram/15 mL Solution Sig: [**11-22**] tablespoons PO every six (6) hours as needed for constipation. 11. nystatin 100,000 unit/g Powder Sig: One (1) application Topical three times a day as needed for rash. 12. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. ursodiol 300 mg Capsule Sig: Three (3) Capsule PO QAM (once a day (in the morning)). 14. ursodiol 300 mg Capsule Sig: Two (2) Capsule PO QPM (once a day (in the evening)). 15. verapamil 120 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day: RESTART on [**2174-11-1**]. 16. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 17. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. biotin 1 mg Tablet Sig: One (1) Tablet PO once a day. 19. Calcium 600 600 mg (1,500 mg) Tablet Sig: Two (2) Tablet PO once a day. 20. cholecalciferol (vitamin D3) 2,000 unit Capsule Sig: One (1) Capsule PO once a day. 21. cyanocobalamin (vitamin B-12) Oral 22. docusate sodium 100 mg Tablet Sig: Two (2) Tablet PO once a day. 23. multivitamin Tablet Sig: One (1) Tablet PO once a day. 24. 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. 25. bacitracin-polymyxin B 500-10,000 unit/g Ointment Sig: One (1) Appl Ophthalmic Q4H (every 4 hours) for 7 days. Disp:*1 tube* Refills:*0* 26. Outpatient Lab Work You should have your electrolytes (chem-10) checked prior to your appointment with your primary care physician [**Last Name (NamePattern4) **] [**2174-1-4**]. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnoses: 1. Right lower extremity cellulitis 2. Hypotension . Secondary Diagnoses: 1. IgM Monoclonal gammopathy of unknown significance 2. Iron deficiency anemia 3. Celiac disease 4. Primary biliary cirrhosis 5. Hypertension 6. Diastolic cardiac dysfunction with left ventricular outflow tract ostruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Patient Discharge Instructions: . You were admitted to the Internal Medicine service at [**Hospital1 1535**] on CC7 regarding management of your presumed lower extremity infection and low blood pressure, which was treated with IV antibiotics and improved. You will continue with IV antibiotics for a total of 7-days while at home. You were feeling well prior to discharge. . Please call your doctor or go to the emergency department if: * You experience new chest pain, pressure, squeezing or tightness. * You develop new or worsening cough, shortness of breath, or wheezing. * You are vomiting and cannot keep down fluids, or your medications. * If 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 an unusual discharge. * Your pain is not improving within 12 hours or is not under control within 24 hours. * Your pain worsens or changes location. * You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. * You develop any other concerning symptoms. . CHANGES IN YOUR MEDICATION RECONCILIATION: . * Upon admission, we ADDED: START: Vancomycin 1 gram IV every 24-hours for 7-days total (started [**2173-12-27**] and ending [**2174-1-2**]) START: Bacitracin-polymyxin B 500-10,000 unit/g Ointment to left eye 6-times daily (every 4 hours) for 7-days (ending [**2174-1-6**]) . You should RESTART your Verapamil 120 mg ER by mouth daily on [**2174-1-1**]. . You should STOP your Lasix medication until discussing the dosing with your primary care physician in clinic next week. . * The following medications were DISCONTINUED on admission and you should NOT resume: DISCONTINUE: Oxycodone . * You should continue all of your other home medications as prescribed, unless otherwise directed above. Followup Instructions: Department: [**State **]When: TUESDAY [**2174-1-4**] at 11:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3747**], MD [**Telephone/Fax (1) 2205**] Building: [**State **] ([**Location (un) **], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: On Street Parking . Department: MEDICAL SPECIALTIES When: WEDNESDAY [**2174-3-2**] at 2:00 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD [**Telephone/Fax (1) 1803**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [**2174-4-27**] at 1 PM With: [**First Name8 (NamePattern2) 2671**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage

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Discharge summary

report

Admission Date: [**2170-2-14**] Discharge Date: [**2170-2-20**] Date of Birth: [**2089-12-10**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2159**] Chief Complaint: respiratory distress, transfer from [**Hospital1 **] [**Location (un) 620**] Major Surgical or Invasive Procedure: None History of Present Illness: 80 y/o Russian speaking only female transferred from [**Hospital1 **] [**Location (un) 620**] after she was found at rehab facility to be in respiratory distress. . Pt is s/p trimalleolar fx, being treated at rehab, cast removed on Monday (3 days PTA), and started physical therapy. Also on Monday, the pt developed dry cough, runny nose, congestion. No CP/SOB. Took Robitussin without benefit. Sx persisted--Tuesday night, noted increasing congestion, cough, refused all meds for sx relief from RN at rehab, around midnight, RN called to bedside b/c pt developed difficulty breathing, SOB, diaphoresis (no chest pain per pt, and no CP documented in OSH records). EMS called, vitals when seen: O2sat 86% on RA, NRB--96%, BP 190/P, HR 76. En route given NTG X 2, lasix, JVP noted to be elev, BP initially with 190s, (blood sugar noted to be 440s, no h/o DM, given 10 units regular insulin IV), w/ increasing SOB, tachypnea, NTP 1 inch ribbon applied, then BP noted to be falling to 80s systolic even after NTP removed. Pt started on dopamine gtt, titrated up to 10mcg/kg/min, with improvement in BP to 112, and was weaned off nitro gtt while being transported from [**Hospital1 18**] [**Location (un) 620**] to [**Hospital1 18**]. At [**Hospital1 **] [**Location (un) 620**], vitals: Temp 97.8 BP: 144/69 P: 74 RR: 38 with o2sat not documented. Labs notable for WBC 4.7, Hct 23, plt 18, lactate 2.2, UA neg with 100 glucose and 30 protein, Na 134, K 4.5, Co2 24.5, BUN 28, Cr 1.5, tbili 1.42 with LFTS AST 10, ALT 24, CK 15, TnT 0.02, tele strip from [**Hospital1 **] [**Location (un) 620**] showing NSR at 60bpm. CXR showing acute pulm edema, CHF. . In the ED here, VSS, satting 100% on 2L NC, BP noted to be 160s/90s with pulse 70s. Pt went into atrial fibrillation to HR 130s, BP 110/60, lasted ~5min then pt spontaneously went into NSR. Ddimer was [**2088**]. CTA completed showing no PE, but + LLL consolidation and mild volume overload. Given 40mg IV lasix in ED, output noted to be ~1.5L from 8am to 1pm. Foley placed. Received 1g CTX IV X 1 and Azithro 500mg po X 1. Also received mucomyst with IVF and 3 amps bicarb for renal protection prior to CTA. Past Medical History: 1. Myelodysplastic syndrome followed at [**Hospital3 **], weekly transfusions 2. Paroxysmal Atrial fibrillation 3. Pacer placement for bradycardia 4. colon cancer with colostomy 5. phlebitis 6. recent right trimalleolar fx, casted Social History: Nonsmoker, no alcohol, no IVDA. Has an apartment but has lived in rehab for the last few weeks b/c of trimalleolar fx. Family History: Father- h/o renal insufficiency, died in Siberia of unknown cause. Mother- also died of unknown causes. Children-healthy. Physical Exam: Vitals: T HR: 69 BP: 165/81 RR: 26 O2sat: 100% 2L NC General: 80 y/o woman breathing comfortably on 2L NC. Speaking in full sentences, in Russian. Does not appear to be in pain. HEENT: PERRL, EOMI. No scleral icterus, MMM Petechiae on palate. Lungs: with crackles [**12-11**] way up the back bilaterally, poor effort CV: RRR S1 and S2 audible, distant heart sounds [**1-11**] body habitus, no m/r/g heard Abd: Obese, Colostomy bag in place with dark green/brown stool, NT, ND, decreased bowel sounds, no masses, no HSM Peripheral: No edema, 2+ pulses PT on the left. the RLE is in splint with bandage in place. No cyanosis. Ext warm. Pertinent Results: EKG: NSR at 70 bpm, LAD, nl int, ST depressions in leads II, III, biphasic T in lead V2, TWF in V3 poor baseline, need to repeat. . CXR: [**2170-2-14**] IMPRESSION: 1. Obscured left hemidiaphragm medially possibly suggesting a left lower lobe collapse or consolidation. 2. Rounded area of lucency in the retrocardiac region may represent air within a dilated esophagus. . CTA chest [**2170-2-14**]: No PE, Partial LLL consolidation c/w PNA, mild volume overload. . CULTURE DATA: [**2170-2-14**]: blood cultures X 2 negative [**2170-2-14**]: blood cultures X 2 negative [**2170-2-14**]: urine culture negative [**2170-2-16**] 2:56 pm SPUTUM Site: EXPECTORATED Source: Expectorated. **FINAL REPORT [**2170-2-18**]** GRAM STAIN (Final [**2170-2-16**]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 3+ (5-10 per 1000X FIELD): BUDDING YEAST. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final [**2170-2-18**]): MODERATE GROWTH OROPHARYNGEAL FLORA. . ABD CT [**2170-2-18**] IMPRESSION: 1. Parastomal hernia in the left lower quadrant, which contains a loop of transverse colon and free fluid, which may represent early incarceration. Clinical correlation recommended. 2. Borderline dilated loops of small bowel in a nonobstructive pattern which may represent focal ileus. 3. Bilateral lower lobe atelectasis and small left pleural effusion. The tiny pleural effusion appears somewhat loculated. 4. Tiny pericardial effusion. 5. Layering gallstone. 6. Calcified granulomata in the spleen, and small splenule. 7. Multiple low-density lesions in the kidneys, too small to fully characterize. 8. Large hiatal hernia. . ABD US [**2170-2-18**] Three radiographs of the abdomen demonstrate physiologically air-distended loops of bowel. Retained contrast material is evident within the bilateral kidneys and ureters, secondary to the patient's recently acquired contrast-enhanced CT examination. The left lower quadrant ostomy is possibly excluded from the imaged field of view. Mild levoscoliosis and marked degenerative change of the thoracolumbar spine is noted. No pneumoperitoneum is evident. IMPRESSION: Nonobstructive bowel gas pattern. . LABS: [**2170-2-14**] 04:01AM BLOOD WBC-2.7* RBC-2.65* Hgb-7.8* Hct-23.9* MCV-90 MCH-29.5 MCHC-32.8 RDW-19.5* Plt Ct-23* [**2170-2-19**] 04:50AM BLOOD WBC-1.4* RBC-3.27* Hgb-9.9* Hct-28.1* MCV-86 MCH-30.2 MCHC-35.1* RDW-18.3* Plt Ct-21* [**2170-2-14**] 04:01AM BLOOD Neuts-70 Bands-0 Lymphs-25 Monos-0 Eos-1 Baso-3* Atyps-1* Metas-0 Myelos-0 [**2170-2-14**] 04:01AM BLOOD PT-14.0* PTT-24.2 INR(PT)-1.2* [**2170-2-14**] 04:01AM BLOOD D-Dimer-[**2088**]* [**2170-2-14**] 04:01AM BLOOD Gran Ct-1640* [**2170-2-16**] 05:10AM BLOOD Gran Ct-270* [**2170-2-17**] 05:55AM BLOOD Gran Ct-420* [**2170-2-18**] 05:40AM BLOOD Gran Ct-430* [**2170-2-19**] 04:50AM BLOOD Gran Ct-360* [**2170-2-14**] 04:01AM BLOOD Glucose-161* UreaN-30* Creat-1.4* Na-136 K-4.2 Cl-103 HCO3-22 AnGap-15 [**2170-2-14**] 01:00PM BLOOD Glucose-119* UreaN-28* Creat-1.2* Na-137 K-3.8 Cl-100 HCO3-27 AnGap-14 [**2170-2-14**] 04:21AM BLOOD cTropnT-0.09* [**2170-2-14**] 04:01AM BLOOD CK(CPK)-22* [**2170-2-14**] 01:00PM BLOOD CK-MB-3 cTropnT-0.07* [**2170-2-14**] 01:00PM BLOOD CK(CPK)-22* [**2170-2-14**] 05:45PM BLOOD CK-MB-3 cTropnT-0.12* [**2170-2-15**] 12:46AM BLOOD CK(CPK)-22* [**2170-2-15**] 12:46AM BLOOD CK-MB-NotDone cTropnT-0.11* [**2170-2-16**] 05:10AM BLOOD ALT-9 AST-19 CK(CPK)-36 [**2170-2-16**] 05:10AM BLOOD CK-MB-NotDone cTropnT-0.05* [**2170-2-17**] 05:45PM BLOOD CK(CPK)-13* [**2170-2-17**] 05:55AM BLOOD CK-MB-NotDone cTropnT-0.03* [**2170-2-17**] 05:45PM BLOOD CK-MB-NotDone cTropnT-0.02* [**2170-2-15**] 12:46AM BLOOD Triglyc-55 HDL-66 CHOL/HD-2.4 LDLcalc-82 [**2170-2-16**] 05:10AM BLOOD TSH-1.4 Brief Hospital Course: Impression: 80 y/o woman transferred from rehab, [**Hospital1 **] [**Location (un) 620**] for likely flash pulmonary edema in setting of HTN, found to develop Afib with RVR, further flash pulmonary edema, demand ischemia ([**Location (un) 7792**]) in setting of Atrial fibrillation with RVR. Rate controlled now with po diltiazem, po amiodarone and s/p diuresis. . CARDIOVASCULAR: 1. [**Name (NI) 7792**], pt had troponin leak in setting of demand ischemia secondary to atrial fibrillation with rapid ventricular response. The pt was rate controlled with HR 60s-70s with a diltiazem drip IV, then transitioned to po diltiazem. She was also given amiodarone drip IV, transitioned to po amiodarone, with a taper of dose. She was aggressively diuresed with IV lasix 40mg qd (she puts out 700cc-1L with this dose), and given additional doses depending on physical exam findings and oxygen requirement on nasal cannula. Her blood pressure was tightly controlled, and she is on both a beta blocker and an ACEI. Her lipid panel was checked, no need for statin. Aspirin was held given her myelodysplastic syndrome. . 2. Acute Pulmonary Edema in setting of AFib with RVR: Most likely flash pulmonary edema given her high systolic blood pressure when she initially presented. Also developed flash pulmonary edema when going into rapid ventricular response on the medical floor. The pt likely has a component of diastolic dysfunction, echo was completed and found to have EF 55%, mod dilated left atrium. She was aggressively diuresed with IV lasix (responds to 40mg IV lasix). She is now satting well on room air (had been requiring 3L NC, with elev JVP and crackles [**2-10**] way up back on initial presentation). Her electrolytes were aggressively repleted for K>4, Mg>2, and this should be continued at [**Hospital 100**] Rehab. She is to continue her maintenance dose of 40mg IV lasix qd, with monitoring of electrolytes (chem 10) qday and repletion of lytes. If the patient's weight increases >3 lbs, then give additional dose IV lasix 40mg X 1. Also, if she starts to require oxygen, or develops increasing oxygen requirement with crackles bilateral lungs and elev JVP, may need to adjust lasix dosing. . 3. RHYTHM: Afib with RVR: The pt went into RVR the night of admission, cardiology was consulted, EP was consulted, and she was transferred to the CCU for DC cardioversion. However, this never occurred because the pt was placed on a diltiazem IV drip, with good rate control, and she changed back into NSR the next AM. She was started on an amiodarone IV drip the next day, no bolus, and weaned off when transitioned to po amiodarone 400mg po tid, which was continued for 3 days, then weaned to 400mg po bid for 3 days (has 2 more days left of this dose), then to continue mainteance dose of 400mg po qd. While in the CCU, EP interrogated her pacemaker. No anticoagulation given myelodysplastic syndrome, so hold coumadin. She was monitored on telemetry this entire hospitalization. She is in sinus rhythm, rate 60-70. Plan is to continue diltiazem po qid and amiodarone 400mg po bid X 2 more days, then taper to 400mg po qd for maintenance rhythm control. She should have her LFTs checked in one month on the amiodarone. She had baseline LFTs checked here and were normal. . 4. LLL PNA- Consolidation seen on CXR and CTA. Pt given 1g CTX IV and 500mg po azithro in ED, and this was continued on medical floor. She became neutropenic in the CCU the following day and was started on Cefepime [**2170-2-16**] for febrile neutropenia/LLL PNA. She did not spike further temps and her oxygen sats remained stable, so Vancomycin was never empirically added. She was given ipratropium nebs q6h with no albuterol b/c of her Atrial fibrillation. She will need to have her CBC checked on Cefepime. Plan is to continue IV cefepime for atleast 2 weeks (has 9 more days) with final duration of antibiotic course being determined by her WBC level and her ANC level (to be decided by Hematologist/Oncologist Dr. [**Last Name (STitle) 10005**] [**Name (STitle) **], and her Primary care physician--[**Name10 (NameIs) 788**] follow up appointments). . 5. Constipation (now resolved). Pt developed severe nausea, vomiting, decr stool output 3 days prior to discharge concerning for incarcerated hernia or bowel obstruction, given her colostomy. Abd CT showed a parastomal hernia, no evid obstruction. KUB showed nonobstructive gas pattern. Pt had large BM followed by 5 BM 2 nights prior to discharge. She began tolerating po well after that, and had continued good stool outpt from the colostomy bag. No abdominal pain. No nausea or vomiting. . 6. New DX of Diabetes Mellitus: Elevated blood sugars at OSH to 440, with no prior h/o DM. With glucose in urine. Fingersticks on the medical floor have been wnl, so her FSBS were changed from QID to [**Hospital1 **]. She was covered with ISS, but she does not need this. She has a follow up appt with [**Last Name (un) **] DM for ? new dx of DM. She is tolerating well po. Her Hgb A1C was found to be 5. . 7. Myelodysplastic syndrome- pt with OSH labs on [**2-8**] not far from pancytopenia seen on CBC on admission. However, pt's WBC and Hct trended down, required 1 unit PRBC while in CCU. Oncologist at [**Hospital3 **] was called, and verified her severe neutropenia. The oncologist stated her prognosis from Myelodysplastic Syndrome was poor. She receives weekly transfusions. She has a follow up appt with Dr. [**Last Name (STitle) **], but the physicians at [**Hospital 100**] Rehab can also transfuse depending on her Hct and plt levels. Her ANC should be followed up as well with her WBC ct. . 8. GERD/hiatal hernia: continue protonix po qd . 9. MDD/Anxiety- continue paroxetine, outpt dose. . 10. FEN: diabetic/cardiac diet, replete lytes for K>4, MG>2 . 11. FULL CODE Medications on Admission: 1. Oxazepam 15mg po qHS prn 2. Albuterol 90 mcg IH 3. Prochlorperazine 10mg po q6h prn 4. Sorbitol 70% prn for constipation 5. Tylenol prn 6. Senna 1 tab po qd 7. Milk of Magnesia prn 8. Dulcolax suppository pr qd prn constipation 9. Vicodin 5/500 q tab po q4h prn 10. Xalatan 0.005% eye drops 1 drop each eye qd 11. Paroxetine 20mg 1 tab po qd 12. Protonix 40mg po qd 13. Altace 5mg po qd 14. MVI 15. Pyridoxine 50mg po bid 16. Colace 100mg po bid 17. Metoprolol 50mg po bid 18. Metamucil 1 tbsp po qd 19. Robitussin prn Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer treatment Inhalation Q6H (every 6 hours) for 14 days. Disp:*56 nebulizer treatment* 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. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*100 Tablet(s)* Refills:*0* 6. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. Disp:*qs Suppository(s)* Refills:*2* 8. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). Disp:*qs 1 bottle* Refills:*0* 9. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO DAILY (Daily). Disp:*30 Wafer(s)* Refills:*2* 10. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). Disp:*qs 1 bottle* Refills:*2* 11. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. Disp:*qs largest stock* Refills:*0* 13. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough. Disp:*30 Capsule(s)* Refills:*0* 14. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 2 days: then change to amiodarone 400mg po qd as maintenance dose (see separate order). . Disp:*8 Tablet(s)* Refills:*0* 15. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day: after 2 days of 400mg amiodarone po bid. . Disp:*30 Tablet(s)* Refills:*2* 16. Furosemide 40 mg IV DAILY Start: In am 17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 18. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 19. Cefepime 1 gm IV Q24H 20. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-11**] Sprays Nasal TID (3 times a day) as needed. Disp:*qs largest stock* Refills:*0* 21. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 22. Anzemet 50 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea for 7 days. Disp:*21 Tablet(s)* Refills:*0* 23. Outpatient Lab Work You will also need your CBC, with ANC checked qweek and LFTs checked qmonth on amiodarone. These results should be reviewed by the physician in the [**Name9 (PRE) 15159**] at [**Hospital 100**] Rehab. You have an appointment with your Hematologist, Dr. [**Last Name (STitle) 10005**] [**Name (STitle) **], who will review your Hematocrit, WBC, ANC and platelets and decide on a transfusion. (see appointment schedule) The physicians at [**Hospital 100**] Rehab can do this as well. For plt count<10, transfuse plt (will depend on level). For Hct<22, transfuse PRBCs, amount depending on Hct level (previously received weekly transfusions). 24. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO once a day: Hold for SBP<110. Disp:*15 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - Acute Rehab Discharge Diagnosis: 1. Atrial fibrillation with Rapid Ventricular Response 2. Flash Pulmonary Edema 3. Hypertension 4. status post pacer interrogation, pacer placed for bradycardia 5. Myelodysplastic syndrome 6. Recent Right Trimalleolar fracture 7. Colon cancer status post colostomy 8. ?New diagnosis Diabetes Mellitus Discharge Condition: Stable Discharge Instructions: If you experience any worsening of your symptoms, please report to the emergency room immediately. Please take all of your medications as directed. Please follow up with your physicians (see information below). Followup Instructions: 1. Please follow up with your Primary Care Physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8555**]. Your appointment is for: [**2170-2-28**] at 4:00pm. Her office number is: [**Telephone/Fax (1) 60945**] should you need to reschedule. 2. Please follow up with [**Last Name (un) **] Diabetes (adjacent to [**Hospital1 18**] [**Hospital Ward Name 517**]). Your appointment is set for: [**2170-7-2**] at 11:30am with Dr. [**Last Name (STitle) 9978**]. Their office number is: [**Telephone/Fax (1) 21119**], and they will be getting in touch with your regarding a possible earlier appointment. 3. Please follow up with Dr. [**Last Name (STitle) 60946**] [**Name (STitle) **], Hematology/Oncology. Your appointment is set for: Friday, [**2170-2-23**] at 10:00am. His office number is: [**Telephone/Fax (1) 60947**] if you need to reschedule your appointment. Completed by:[**2170-2-20**]

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icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

17718, 17791

7834, 13693

393, 399

18144, 18153

3818, 7811

18414, 19362

3015, 3141

14275, 17695

17812, 18123

13719, 14252

18177, 18391

3156, 3799

277, 355

427, 2601

2623, 2862

2878, 2999

27,080

101,953

23099

Discharge summary

report

Admission Date: [**2121-4-4**] Discharge Date: [**2121-4-21**] Date of Birth: [**2067-9-28**] Sex: M Service: NEUROLOGY Allergies: IV Dye, Iodine Containing Attending:[**First Name3 (LF) 618**] Chief Complaint: R putaminal hemorrhage Major Surgical or Invasive Procedure: Endotracheal Intubation Tracheostomy History of Present Illness: Mr. [**Known lastname 59501**] is a 53 year old male with history of nephrolithiasis and ? pyelonephritis who presents with large R putaminal hemorrhage. The patient complained of feeling warm earlier today, and mild low back pain consistent with his history of kidney for percocet for the pain. The patient had entertained guests in his home this evening and was feeling well. He developed low back pain in the evening, took a percocet for the pain, went to his prayer room, and he was then found by his wife on the floor, vomiting and unable to get up. He was able to speak to her and asked that he be put in bed. He never complained of having any headache. His wife called EMS. The patient was intubated for airway protection en route to the OSH by EMS. At the [**Hospital3 20284**] Center the pt's head CT revealed a large right putaminal hemorrhage extending posteriorly and inferiorly in the right posterior midbrain with blood in the third ventricle. The patient was given phosphenytoin 1500mg, Ativan 2mg, Pancuronium, zofran and transferred to [**Hospital1 18**] for further care. At present the pt is unable to provide a ROS. His wife reports recent low back pain and perhaps fevers, but he did not take his temperature at home. Otherwise he has been feeling well recently without N/V/D. No recent wt loss. He does not have a history of headaches. Past Medical History: Nephrolithiasis- as above No known h/o hypertension Social History: Married, has two children, he works as a laotian translator at [**Hospital3 1810**] and also formerly at [**Hospital1 18**], he has also worked as a court transcriptionist. He smoked for many years, quit 2 years ago. He does not drink any alcohol. Wife reports that he has never used any illicit or IV drugs. Family History: pt's wife is unfamiliar with his FH, does not recall any h/o stroke, ICH or bleeding diasthesis. Physical Exam: PHYSICAL EXAM: Vitals: T 99, HR 60 (regular), BP 110/62, R 16, 97% on CMV Gen- critically ill, male on gurney, spontaneous extensor posturing of left hemibody, biting on ET tube. HEENT- NCAT, anicteric, OP clear, no oral trauma Neck- no carotid bruits bilat CV- RRR, 2/6 SEM heard best at apex PULM- CTA B Extrem- no CCE SKIN- multiple tattoos, R thigh, chest, patchy blanching erythematous reticular rash on anterior chest. NEUROLOGIC EXAM: MS- no response to voice, not following commands. He does not localize sternal rub. CN- right pupil dilated to 9mm unreactive to light, left pupil 3mm-->2mm, absent doll's eye reflex, intact corneal reflex bilaterally, brisk gag reflex. Motor- occasional fasciculation of left anterior quads. appears to withdraw with the RUE purposefully to noxious stimulation. Extensor posturing of LUE and LLE with noxious stimulation. Withdraws right leg to noxious. Sensation- intact to noxious throughout. Pt flexes R arm to noxious on left leg, but is unable to localize to sternal rub. Reflexes- 2+ on R [**Hospital1 **], tri, brachioradialis and patellar, ankle. On the left there are 3+ reflexes in the [**Hospital1 **], tri, brachioradialis. The left patellar reflex spreads to the left leg inducing clonus- 4+. left toe is upgoing. right toe is downgoing. Pertinent Results: Labs: Trop-T: <0.01 BUN 11, Cr 0.6 CK: 132 MB: 3 [**Doctor First Name **]: 131 MCV 98 WBC 12.4, hgb 14.7, hct 45, Platelets 134 PT: 14.1 PTT: 31.3 INR: 1.2 At OSH: UA postive for RBC's, 3+ protein. PTT 28, INR 1.2 EKG (from OSH)- NSR with left atrial enlargement, RBBB. Imaging: Head CT [**2121-4-4**]: FINDINGS: There is acute intraparenchymal hemorrhage in the right basal ganglia measuring roughly 4 x 3 cm, which extends inferiorly into the right pons and mid brain. There is a moderate amount of associated intraventricular blood seen within the lateral ventricles, greater on the right than on the left. Small amount of blood is seen within the third ventricle. There is slight effacement of the suprasellar cistern, suggesting early uncal herniation. There is minimal, 2 mm leftward subfalcine herniation. Edema surrounding the area of hemorrhage causes mild mass effect on adjacent sulci. There is no extra-axial hemorrhage. There is no evidence of infarction. There is no fracture. IMPRESSION: Acute intraparenchymal hemorrhage in the right basal ganglia, with extension into the right pons and mid brain. Moderate intraventricular extension into the lateral ventricles and third ventricle. Early uncal herniation. NOTE ADDED AT ATTENDING REVIEW: Although I agree with most of the above report, there is no evidence of uncal herniation associated with this globus pallidus hematoma. Head CT [**2121-4-5**]: NON-CONTRAST HEAD CT: Since prior examination, there has been no significant change in the hemorrhage within the right globus pallidus extending into the midbrain. Although there is less blood in the frontal [**Doctor Last Name 534**] of the lateral ventricles, the extent of hemorrhage within the posterior [**Doctor Last Name 534**] of the lateral ventricles, third ventricle, and fourth ventricle is not appreciably changed. No new hemorrhage is identified. This is associated with mildly increased hydrocephalus. A 5 mm vague hyperdensity is seen within the inferior brainstem (series 2, image 4), which was retrospectively present on prior exam and may represent tiny focus of blood. Copious secretions are seen within the nasopharynx. The visualized paranasal sinuses and mastoid air cells remain normally aerated. IMPRESSION: 1. Stable hemorrhage within the right globus pallidus extending into the mid brain. 2. Minimally increased hydrocephalus. CXR [**2121-4-4**]: FINDINGS: Single portable supine chest radiograph is reviewed without comparison. Endotracheal tube is in place, just below the thoracic inlet, 5.4 cm above the carina. Tube could be advanced for more optimal positioning. Cardiomediastinal contours are within normal limits allowing for portable supine technique. The lungs are clear. There is no pleural effusion or pneumothorax. IMPRESSION: Endotracheal tube tip seen just below the thoracic inlet, 5.4 cm above the carina. CXR [**2121-4-6**]: SINGLE FRONTAL VIEW OF THE CHEST: The nasogastric tube has been removed and Dobbhoff tube placed with tip terminating in similar location within the proximal stomach. An endotracheal tube tip terminates 3 cm from the carina. The cardiomediastinal silhouette is stable and unremarkable. The lungs are clear. There is no effusion. IMPRESSION: Standard Dobbhoff tube tip placement terminating over proximal stomach. KUB [**2121-4-9**]: IMPRESSION: No evidence of ileus or obstruction CT TORSO [**2121-4-14**]: FINDINGS: The lung volumes are low. The patient is status post tracheostomy. The airways are patent to the subsubsegmental level. The heart and great vessels are unremarkable. There are no pulmonary nodules. There is no mediastinal or axillary adenopathy. There are bilateral moderate, pleural effusions with adjacent atelectasis. CT ABDOMEN WITH IV CONTRAST: There is massive ascites. The right lobe of the liver is borderline small. The caudate lobe is somewhat prominent, as is the left lobe, consistent with cirrhosis. There is a hypoattenuating liver mass measuring 4.7 x 3.1 cm, in segment IV A of the liver, which encroaches on the IVC and the portal vein. There are other smaller liver lesions, which are too small to characterize. The gallbladder, pancreas, spleen, adrenals are normal. There is a cyst in the upper pole of the left kidney. The bowel shows generalized edema likely due to the patient's cirrhosis. The SMA, SMV, celiac artery, and [**Female First Name (un) 899**] are all opacified. There is no evidence of bowel obstruction or ischemia. There is no mesenteric or retroperitoneal adenopathy. CT PELVIS WITH IV CONTRAST: The free fluid tracks down into the pelvis. There is again bowel wall edema. The bladder is collapsed with a Foley in it. There is no pelvic or inguinal adenopathy. MUSCULOSKELETAL: No suspicious osseous lytic bony lesions. IMPRESSION: 1. No evidence of bowel obstruction. Patent SMA, SMV, celiac, and [**Female First Name (un) 899**], without evidence of bowel ischemia, although there is bowel wall edema, likely due to underlying cirrhosis. 2. New liver mass in segment IV A, which in the setting of the prominent left lobe, caudate lobe, and borderline small right lobe with massive ascites is concerning for a primary liver lesion, such as hepatocellular carcinoma, or less likely a cholangiocarcinoma. 3. Low lung volumes with bilateral pleural effusions and adjacent atelectasis. PERITONEAL FLUID [**2121-4-15**]: NEGATIVE FOR MALIGNANT CELLS. Mesothelial cells, neutrophils, histiocytes and lymphocytes. ABDOMINAL ULTRASOUND [**2121-4-16**]: This study was done portably in the intensive care unit. Only portions of the liver could be imaged,and the left lobe and known left lobe mass could not be visualized due to the high position deep to the sternum. The right lobe was well imaged and showed no masses. The gallbladder was not overly distended, but the wall was thickened and edematous undoubtedly related to the underlying liver disease. There was marked ascites surrounding the liver, which had a somewhat coarse nodular texture. Color flow and pulse Doppler assessment was performed. The hepatic veins were well identified and fully patent with normal waveforms. Hepatic artery was also easily identified and patent as well as the inferior vena cava. However, no detectable flow could be identified within the right portal vein either by color flow or pulse Doppler. The imaged portion of the portal vein included only the right portal vein, but not the left or main portal, which were obscured or impossible to access. CONCLUSION: Cirrhotic liver with marked ascites. Limited views do not allow for visualization of the known left lobe mass. Doppler assessment shows patency of the hepatic artery and hepatic veins, but no flow could be detected in the right portal vein, even at low flow settings. This either indicates occlusion or extremely low velocity flow, less than 10 cm/sec. It is not possible to make distinction between these two possibilities on this portable study. Brief Hospital Course: Mr. [**Known lastname 59501**] was admitted to the Neuro ICU for close monitoring and blood pressure management after diagnosis of his putamenal hemorrhage in the ED. His blood pressure was controlled with a nicardipine gtt initially. He was kept euglycemic with insulin sliding scale, and Tylenol was administered for any temperature greater than 100.4F. It was presumed that the etiology was long-standing hypertension, with an acute hypertensive episode that likely led to the bleed perhaps precipitated by the pain due to his renal stones. To improve his intracranial pressure, he was hyperventilated and treated with mannitol; his head elevation was maintained greater than 30 degrees. Neurosurgery was consulted for possible EVD placement, but as there was no significant hydrocephalus and his 4th ventricle appeared patent, no drain was placed. Mr. [**Known lastname 59501**] was monitored with a repeat CT scan after 6 hours, which showed no change in the hemorrhage and only minimal increase in the hydrocephalus. Throughout his hospitalization, his neurologic status showed no improvement. He continued to have no pupillary reaction, minimal oculocephalic response, and decerebrate posturing. Despite his poor prognosis, his family wished to continue aggressive care. This was addressed with them in multiple family meetings, nearly daily for the first week of his hospitalization. Because no significant neurologic recovery was expected, a tracheostomy was performed at the end of his first week. A percutaneous enterogastrostomy (PEG) was planned as well, but before this could be performed, he developed significant ascites. To investigate the cause of this ascites, a CT torso was performed (lungs were evaluated for possible pneumonia, which was not seen). The CT of the abdomen and pelvis revealed massive ascites with one large liver mass and several smaller liver nodules, consistent with a primary hepatocellular carcinoma. At this point, the even poorer prognosis was discussed with the family, who still wanted to proceed with life-prolonging measures. The day after this CT, he underwent paracentesis for diagnostic and therapeutic measures. No malignant cells were seen in the ascitic fluid and there was no evidence of peritonitis. Following the paracentesis, he became hypotensive with systolic pressures in the 70s; he was given albumin to restore intravascular volume. Albumin needed to be given repeatedly over the next four days until his death to maintain blood pressure. At the same time, he began to develop a coagulopathy due to his failing liver. He received several units of fresh frozen plasma (FFP) and several doses of Vitamin K over the final 4 days of his life. Similarly, he began to develop renal failure due to hepatorenal syndrome. His creatinine climbed as high as 2.3. He was supported with the albumin in an effort to maintain intravascular volume. After several days of these heroic life-prolonging measures, a meeting was held with his providers (the Neurology and the ICU teams, including nursing), his family, social workers, and the Legal/Ethics Consult team. It was explained to his family that despite all the best medical care, there was no chance of his surviving. The Legal/Ethics consult determined that the hospital and the providers were under no obligation to provide treatment that could not produce the goal of survival, which his family identified as the goal of therapy (see separate note from Legal/Ethics consult on OMR). Therefore, it was agreed that care would be withdrawn. Mr. [**Known lastname 59501**] died within 48 hours, on [**2121-4-21**]. Medications on Admission: Meds: Percocet PRN- filled Rx a few days ago Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: 1. Hypertensive intracerebral hemorrhage, right putamen, with intraventricular and midbrain extension. 2. Hepatocellular carcinoma 3. Coagulopathy due to failed production of clotting factors 4. Hepatorenal syndrome Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] Completed by:[**2121-5-2**]

[ "155.0", "786.01", "486", "452", "070.70", "518.81", "V13.01", "789.51", "276.4", "431" ]

icd9cm

[ [ [] ] ]

[ "31.1", "96.72", "38.91", "38.93", "96.6" ]

icd9pcs

[ [ [] ] ]

14351, 14360

10600, 14226

309, 347

14619, 14628

3591, 5038

14680, 14805

2156, 2255

14322, 14328

14381, 14598

14252, 14299

14652, 14657

2285, 2696

246, 271

375, 1737

5047, 10577

2713, 3572

1759, 1813

1829, 2140

14,898

135,352

17325

Discharge summary

report

Admission Date: [**2160-10-13**] Discharge Date: [**2160-10-24**] Date of Birth: [**2096-4-23**] Sex: M Service: MEDICINE Allergies: Penicillins / Nsaids / Rapamune Attending:[**First Name3 (LF) 1666**] Chief Complaint: Complete Heart Block & Ventricular Tachycardia Major Surgical or Invasive Procedure: s/p temporary pacemaker line removal s/p right PICC line placement (and removal) s/p left PICC line placement ([**2160-10-22**]) History of Present Illness: 64yo man w/ h/o multiple medical problems including [**Name (NI) 2320**], CAD, HepC/ETOH cirrhosis & HCC s/p orthotopic liver tx ('[**57**]) on prograf w/ post-transplant course complicated by renal insufficiency, tracheostomy, chronic colonization/infections w/ mult resistant organisms who was transferred from [**Location (un) 745**] [**Hospital 3714**] Hospital to [**Hospital1 18**] CCU for pacemaker/ICD placement. Pt initially presented to NWH on [**2159-10-13**] w/ & AV block in setting of hyperkalemia. Pt tx'd w/ RIJ temporary pacing wire at NWH, during which he developed Ventricular Tachycardia. Pt out of AV block, and in sinus rhythm upon arrival at [**Hospital1 18**]. Past Medical History: 1. Liver transfusion for Hepatitis C/EtOH cirrhosis & hepatocellular carcinoma, on tacrolimus followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**]. 2. Tracheostomy: x2, [**8-11**] for chronic vent dependency, subglottic stenosis, tracheomalacia 3. DM2 4. OSA/Pickwickian syndrome 5. COPD 6. Diastolic dysfunction 7. CKD 8. Bipolar d/o 9. HTN 10. H/o VRE, MRSA, C. diff, and resistant Pseudomonas infections 11. Hiatal hernia 12. Pulmonary hypertension Social History: Quit tobacco 8 years ago. Quit alcohol 17 years prior to admission. Denies any recreational drugs. Family History: Non-contributory Physical Exam: VS: T: 99.2 HR: 70 RR: 19 bp: 131/91 SpO2: 97% on ventilatory mask 0.35 FIO2 Gen: A&O*4, appears mildly distressed HEENT: PERRLA, EOMI, 2mm pupils Neck: trach, pacemaker insertion site C/D/I Heart: temp pacemaker set at HR 50/ 10mV, RRR Lung: coarse rhonchi louder on LLL than RLL Abd: soft, NT, ND Ext: 0.5cm pustule on distal lateral LLE surrounded by 1 cm erythematous border Pertinent Results: Admission labs: [**2160-10-13**] 08:22PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014 [**2160-10-13**] 08:22PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2160-10-13**] 08:22PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0-2 [**2160-10-13**] 08:21PM GLUCOSE-272* UREA N-48* CREAT-2.0* SODIUM-143 POTASSIUM-4.7 CHLORIDE-101 TOTAL CO2-31 ANION GAP-16 [**2160-10-13**] 08:21PM ALT(SGPT)-23 AST(SGOT)-20 ALK PHOS-106 TOT BILI-0.2 [**2160-10-13**] 08:21PM ALBUMIN-3.2* CALCIUM-8.8 PHOSPHATE-4.2 MAGNESIUM-1.7 [**2160-10-13**] 08:21PM WBC-4.8 RBC-3.03* HGB-8.8* HCT-24.7* MCV-82 MCH-29.0 MCHC-35.5* RDW-15.7* [**2160-10-13**] 08:21PM PLT COUNT-175 [**2160-10-13**] 08:21PM PT-12.5 PTT-25.8 INR(PT)-1.1 . . Discharge Labs: [**2160-10-24**] 05:01AM BLOOD WBC-4.6 RBC-2.95* Hgb-8.5* Hct-23.8* MCV-81* MCH-28.8 MCHC-35.7* RDW-16.4* Plt Ct-168 [**2160-10-24**] 05:01AM BLOOD Glucose-99 UreaN-34* Creat-1.9* Na-141 K-4.1 Cl-101 HCO3-32 AnGap-12 [**2160-10-22**] 08:20AM BLOOD ALT-86* AST-34 LD(LDH)-239 AlkPhos-511* TotBili-0.3 [**2160-10-24**] 05:01AM BLOOD FK506-4.0* . . CXR: [**2160-10-13**] FINDINGS: A temporary pacemaker lead has been placed via a left internal jugular approach and there is a defibrillator pad overlying the lower right hemithorax. There is more marked elevation of the left hemidiaphragm. The heart and mediastinal contours are stable. The pulmonary vasculature is normal. The pleural spaces are normal and the lungs are clear, with the left costophrenic angle excluded from the radiograph. IMPRESSION: Elevated left hemidiaphragm, with no evidence of acute cardiopulmonary process. . Echocardiogram: [**2160-10-14**] The left atrium is elongated. 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 normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2158-8-15**] , estimated pulmonary artery pressure is now lower. . TEE [**2160-10-20**]: Conclusions: No atrial septal defect is seen by 2D or color Doppler. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: No echocardiographic evidence of endocarditis or paravalvular abcess. . ABD u/s: INDICATION: Liver transplant with LFT abnormalities. LIVER DOPPLER: The right common, middle, and left hepatic veins appear patent with appropriate directionality of flow. The main hepatic artery is patent. The portal veins are patent with hepatopetal flow. Incidental note is made of a small cyst in the right lobe of the liver. There is no evidence of biliary ductal dilatation. IMPRESSION: Patent hepatic vasculature . [**2160-10-24**] RIGHT LOWER EXTREMITY VENOUS ULTRASOUND: Using the linear probe, grayscale and color Doppler son[**Name (NI) 1417**] of the right common femoral, superficial femoral, and popliteal vessels were performed. There is no intraluminal thrombus. The vessels demonstrate normal flow, compressibility, respiratory variability, and augmentation. IMPRESSION: No evidence of DVT. Brief Hospital Course: A/P: 64 y.o male w/ h/o HCV cirrhosis s/p liver transplant, and several other comorbidities presents s/p complete heart block. . #Paroxysmal AV Block: pt presented to OSH w/ AV block, possibly secondary to hyperkalemia, which is thought to be due to pt's FK506/tacrolimus. Pt had temp pacer wire placed at OSH. By time of transfer to [**Hospital1 18**], pt was out of AB blocke & in NSR. His temp line was eventually removed here as there were no further signs of AV block. He was monitored on telemetry. Placement of permanent pacer delayed due infectious issues. Pt spiked temps, had (+) bld and line cx's--bld cx grew enterococcus and PICC line grew coag negative staph. Given these issues, plan made for pt to have permanent pacer placed after completion of 4wk course of antibiotics, followed by 2wks of monitoring for fever and blood cultures. If pt is fever free and has no further positive cultures during this period, he will go for pacemaker placement with Dr. [**Last Name (STitle) **] of [**Hospital1 18**]. . # Infections: h/o MRSA, VRE and recurrent PNA. Pt had recurrent fevers during early part of hospital stay. Fevers thought to be due to bacteremia--bld cx's grew enterococcus (last (+) blood cx from [**10-14**]), which was sensitive to vanco. Pt's right PICC line (from [**10-15**]) grew coag negative staph resistant to oxacillin. Subsequent surveillane cultures were negative. Source of enterococcus in blood not identified. Pt had pustule on LLE, but not felt to be source of infection. Pt had no further positive blood cultures after those listed above. He last spiked a tempurate on the night of [**10-17**]. Pt did have pseudomonas in the sputum, which was treated for a period with cefepime. However, pt had little evidence of respiratory infection and the pseudomonas was thought to be colonizers, thus the cefepime was discontinued. Pt underwent TEE which was negative for endocarditis or paravalvular abscess. Given no clear source for enterococcal baceremia & plan for pacemaker in near future, ID recommended longer course of Abx--4 weeks total, starting from date of last positive blood culture [**2160-10-15**]. It may be possible to change to ampicillin for treatment of enterococcal infection (since amp sensitive); however, this was not done as pt's right arm still emdematous & slightly erythematous from thrombophlebitis (from initial PICC line, which grew coag negative staph, resistant to oxacillin). If pt's right arm improves in appearance, suggesting clearance of thrombophlebitis, vanco could be changed to ampicillin. . # Hyperkalemia: worked up thoroughly. Primary cause thought to be pt's KF506/tacrolimus. Unfortunately, pt required increased dose of FK506 to keep FK level in target range, which led to frequent elevations in potassium. Pt was treated aggressively with kayexylate & K improved. EKG's did not show changes associated with elevated K. . # Liver transplant: LFTs bumped [**10-18**], then resolved after discontinuation of fluconazole, which was thought to be the cause. No clear evidence of rejection. U/S unremarkable. FK level monitored closely and adjusted for goal level of 4 to 6. Pt continued on prednisone and prophylactic bactrim. . # Anemia: pt has baseline anemia of chronic disease. Stools guaiac negative. Baseline Hct mid to low 20's. 23.4 on day of discharge. Pt treated with Epogen & iron. . # Baslic vein thrombophbletis: partial, non-occlusive thrombosis of Right basilic vein on U/S. Associated swelling & mild erythema. No abscess on U/S. Treated symptomatically. . # DM2: Pt's glucose was managed with humalog sliding scale & daily glargine. . # Tracheostomy: 02 via trach mask at 35%. Satting in mid to high 90's. Albuterol & atrovent given PRN . # Chronic renal insufficiency: developed post-liver transplant. Cause not completely clear. Baseline Crt 1.5 - 2.2; pt currently 1.9. . # Pain: due to basilic thrombophlebitis and rib pain from coughing. Treated pain control with morphine sulfate immediate release PO. . # Anxiety/Bipolar Depression: Pt treated w/ Ativan PRN for anxiety & zyprexa for bipolar. Social work was asked to see him; however, he refused intervention. . # H/o diastolic dysfunction: Pt stable throughout admission. Repeat echo (EF>65%) & mild LVH, trivial MR & TR. . #Right leg pain: on morning of discharge, pt complained pain on right posterior thigh. Pt reports it feels "muscular" in nature, and that he "slept on it wrong." However, given his risk for DVT, lower ext u/s was performed, which showed no evidence of DVT. Physical exam was unremarkable. Pain resolved w/ MSIR. . # FEN: pt requires pureed diet based on previous swallow study. . # Prophylaxis: SC Heparin, Protonix, bowel regimen PRN . # code status: FULL Medications on Admission: Prograf 1 mg [**Hospital1 **] Bactrim DS one tablet per day Keflex 500mg PO q6H Diflucan 200mg PO daily Prednisone 5mg PO daily Norvasc 10 mg PO daily Protonix 40mg PO daily Olanzapine 2.5mg PO daily zinc sulfate 220 mg po daily sliding scale insulin PRN Heparin 5000 units subcutaneously TID Ativan 1mg PO q6H PRN Motrin 600mg PO PRN Hydromorphone 0.5-2mg IV q2H PRN Artificial tears Miconazole powder PRN Discharge Medications: 1. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed). 12. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID, PRN (). 13. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for SOB, wheeze. 14. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 15. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 16. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for anxiety/insomnia. 18. Insulin Lispro (Human) 100 unit/mL Solution Sig: per Insulin Flowsheet/sliding scale Subcutaneous qACHS. 19. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1) Intravenous Q8H (every 8 hours) as needed for nausea. 20. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q 24H (Every 24 Hours) for 20 days. 21. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO QAM (once a day (in the morning)) as needed for s/p liver transplant. 22. Tacrolimus 0.5 mg Capsule Sig: Two (2) Capsule PO QPM (once a day (in the evening)). 23. Sodium Polystyrene Sulfonate 15 g/60mL Suspension Sig: Two (2) PO q2HR PRN hyperkalemia for 1 doses. 24. 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. 25. Insulin Glargine 100 unit/mL Solution Sig: 10units Subcutaneous once a day. 26. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Hospital1 **] Discharge Diagnosis: Primary: Paroxysmal AV Block Hyperkalemia due to FK506 (tacrolimus) Enterococcal Bacteremia Coagulase negative staphyloccocal PICC infection Right Basilic vein thrombophlebitis . Secondary: Orthotopic Liver Transplant Diabetes (type II) tracheostomy Bipolar d/o Chronic Kidney Disease H/o VRE & MRSA Discharge Condition: Good, afebrile x 7 days, cultures no growth since [**2160-10-15**], minimal activity, potassium 4.1 BUN 34 Crt 1.9 Discharge Instructions: You were admitted to the hospital with an irregular heart rhythm. This resolved on its own, and did not recurr. However, you will need to get a pacemaker in the future, once your blood infection is fully treated. . If you have chest pain, shortness of breath, faint, fever, rash, nausea, vomiting, diarrhea, bloody stools, abdominal pain, please contact a doctor or go to the emergency room. . MR. [**Known lastname 1182**] will require a number of blood tests be drawn regularly, see below. . 1. Potassium should be checked on [**2160-10-26**] and treated PRN. . 2. Weekly, on Wednesdays, CBC with differential, BUN, & Crt, LFTs and vancomycin trough need to be checked. These results should be faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**] at [**Telephone/Fax (1) 1419**]. . 3. Weekly, on Wednesdays, FK506 (aka tacrolimus) levels, potassium, liver function tests need to be checked in the AM, 12 hours after the PM dose of FK506/tacrolimus was given. These results need to be faxed to [**Doctor Last Name 1022**], attention "Transplant Coordinator" in the [**Hospital1 **] Transplant Department. Fax # [**Telephone/Fax (1) 697**]. . 4. Blood cultures need to be drawn at the rehab facility on [**2160-11-14**] and [**2160-11-21**]. Please fax the results of these to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**] at [**Telephone/Fax (1) 1419**]. Followup Instructions: The patient has the following appointments scheduled: . Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **], MD (PCP) [**Telephone/Fax (1) 45347**] Appointment should be in [**6-16**] days . DR. [**First Name (STitle) **] [**Doctor Last Name 9406**] (of infectious disease at [**Hospital3 **] [**Hospital 1225**] Medical Center in [**Location (un) 86**]) Date/Time:[**2160-11-18**] 11:00 Phone:[**Telephone/Fax (1) 457**]--call if you have questions or need directions. . DR. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] (of electrophysiology) Date/Time:[**2160-11-20**] 1:00 Phone:[**Telephone/Fax (1) 2934**] . [**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2160-12-18**] 10:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]

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icd9cm

[ [ [] ] ]

[ "38.93", "89.45", "88.72" ]

icd9pcs

[ [ [] ] ]

13958, 14033

6274, 11051

341, 472

14377, 14494

2263, 2263

15961, 16876

1830, 1848

11509, 13935

14054, 14356

11077, 11486

14518, 15938

3086, 6251

1863, 2244

255, 303

500, 1190

2279, 3070

1212, 1697

1713, 1814

74,223

184,394

47550

Discharge summary

report

Admission Date: [**2126-12-3**] Discharge Date: [**2126-12-10**] Date of Birth: [**2045-11-3**] Sex: M Service: MEDICINE Allergies: Accupril Attending:[**First Name3 (LF) 425**] Chief Complaint: fever Major Surgical or Invasive Procedure: pericardiocentitis History of Present Illness: This is a 81 year-old female with a history of severe dCHF, CAD s/p cath [**2121**] (prox LAD), large pericardial effusion, restictive cardiomyopathy, right ventricular contractile dysfunction, severe TR, a-fib on coumadin, HTN, HL, hypothyroidism, who presents with fever and hypotension. The patient was seen at his PCP office on [**11-28**] with 3 weeks of SOB and 1 week of productive cough. He underwent a CXR that showed a right middle lobe density (infiltrate vs atelectasis), organomegally with a large pericardial effusion, mild CHF. Her WBC count was 7.1. He was started on Moxifloxacin and torsemide was increased to 20mg daily. He states that his breathing and cough improved, but still remains SOB. He felt warm on Friday, but took tylenol and did not have any further fevers. He reports very poor po intake and weight loss of 9lbs over the last week. He noticed pain in his right 2nd digit that began to turn red and have pain. It was associated with swelling and worsening pain. . In the ED, 101.0 86 87/59 22 98% 4L. He was noted to have erythema and lower ext edema on his right foot and leg. Labs were significant for WBC 8.7, lactate 2.0, INR: 3.3 and Cr. 2.0. CXR showed massive cardiomegaly and difficult to assess infiltrates. He continued to be hypotensive to the SBP 70's and a RIJ was attempted. Given his INR the line was aborted and a small hematoma formed. An umcomplicated right femoral line was placed. He was given 2L IVF and started on norepinephrine 0.06. He was covered with Vancomycin and Zosyn empirically. A bedside ECHO was performed and showed a large chronic posterior effusion that reportly did not show evidence of tamponade. . Vitals on transfer were 96 105/60 24 94%3L. On arrive the patient was bleeding from his RIJ and 10 minutes of pressure were applied and a new dressing was placed. A pulsus was checked and was 8. The patient reports his breathing is comfortable as long as he does not move. . Of note, he was treated for left leg cellulitis with 10 days of bactrim and 17 days of clindamycin finishing [**2126-11-1**]. . ROS: The patient denies any chills, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. . Past Medical History: -Chronic permanent atrial fibrillation -CAD s/p cardiac cath [**2121**] showing a 95% lesion in the proximal LAD, which was stented with a Cypher stent -Prior concern for amyloid cardiomyopathy (had had marked LVH with very enlarged right and left atria). s/p negative abdominal wall fat biopsy [**11/2122**] (Fibroadipose tissue; no diagnostic abnormalities recognized; amyloid stains are negative. The controls are appropriate) -Hypertrophic obstructive cardiomyopathy. An echocardiogram in [**2123-4-30**] showed an LVEF > 65% with a peak resting LVOT gradient of 40 mmHg. This gradient is slightly higher than it had been seen in [**2122-8-30**]. -Chronic wheezing and asthmatic-type symptoms. -Eosinophilia. -Possible strongyloidiasis leading to eosinophilia and even pulmonary symptoms. Treated with ivermectin 25 mg per day for two days -FVC of 60% predicted and FEV1 of 69% predicted. It was no significant change with bronchodilator. -HTN -Hypercholesterolemia -Hyperthyroidism -BPH -OA s/p total knee replacement -OSA on BiPAP at home -pulmonary artery is significantly enlarged at 5.3 cm as well as an enlarged ascending aorta of 4.5 cm Social History: Lives alone at home, completely independent in ADLs. Has a live-in house keeper. Smoked 1ppd x 20yrs, quit 20 yrs ago. [**12-1**] glasses of wine per night. Family History: Mother died of heart disease at young age. Brother has [**Name2 (NI) 499**] ca and CAD. Son recently died of [**Name2 (NI) 499**] ca in his 50's. Physical Exam: On Admission GEN: eldery male, no acute distress HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, dry MM NECK: dressing over right neck with 2cm hematoma and oozing thru dressing. Could not assess JVD, no cervical lymphadenopathy, trachea midline COR: S1&S1 irregularly irregular II/VI SEM no G/R PULM: bibasilar crackles, no W/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: R femoral CVL in place with dried blood. trace edema on the left, +2 edema in the foot and right leg. erythema over the dorsum with severe pain especially on on the 2nd digit. NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Patellar DTR +1. Plantar reflex downgoing. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [**2126-12-3**] 07:45AM WBC-8.7 RBC-4.09* HGB-12.3* HCT-37.4* MCV-92 MCH-30.1 MCHC-32.9 RDW-16.1* [**2126-12-3**] 07:45AM PLT COUNT-232 [**2126-12-3**] 07:45AM NEUTS-87.7* LYMPHS-8.4* MONOS-3.3 EOS-0.2 BASOS-0.3 [**2126-12-3**] 07:45AM GLUCOSE-146* UREA N-30* CREAT-2.0* SODIUM-141 POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-24 ANION GAP-19 [**2126-12-3**] 07:45AM ALT(SGPT)-35 AST(SGOT)-52* LD(LDH)-432* CK(CPK)-101 ALK PHOS-186* TOT BILI-2.3* [**2126-12-3**] 07:45AM LIPASE-30 [**2126-12-3**] 07:45AM PT-33.0* PTT-30.5 INR(PT)-3.3* [**2126-12-3**] 07:45AM ALBUMIN-4.2 [**2126-12-3**] 07:45AM CK-MB-3 cTropnT-0.18* [**2126-12-3**] 03:34PM CK-MB-3 cTropnT-0.16* [**2126-12-3**] 11:20PM CK-MB-3 cTropnT-0.16* [**2126-12-3**] 11:20PM CORTISOL-16.8 [**2126-12-3**] 03:34PM URIC ACID-8.8* [**2126-12-3**] 12:23PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2126-12-3**] 12:23PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.014 [**2126-12-3**] 12:23PM URINE OSMOLAL-426 [**2126-12-3**] 12:23PM URINE RBC-18* WBC-2 BACTERIA-NONE YEAST-NONE EPI-<1 [**2126-12-3**] 12:23PM URINE HYALINE-5* [**2126-12-3**] 12:23PM URINE URIC ACID-MANY [**2126-12-3**] 12:23PM URINE MUCOUS-RARE [**2126-12-3**] 12:23PM URINE EOS-NEGATIVE [**2126-12-3**] 11:20PM ALT(SGPT)-28 AST(SGOT)-25 LD(LDH)-178 CK(CPK)-63 TOT BILI-1.7* DIR BILI-0.8* INDIR BIL-0.9 . ECG: a-fib at 102, normal axis, low voltages, old left bundle, no significant changes from [**2126-9-16**]. . CXR ([**12-4**]) FINDINGS: Massive cardiomegaly is unchanged. There is a new right lower lobe consolidation. There is a small left pleural effusion, if any. No right pleural effusion is seen. There is no pneumothorax identified. Severe bilateral shoulder degenerative changes are noted. IMPRESSION: 1. New right lower lobe consolidation, concerning for pneumonia. 2. Unchanged massive cardiomegaly, possibly a combination of an enlarged heart and a pericardial effusion. . Foot X-ray: IMPRESSION: Findings consistent with tophaceous gout. Vasculopathy. . TTE The left atrium is dilated. The right atrium is dilated. The estimated right atrial pressure is 10-20mmHg. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is small. Left ventricular systolic function is preserved. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is dilated with depressed free wall contractility. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is at least mild pulmonary artery systolic hypertension. The effusion appears circumferential. The pericardial effusion is large around the right atrium and lateral and posterior to the left ventricle. However the effusion is <1cm wide anterior to the mid to apical right ventricular wall. There are no echocardiographic signs of tamponade. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. Compared with the prior study (images reviewed) of [**2126-9-16**], the effusion appears similar. Mitral regurgitation is now less prominent. . TTE [**12-6**] AM: There is symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular free wall is hypertrophied. The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. There is a moderate sized pericardial effusion. The effusion appears free-flowing and in the supine position mostly pools lateral to the LV (2 cm). There is no echocardiographic evidence of tamponade. IMPRESSION: Moderate, apparently free-flowing residual pericardial effusion. . TTE [**12-7**] AM There is symmetric left ventricular hypertrophy. The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal with depressed free wall contractility. There is a small to moderate sized pericardial effusion outside of the lateral LV wall with the patient in supine position. . TTE [**12-9**]: There is symmetric left ventricular hypertrophy. The left ventricular cavity is small. Overall left ventricular systolic function is normal to hyperdynamic (LVEF>55%). RV with depressed free wall contractility. There is a moderate sized pericardial effusion (mainly posterior). The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**12-6**]/201, no significant change. . Myocardial Biopsy: The biopsy specimen consists of four tissue fragments for evaluation. Two larger fragments show marked infiltration of cardiac muscle with amyloid (confirmed on [**Country 7018**] red stain). Involved myocytes demonstrate varying states of degeneration. Background subendocardial and interstitial fibrosis is also noted (highlighted by Masson's trichrome stain). No stainable iron is seen on iron stain. No inflammatory infiltrate or granulomas are identified. Brief Hospital Course: This is a 81 year-old male with a history of severe dCHF, CAD s/p cath [**2121**] (prox LAD), large pericardial effusion, restictive cardiomyopathy, right ventricular contractile dysfunction, sever TR, a-fib on coumadin, HTN, HL, hypothyroidism, who presented with SIRS, large pericardial effusion s/p paricardiocentesis with a pericardial drain. . # SIRS: Pt presented to the ED with hypotension and initially received 2L IVF and norepinephrine to maintain MAPS > 65 following insertion of a femoral line with fevers to 101. He was treated for pnueumonia, thought to be the source, with ceftriaxone and azythromycin. He completed an antibiotic course and was weaned from pressor support and remained afebrile with negative cultures for the remainder of the hospitalization. . # Pericardial Effusion: Pt has a chronic large pericardial effusion. ECHO showed that the effusion was stable from [**2126-8-30**] and there was no ECHO evidence of tamponade, although the pulm HTN and dilated/hypokinetic RV could mask signs. Therapeutic and diagnostic pericardiocentesis was performed in the cath lab, along with myocardial biopsy. Pericardial drain was placed for 48 hours, and subsequently removed without complication. Patient had no signs of tamponade and subsequent echos showed that the residual effusion had been effectively drained. . #Restrictive cardiomyopathy/diastolic heart failure - Pt has a known chronic restrictive cardiomyopathy with resultant severe diastolic dysfunciton. Myocardial biopsy came back positive for amyloid, likely senile amyloidosis, even given prior negative fat pad biopsy. He was continued on his home dose of torsemide 20 mg daily for diuresis during admission. . #. Gout: Patient had MTP pain consistent with gout, which improved on a steroid taper. . # CAD: pt is s/p cardiac cath [**2121**] showing a 95% lesion in the proximal LAD. No current CP or ECG changes during admission. He was continued on ASA 325mg, beta blocker. [**Last Name (un) **] was held on discharge. . #. HTN: Metoprolo,XL as above, [**Last Name (un) **] held on discharge. . #. Hypercholesterolemia: continued on home statin. . #. OSA: Patient on CPAP at night, settings adjusted as patient has lost weight since his settings were last adjusted. Home sleep agency was notified Medications on Admission: Lipitor 80mg daily Budesonide- Formoterol 160 mcg-4.5 mcg/Actuation HFA [**Hospital1 **] Vit D 50,000U qweek Metformin 500mg daily Toprol XL 50mg daily Nitro SL prn Olmesartan 10mg daily Oxycodone-acetaminophen 1 tab qhs KCl 20mEq daily Viagra Flomax 0.4mg daily Torsemide 20mg daily Coumadin 4.5 mg x 2 days; 5 mg x 5 days ASA 325mg daily Ferrous Sulfate 325mg daily Multivitamin daily Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. budesonide-formoterol 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) puff Inhalation twice a day. 4. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. 5. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 6. nitroglycerin Sublingual 7. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for pain. 8. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 9. Outpatient Lab Work Please check Chem 7 and INR on Thursday [**2126-12-12**] and call results to Dr. [**First Name (STitle) 1395**] at [**Telephone/Fax (1) 2205**] 10. torsemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 11. warfarin 5 mg Tablet Sig: One (1) Tablet PO weekdays. 12. warfarin 1 mg Tablet Sig: 4.5 Tablets PO once a day: Sat and Sun only. 13. FerrouSul 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 14. Multi-Day Tablet Sig: One (1) Tablet PO once a day. 15. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 days. Disp:*2 Tablet(s)* Refills:*0* 16. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. 17. metoprolol succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Amyloid Heart Disease Pericardial effusion Atrial Fibrillation with rapid ventricular response. Gout Chronic Diastolic Congestive Heart Failure: EF 55%, no [**Last Name (un) **] because of low BP Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You had a reoccurance of the pericardial effusion and required a tap to drain the fluid again. We checked an echocardiogram before you left and although the fluid has reaccumulated somewhat, you do not need another tap. Your biopsy was positive for a constrictive heart disease called amyloid. There is no treatment for this condition so we will try to optimize your heart function with medicines. You will see Dr. [**First Name (STitle) 437**] in 2 weeks and will have another echocardiogram at that time. Please try to rest once you go home and let your family help you. We made the following changes to your medicines: 1. Increase your Metoprolol to 100 mg daily 2. Stop taking Olmesartan 3. Start taking prednisone to treat the gout in your right foot, you will take 5 mg for 2 more days, then stop. . Weigh yourself every morning, call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. Followup Instructions: Department: [**State **]When: THURSDAY [**2126-12-12**] at 10:45 AM With: [**Name6 (MD) **] [**Name8 (MD) 9862**], MD [**Telephone/Fax (1) 2205**] Building: [**State **] ([**Location (un) **], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: On Street Parking Department: CARDIAC SERVICES When: MONDAY [**2126-12-30**] at 10:00 AM With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage An ECHO will be scheduled at the same time. Department: RHEUMATOLOGY When: THURSDAY [**2127-1-2**] at 10:15 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 20135**], 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: CARDIAC SERVICES When: WEDNESDAY [**2127-2-12**] at 10:00 AM With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: WEDNESDAY [**2127-2-12**] at 11:00 AM With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) **] [**Name8 (MD) **], MD Phone: [**Telephone/Fax (1) 612**] [**1-1**] at 8:20aM [**Hospital Ward Name 23**] [**Location (un) 436**], [**Hospital Ward Name 23**] Clinical Center

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icd9cm

[ [ [] ] ]

[ "37.0", "37.25", "37.21" ]

icd9pcs

[ [ [] ] ]

14708, 14766

10441, 12733

276, 296

15006, 15006

5064, 10418

16189, 17943

4049, 4197

13171, 14685

14787, 14985

12759, 13148

15189, 16166

4212, 5045

230, 237

324, 2684

15021, 15165

2706, 3857

3873, 4033

15,009

117,813

49819

Discharge summary

report

Admission Date: [**2176-11-12**] Discharge Date: [**2176-11-18**] Date of Birth: [**2099-7-15**] Sex: F Service: MEDICINE Allergies: Morphine / Iodine; Iodine Containing / Lipitor / Phenothiazines Attending:[**First Name3 (LF) 2387**] Chief Complaint: 77-yo-woman with DM2, CRI, HTN, CHF, CAD called out of MICU to floor, awaiting permacath placement [**11-14**] for dialysis. Had been admitted to MICU for mgmt of acidosis in the setting of ARF. Major Surgical or Invasive Procedure: Placement of right inferior jugular tunneled catheter for hemodialysis History of Present Illness: Presented to ED [**11-12**] w/ tremor for 3 days, decreased appetite, also urinary frequency x 1 week. See original MICU admission H&P for full history and review of systems. In the [**Name (NI) **], pt was found to have ARF w/ creatinine 6.1, K 4.8, and bicarb 10. ABG was 7.1/36/99 on room air. Pt was admitted to the MICU for management of acidosis/uremia. Past Medical History: Primary: Bronchitis Anemia of Chronic Renal Disease Possible Mastitis Secondary: CAD/CHF s/p CABGx3 -- multiple caths, 3 stents [**5-31**], [**9-30**], [**11-30**] HTN IDDM CRI (Cr 2.4-2.7) Hypothyroid OA Wheelchair bound [**1-31**] left knee removal right THR, left TKR Polycythemia d/t erythropoetin, d/c'd [**2175-7-30**] Social History: No ETOH, NO Tobacco, NO drugs. [**Name (NI) 1094**] husband and children present and supportive. Family History: non-contributory Physical Exam: 131/43 61 15 100% on 2.5L Gen: morbidly obese woman, NAD, A+Ox3 conversing fluently HEENT: anicteric, EOMI, MMM, no JVD CV: RRR, +S3, +Systolic murmur loudest at apex Pulm: CTAB Abd: obese, +BS, soft, NT, ND Ext: warm, palpable DP pulses B, + non-pitting edema to mid-leg, venous stasis skin changes; ecchymosis over forearms bilaterally Neuro: A+O x 3. + Asterixis bilaterally Guaiac negative Pertinent Results: [**2176-11-12**] 07:48PM GLUCOSE-164* UREA N-110* CREAT-5.8* SODIUM-143 POTASSIUM-4.6 CHLORIDE-113* TOTAL CO2-12* ANION GAP-23* [**2176-11-12**] 07:48PM CK(CPK)-28 [**2176-11-12**] 07:48PM cTropnT-0.05* [**2176-11-12**] 04:15PM ABG PO2-99 PCO2-36 PH-7.10* TOTAL CO2-12* BASE XS--17 [**2176-11-12**] 04:15PM LACTATE-0.7 NA+-142 K+-4.3 CL--115* [**2176-11-12**] 04:15PM HGB-11.6* calcHCT-35 [**2176-11-12**] 04:15PM freeCa-1.23 [**2176-11-12**] 03:48PM WBC-6.2 RBC-4.01*# HGB-12.8# HCT-42.8# MCV-107*# MCH-31.9 MCHC-29.9*# RDW-16.6* [**2176-11-12**] 03:48PM NEUTS-75.3* BANDS-0 LYMPHS-16.8* MONOS-3.8 EOS-3.0 BASOS-1.2 [**2176-11-12**] 03:48PM PLT COUNT-132* [**2176-11-12**] 01:55PM URINE COLOR-Straw APPEAR-Cloudy SP [**Last Name (un) 155**]-1.014 [**2176-11-12**] 01:55PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2176-11-12**] 01:55PM URINE RBC-[**6-7**]* WBC->1000 BACTERIA-MANY YEAST-NONE EPI-0 [**2176-11-12**] 01:25PM GLUCOSE-111* UREA N-113* CREAT-6.1*# SODIUM-142 POTASSIUM-4.5 CHLORIDE-112* TOTAL CO2-10* ANION GAP-25* [**2176-11-12**] 01:25PM CK(CPK)-32 [**2176-11-12**] 01:25PM CK-MB-NotDone cTropnT-0.06* [**2176-11-12**] 01:25PM ASA-NEG ETHANOL-NEG ACETMNPHN-6.6 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG Brief Hospital Course: 77-yo-woman w/ DM2, CAD, HTN, CRI and ARF, CHF presenting w/ improving tremor, improving acidemia secondary to uremia, also w/ UTI and anemia. . 1. Non-oliguric ARF on CRF, Uremia/Acidemia: ARF with Cr increase from 3 to 6.1 was likely secondary to prerenal azotemia from hypovolemia, given decreased PO intake over past 2 weeks, though FENa of 4% supports intrinsic renal etiology. UTI is another possible exacerbating factor, though unlikely as no signs of pyelonephritis. The pt had evidence of uremia with decreasing appetite, asterixis, and acidosis, no hyperkalemia. The patient was admitted to the MICU on presentation for management of uremia and acidosis. A bicarbonate gtt was initiated [**11-12**], and discontinued [**11-13**], after repeat ABG was 7.24/47/133/21. Asterixis/tremor subsequently diminished. The patient was transferred from the MICU to the Medicine floor service on [**11-13**]. The patient was followed by the nephrology team during the course of her admission. Renal U/S performed [**11-13**] showed no obstruction or hydronephrosis. Given the pt's diabetes and worsening renal status, the nephrology team recommended initiation of hemodialysis. The pt received a tunneled right IJ catheter placed by IR on [**11-14**], and started hemodialysis [**11-15**]. She received daily hemodialysis on [**11-15**]. During her admission, the patient had weight, fluid status, and electrolytes monitored daily. She also was started on Lisinopril by the nephrology team. She was also seen by transplant surgery, to discuss eventual need for AV fistula placement for hemodialysis. The patient was subsequently set up for outpatient dialysis, and had her first appointment [**11-20**] at 11:15AM. . 2. UTI: The pt was found to have a UTI on UA on admission, but no fever or other signs of systemic infection. Her acute urinary infection may have contributed to her ARF. UCx >100,000 enterococcus, initially treated empirically w/ levofloxacin; the patient received a full 3 day course which finished [**11-14**]; however, urine culture/sensitivities subsequently came back as Levo resistant, and the pt's foley was removed, and she was started on Vancomycin [**11-16**]. The pt was renally dosed, based on trough levels; [**11-17**] Vanc trough was 6.8, and the patient received an additional dose that day. Trough on [**11-18**] was 17.7, and no further doses of vancomycin were given. The pt remained afebrile, with no elevation in white count. . 3. CAD: The patient had a h/o CABG, stents, severe 3VD, w/ some partially reversible defects on last PMIBI. No cardiac symptoms or EKG changes on admission. On admssion, troponin was elevated at 0.06, however CK/MB were normal, and tropinin levels remained constant; therefore, elevated troponin therefore most likely due to renal failure. On [**11-15**] during her first hemodialysis session, the pt developed 5/10 chest pain which lasted 5 minutes, and spontaneously resolved, no associated symptoms. EKG showed new left bundle (previously had IVCD) and peaked T waves. The patient never had any further chest pain, shortness of breath or palpitations. She remained on her home regimen of ASA, Plavix, Metoprolol, Nitropatch, and statin. 4 Hypercarbia: The patient's ABGs showed respiratory acidosis along with metabolic acidosis. The patient is a very obese woman who reportedly snores at night, thus calling into question possibility of pickwickean syndrome vs. sleep apnea. Pulm consult was requested, who stated that the patient has a physiologically abnormal response to hypercarbia, and recommmended obtaining a sleep study as outpatient. During the course of her admission, the team also attempted to limit administration of narcotics, in order to minimize respiratory depression. ABG's were checked daily until [**11-15**]; post-dialysis ABG was attempted by multiple providers but failed, and pt refused further attempts. Renal team subsequently followed bicarbonate levels on chem-10 during daily dialysis. . 5. DM2: Controlled w/ home regimen of NPH 25units qam, Humalog SS . 5. HTN: Metoprolol, clonidine, nitro patch, lisinopril 2.5 mg qd was started [**11-16**]. . 6. Anemia: Secondary to chronic renal disease, Hct decreased from 42 [**11-12**] to 32.8 [**11-13**]. Guaiac negative. Possibly was hemoconcentrated on admission, then hydrated resulting in dilution. Erythropoietin was given at at each dialysis session. Iron was discontinued, and the pt was started on nephrocaps. . 7. Hypothyroid: Controlled w/ home regimen of Levoxyl. . 8. FEN: cardiac/[**Doctor First Name **] diet . 9. Proph: heparin sc, PPI, bowel regimen . 10. Access: Peripheral IV - PICC attempted by RN but failed. . 12. CODE STATUS: Pt was initially DNR/DNI, however, pt subseuqently discussed code status with Dr. [**Last Name (STitle) **] on [**11-15**], when she stated that she wished to be full code, and would accept intubation, shock, pharmacotherapy - however, that she did not wish to have prolonged measures. The patient was discharged on [**11-18**], after receiving her 3rd in-house course of hemodialysis; she was scheduled for her first outpatient dialysis session for [**11-20**]. Discharge Medications: 1. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 3. Calcium Acetate 667 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Tablet(s)* Refills:*2* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Chronic renal failure/Acute renal failure, DMTypeII, coronary artery disease, hypertension, urinary tract infection Discharge Condition: Stable Discharge Instructions: Outpatient hemodialysis as instructed. Call your primary care provider with any shortness of breath, chest pain, edema/swelling, fever/chills, confusion, tremor, any other worrisome symptoms Followup Instructions: - You have an appointment for dialysis at [**Location (un) **] [**Location (un) **], Wednesday [**11-20**] 11:15AM, then on Tues/Thurs/Saturday - Please call Dr.[**Name (NI) 5452**] office for follow-up appointment in [**2-1**] weeks - Please call [**Telephone/Fax (1) 6856**] to schedule a sleep study to evaluate for sleep apnea Completed by:[**2176-11-18**]

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icd9cm

[ [ [] ] ]

[ "39.95", "38.95" ]

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36213

Discharge summary

report

Admission Date: [**2133-11-11**] Discharge Date: [**2133-11-15**] Service: NEUROSURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 1835**] Chief Complaint: Unsteady gate Major Surgical or Invasive Procedure: None History of Present Illness: 84y/o gentleman transferred from outside hospital for initial complaint of disorientation and unsteady gate, a Ct scan of the head there revealed a acute on Chronic SDH bilaterally, but greater on the left. On questioning here in the ED, the pt. denies history of falls. He expresses that he has been having difficulty with gate and balance for about a month and had difficulty standing this morning. Pt. is on Coumadin for DVTs and presented with an INR of 3.0, he was given one unit of FFP at the outside facility. Past Medical History: - coronary artery disease s/p MI and CABG [**44**] yrs ago - lower extremity DVT in [**8-/2133**] (now off anticoagulation due to SDH; bliateral LENIs earlier this month show no clot) - colon cancer (stage, therapy, status otherwise unknown) - hyperlipidemia - hypertension - chronic kidney disease, stage II with baseline creatinine 1.2 Social History: Lives with son Family History: NC Physical Exam: BP:208 / 80 HR: 60 R O2Sats Gen: WD/WN, comfortable, NAD. HEENT: Pupils:pinpoint bilaterally EOMs: intact Neck: Rigid collar in place Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Cranial Nerves: I: Not tested II: Pupils equally round, pinpoint, flicker reactivity. 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. Sligth Right pronator drift Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**4-13**] throughout. Sensation: Intact to light touch, Reflexes: B T Br Pa Ac Right 2+------------- Left 2-------------- Toes upgoing bilaterally Coordination: slight R finger to nose dysmetria Upon Discharge: Denies HA, ROS negative A&O [**1-11**], has baseline dementia, sl. R pronator drift, face/smile symmetric. MAE, Full strength. Pertinent Results: [**2133-11-11**] GLUCOSE-87 UREA N-27* CREAT-1.4* SODIUM-135 POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-27 ANION GAP-13 [**2133-11-11**] WBC-14.3*# RBC-3.88* HGB-11.8* HCT-34.2* MCV-88 MCH-30.5 MCHC-34.6 RDW-13.5 [**2133-11-11**] PT-23.2* PTT-29.1 INR(PT)-2.2* [**2133-11-13**] BLOOD WBC-7.7 RBC-3.41* Hgb-10.2* Hct-29.7* MCV-87 MCH-29.8 MCHC-34.1 RDW-13.5 Plt Ct-212 [**2133-11-13**] 07:15AM BLOOD PT-13.4 PTT-24.8 INR(PT)-1.2* [**2133-11-13**] 07:15AM BLOOD Glucose-108* UreaN-22* Creat-1.4* Na-130* K-3.8 Cl-97 HCO3-24 AnGap-13 Head CT [**11-11**] 11a:Acute on chronic left basal frontal subdural hematoma with 5 mm of midline shift as detailed above. Scattered foci of subdural hematoma along the basal right frontal lobe and right temporal lobe as well. No skull fracture identified. Head CT [**11-11**] 7p: Little change to acute on chronic subdural hematomas. There is no evidence of new intracranial herniation. Head CT [**11-12**] 8p:Little change to the acute-on-chronic bilateral subdural hematomas. No evidence for new intracranial hemorrhage or herniation. Brief Hospital Course: 84M admitted the ICU for observation of Bilat. Acute on Chronic SDH. He was on Coumadin for a DVT which has since now resolved based on recent U/S of BLE. His INR was reversed and pt had subsequent stable head CTs and stable neurologic exams. He was transferred to the SDU where he remained stable and was seen by PT and OT who recommended home therapy. On [**11-13**] his foley was d/c'd and he was tolerating Reg diet. His Sodium dropped from 135 to 130 the day prior and he was placed on free water restrictiion and Sodium was monitored. He was placed on a fulid restriction and salt tabs and his sodium came up to 132 on the day of discharge. He was sent home with a fluid restricion and direction to follow up with his pcp for additional lab work and follow up Na level within a week of his discharge date. He will follow up with Dr. [**Last Name (STitle) **] for schedualing of elective drainage of his subdurals on an elective basis. Medications on Admission: Provigil Coumadin Folic acid Triamterene-Hydrochlorothiazid Doxazosin Donepezil Discharge Medications: 1. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Doxazosin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 7. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*0* 8. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 10. Multivitamins Tablet, Chewable Sig: One (1) Tablet PO DAILY (Daily). 11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 13. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 14. Sodium Chloride 1 gram Tablet Sig: One (1) Tablet PO twice a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 3894**] Health VNA Discharge Diagnosis: Bilateral Acute on Chronic SDH Discharge Condition: Neurologically stable Discharge Instructions: ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. . You may return to your day program. . Please Make an appointment to see your PCP by Wed of this week for blood work, your Sodium level has been low here in the hospital and you were placed on fluid restriction with a max intake of water of 1000 ml, and you have been perscribed Salt tabs. Please have your PCP check your Sodium level again this week. You can increase your intake of salt and drink V8 or Gateraid when possible. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in 4 weeks to discuss surgical options. ??????You will need a CT scan of the brain without contrast prior to your visit, our office will arrange this for you, just be sure to mention that you need a CT when you call for your appointment. Completed by:[**2134-2-7**]

[ "V45.81", "401.9", "294.8", "276.1", "414.00", "V12.51", "V58.61", "432.1" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5894, 5956

3648, 4590

239, 246

6031, 6055

2553, 3625

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274, 794

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32,291

147,151

33666

Discharge summary

report

Admission Date: [**2171-1-5**] Discharge Date: [**2171-1-12**] Date of Birth: [**2125-9-14**] Sex: M Service: CARDIOTHORACIC Allergies: Percodan / Codeine Attending:[**First Name3 (LF) 922**] Chief Complaint: Abdominal and Chest Pain Major Surgical or Invasive Procedure: none History of Present Illness: 45 y/o male with presented to OSH with acute abdominal and chest pain. Along with nausea, shortness of breath and pain radiating to back. Blood pressure at OSH was 200's/100's. Transferred to [**Hospital1 18**] after CT showed Type B Aortic Dissection. Past Medical History: Malformed Eustachian tubes s/p surgery, s/p T&A, s/p deviated septum repair Social History: Quit smoking 20 yrs ago. Denies ETOH use. Family History: Father with MI/CAD over age 60 Physical Exam: VS: 91 13 179/98 5'9" 310lbs Gen: WD/WN obese male in NAD Skin: Unremarkable HEENT: EOMI, PERRL, NCAT Neck: Supple, FROM -JVD Chest: CATB -w/r/r Heart: RRR -c/r/m/g Abd: Soft, NT/ND +BS, +RUQ tenderness, obese Ext: Warm, well-perfused -edema Neuro: A&O x 3, MAE, non-focal Pertinent Results: CT Chest/Abd 2/16:1. Type B aortic dissection extending from just distal to the takeoff of the left subclavian artery and extending to the aortic bifurcation. Poor opacification of renal arteries mostly due to timing, but the left renal artery is likely supplied by true and false lumens and compromised flow is suspected. Small focal areas in the upper pole of decreased perfusion concerning for ischemia. Slight left renal cortical increased assymetric enhancement elsewehere raises question of delayed nephrogram from outside CT with contrast. An MRA of the kidneys could be performed to further assess. 2. Findings consistent with arteriovenous malformation in the posterior right lobe of the liver. Renal Scan [**1-8**]: Symmetric perfusion, concentration, and excretion in both kidneys. CT neck [**1-9**]: Evaluation of the origins and proximal portions of the great vessels is somewhat limited by patient body habitus, but no definite evidence of involvement of the origins of the great vessels by the aortic dissection of the descending thoracic aorta. No aneurysms, stenoses, or occlusions of the cervical vessels. CT Chest/Abd [**1-9**]: 1. Unchanged extent and configuration of type B aortic dissection extending from the origin of left subclavian artery to distal abdominal aorta. Mild increase in thickness of the aortic wall in the distal arch, however, suggests expansion of intramural hematoma. 2. Patent aortic arch branch vessels, celiac and superior mesenteric arteries and right renal artery arising from true lumen. The left renal artery and possibly the inferior mesenteric artery arise from the false lumen, but opacify. 3. Unchanged, probable arterioportal fistula, right lobe of the liver. 4. Increased bilateral pleural effusions and pulmonary edema. 5. Sigmoid diverticulosis. 6. Bilateral hypodense renal lesions most likely representing cysts. Ultrasound or MR could be performed for confirmation. [**2171-1-5**] 04:35AM BLOOD WBC-11.1* RBC-4.20* Hgb-14.1 Hct-39.3* MCV-94 MCH-33.5* MCHC-35.8* RDW-13.3 Plt Ct-224 [**2171-1-10**] 02:38AM BLOOD WBC-9.5 RBC-3.92* Hgb-13.3* Hct-36.7* MCV-94 MCH-34.1* MCHC-36.3* RDW-12.7 Plt Ct-321 [**2171-1-5**] 04:35AM BLOOD PT-12.1 PTT-22.6 INR(PT)-1.0 [**2171-1-7**] 02:38AM BLOOD PT-11.6 PTT-24.8 INR(PT)-1.0 [**2171-1-5**] 04:35AM BLOOD Glucose-205* UreaN-12 Creat-1.0 Na-138 K-3.7 Cl-99 HCO3-28 AnGap-15 [**2171-1-10**] 02:38AM BLOOD Glucose-128* UreaN-15 Creat-0.9 Na-137 K-3.6 Cl-105 HCO3-23 AnGap-13 [**2171-1-10**] 02:38AM BLOOD ALT-29 AST-39 LD(LDH)-292* AlkPhos-92 Amylase-57 TotBili-0.7 [**2171-1-8**] 02:04AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.2 Brief Hospital Course: As mentioned in the HPI, Mr. [**Known lastname 77933**] was transferred from OSH following a CT which showed a Type B aortic dissection. He was admitted to the CVICU for further work-up and treated for his hypertension with Nipride and Esmolol gtt. During hospital course medications were adjusted for strict blood pressure control. Chest and Abd CT on day of admission again revealed a Type B dissection. Vascular surgery were consulted. Pulmonary Medicine were also consulted for possible obstructive sleep apnea and he was started on BiPAP. He continued to remain stable while in the CVICU and his IV hypertension medications were eventually switched to PO. He transferred to the telemetry floor on [**1-10**]. Cardiology was consulted for further management of his blood pressure and to coordinate follow-up cardiologist upon discharge. On [**1-12**] he appeared to be doing well and was discharged home with the appropriate follow-up appointments and medications. Medications on Admission: none Discharge Medications: 1. 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:*1* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*1* 7. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q6H (every 6 hours). Disp:*360 Tablet(s)* Refills:*1* 8. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 10. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTHUR (every Thursday). Disp:*4 Patch Weekly(s)* Refills:*2* Discharge Disposition: Home with Service Discharge Diagnosis: Type B Aortic Dissection Sleep Apnea Discharge Condition: Good Discharge Instructions: Please take all you medications as instructed and make appropriate follow-up appoinments. Followup Instructions: Cardiac Surgeon - Dr. [**Last Name (STitle) 914**] in [**12-23**] weeks Vascular Surgeon - Dr. [**Last Name (STitle) **] in [**12-23**] weeks Cardiologist - Dr.[**Name (NI) 3733**] ([**Telephone/Fax (1) 1989**]) in [**12-23**] weeks Sleep Clinic ([**Telephone/Fax (1) 612**]) in [**1-22**] weeks Completed by:[**2171-1-12**]

[ "V15.82", "278.00", "593.2", "327.23", "441.01", "562.10", "401.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6009, 6028

3755, 4725

308, 314

6108, 6114

1110, 3732

6252, 6578

770, 802

4780, 5986

6049, 6087

4751, 4757

6138, 6229

817, 1091

244, 270

342, 596

618, 695

711, 754

67,819

134,703

44013

Discharge summary

report

Admission Date: [**2183-2-3**] Discharge Date: [**2183-2-10**] Date of Birth: [**2123-7-2**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1990**] Chief Complaint: Difficulty Breathing Major Surgical or Invasive Procedure: None History of Present Illness: 59M with +tobacco history, previous visits to ED for COPD exacerbations (per ED report), s/p CVA x2, psychotic d/o who presents with difficulty breathing x1day. No chest pain, no cough. Not using albuterol inhalers at home as directed, but did endorse relief of sx when used inhaler. Continues to smoke, though at much reduced quantity (few cig per day). No known sick contacts, but attends adult day care. No recent long car rides, flights, travel. Did not check temperature at home, and has not felt feverish. Received flu shot 3-4 months ago from daycare program. . In the ED, vitals were T101.6 HR 116 136/70 20 98% 2L NC. Then 102.6 107 172/106 24 98% 15L NRB . Pt received nebs x 2 and had improvement in breathing. Attempted peak flow, but pt couldn't quite understand. Given Levofloxaxin 750mg x1 and prednisone 60mg x1. Also given Tylenol for fever. EKG showed sinus tachy without signs of ischemia. At time of transfer, pt was satting 98% on 2L NC. . Of note, pt was admitted 3 weeks ago for cellulitic black eschar on lateral aspect of left foot. Had followed up with podiatry as an outpatient, and Dr. [**Last Name (STitle) **] felt lesion was healing well on [**2183-1-29**]. . On the floor, pt states he is "very well, thank you." Denying F/C, N/V, change in urinary habits, CP, DOE, SOB (current), rhinorrhea, cough, hemoptysis or other phlegm, orthopnea. Past Medical History: * Status post two cerebrovascular accidents complicated by L hemiplegia ([**2174**]) * Hypertension * Coronary Artery Disease * Hypercholesterolemia * Psychotic disorder NOS, mental baseline per family is child-like * Anxiety disorder Social History: Patient immigrated to [**State 760**], then [**Location (un) 86**] from [**Male First Name (un) 1056**] in his mid teens. Formerly worked as a teacher's aid, performing dancing and comedy on the side. Requires constant care and supervision from adult daycare, niece, sister, and other family since his stroke and hemiparesis. He is wheelchair bound. Smoked for ~40 years, before CVA 4PPD, now 1/2PPD. Denies EtOH, other drugs Family History: One relative with CVA, niece with pulmonary fibrosis, brother with DM2. [**Name2 (NI) **] known cancer or MI in family. Physical Exam: PHYSICAL EXAMINATION AT ADMISSION: VS: 100.8, 114/74, 110, 20@98%(RA) Gen: NAD. Mood and affect slightly childish and difficulty attending to questions. Pleasant and cooperative. Resting in bed. HEENT: NCAT. Acne. R pupil appeared to be [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **], but both eyes difficult to examine. EOM appeared to be intact. Anicteric sclera. MMM, OP clear. Dentures in place. Neck: Supple. JVP not elevated. No carotid bruits noted. CV: Slight tachycardia. Normal S1, S2. No murmur, rubs, or gallops. Chest: Respiration unlabored, no accessory muscle use. CTAB. Poor air movement bilaterally, but no wheezing appreciated. Abd: BS present. Soft, NT, ND. No HSM detected. Ext: WWP, no cyanosis or clubbing. No edema. Distal pulses radial 2+, DP/PT unappreciated; No asymmetry in color or size of LE, no pain in palpation of gastrocnemius. Skin: L lateral foot with healing eschar, no surrounding erythema. No rashes, ecchymoses noted. Neuro/Psych: CNs II-XII intact as best as can appreciate with level of cooperation. 5/5 strength in right U/L extremities. [**3-18**] on LUE, hamstring; [**12-18**] in dorsiflexion; L foot kept in plantar flexion. DTRs 2+ BL (biceps, patellar); clonus noted in L ankle with + Babinski. Sensation intact to LT, temperature. Cerebellum not formally tested, but pt able to initiate complex movements (e.g. crossing legs) bilaterally. WC bound at baseline. PHYSICAL EXAMINATION AT DISCHARGE: VS: Tm 98.3 Tc 97.8, HR 84(84-140) 110/70(110-148/70-88) 20 96RA GEN: NAD, lying on left side hunched over in bed HEENT: NC/AT,Mild nasal congestion. CV: RRR, nl s1 and s2, no m/r/g appreciated PULM: Left lung decreased breath sounds on (dependent), Breathing unlabored. ABD: soft, protuberant, non-tender, +BS EXT: wwp, radial pulses palpated, pedal pulses not palpable SKIN: left eschar wrapped in kerlix NEURO: arousable, stable left hemiplegia with clonus of the left foot Pertinent Results: IMAGING: [**2183-2-3**] CXR: Cardiac, mediastinal and hilar contours are normal. There is no pleural effusion or pneumothorax. There is no focal consolidation. No acute intrathoracic abnormality . [**2183-2-5**], CXR: Previous chest radiographs documented hyperinflation likely due to emphysema or small airways obstruction. Today's study shows normal lung volumes, although there is distortion of the pulmonary vascular branching in the upper lobes suggesting emphysema. Most significant is interstitial abnormality at both lung bases, chronicity indeterminate, that could be acute viral pneumonia or chronic interstitial disease such as non-specific interstitial pneumonitis. Of note, the heart is not enlarged. There is no pulmonary vascular or mediastinal venous engorgement and no pleural effusion. . **FINAL REPORT [**2183-2-5**]** DIRECT INFLUENZA A ANTIGEN TEST (Final [**2183-2-5**]): POSITIVE FOR INFLUENZA A VIRAL ANTIGEN. REPORTED BY PHONE TO [**First Name8 (NamePattern2) 4224**] [**Last Name (NamePattern1) **] [**2183-2-5**] 10:40AM. DIRECT INFLUENZA B ANTIGEN TEST (Final [**2183-2-5**]): Negative for Influenza B. . -Legionella negative. -Urine and blood cx NEGATIVE ################################################################ Labs: [**2183-2-3**] 01:35PM BLOOD WBC-6.6 RBC-4.17* Hgb-13.9* Hct-40.5 MCV-97 MCH-33.3* MCHC-34.4 RDW-13.1 Plt Ct-154 [**2183-2-5**] 11:07AM BLOOD WBC-7.3 RBC-4.19* Hgb-13.7* Hct-40.6 MCV-97 MCH-32.7* MCHC-33.8 RDW-13.2 Plt Ct-147* [**2183-2-10**] 05:50AM BLOOD WBC-7.6 RBC-4.10* Hgb-13.3* Hct-39.6* MCV-97 MCH-32.5* MCHC-33.7 RDW-12.9 Plt Ct-225 . [**2183-2-5**] 12:45PM BLOOD PT-12.7 PTT-26.1 INR(PT)-1.1 , [**2183-2-3**] 01:35PM BLOOD Glucose-97 UreaN-13 Creat-1.0 Na-134 K-4.7 Cl-99 HCO3-26 AnGap-14 [**2183-2-7**] 05:35AM BLOOD Glucose-143* UreaN-25* Creat-1.0 Na-136 K-3.8 Cl-99 HCO3-28 AnGap-13 [**2183-2-9**] 06:20AM BLOOD Glucose-88 UreaN-24* Creat-0.9 Na-142 K-3.7 Cl-107 HCO3-27 AnGap-12 [**2183-2-10**] 05:50AM BLOOD Glucose-91 UreaN-33* Creat-1.1 Na-139 K-3.9 Cl-106 HCO3-28 AnGap-9 . [**2183-2-6**] 06:38AM BLOOD Calcium-9.4 Phos-3.9 Mg-2.3 [**2183-2-9**] 06:20AM BLOOD Calcium-9.2 Phos-3.3 Mg-2.0 . [**2183-2-3**] 02:53PM BLOOD Lactate-1.1 [**2183-2-5**] 12:50PM BLOOD Lactate-1.0 Brief Hospital Course: Mr. [**Known lastname 68250**] is a 59 year old man with a history of left sided hemiplegia secondary to CVA x2, HTN, significant tobacco use and emphysema (COPD per ED report) who presented with difficulty breathing. At presentation to the ED, he was additionally found to be tachycardic and febrile. # Dyspnea: The acute onset of shortness of breath is likely due to underlying COPD exacerbated by influenza infection, possibly with bacterial superinfection and worsened by anxiety. At presentation, there was minimal concern for PE given the lack of risk factors; however, the patient has limited mobility at baseline and was tachycardic at presentations. Consistent with a COPD exacerbation, wheezes were noted at presentation, and again during periods of shortness of breath. He was started on steroids, azithromycin, and standing nebulizers. The patient had received a flu vaccine this year, but DFA for influenza was sent given his poor respiratory status and fever, and returned positive on HD2. The morning of hospital day 2, Mr. [**Known lastname 68250**] began suffering from worsening respiratory distress, and required transfer to the intensive care unit for closer observation. Oseltamivir was given for influenza, as were antibiotics for concern for a secondary bacterial infection causing pneumonia. With BiPAP and neb treatment, he improved, and the following day returned to the floor. He never required intubation. A chest radiograph revealed emphysema and bibasilar interstitial infiltrates concerning for viral pneumonia or a chronic interstitial disease. Given that his decompensation occurred after being admitted for >36 hours, suspicion for bacterial superinfection was sufficiently high to initiate treatment for common causes of community acquired pneumonia. Of note, patient's respiratory status also decompensated with increased anxiety, and anxiety was managed using outpatient regimen of Ativan TID PRN. # Sinus Tachycardia: The patient was tachycardic in the ED and on the floor. This was most likely due his response to infection, but use of albuterol and dehydration likely contributed. The tachycardia could have also been related to rebound tachycardia from holding atenolol. The tachycardia improved in conjunction with improvement in his shortness of breath and restarting his atenolol at half dose - 50mg PO daily. # Left Lateral Foot Eschar: The pressure ulcer, which resulted in a recent hospital admission, likely is due to the patient's proclivity towards lying and sleeping on his left lateral side in combination with left hemiplegia. Per the podiatry recommendations, Silvadene was applied with daily dressing changes, and a waffle boot was placed on the left foot as tolerated to avoid injury from continued pressure. He will have daily dressing changes and follow up with podiatry. # Hypertension: The patient was continued on home enalapril and hydrochlorothiazide. Home atenolol was held briefly after the ICU transfer for concern that it would exacerbate poor respiratory function. Atenolol was restarted and his BP was stable at the time of discharge. # Anxiety/Psychosis NOS: Home medications were continued, which include fluoxetine, olanzapine, trazodone and lorazepam. Trazodone and lorazepam were held briefly after the ICU transfer for concern that they would exacerbate poor respiratory function. Lorazepam was restarted and trazadone was held to be restarted by his PCP. # Hyperlipidemia: Home simvastatin was continued. # s/p Cerebrovascular Accident with residual left-sided hemiplegia: Continued home dipyridamole-aspirin and tizanidine. Tizanidine was held during and briefly after the ICU transfer for concern that the sedating effects would exacerbate respiratory distress. Pt respiratory status is stable, and Tizanidine was restarted at the time of discharge and for him to be followed by his PCP and nurse practitioner. # Code: confirmed full Medications on Admission: 1. atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day. 2. dipyridamole-aspirin 200-25 mg Cap, Multiphasic Release 12 hr Sig: One (1) Cap PO BID (2 times a day). 3. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. olanzapine 5 mg Tablet Sig: One (1) Tablet PO at bedtime. 7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia --> Per pharmacy, filled [**1-23**] at 1/2 tab q6 hours 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 11. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). --> not taking, finished course 12. enalapril maleate 20 mg Tablet Sig: One (1) Tablet PO once a day. 13. lorazepam 1 mg Tablet Sig: One (1) Tablet PO once a day as needed for anxiety. 14. calcium and vit D Sig: continue home regimen twice a day. 15. Tizanadine 4mg PO BID 16. Silvadene cream TP to Left foot qday --> pt's niece reports occasional inhaler use, but pharmacy hasn't had Rx filled since [**2181-12-14**] Discharge Medications: 1. silver sulfadiazine 1 % Cream Sig: One (1) Appl Topical DAILY (Daily). 2. dipyridamole-aspirin 200-25 mg Cap, ER Multiphase 12 hr Sig: One (1) Cap PO BID (2 times a day). 3. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. calcium carbonate Oral 8. cholecalciferol (vitamin D3) Oral 9. enalapril maleate 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 11. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)). 12. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. lorazepam 1 mg Tablet Sig: One (1) Tablet PO NOON (At Noon) as needed for agitation, anxiety. 15. 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. Disp:*1 inhaler* Refills:*0* 16. Aggrenox 200-25 mg Cap, ER Multiphase 12 hr Sig: One (1) Cap, ER Multiphase 12 hr PO twice a day. 17. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 1 days. Disp:*3 Tablet(s)* Refills:*0* 18. prednisone 10 mg Tablet Sig: Three (3) Tablet PO taper for 8 days: 30mg (3 tabs)through [**2-11**]; On [**2-12**] take 20mg (2tabs) through [**2-14**]; on [**2-15**] take 10mg through [**2-17**] . Disp:*12 Tablet(s)* Refills:*0* 19. tizanidine 4 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home With Service Facility: guardian healthcare Discharge Diagnosis: Principle: -Dyspnea, multifactorial . Secondary: -Emphysema -Influenza A -Anxiety -Left lateral foot ulcer -Hypertension -Hyperlipidemia -Cerebrovascular Accident -Psychosis NOS Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname 68250**], It was a pleasure taking care of you at the [**Hospital1 18**]. You came to the emergency department with difficulty breathing and a fever. You were admitted to the hospital and were treated with inhaled medications to improve your breathing. We then discovered that you had the flu (influenza). Your respiratory infection was treated with Oseltamivir and several antibiotics for a bacterial infection of your lungs (in addition to the flu). You are now doing much better and are ready for discharge to home. Please continue your home medications as directed. The following additional medications were prescribed: - START Augmentin 500 mg every 8 hours, for 1 day end [**2183-2-11**] - START Prednisone, and taper your dose as follows:30mg through [**2-11**]; then 20mg through [**2-14**]; then 10mg through [**2-17**] - START using an inhaler to help your breathing - DECREASE your dose of atenolol to 50mg daily Please call your primary care doctor if your symptoms return. Dial 911 if it is an emergency. Followup Instructions: Your nurse will visit you at home after your discharge from the hospital. Department: PODIATRY When: THURSDAY [**2183-2-27**] at 2:20 PM With: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM [**Telephone/Fax (1) 543**] Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

13970, 14020

6872, 10810

323, 330

14242, 14242

4574, 6849

15498, 15952

2464, 2586

12181, 13947

14041, 14221

10836, 12158

14422, 15475

2601, 4062

4076, 4555

263, 285

358, 1745

14257, 14398

1767, 2003

2019, 2448

60,788

152,778

41529

Discharge summary

report

Admission Date: [**2180-1-26**] Discharge Date: [**2180-2-8**] Date of Birth: [**2117-3-3**] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1406**] Chief Complaint: Unstable angina Major Surgical or Invasive Procedure: [**2180-1-31**] Coronary artery bypass grafting x3 with left internal mammary artery to the left anterior descending artery and reverse saphenous vein graft to the obtuse marginal and the right coronary artery History of Present Illness: 62 year old female with known hypertension, hypercholesterolemia, and intermittent chest pain x 1 year. She presented to her PCP [**Last Name (NamePattern4) **] [**1-25**] with chest pressure and on exam was found to be very hypertensive. She was transferred to OSH ED and upon arrival her documented blood pressure was 253/135. She describes her chest pain as substernal pressure that radiates to the left arm, occasionally bilateral upper extremities, shortness of breath, nausea, and occasional back discomfort is associated. It lasts 15-30 minutes, resolves on its own, worsens with exertion, and is increasing in frequency, and at rest. She was cathed at OSH and found to have significant coronary stenosis in multiple vessels. She was transferred to [**Hospital1 18**] for evaluation of coronary revascularization. Past Medical History: Hypertension Hyperlipidemia Obesity Past Surgical History: s/p Hysterectomy s/p (R)elbow Fx'[**76**] repair s/p breast reduction Social History: Lives with:married. Has 2 daughters Occupation:[**Name2 (NI) **] Tobacco:denies ETOH:occ. Family History: + Heart dz-x2 open heart surgies. Mother +Diabetes. Brother +MI Physical Exam: Pulse:85 Resp:18 O2 sat: 98%RA B/P Right: 142/88 Left: Height: 60 inches Weight: 83.9 General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally (distant)[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[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: - Pertinent Results: [**2180-1-31**] Echo: PRE-CPB:1. The left atrium is mildly dilated. No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No spontaneous echo contrast is seen in the left atrial appendage. No thrombus is seen in the left atrial appendage. 2. No thrombus is seen in the right atrial appendage No atrial septal defect is seen by 2D or color Doppler. 3. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %). 4. Right ventricular chamber size and free wall motion are normal. 5. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta.6. There are three aortic valve leaflets. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. 7. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 8. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results. POST-CPB: On infusion of phenylephrine. A pacing for sinus bradycardia. Well-preserved biventricular systolic function with LVEF now 55%. Trace MR is improved from pre cpb. Aortic contour is normal post decannulation. Brief Hospital Course: The patient was transferred from the outside hospital for coronary bypass evaluation. The usual preoperative workup was performed. Echo revealed EF 65% with 1+MR. There was no acute process on chest x-ray. The patient was started on a heparin drip and time was allowed for Plavix washout. The patient was brought to the operating room on [**2180-1-31**] the patient underwent CABG x 3. Please see operative note for surgical details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. By post-op day one he was weaned from sedation, awoke neurologically intact and extubated. The patient was also hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery on post-op day one. Chest tubes and pacing wires were discontinued without complication. On POD#2 patient was noted to have new right facial droop and slurred speech. She was without addtional motor deficits at that time. The stroke service was consulted but Mrs. [**Known lastname 3314**] refused evaluation and work up. She was placed on a full strength aspirin which was changed to baby aspirin when she placed on coumadin for post operative afib. She was also treated with amiodarone and her betablocker was increased. Her goal SBP is 130 for cerebral perfusion per neruology curbside consult. The neuro event and the post operative afib was communicated to Dr. [**First Name (STitle) 1022**] via telephone on day of discharge. DR. [**First Name (STitle) 1022**] will also be following her coumadin dosing. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 8, the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home in good condition with VNA services with the appropriate medications and follow up instructions. Medications on Admission: Medications at home: noncompliant with prescribed meds. Occasionally takes ASA for headaches. Meds on Transfer:Lopressor 50(2),ASA, Lisinopril 40(1), HCTZ 12.5(1), Protonix 40(1) Plavix - last dose:[**2180-1-26**] -75mg. On [**1-25**]=300mg load Discharge Medications: 1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 4. 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:*1* 5. 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* 6. warfarin 2.5 mg Tablet Sig: as directed for afib Tablet PO once a day: Goal INR 2.0-2.5 for afib. Disp:*60 Tablet(s)* Refills:*2* 7. Outpatient Lab Work INR draw on [**2180-2-9**] and fax results to Dr. [**First Name (STitle) 1022**] [**Telephone/Fax (1) 90334**] or call [**Telephone/Fax (1) 81482**] Goal INR 2.0-2.5 for afib 8. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg twice daily until [**2180-2-14**] then decrease to once daily until [**2180-2-21**] then 200mg daily ongoing. Disp:*120 Tablet(s)* Refills:*2* 10. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. Disp:*180 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: all care vna Discharge Diagnosis: Coronary Artery Disease, s/p Coronary Artery Bypass Graft x 3 new right facial droop and right sided weakness post surgery (*patient refused evaluation by Neurology*) Post operative afib PMH: Hypertension Hyperlipidemia Obesity Post cardiac surgery atrial fibrillation Past Surgical History: s/p Hysterectomy s/p (R)elbow Fx'[**76**] repair s/p breast reduction Discharge Condition: Alert and oriented x3 - new right sided facial droop and right sided weakness Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema: trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Coumadin for afib Goal INR 2.0-2.5 First INR draw [**2180-2-9**] and fax results to Dr. [**First Name (STitle) 1022**] [**Telephone/Fax (1) 90334**] or call result to [**Telephone/Fax (1) 90335**] for coumadin dosing. Followup Instructions: You are scheduled for the following appointments: Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on [**2180-3-1**] at 1pm [**Telephone/Fax (1) 170**] Primary care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**] on [**2180-2-10**] ANYTIME of day [**Telephone/Fax (1) 81482**] Please call to schedule the following: Cardiologist Dr. [**First Name (STitle) **] to be seen in 3 weeks Coumadin for afib Goal INR 2.0-2.5 First INR draw [**2180-2-9**] and fax results to Dr. [**First Name (STitle) 1022**] [**Telephone/Fax (1) 90334**] or call result to [**Telephone/Fax (1) 90335**] for coumadin dosing. **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:[**2180-2-8**]

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icd9cm

[ [ [] ] ]

[ "36.15", "38.93", "39.61", "36.12" ]

icd9pcs

[ [ [] ] ]

7821, 7864

3786, 5910

324, 535

8273, 8489

2389, 3763

9580, 10418

1663, 1728

6208, 7798

7886, 8157

5936, 5936

8513, 9557

5957, 6031

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1743, 2370

269, 286

563, 1387

1409, 1446

1556, 1647

6048, 6185

46,081

135,870

42368+58520

Discharge summary

report+addendum

Admission Date: [**2137-1-2**] Discharge Date: [**2137-1-10**] Date of Birth: [**2055-3-1**] Sex: F Service: NEUROSURGERY Allergies: Ultram Attending:[**First Name3 (LF) 1835**] Chief Complaint: confusion and facial droop Major Surgical or Invasive Procedure: [**2137-1-7**]: Right frontal craniotomy and resection of lesion History of Present Illness: 81F with h/o HTN presented to [**Hospital6 **] today with 10 days of confusion and left facial droop. No other complaints--denies HA, fevers, falls, syncopal episodes, dyscoordination, vertigo. CT at [**Last Name (LF) 1724**], [**First Name3 (LF) **] report, with 5x5cm likely primary GBM, right frontal. Transferred here for w/u Past Medical History: HTN, colon cancer [**2111**], appendectomy, cholecystectomy, Left TKR ([**3-10**]) Social History: NC Family History: NC Physical Exam: On Admission: O: T: 97.8 BP: 159/89 HR: 90 R 18 O2Sats 98% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: [**3-1**] EOMs intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**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, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric except for minimal L marginal weakness 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. Reflexes: B T Br Pa Ac symmetric bilaterally Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin On discharge: nonfocal Pertinent Results: [**2137-1-2**] CTA Head: 1. Right frontal intra-axial mass which, in correlation with recent MRI, demonstrates imaging characteristics compatible with a high-grade glial neoplasm. 2. Stable but extensive edema and mass effect about the right frontal mass as compared to study of [**2137-1-1**] at 7:04 p.m., with unchanged degree of leftward shift of normally midline structures. 3. CTA shows patent vessels and no significant vascular abnormality associated with the mass. Neoplasm appears to have venous drainage both via the right basal vein of [**Doctor Last Name **] and directly into the right internal cerebral vein. [**1-3**] CT Torso- IMPRESSION: 1. No lymphadenopathy or evidence of malignancy identified in the chest, abdomen or pelvis. 2. Two subcentimeter liver lesions are too small to fully characterize but likely represent cysts. 3. Multilevel DJD as detailed above. [**2137-1-8**] MRI Brain- Post-surgical changes as described above, with enhancing nodular area in the periphery of the surgical resection cavity and persistent mass effect and leftward shift of midline structures Brief Hospital Course: Mrs. [**Known lastname 9973**] was transferred from an outside hospital with a report of a right frontal tumor. CT head and MRI brain with and without contrast from OSH revealed a 5x5cm enhancing mass in the right frontal lobe abutting the right lateral ventricle. She was admitted to the neurosurgery service and started on Dexamethasone 4mg Q8 hrs for cerebral edema and Keppra 500mg [**Hospital1 **] for seizure prophylaxis. CT Torso was obtained to assess for possible primary tumor given her history of colon cancer. This showed no evidence of emtastatic disease. Neuro-oncology and Radiation oncology were consulted. Given the size and location of the tumor the decision was made to proceed with surgical resection followed by chemotherapy and/or radiation therapy. She remained stable on the floor on [**1-3**] - [**1-6**] while awaiting surgical itnervention. On [**1-7**] the patient underwent right frontal craniotomy. Surgery was without complication. She was extubated and transferred to the SICU. Post op Head CT revealed expected post-op changes with pneumocephalus and residual tumor. She was placed on 100% NRB for 24 hours for the pneumocephalus. On teh morning of [**1-8**] she was seen and examined and found to have a left nasolabial fold flattening that was symmetric on smile but was otherwise intact. She underwent an MRi scan with and without contrast that showed residual tumor near the anterior [**Doctor Last Name 534**] of the right lateral ventricle c/w the the CT scan. Overnight, patient was intermittently confused, but was able to calm down and on [**1-9**], was lucid and able to describe the events which took place. She remains intact on examination and was transferred to the floor. PT consult was placed. On [**1-10**] she remained stable ont eh floor and PT and OT evalauted her and felt she was approriate for discharge to home with Home PT and OT. She was discharged on the afternoon of [**1-10**] with instructions for followup. Medications on Admission: ASA 81, Lisinopril, HCTZ, fish, oil Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 5. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. dexamethasone 2 mg Tablet Sig: per taper Tablet PO taper: Take 3mg (1.5 tabs) every 6 hours on [**1-10**] and [**1-11**], Take 2mg (1 tab) every 6 hours on [**1-12**] and [**1-13**], then Take 2mg (1 tab) every 12 hours until follow-up appointment. Disp:*120 Tablet(s)* Refills:*2* 7. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**12-31**] Tablets PO Q4H (every 4 hours) as needed for headache. Disp:*45 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Doctor Last Name **] Green Nursing & Rehab Center - [**Hospital1 **] Discharge Diagnosis: Right Frontal Tumor Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [**7-9**] days (from your date of surgery) for removal of your staples/sutures and/or 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 [**2137-1-21**] 09:30a. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your appointment, or require additional directions. ??????You will not need an MRI of the brain with/ or without gadolinium contrast. Completed by:[**2137-1-10**] Name: [**Known lastname 14446**],[**Known firstname 1435**] Unit No: [**Numeric Identifier 14447**] Admission Date: [**2137-1-2**] Discharge Date: [**2137-1-10**] Date of Birth: [**2055-3-1**] Sex: F Service: NEUROSURGERY Allergies: Ultram Attending:[**First Name3 (LF) 599**] Addendum: After patient was planned for discharge, she was again evaluated by PT and OT per families request. After further evaluation it was determined she could be discharged to a skilled nursing facility secondary to deconditioning. She was offered a bed at a rehab on the evening of [**2137-1-10**] and was discharged there for further care. Discharge Disposition: Extended Care Facility: [**Doctor Last Name 7545**] Green Nursing & Rehab Center - [**Hospital1 1947**] [**Name6 (MD) **] [**Last Name (NamePattern4) 603**] MD [**MD Number(2) 604**] Completed by:[**2137-1-10**]

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Discharge summary

report

Admission Date: [**2180-3-3**] Discharge Date: [**2180-3-5**] Date of Birth: [**2100-7-26**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3705**] Chief Complaint: hemoptysis Major Surgical or Invasive Procedure: bronchoscopy History of Present Illness: 79 Chinese-speaking woman with PMH of HTN, tuberculosis about 50 years ago, hx of hemoptysis in [**2177**] and [**2178**], who presents with 1 day of hemoptysis. Patient was in her usual state of good health when she started coughing and brought up what she estimates is 2 teaspoons of blood mixed with mucous. She has 4-5 episodes of hemoptysis accompanied by a sensation of "itchy throat" over ~ 6 hours and called her daughter who brought her in to the [**Name (NI) **]. . From Pulmonary note [**2179-2-12**]: "Patient first presented with respiratory complaints in the fall of [**2176**]. At the time she had a cough and an abnormal chest x-ray. In [**2177-7-30**] a chest CT revealed multiple small bilateral nodules some of which were calcified consistent with old granulomatous infection and a prominent pulmonary artery. She underwent PFTs which showed normal FEV1, total lung capacity, and DLCO. A followup chest CT one year later in [**2178-9-29**] revealed stable nodules but a segment of the right upper lobe bronchus was dilated. Followup CT in [**Month (only) 956**] of [**2178**] revealed segmental right upper lobe occlusion, question extrinsic compression from calcified lymph node versus endobronchial lesion, bronchoscopy recommended." . The bronch was performed at [**Hospital1 18**] by DFK with normal airways, no evidence of scarring or obstruction. . Patient currently denies chronic cough, fever, SOB, night sweats, or wt loss. . In the ED, patient had a CXR which was clear and a CTA which was negative for PE. IP was consulted and asked that patient be admitted to the MICU for bronchoscopy. Past Medical History: Hx of tuberculosis ~ 50 years ago, ?treated HTN cardiolmegaly syncope Social History: Born and raised in [**Country 5142**] but came to the U.S. in [**2163**]. She was a homemaker her whole life and has 5 children. She is a lifelong nonsmoker and does not drink alcohol. She has excellent exercise tolerance and is able to climb stairs, and walk distances, clean the house with no complaints. She has no pets, birds, or other occupational exposures. She lives with her daughter. Family History: NC Physical Exam: VS: T: 97.1 BP: 131/51 HR: 69 O2 sat: 100% GEN: elderly woman lying in bed, NAD HEENT: MMM, OP clear, PERRLA, neck supple CV: RRR, 2/6 systolic murmur loudest at LUSB PULM: CTAB except for faint crackles at RU lung field ABD: soft, non-tender, non-distended, + BS EXT: no edema, + 2 DP pulses NEURO: alert, oriented Pertinent Results: CXR: IMPRESSION: No acute cardiopulmonary process. . PFT's ([**2179-2-12**]): Pulmonary Report SPIROMETRY Study Date of [**2179-2-12**] 10:59 AM SPIROMETRY 10:59 AM Pre drug Post drug Actual Pred %Pred Actual %Pred %chg FVC 1.73 2.01 86 FEV1 1.46 1.32 111 MMF 1.82 1.72 106 FEV1/FVC 85 66 129 Dx: Dyspnea, Cough. Medications unavailable. Good pt effort and test quality. Mechanics: The FVC and FEV1 are within normal limits while the FEV1/FVC ratio is elevated. Flow-Volume Loop: Normal expiratory contour. Impression: Spirometry is within normal limits. Since [**2177-8-28**], there is no significant change. . BRONCHOSCOPY: DESCRIPTION OF PROCEDURE: The airway was anesthetized with aerosolized 1% lidocaine. The patient was then given conscious sedation with Versed 2 mg and Fantanyl 100 mg and bronchoscope was passed orally into the trachea where there was normal trachea. Sharp carina. Airways were patent in the right upper lobe, right middle lobe and right lower lobe to subsegments. Airways were patent in the left upper lobe, lingula and left lower lobe subsegments. IMPRESSION: Normal airways, no evidence of scarring or obstruction. . [**3-3**]: CTA: IMPRESSION: 1) No pulmonary embolism. 2) No interval change in the segmental tree-in-[**Male First Name (un) 239**] opacities in the posterior aspect of the right upper lobe distal to the calcified endobronchial lesion. 3) Multiple small pulmonary nodules, please see prior CT report of [**2180-2-3**] for description and recommendations. 4) Calcified mediastinal lymphadenopathy consistent with chronic granulomatous disease. 5) Stable aneurysm of the aortic arch. Brief Hospital Course: A/P: 79 Chinese-speaking woman with PMH of HTN, tuberculosis about 50 years ago, who presents with 1 day of hemoptysis . # hemoptysis: Patient has had hemoptysis before in [**2177**] and [**2178**], has been extensively worked up for TB. Given that she is otherwise healthy seems unlikely to be active TB. We sent sputum and gram stain was negative for acid-fast bacilli. Given the tree-and-[**Male First Name (un) 239**] appearance adjacent to the stable lung nodule, suspected that the hemoptysis is from bronchiolitis. IP was consulted and on bronch found fresh blood in the R posterior upper segment which is likely from a bleeding bronchial artery. Given the risk of infarction of the brain or spine with embolization, IP opted to observe patient. Patient had [**11-30**] episodes of minimal hemoptysis after the bronch, with stable HCT. Patient was called out to the floor for further observation. - IP following: felt that BAL negative for AFB was enough to rule out for TB. as long as hemoptysis slowed overnight which it did, she is stable for D/c home and follow up in pulmonary clinic with Dr [**Last Name (STitle) **]. - QD HCT stable. . # HTN: cont cozaar . # osteoporosis: cont calcium . #FEN: regular . #ACCESS: PIV . #PPX: PPI, ambulate, bowel meds PRN . COMMUNICATION: patient, daughter Medications on Admission: ASA 81 mg Cozaar Fosamax Calcium meclizine PRN Discharge Medications: 1. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: hemoptysis bronchiolitis pulmonary bleeding Discharge Condition: stable Discharge Instructions: Take your usual home medications. We have not started or stopped any medications. You had a bronchoscopy to look at your airways. It showed some blood in your lung which is probably from a bronchial artery. While it is possible to stop the bleeding by treating this artery, there is some associated risk. Your physicians have decided that the risks from the procedure are currently higher than the risk from your bleeding. Be sure to return to the emergency department immediately if you have any further bleeding, or any other concerning symptoms. Followup Instructions: 1. Follow up with your primary care doctor in [**11-30**] weeks. 2. Provider: [**Name10 (NameIs) **] LAB TESTING Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2180-3-22**] 1:00 3. Follow up with Dr [**Last Name (STitle) **], pulmonologist, by calling [**Telephone/Fax (1) 612**].

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icd9cm

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Discharge summary

report

Admission Date: [**2131-3-11**] Discharge Date: [**2131-3-21**] Date of Birth: [**2077-9-26**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 12174**] Chief Complaint: OSH transfer for hepatic hydrothorax and transplant listing Major Surgical or Invasive Procedure: Chest tube placement TIPS History of Present Illness: 53 year old male with history of chronic hepatitis C cirrhosis complicated by variceal bleeding (grade [**1-9**]), ascites who presents from [**State 20192**] Center for hepatic hydrothorax and recent acute renal failure. The patient initlaly presented to OSH on [**2131-3-3**] with significant shortness of breath. He had endorsed not getting regular refills on his diuretics and thus had not been taking them for 6-8 weeks. He was found to be tachypneic to RR32 and saturating 99% on a nonre-breather. CXR showed a massive pleural effusion with mediastinal shift, renal function was normal on labs. The patient was admitted to the OSH ICU and started empirically on ceftriaxone (for ?healthcare associated pneumonia vs. SBP). He underwent thoracentesis with 2L removal of fluid on [**3-3**] and then again on [**3-4**] (4L total). . His creatinine quickly increased to a peak of 2.5 2/25-28/[**2131**]. He was volume resuscitated for hypotension; thus ATN/prerenal was felt to be a possible etiology to his acute renal failure. The patient was restarted on his diuretics, although at slightly decreased lasix dose compared to home (80mg at home), and increased spironolactone compared to home (100mg at home). Because his creatinine stabilized and he was developing worsening abdominal ascites, large volume (3.5L) paracentesis was performed on [**2131-3-7**]. The fluid was negative for SBP. The patient also completed 7 day course of CTX for presumed healthcare associated pneumonia on [**2131-3-10**]. Yesterday, the patient developed progressive shortness of breath again and was transferred to [**Hospital1 18**] for further management, possible TIPS, possible transplant. . Of note, the patient recently moved from [**Hospital1 189**], MA to [**Location (un) 8117**], [**Location (un) 3844**] and has not established care there with any physicians. The patient recounted that he has a living donor already and was planning on transplant at [**Hospital1 18**]. He called [**First Name8 (NamePattern2) 2808**] [**Last Name (NamePattern1) 805**], however, in the [**Hospital 1326**] Clinic and was surprised to find he was not being considered for transplant. . ROS: Positive per HPI; denies fever, chills, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: 1. Hep C- chronically on pegylated interferon (trial) 2. Grade I esophageal varices 3. cirrhosis of the liver Social History: Currently denies alcohol, tobacco or IVDU. -Home: Married, has children -Work: Former postal service worker, now retired Family History: Non contributory Physical Exam: GENERAL: Chronically ill-appearing, in NAD, slightly disheveled. Not jaundiced. HEENT: Sclera anicteric. MMM. Normal oro/nasopharynx CARDIAC: RRR with no murmurs/gallops/rubs LUNGS: CTA on left with no wheezing, rales, or rhonchi. Dullness to percussion and poor inspiratory effort, decreased/minimal breath sounds on right. ABDOMEN: Distended but soft, non-tender to palpation. Dullness to percussion over dependent areas but tympanic anteriorly. No HSM or tenderness appreciated. EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. No lower extremity edema. Upon discharge, improved right sided breath sounds, abdomen is soft and non-distended Pertinent Results: Admission: [**2131-3-11**] 09:10PM BLOOD WBC-4.9# RBC-2.90* Hgb-10.9* Hct-30.4* MCV-105* MCH-37.6* MCHC-35.9* RDW-14.9 Plt Ct-38* [**2131-3-11**] 09:10PM BLOOD PT-15.2* PTT-31.0 INR(PT)-1.4* [**2131-3-11**] 09:10PM BLOOD Glucose-100 UreaN-14 Creat-0.9 Na-141 K-3.4 Cl-105 HCO3-28 AnGap-11 [**2131-3-11**] 09:10PM BLOOD ALT-50* AST-81* LD(LDH)-282* AlkPhos-79 TotBili-2.7* [**2131-3-11**] 09:10PM BLOOD Albumin-2.7* Calcium-8.5 Phos-2.5* Mg-1.4* Discharge: [**2131-3-21**] 06:15AM BLOOD WBC-5.7 RBC-2.82* Hgb-10.1* Hct-29.8* MCV-106* MCH-35.9* MCHC-33.9 RDW-15.8* Plt Ct-51* [**2131-3-21**] 06:15AM BLOOD PT-15.9* PTT-60.8* INR(PT)-1.5* [**2131-3-21**] 06:15AM BLOOD Glucose-88 UreaN-13 Creat-0.8 Na-136 K-3.9 Cl-102 HCO3-27 AnGap-11 [**2131-3-21**] 06:15AM BLOOD ALT-84* AST-88* LD(LDH)-180 AlkPhos-79 TotBili-3.2* [**2131-3-21**] 06:15AM BLOOD Albumin-2.6* Calcium-8.2* Phos-2.8 Mg-1.9 Pertinent: Echo (done pre-op for TIPS): The left atrium is normal in size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal global biventricular systolic function. Normal estimated pulmonary artery systolic pressure. CT Chest: IMPRESSION: 1. Large right tension hydropneumothorax. 2. Right lower lobe collapse. 3. 9-mm ground glass peripheral opacity in the left lung, of unclear significance. This may represent a small focus of infection or nodule. Attention is recommended on followup. If no followup exam is performed, then followup CT is recommended in three months. These findings and recommendations were discussed with Dr. [**Last Name (STitle) 5144**] by Dr. [**Last Name (STitle) 7867**] by phone at 1:28 p.m. on [**2131-3-18**]. The study and the report were reviewed by the staff radiologist. TIPS Report: TIPS INDICATION: 53-year-old man with HCV cirrhosis with persistent ascites and hepatic hydrothorax, drained 8-9 liters from right pleural space with rapid reaccumulation. OPERATORS: Dr. [**First Name (STitle) **] [**Name (STitle) 19199**] (fellow), Mark Ashkan (resident) and [**First Name8 (NamePattern2) **] [**Doctor Last Name 4154**] (attending physician). Dr. [**First Name (STitle) 4154**] was present throughout the procedure. CONTRAST: Sterile 120 mL Omnipaque 350. SEDATION: General endotracheal anesthesia provided by the anesthesiologist. PROCEDURE AND FINDINGS: Consent was obtained from patient after explaining the benefits, risks and alternatives. Patient was placed supine on the imaging table in the interventional suite. Timeout was performed as per [**Hospital1 18**] protocol. Limited [**Doctor Last Name 352**]-scale son[**Name (NI) **] of the abdomen revealed a small amount of ascites. It was decided not to perform paracentesis. Under aseptic conditions and son[**Name (NI) 493**] guidance, a micropuncture needle was placed in the right internal jugular vein. 0.018 wire was advanced through the needle and into the SVC. Needle was exchanged for a 5 French coaxial sheath. Inner cannula and wire were removed to place a 0.035 [**Doctor Last Name **] wire. After removing the microsheath and placing a small incision at the access site, a 5 French MPA equivalent catheter was used to negotiate the wire into the IVC. After removing the catheter, the tract was dilated with 8- and 12-French dilators sequentially. A 10 French sheath was then placed over the wire and advanced into the upper IVC. Inner cannula was removed. Sidearm of the sheath was aspirated and flushed, and connected to a continuous heparinized saline flush. The 5 French MPA equivalent catheter was then placed over the wire and within the sheath and advanced into the IVC. After retracting the sheath to the lower cavoatrial junction, catheter-0.035 Glidewire combination was placed in the right hepatic vein. Position was confirmed with lateral fluoroscopy as well. Glidewire was then replaced with the [**Doctor Last Name **] wire, which was advanced into the right hepatic vein. Catheter was then removed to place an occlusion balloon set, which was advanced into the right hepatic vein. Right hepatic venogram was performed. Balloon was then inflated. Occlusion/wedged hepatic pressure and right atrial pressures were measured. CO2 portovenography was then performed while the balloon was kept inflated, in AP and lateral projections. Sheath was then advanced into the right hepatic vein. After deflating the occlusion balloon, the catheter was removed over [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] wire that was placed in the right hepatic vein. Curved blunt sheath metallic cannula was then placed over the wire and within the sheath and advanced into the right hepatic vein. After appropriately positioning the outer sheath and removing the wire, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 29723**]-[**Last Name (un) 29724**] sheath needle was placed within the metallic cannula (that was directed anteriorly), a single pass was used to access the right posterior portal vein transhepatically. After removing the needle, a 0.035 Glidewire was advanced through the sheath of the needle and into the SMV. The needle sheath was then exchanged for a 5 French angled glide cath, that was then advanced over the wire and into the SMV. The angled glide cath was then used to direct the wire into the splenic vein. Glidewire was then exchanged for a 0.035 stiff Amplatz wire that was advanced into the splenic vein. The sheath of the blunt cannula was then advanced into the right portal vein while fixing the metallic cannula. The outer 10 French sheath was then advanced over the sheath cannula into the right portal vein. After removing the glide cath and subsequently the metallic cannula, a 5 French pigtail marked catheter was placed over the wire and within the cannula sheath and advanced into the main portal vein. After removing the wire, main portal vein pressure was measured. Portovenography was then performed by injecting sterile contrast material. After removing the marked pigtail catheter over an Amplatz wire that was placed in the splenic vein, a 10 x 60 x 20 mm Viatorr TIPS stent was placed appropriately with the uncovered portion in the right portal vein. The stent was then balloon dilated with a 10 x 4 mm balloon. While inflating the balloon, a waist was noted that was successfully dilated at 18 mmHg pressure. Post-stent placement and balloon dilatation portovenography was then performed by placing the marked pigtail catheter in the main portal vein and after removing the wire. A repeat lower cavoatrial junction and main portal vein pressures were measured. Pigtail catheter and subsequently the 10 French sheath were removed over an Amplatz wire, that was also removed. Firm pressure was applied to the venotomy site for about 10 minutes to achieve complete hemostasis. Site was dressed in a sterile manner. No immediate post-procedure complication was seen. However, the anesthesiologist had some difficulty in extubating the patient and hence the patient was decided to be transferred to MICU for overnight observation in an intubated state. Incidental note of a large right hydropneumothorax with significant mediastinal shift to the left was noted, that was unchanged at the end of the procedure (and stable compared to pre-procedure CXR). Right-sided pleural pigtail drainage catheter was also seen. ET tube during the procedure was relatively low lying. Post-reintubation at the end of the procedure, report was called in to Dr. [**First Name8 (NamePattern2) 7568**] [**Last Name (NamePattern1) 12130**] at around 7:30 p.m. and advised to perform a portable chest radiograph to assess for ET tube tip. FINDINGS: 1. Pre-TIPS stenting, cavoatrial junction, wedged/occlusion hepatic and main portal pressures measured 11-, 41- and 35-mmHg, with a calculated portosystemic shunt of 24 mmHg. 2. Right hepatic venogram demonstrated conventional anatomy. 3. Indirect CO2 portovenography demonstrated the central portal vein anatomy. 4. Direct pre-TIPS portovenography from the main portal vein demonstrated opacification of intrahepatic portal branches, main, right and left portal veins, and SMV (which was dimunitive). 5. Post-TIPS cavoatrial junction and main portal vein pressures measured 12- and 17-mmHg, respectively. Calculated portosystemic shunt was 5 mmHg. 6. Post-TIPS portovenography from the main portal vein demonstrated brisk flow of contrast through the main portal vein into the hepatic vein via the stent. There is also opacification of central portion of the left portal vein. Intrahepatic portal venous branches and SMV were not opacified. These were expected. IMPRESSION: Uncomplicated portovenography, pressure measurements and TIPS with a 10 x 60 x 20 mm Viatorr stent extending from the right hepatic vein to the right portal vein. Results were discussed in person with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] at around 7 p.m. on [**2131-3-15**]. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: Mr. [**Known lastname 12536**] is a 53 year old man with a past medical history of chronic hepatitis C cirrhosis complicated by variceal bleeding (grade [**1-9**]) and ascites who presented from [**Hospital 28448**] Center for management of hepatic hydrothorax and ascites which has improved dramatically following TIPS. . # Hepatic hydrothorax: Ascites accumulated in setting of progressive liver cirrhosis and medication non-compliance. Paracentesis of 2.5L was performed followed by a therapeutic thoracentesis (6 L). Thoracentesis was complicated by resultant pneumothorax secondary to trapped lung for which IP was consulted. IP recommended conservative management for trapped lung. The trapped lung will either resolve on its own or require outpatient semi-elective surgery in several weeks. Mr. [**Known lastname 12536**] was seen by thorac surgery who recommended outpatient follow up. Chest tube was removed on [**3-19**] without incident and without worsening of pneumothorax. Note that some pneumothorax is unavoidable in setting of trapped lung and area of pneumothorax will slowly fill with pleural fluid. TIPS was performed on [**3-15**], and post-operative course was complicated by failure to wean from mechanical ventilation immediately following surgery. Mr. [**Known lastname 12536**] was extubated early the next day and remained hemodynamically stable, he was transferred to the floor in stable condition where he remained stable from a respiratory standpoint 95-98% on RA at rest. On exercise, Mr. [**Known lastname 12536**] did have an oxygen requirement 85% on RA with ambulation 98% on 2L NC. Due to Mr. [**Known lastname 29725**] level of deconditioning physical therapy worked with him, and Mr. [**Name13 (STitle) 29726**] was able to progress to the point where he could be discharged to home. . # HCV cirrhosis: Complicated by variceal bleeding status post banding and ascites. No known encephalopathy or SBP in the past, but following TIPS Mr. [**Known lastname 12536**] was prophylactically placed on standing lactulose. Beta blockers were initially held due to low pressures, but nadolol was started on discharge. . # Liver transplant: Patient may be candidate for listing. He had presumed he was already listed until speaking with Transplant Center. Patient unaware, however, that [**Hospital1 18**] no longer/does not perform living donor transplants. Mr. [**Known lastname 12536**] was informed regarding the importance of following up with Dr. [**Last Name (STitle) **] on a regular basis, and that compliance with medical therapy and adherence to follow up appointments are necessary for transplant listing. Medications on Admission: * Citalopram 20mg daily * Furosemide 80mg daily * Propranolol 20mg twice daily * Spironolactone 100mg daily * Acetaminophen 1000mg 1-2 times daily PRN headache * Multivitamin/FA/Ca/Fe/min/lycopen/lutein daily * Ipratropium 17mcg 2 puffs q6 hours PRN SOB, wheeze * Albuterol 90mcg 2 puffs QID PRN SOB, wheeze Discharge Medications: 1. Home Oxygen 2L NC continuous pulse dose for diagnosis: trapped lung 2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO twice a day as needed for pain: do not exceed 4 pills daily. 5. multivitamin Tablet Sig: One (1) Tablet PO once a day. 6. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB. 7. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for SOB. 8. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*30 Patch 24 hr(s)* Refills:*0* 9. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). Disp:*2700 ML(s)* Refills:*0* 10. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital3 6011**] Care Discharge Diagnosis: Primary: 1. Hepatic hydrothorax 2. Iatrogenic pneumothorax 3. Trapped lung Secondary: 1. Cirrhosis secondary to hepatitis C Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Mr. [**Known lastname 12536**], It was a pleasure caring for you at [**Hospital1 18**]. You were having difficuly with your breathing, so you received 2 procedures to help prevent the fluid build-up in your stomach and your lungs. One of the procedures (thoracentesis) was complicated by extra air leaving your lungs and as a result, your right lung is not able to expand all the way. The thoracic surgery team will see you as an outpatient to address this issue. Otherwise, you will be able to use oxygen at home if you are feeling short of breath. Do not smoke while wearing oxygen. You could blow yourself up! The following medication changes were made to your regimen while you were here: 1. STOP Lasix as your blood pressures are somewhat low and your volume problem has been corrected with TIPS 2. DECREASE spironolactone to 25mg daily 3. STOP propranolol as your blood pressures have been fairly low 4. START nadolol 20mg daily instead of the propranolol 5. START Nicotine replacement to help you quit smoking. Quitting smoking is the single best thing you can do for your health 6. START Lactulose 30mL three times daily to help keep you from being confused. Followup Instructions: Department: LIVER CENTER When: MONDAY [**2131-3-26**] at 9:20 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Name: [**Last Name (LF) **],[**First Name3 (LF) **] K Location: [**Location (un) **] PRIMARY CARE Address: [**Location (un) 29727**], [**Location (un) **],[**Numeric Identifier 29728**] Phone: [**Telephone/Fax (1) 29729**] Appointment: TUESDAY [**3-27**] AT 3PM Department: THORACIC SURGERY When: THURSDAY [**2131-4-5**] at 11:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15855**], MD [**Telephone/Fax (1) 2348**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "511.89", "311", "070.54", "571.5", "E879.8", "530.81", "789.59", "512.1", "518.51" ]

icd9cm

[ [ [] ] ]

[ "34.04", "34.91", "54.91", "96.71", "39.1" ]

icd9pcs

[ [ [] ] ]

17517, 17573

13484, 16137

366, 393

17742, 17742

3820, 13461

19122, 20008

3110, 3128

16496, 17494

17594, 17721

16163, 16473

17925, 19099

3143, 3801

266, 328

421, 2819

17757, 17901

2841, 2955

2971, 3094

5,018

154,356

14230+56522+56523

Discharge summary

report+addendum+addendum

Admission Date: [**2173-4-10**] Discharge Date: Date of Birth: [**2126-5-6**] Sex: M Service: Medicine DATE OF DISCHARGE: Unknown. HISTORY OF THE PRESENT ILLNESS: This is a 46-year-old male from [**Country 37027**] who is a diplomat living in [**Country 3587**], who was diagnosed with HIV three years ago and who came to the United States for further care. He initially presented to Dr. [**Last Name (STitle) **] at [**Street Address(1) 42301**] Clinic on [**2173-3-25**] complaining of weight loss, intermittent fevers and fatigue. He has labs drawn at that time and the patient returned for followup on [**4-2**]. At this appointment he complained of diarrhea. Stool culture was done. Arrangements were made for him to followup in the infectious disease clinic on [**4-5**]. Apparently, the patient missed this appointment. However, he did have a chest x-ray done at that time, which was read as normal. The patient then presented to the emergency room on [**4-9**], complaining of diarrhea and fevers, fatigue at home, fever and chills, watery diarrhea, with no blood and occurring up to three times per day. He denied any nausea or vomiting. He had some mild abdominal discomfort. He also complained of generalized weakness. He denied any urinary symptoms. In the emergency room, the labs showed elevated LFTs as well as amylase and lipase. He had an abdominal CT, which showed peripancreatic multiloculated fluid collection. Retroperitoneal lymphadenopathy and colonic ileus. He was given five liters normal saline and one dose of Levofloxacin and Flagyl. The patient was evaluated by the department of surgery in the emergency room and they recommended medical management. He was then transferred to the intensive care unit. On arrival to the unit, he was febrile. He had stable blood pressure. He reported continued left lower quadrant pain. PAST MEDICAL HISTORY: 1. History is significant for HIV originally diagnosed three years prior. 2. Recent visit to [**Country 6257**] in [**2173-1-22**] for abdominal pain and retesting of HIV status. The patient was started on Bactrim prophylactically at that time. MEDICATIONS ON ADMISSION: Bactrim. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient is a diplomat from a [**Country 37027**], living and working in [**Country 3587**]. His wife died three years ago from AIDS. He has four children, the eldest of which is traveling with him. He has no history of tobacco use. He does have a history of alcohol use. However, he denies drinking in the past year. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: Examination on admission revealed the following: Temperature 102.8, heart rate 144, blood pressure 124/80, respiratory rate 23, oxygen saturation 93% on room air. GENERAL: The patient is alert, no acute distress. HEENT: Mucous membranes moist. NECK: Supple with no apparent cervical adenopathy. CARDIOVASCULAR: Regular rate and rhythm, tachycardia, no murmur. LUNGS: Lungs were clear to auscultation bilaterally. ABDOMEN: Positive bowel sounds. Left lower quadrant tenderness with voluntary guarding, no rebound. EXTREMITIES: Thin, no edema, warm, small left axillary lymph node. Bilateral inguinal adenopathy, left greater than right. RECTAL: Examination was guaiac negative in the emergency room. LABORATORY DATA: Labs on admission revealed the following: White count 4.7, hematocrit 30.4, platelet count 133,000, neutrophils 95%, lymphocytes 5%, monocytes 1%. Hemoglobin A1c 6.3, ESR 105, TSH 1.3, CD4 count 73, HIV viral load greater than 100,000, albumin 2.4, AST 302, ALT 173, alkaline phosphatase 153, total bilirubin 0.6, amylase 263, lipase 499. Urinalysis: Moderate blood, trace protein, no white blood cells or red blood cells. Hepatitis B surface antigen and surface antibody negative. Hepatitis B core antibody, IgG positive, IgM negative, RPR negative. Hepatitis C virus antibody negative. Stool culture on [**4-3**], positive for Shigella flexneri, Gastrodiscus hominis. Chest x-ray in the emergency room showed clear lungs with dilated loops of bowel. EKG: Sinus tachycardia with a rate of 140, normal access, normal intervals, T-wave flattening in leads 1 and AVL. No comparison EKG available. HOSPITAL COURSE: This is a 46-year-old male with HIV and a CD4 count of 73, who was admitted to the hospital complaining of several-month history of fatigue, weight loss, sweats, and diarrhea. HOSPITAL COURSE: Initially, the patient was admitted to the intensive care unit because of his profound dehydration. The focus of his clinical care was initially on his pancreatitis, given his elevated amylase and lipase, elevated transaminases, tender abdomen, and peripancreatic-fluid collection seen on CT examination. However, upon transfer from the intensive care unit, further history taking revealed that the patient gave a history very suspicious for tuberculosis given his 30 pound weight loss over the past three months, night sweats, fevers, and chronic cough. The patient was then placed on precautions and subsequently found to have disseminated tuberculosis. INFECTIOUS DISEASE: The patient was started on Ciprofloxacin for Shigella in his stool. He completed a one-week course of Ciprofloxacin for this and his diarrhea resolved. The patient was placed on respiratory precautions on [**4-12**], when he was transferred to the [**Company 191**] service from the intensive care unit. He had further workup for possible tuberculosis including a repeat chest x-ray, which was suspicious for an atypical pneumonia and a chest CT, which showed multiple tiny nodules very suspicious for miliary tuberculosis. The surgical service biopsied his left inguinal lymph node on [**4-14**]. This showed moderate AFB and subsequently this organism was identified by the state laboratory as mycobacterium tuberculosis. The infectious disease service recommended starting the patient on Rifabutin, Ethambutol, INH, and Pyrazinamide. This was done starting on [**2173-4-13**] for presumed disseminated tuberculosis. The patient continued having fevers for the next week or so. Initially after starting RIPE therapy, the patient was afebrile. However, the patient then started having very high fevers, as high as 104, which was thought to be a paradoxical reaction to the antibiotics. The patient had multiple blood cultures drawn, which were all negative. He also had a bronchoscopy done on [**4-21**], for bronchial lavage. The lavaged specimen was negative for AFB, PCP, [**Name10 (NameIs) **] fungus for bacteria at the time of this dictation. The patient had also had an induced sputum done on the 22nd. This showed acid-fast bacilli on staining. Because the patient had a sputum, which was positive for AFB the patient was continued on his respiratory precautions until he had been on his RIPE therapy for two weeks. This will be on [**2173-4-26**]. A full course of therapy will be determined by the infectious disease service. His lymph node biopsy also showed E coli, which was sensitive to Ceftriaxone. The patient was treated with a 14-day course of Ceftriaxone. He also had E coli sensitive to Ceftriaxone in his urine. The patient had initially been taken off his Bactrim prophylaxis due to his elevated transaminases, however, this was restarted once the transaminases gradually came down. The patient had HIV genotyping done as a baseline before starting heart therapy. The infectious disease service will advise us as to when this will begin. GASTROINTESTINAL: Pancreatitis with peripancreatic fluid collection. The patient was observed clinically. Transaminases gradually came down after a small bump after starting RIPE therapy. However, gradually his enzymes came down again. He will have a follow up abdominal CT scan to re-evaluate his peripancreatic fluid collection prior to discharge. He had a full workup to evaluate. Full workup can be seen on CCC. The conclusion of which was that there was no identifiable cause for the pancreatitis or elevated LFTs other than the disseminated tuberculosis. CARDIOVASCULAR: The patient was stable from a cardiovascular point of view throughout the hospitalization. HEMATOLOGY: The patient had a pancytopenia on admission, which gradually worsened. It was thought that this was most likely due to bone marrow involvement by the disseminated tuberculosis. The lymph node biopsy was negative for lymphoma. He received a total of two units of packed red blood cells for hematocrit of 21, prior to the lymph node biopsy. Cell counts initially came up, however, they began to fall again and a hematology consultation was requested for bone narrow biopsy. This was performed on [**2173-4-23**]; results of which were pending at the time of this dictation. PULMONARY: The patient briefly had an oxygen requirement of four liters oxygen saturation via nasal cannula at the time of his diagnosis of tuberculosis. After initiating RIPE therapy the pulmonary status gradually improved. He was also noted to have bilateral pleural effusions. At the time of the chest CT, these gradually resolved and were very small. By the time of this dictation, these were not tapped. The patient had bronchoscopy by the pulmonary service as described under infectious disease. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was severely dehydrated initially with a sodium of 117. This corrected rapidly after receiving five liters or normal saline. The patient was continued on maintenance IV fluids due to continued dehydration due to high fevers and poor p.o. intake. He had a workup for his hyponatremia, including a cortisol level, which was normal. VASCULAR: The patient was found to have a right common iliac clot on the abdominal CT. Bilateral lower extremity ultrasounds were done to rule out DVTs of the lower extremities. These were negative. The patient was started on heparin drip for his right common iliac clot. He will need to continue on anticoagulation therapy for six months for his clot. He should be started on Coumadin once his procedures have all been completed. DR.[**Last Name (STitle) **],ALEXSANDER 12-AAD Dictated By:[**Last Name (NamePattern1) 7896**] MEDQUIST36 D: [**2173-4-23**] 14:11 T: [**2173-4-23**] 15:08 JOB#: [**Job Number 42302**] Name: [**Known lastname 1634**], [**Known firstname 7661**] [**Doctor First Name **] Unit No: [**Numeric Identifier 7662**] Admission Date: [**2173-4-10**] Discharge Date: [**2173-5-14**] Date of Birth: [**2126-5-6**] Sex: M Service: [**Company 112**] ADDENDUM: HOSPITAL COURSE: From an ID standpoint, the patient continued to be treated for miliary tuberculosis with Rifabutin, Isoniazid, Pyrazinamide and Ethambutol. He continued to have marked lymphadenopathy of the left supraclavicular node and left inguinal node. The patient had his left inguinal node drained by surgery and it continued to weep serosanguineous drainage. His left supraclavicular node also began to weep serosanguineous drainage. The surgery team did not feel that open drainage of this would be beneficial. The patient was eventually started on Prednisone 20 mg po q day for treatment of this paradoxical reaction in the hope of curtailing a worsening paradoxical response when the patient started HAART therapy. The patient completed a 14 day course of Ceftriaxone for E. coli that was present in one of the lymph node cultures. An initial set of acid fast bacterial sputum cultures revealed continued presence of mycobacterium tuberculosis. The patient had a second set of three which were pending at the time of this dictation. If these are negative, the patient will likely be able to come off of respiratory precautions. Infectious disease continued to follow the patient throughout the hospitalization. The hope was if the three AFB sputums were negative, he would be able to start HAART with a plan to begin Efavirenz and Trizivir. From a hematological standpoint the patient showed evidence of trilineage depression in his cell counts and a bone marrow biopsy was performed by the hematology/oncology team which revealed hypocellular marrow. This was believed to be secondary to chronic illness from the patient's HIV disease and tuberculosis. The patient's hematocrit remained stable throughout the admission in the mid to low 20's. The plan was to transfuse for hematocrit less than 20. From a venous thromboembolism standpoint the patient continued to be treated for his right common iliac DVT. He was eventually started on Coumadin and attained a therapeutic INR on a regimen of Coumadin 7.5 mg po q day. The Heparin drip was then discontinued. From a GI standpoint the patient continued to have a peripancreatic fluid collection that remained stable on a repeat abdominal CT. From a pulmonary standpoint the patient continued with miliary TB and stable pleural effusions. From a renal standpoint the patient had very mild acute renal insufficiency with prerenal physiology. He had hyponatremia which was likely secondary to hypovolemia and SIADH as well as episodes of hyperkalemia. The patient was given normal saline with improvement in his serum sodium and Kayexalate with decrease in his hyperkalemia. This is an ongoing summary of hospital course and the remainder of this hospital course will be dictated by the intern that picks up this patient. [**Name6 (MD) 1034**] [**Name8 (MD) 1035**], M.D. [**MD Number(1) 1036**] Dictated By:[**Last Name (NamePattern1) 2134**] MEDQUIST36 D: [**2173-5-14**] 08:47 T: [**2173-5-17**] 11:27 JOB#: [**Job Number 7663**] Name: [**Known lastname 1634**], [**Known firstname 7661**] [**Doctor First Name **] Unit No: [**Numeric Identifier 7662**] Admission Date: [**2173-4-10**] Discharge Date: [**2173-5-21**] Date of Birth: [**2126-5-6**] Sex: M Service: [**Company 112**] Medicine ADDENDUM: HOSPITAL COURSE: ID: The patient was started on heart therapy on Tuesday, [**5-18**], and continued on Prednisone and monitored for side effects and effects, tolerated medications well. Heme: DVT, patient's INR went up to 4.0 through the week. Coumadin was held and restarted at previous level of 7.5 mg. His target INR is 2.0-3.0. Skin: Patient had open wound secondary to scrofula on neck DISCHARGE CONDITION: Good. DISCHARGE STATUS: Home to a hotel. Patient to follow-up in [**Hospital **] Clinic 1 p.m. on Monday with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7664**]. Patient to have INR/PT drawn on the same day and to see Dr. [**Last Name (STitle) 4720**] in [**Hospital6 7665**], Center Suite, at 3 p.m. on Tuesday. DISCHARGE DIAGNOSIS: 1. HIV TB. DISCHARGE MEDICATIONS: Rifabutin 300 mg po q d, Pyridoxine 100 mg po q d, Isoniazid 300 mg po q d, Ethambutol 800 mg po q d, Pyrazinamide 1 mg po q d, Bactrim DS one double strength tablet po q d, Coumadin 7.5 mg po q d, Prednisone 20 mg po q d, Trizavir one tablet po bid, Nevirapine 200 mg po q d. [**Name6 (MD) 1034**] [**Name8 (MD) 1035**], M.D. [**MD Number(1) 1036**] Dictated By:[**Last Name (NamePattern1) 7666**] MEDQUIST36 D: [**2173-5-21**] 14:59 T: [**2173-6-2**] 09:56 JOB#: [**Job Number 7667**]

[ "004.9", "018.94", "577.0", "276.5", "511.9", "560.1", "444.22", "284.8", "042" ]

icd9cm

[ [ [] ] ]

[ "41.31", "33.24", "86.28", "40.11" ]

icd9pcs

[ [ [] ] ]

14463, 14800

2611, 2629

14858, 15384

14821, 14834

2186, 2250

14061, 14441

2652, 4295

1910, 2159

2267, 2594

17,589

153,192

45504+58828

Discharge summary

report+addendum

Admission Date: [**2113-9-5**] Discharge Date: [**2113-9-7**] Date of Birth: [**2050-9-6**] Sex: F Service: [**Company 191**] MEDICINE ADMISSION DIAGNOSIS: Urosepsis. HISTORY OF PRESENT ILLNESS: Patient, briefly, is a 62-year-old female with past medical history of Takayasu's's arteritis, IPF, chronic low back pain, and multiple medical admissions for nausea, vomiting, and abdominal pain, who presented to the Emergency Department with nausea, vomiting, and abdominal pain on [**9-5**]. Patient has had prior negative GI workups including EGD, colonoscopies, small intestinal biopsy, CT scan of the abdomen and pelvis, CT angiogram, blood, urine, stool cultures, which have all been negative. The patient also has questionable narcotic seeking behavior, as she often times fires physicians for not prescribing narcotics. Patient was originally admitted to the MICU, where patient was ruled out for pulmonary embolus with a negative CT angiogram, and was started on a steroid stress taper, and treated with ceftriaxone x1 gram and Zithro 500 mg po x1 for questionable urosepsis. However, it was later discovered that patient has bilateral subclavian stenosis causing blood pressure in her arms to be lower than normal blood pressure. Originally presenting with blood pressure in arms around the 80s with a heart rate 120s, however, later realized that blood pressure in the legs is around 110. The patient was then switched to po levofloxacin and was transferred to the floor for low back pain. PAST MEDICAL HISTORY: 1. Takayasu's diagnosed in [**2109**]. 2. IPF diagnosed in [**2109**] with negative ANCA, negative [**Doctor First Name **]. 3. Parkinson's. 4. Questionable chronic obstructive pulmonary disease on home O2 2 liters with a FEV1 of 45%, FVC of 53%. 5. Diabetes type 2. 6. Osteoporosis. 7. Anxiety. 8. Chronic low back pain with a MRI showing mild disk herniation at the L3-4 region. 9. Neurogenic bladder. 10. History of pulmonary embolus [**8-9**]. 11. 1+ MS with an echocardiogram done in [**3-13**] which is otherwise unremarkable. 12. Multiple falls. 13. Bilateral subclavian stenosis. ALLERGIES: Questionable sulfa. MEDICATIONS AT HOME: 1. Percocet max eight tablets a day. 2. Alendronate 70 mg q8. 3. Albuterol MDI prn. 4. Salmeterol 2 puffs [**Hospital1 **]. 5. Flovent 110 mcg two puffs [**Hospital1 **]. 6. Prozac 60 mg po q day. 7. Protonix 40 mg q day. 8. Sinemet 500/200 [**Hospital1 **]. 9. Aspirin 325 q day. 10. Klonopin 0.5 [**Hospital1 **]. 11. Lasix 40 q day. 12. Prednisone 5 q day. 13. CellCept [**Pager number **] [**Hospital1 **]. 14. Calcium carbonate. 15. Metformin 500 tid. 16. Synthroid 50 q day. 17. Colace. 18. Senna. 19. Vioxx. 20. Trazodone. 21. Methadone. SOCIAL HISTORY: The patient lives alone. Does activities of daily living herself. Uses walker to get around. Has a 10 pack year history of tobacco, quit in [**2108**], no alcohol, and no IV drug abuse. FAMILY HISTORY: No rheumatologic disease. No coronary artery disease. No cancers. PHYSICAL EXAMINATION ON ADMISSION: On admission to the floor, vitals: Temperature is 98.4, heart rate 119, blood pressure 92/54, respiratory rate 20, and 97% on 3.5 liters nasal cannula. General: Pleasant elderly female alert, speaking in full sentences. HEENT: Extraocular muscles are intact. Moist mucous membranes. Cardiovascular: Regular rate, no murmurs, rubs, or gallops. Chest was clear to auscultation bilaterally. Abdomen is soft, nontender, nondistended, good bowel sounds, no hepatosplenomegaly, and no flank pain. Extremities: No clubbing, cyanosis, or edema, +[**6-12**] lower extremity strength. PERTINENT LABORATORIES: On admission, patient's white blood cells are 24.5 with 75.7 neutrophils. Urinalysis shows moderate leukocytosis with white blood cell count greater than 50. Otherwise cortisol levels are 9.5. TSH was 0.83. Chest CT scan showed no pulmonary embolus, IPF, proximal narrowing of right and left subclavian arteries. Chest x-ray has no congestive heart failure and IPF changes. SUMMARY OF HOSPITAL COURSE: 1. Urinary tract infection: Patient was originally thought to be uroseptic with low blood pressure taken from the arms with a positive urinalysis. Urine cultures later grew gram-negative rods and patient was covered with levofloxacin. Patient will be sent home with a 10 day course of levofloxacin for adequate gram-negative coverage. 2. Takayasu's and IPF: Patient was started on a steroid taper and will wean steroid taper to baseline 5 q day as an outpatient. Patient was continued on CellCept. Cortisol levels were normal and blood pressure were normal during admission. Takayasu's and IPF were stable. 3. Diabetes type 2: The patient was on a regular insulin-sliding scale with no abnormal dextrose during hospital admission. 4. Chronic obstructive pulmonary disease: Patient was continued on albuterol, salmeterol, fluticasone with no exacerbations of chronic obstructive pulmonary disease during admission. 5. Parkinson's: The patient was continued on carbidopa/levodopa. 6. Hypothyroidism: Patient was continued on levofloxacin. DISPOSITION: Physical Therapy was consulted and recommendations to follow. CONDITION ON DISCHARGE: Fair. DISCHARGE DIAGNOSES: 1. Urinary tract infection. 2. Takayasu's. 3. Idiopathic pulmonary fibrosis. 4. Diabetes type 2. 5. Chronic obstructive pulmonary disease. 6. Parkinson's. 7. Hypothyroidism. DISCHARGE MEDICATIONS: 1. Percocet max 8 tablets a day. 2. Albuterol 90 mcg 1-2 puffs q6h prn. 3. Salmeterol 50 mcg one dose INH q12h. 4. Fluticasone 110 mcg two puffs [**Hospital1 **]. 5. Fluoxetine 60 mg po q day. 6. Pantoprazole 40 mg po q day. 7. Carbidopa/levodopa 50/200 one tablet po bid. 8. Aspirin 325 q day. 9. Clonazepam 0.5 mg po bid. 10. Mycophenolate mofetil 500 mg po bid. 11. Calcium carbonate 500 mg po bid. 12. Levothyroxine 50 mcg po q day. 13. Docusate 100 mg po bid. 14. Senna one tablet po bid prn. 15. Trazodone 25 mg po q hs prn. 16. Levofloxacin 250 mg po q day x10 day, 10 day prescription was given. FOLLOW-UP PLANS: Patient is to followup with primary care physician [**Last Name (NamePattern4) **] [**2-9**] weeks. PCP is [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Patient already has an appointment scheduled on [**2113-9-7**] at 3 o'clock. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**] Dictated By:[**Last Name (STitle) 26753**] MEDQUIST36 D: [**2113-9-7**] 10:23 T: [**2113-9-7**] 10:37 JOB#: [**Job Number 97086**] Patient was advised of risks and benefits, and informed of medical opinion that transfer to rehabilitation was recommended. She refused and was therefore discharge AMA. Name: [**Known lastname 15450**], [**Known firstname **] [**Last Name (NamePattern1) **] Unit No: [**Numeric Identifier 15451**] Admission Date: [**2113-9-5**] Discharge Date: [**2113-9-7**] Date of Birth: [**2050-9-6**] Sex: F Service: ADDENDUM TO DISCHARGE SUMMARY The patient, on the day of discharge, decided to leave against medical advice. The patient was recommended to go to rehabilitation center because of gait disturbances, however, the patient refused to go to any rehabilitation center but [**Hospital1 **]. [**Hospital1 **] evaluated her and rejected her. The patient was notified of all the risks of leaving against medical advice including death. The case was discussed with Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) **] and myself, and case manager [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 15472**]. Per note, the patient has left against medical advice from several rehabilitation centers and hospital admissions and [**Hospital6 15473**] and [**Hospital1 536**] before. The patient, on discharge, repeatedly asked for percocet, so two percocet were given and primary care physician was notified of events. The patient's daughter was also called and notified of events. The patient was discharged with Levofloxacin for a ten day course for treating a urinary tract infection, however, the patient stated that she will not take Levofloxacin. In summary, the patient left against medical advice on [**2113-9-7**]. [**First Name11 (Name Pattern1) 126**] [**Last Name (NamePattern4) 2098**], M.D. [**MD Number(1) 2099**] Dictated By:[**Last Name (STitle) 4724**] MEDQUIST36 D: [**2113-9-7**] 16:46 T: [**2113-9-7**] 17:54 JOB#: [**Job Number 15474**]

[ "724.2", "599.0", "332.0", "250.00", "446.7", "244.9", "516.3", "496" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

2958, 3048

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5465, 6070

2188, 2734

4084, 5214

174, 186

6088, 8567

215, 1523

3063, 4056

1545, 2167

2751, 2941

5239, 5246

27,905

125,926

1066

Discharge summary

report

Admission Date: [**2166-6-10**] Discharge Date: [**2166-7-4**] Date of Birth: [**2135-2-7**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 495**] Chief Complaint: sepsis Major Surgical or Invasive Procedure: PEG placement Intubation, tracheostomy Central line History of Present Illness: This is a 31 yo F with a past medical history significant for hemorrhagic CVA 3 years ago, with a prolonged post CVA course, c/b tracheostomy and residual aphasia and r-sided hemiparesis, aspiration pneumonias, who per her mother has had a recent progressive decline with difficulty swallowing. On the day of admission to the OSH, the patient developed abdominal pain and vomiting and was admitted for further work-up. She was found to be tachycardic to the 140's, febrile to 103.8 (rectal), BP 138/114. A femoral line was placed as PIV access, and a RIJ were unable to be obtained. She had progressive respiratory distress and was then intubated for airway protection. She was transferred to the OSH ICU for presumed aspiration pneumonia, sepsis, ARF and respiratory failure. . At the OSH, the patient was started levofloxacin/timentin/vancomycin, OG tube was placed, was given IVF, and was placed on steroids. Per her mother, she has no seizure history, but is maintained on valproate, and was restarted on this at the OSH. She was transferred to [**Hospital1 18**] to the [**Hospital Unit Name 153**] for further management of her renal failure and possible sepsis. . When the patient arrived she was on a propofol gtt, and was having tongue and eyelid fasciculations. She withdrew to pain but was otherwise unresponsive. Vitals were stable. Past Medical History: - Diabetes Mellitus type 1 (dx at age 3), hx of hypoglycemic episodes - CVA (hemorrhagic) at 27 with residual aphasia and r-hemiparesis, tracheostomy post CVA now decannulated. - blindness in one eye - history of aspiration pneumonia - although patient is on valproate, no reported history of stroke - depression Social History: remote smoking history at age 18, lived in CA and has lived at the Greenery since coming to MA. Family History: healthy brother/sister. Maternal family history of DM. Physical Exam: Vitals: T 99.4 HR 90 BP 138/88 sats 98% on AC 450x16 peep 5 FiO2 60% General: intubated, sedated, not responding to voice. HEENT: left ptosis. PERRL. anicteric. Neck:supple, JVP elevated 8cmH20 Lungs: diffuse rhonchi Chest: RRR II/VI sem at base Abd: soft NT, mild distention +BS Ext: no e/c/c Neuro: withdraws to pain, left-sided facial drooping, left sided ptosis; unclear [**Name2 (NI) 6954**] response. No clonus. Pertinent Results: Admission labs: [**2166-6-10**] 06:58PM GLUCOSE-123* UREA N-16 CREAT-1.0 SODIUM-148* POTASSIUM-2.9* CHLORIDE-114* TOTAL CO2-25 ANION GAP-12 [**2166-6-10**] 06:58PM ALT(SGPT)-9 AST(SGOT)-16 LD(LDH)-204 ALK PHOS-61 AMYLASE-33 TOT BILI-0.2 [**2166-6-10**] 06:58PM LIPASE-7 [**2166-6-10**] 06:58PM ALBUMIN-2.3* CALCIUM-8.6 PHOSPHATE-3.3 MAGNESIUM-1.7 [**2166-6-10**] 06:58PM WBC-11.9* RBC-2.64* HGB-8.8* HCT-25.9* MCV-98 MCH-33.2* MCHC-33.9 RDW-15.4 . Imaging: EEG Study Date of [**2166-6-11**]: IMPRESSION: This telemetry captured six pushbutton activations, but they showed the same background as on routine sampling. Overall, the EEG showed a widespread encephalopathy with a slow low voltage background but also with some asymmetry. Background voltages were notably lower on the left side, and there was additional focal slowing on that side, as well. The recording indicates a widespread encephalopathy. Medications, metabolic disturbances, and infection are among the most common causes. Raised pressure and anoxia are other possibilities. The leftsided findings raise concern for a structural abnormality on that side. There were no epileptiform features. . CT HEAD W/O CONTRAST [**2166-6-12**] 5:57 PM 1. Cystic encephalomalacia of the left basal ganglia extending into the left frontal lobe are likely the sequelae of prior infarct, trauma, surgery. Correlate with history. While there is no evidence of recent infarction, evaluation is limited on CT, and MR [**First Name (Titles) 151**] [**Last Name (Titles) 3631**]- weighted imaging is recommended if clinically indicated. 2. Extensive paranasal sinus mucosal thickening as described. . CT ABDOMEN W/O CONTRAST [**2166-6-12**] 5:58 PM 1. Diffuse bibasilar centrilobular nodules and frank consolidation likely represents an infectious process. Consider aspiration. 2. Extensive atherosclerotic calcification. . ECHO Study Date of [**2166-6-12**] Conclusions: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. A left ventricular mass/thrombus cannot be excluded. Overall left ventricular systolic function is moderately depressed (ejection fraction 30-40 percent)secondary to severe hypokinesis/akinesis of the apical half of the left ventricle. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. There is mild pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. The main pulmonary artery is ,markedly dilated. The branch pulmonary arteries are dilated. There is no pericardial effusion. . LUNG SCAN [**2166-6-18**] IMPRESSION: Limited evaluation. No large perfusion or ventilation defects. Low likelihood pulmonary embolism. . CHEST (PORTABLE AP) [**2166-6-19**] 5:09 AM REPORT: The patient has a left-sided subclavian line, inserting at the cavoatrial junction. ET tube appears in good position well above the trachea. The degree of left basal opacity has probably continued to improve slightly from prior day. Lungs otherwise appear grossly clear. There is some mild increased density over the left mid lung parenchyma when compared to the right but this is not as marked as on [**6-17**]. . [**2166-6-27**] PEG placement: PROCEDURE/FINDINGS: After explanation of the potential risks and benefits of the procedure, written informed consent was obtained from the [**Hospital 228**] healthcare proxy (patient's mother). Preprocedure timeout was performed to confirm patient and proposed procedure. Patient was placed supine on the angiographic table and abdomen prepped and draped in standard sterile fashion. Guide wire was advanced through the existing torn GJ tube under constant fluoroscopic guidance, and a new 18 French x 45 cm MIC GJ tube was exchanged over the wire. Injection of contrast through the tube confirms the G-tube tip to be within the stomach, and the distal J-tube tip to be within the jejunum. The balloon was inflated with approximately 10 cc of saline and contrast, and the tube was secured to the skin with Flexi-Trak. Final spot fluoroscopic view of contrast confirms positioning of the tube. Patient tolerated the procedure well without immediate complication. IMPRESSION: Uneventful exchange over a wire of 18 French x 45 cm MIC GJ tube. Catheter is ready for use. 7/20:07: CT OF THE CHEST WITH CONTRAST: There is a right subclavian central line with its tip in the right atrium. There is a tracheostomy tube in place. The aorta is normal in caliber. There is enlargement of the main pulmonary artery, which measures approximately 3.6 cm in diameter. Coronary artery calcifications are noted. There is bibasilar atelectasis with additional more patchy areas of airspace disease, some of which are somewhat nodular and may be infectious in etiology. These findings have improved since the prior study. There is a very prominent right paratracheal lymph node that measures 2.7 x 1.8 cm. Several smaller subcentimeter lymph nodes are noted in the prevascular/AP window regions. Several prominent lymph nodes are noted in the left axilla which may be reactive in nature. The largest lymph node measures 1.9 cm in greatest dimension. CT OF THE ABDOMEN WITH CONTRAST: The liver is mildly enlarged measuring approximately 20 cm in sagittal dimension. There is trace amount of ascites in the abdomen. The gallbladder is not distended. There is trace amount of pericholecystic fluid. There is no definite gallbladder wall thickening. The small and large bowel are unremarkable. A G-tube is again noted. There is no evidence of colitis or diverticulitis. Heavy atherosclerotic calcifications are noted in the aorta, renal arteries, splenic artery and mesenteric arteries. There is no evidence for intraabdominal abscess. CT OF THE PELVIS WITH CONTRAST: The uterus and adnexal regions are within normal limits. The urinary bladder is not fully distended, which limits its evaluation. Small amount of air is present in the urinary bladder likely due to a Foley catheter in place. There is a rectal tube in place. IMPRESSION: 1. No evidence of intraabdominal abscess, colitis, or diverticulitis. 2. Enlarged main pulmonary artery suggestive of pulmonary artery hypertension. 3. Extensive atherosclerotic calcifications involving coronary arteries, aorta, and multiple other intraabdominal vessels. 4. Mild hepatomegaly and trace amount of ascites. 5. Interval improvement in previously noted pleural effusions. Interval improvement in bibasilar airspace disease. Residual patchy and somewhat nodular opacities at both lung bases may be infectious in etiology. 6. Enlarged paratracheal lymph node measuring 2.7x1.8 cm. A follow- up CT is recommended to assess for interval change if clinically indicated. [**2166-6-27**] Liver ultrasound: FINDINGS: The liver is of normal size with normal echogenicity. There is no extra- or intrahepatic biliary duct dilatation with the common bile duct measuring approximately 4 mm. The gallbladder was slightly dilatated with moderate wall thickness and there was no evidence of stones or sludge. IMPRESSION: Cannot include or exclude cholecystitis. If clinically indicated would consider a HIDA scan. [**2166-7-2**]: CXR: ONE VIEW. Comparison with the previous study done [**2166-6-30**]. There is a persistent area of increased density at the left lung base consistent with atelectasis and/or consolidation. The right lung remains clear. The heart and mediastinal structures are unremarkable. The tracheostomy tube and right subclavian catheter remain in place. IMPRESSION: No significant interval change. DISCHARGE LABS: WBC: 8.2 HCT 23.2 Plt 499 Gluc 80 BUN 14 CREAT 0.7 Na 141 K 3.8 Cl 101 Hc03 36* AG 8 Valproate 24 (from 18) Brief Hospital Course: 31 yo F with h/o DMI, hemorrhagic CVA in [**2162**] with residual aphasia and R-sided hemiparesis, and recurrent aspiration PNAs who was transferred to the [**Hospital1 18**] [**Hospital Unit Name 153**] from OSH for presumed sepsis, ARF, and respiratory failure. Now with difficulty extubating. . 1. Respiratory distress: Mostly likely etiology is aspiration pneumonia v. acute pnumonitis. Pt had a bronchial lavage culture from [**6-17**] that is pending; no organism were seen on gram stain. Pt was initially on levofloxacin for 5 days and then changed over to Zosym 4.5 g q6h (currently day [**1-18**]) for broader coverage. She was also being diuresed, initially with Lasix gtt then boluses) as tolerated by her renal function. Unfortunately, she remains +6 L for hospital stay. Pt also got a V/Q scan that showed low likelihood for PE. She is also on albuterol and atrovent nebs. Although pt appeared to be able to be weaned, she failed extubation on [**6-17**]. Of note, pt tends to have a high RSBI which may not be absolutely indicative of ability to ween. Causes for failure to extubate include (aspiration) pneumonia, diaphragm atrophy, neurological (R-sided hemiparesis), excess secretions (stridor heard during extubation), hyperthyroid-induced myopathy?. Tracheostomy was placed on [**6-21**] and attempts were made to decrease ventilator settings. These were limited by tachypnea and low tidal volumes. However, as the patient's pneumonia was treated and she was diuresed, transition to pressure support was possible. She has been stable on pressure support ventilation. Diuresis should be maintained as the patient has persistent lower extremity edema and improved respiratory status with diuresis. However, electrolytes and renal function should be followed to direct diuresis. She had had decreased output to the lasix on last day of admission, and bumex could be considered with thiazide to improve diuresis. Pt did pull trach out the night prior to discharge, but it was immediately replaced and there were no complications. 2. Persistent fevers: Patient started spiking fevers on [**2166-6-24**]. The cause was unclear and possibly initially due to infection as patient had pneumonia and then eventually thought to be due to drug fever also. However, despite antibiotics that were tailored to culture sensitivities her fevers were unchanged. Therefore other causes were evaluated for persisent fevers. She had serial blood cultures drawn that did not show any growth. She continued to have growth from her sputum cultures. Her central line was changed over a wire, and a number of medications were stopped. Eosinophilia developed over several days as well as urine eosinophils. This suggested that her persistent fevers may have been due to medications. Therefore all medications that were potentially pyrogenic medications were discontinued, with last discontinued medications meropenem and vancomycin. As well her central line was removed. After these interventions, her temperature was less than <101 for greater than 48 hours. 3. DMI: Initially despite insulin gtt, pt tends to have labile blood sugars. However, once the patient was on a stable tube feeding regimen, the glucose levels were somewhat better controlled. The patient did have more elevated sugars late in the day. [**Last Name (un) **] consult directed the care of the patient amd recommended glargine 24 Units at bedtime. 4. Hypothyroidism (TSH 0.02, fT4 3.9): Pt started on methimazol 5 mg po bid on [**6-18**]. Thyroid stim. ab was sent to assess for [**Doctor Last Name 933**] [**First Name8 (NamePattern2) **] [**Last Name (un) **] recs and level was 100 (normal <125). However with the persistent fevers that the patient sustained, the methimazole was changed to Propylthiouracil. Her thyroid function tests should be checked [**7-7**] to confirm that she is at the correct dosage. Additionally she will need follow up with endocrinology after discharge (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]). 5. Seizure: Pt has h/o seizure per OSH records. EEG here shows encephalopathy, but did have twitching when level of valproate was subtherapeutic. She was evaluated by neurology and felt not to have signs of seizure activity. Based on neurology recommendations she should have a goal level of 40-50. The level has been low and the daily dose has been increased last on [**7-2**] to 1g PO Q6hours. This dose should be continued for now, but levels should be checked daily until she is therapeutic and then after as determined by overseeing physician. . 6. Abdominal pain: Pt had neg. CT abd ([**6-12**]). She again had abdominal pain but a normal CT abdomen, pelvis. She continued to have discomfort and an abdominal ultrasound was inconclusive. LFTs were negative. Pt was on metoclopramide for gastroparesis [**1-10**] DMI, but this was discontinued in the concern that this was causing fevers. However, if the patient is afebrile, it is possible that the metocopramide could be restarted on a trial basis to see if she becomes febrile again. . 7. Chronic anemia: She had persistent anemia and occasionally required transfusions to keep her hct above 21. She received a total of 3 units PRBCs [**6-13**], [**6-21**], [**6-28**]. Since then her hematorcit has been stable in the 23-25 range. Pt is on ferrous sulfate PO. Cause of continued anemia is thought due to chronic disease and frequent blood draws (iatrogenic) in the setting of persistent fevers. . 8. ARF, now resolved at baseline Cr of 1.0: Pt's Cr had increased during hospital stay with aggressive diuresing. Furosemide was held for past 3 days with return of Cr to baseline. She was again diuresed and renal function has remained stable. . 9. HTN: Pt's BP is usually stable but has been intermittently elevated. Pt is on metoprolol (increased to 175 [**Hospital1 **] [**6-18**]) and diltiazem. Pt was also restarted on home dosing of lisinopril 10 qd on [**6-18**] that was increased to 20 mg. Her systolic blood pressures range in the 120-150s with this regimen. However, if continues to be elevated, would recommended increasing BP meds. . 10. Depression: Stable on fluoxetine initially, as above this was stopped in an attempt to determine the cause of her fevers. However, this should be restarted if patient remains afebrile on a trial basis. . 11. FEN: Pt is on TFs per nutrition recs at goal. . 12. Prophylaxis: Patient was maintained on heparin subcutaneous, pneumoboots, proton pump inhibitor and bowel meds . 13. Code: FULL . 13. Communication: Mother [**Name (NI) **] [**Name (NI) 6955**] (Proxy), [**Telephone/Fax (1) 6956**] Medications on Admission: Medications at home: albuterol aspirin 81 mg avelox buspar 10 mg [**Hospital1 **] cartia 240mg [**Hospital1 **] Catapres 0.2mg/24hours Folic acid guaifenesin fluoxetine humalog sliding scale L-carnitine lasix prn for edema lisinopril Levemir flexpen metoprolol 150mg [**Hospital1 **] MOM mvi omeprazole percocet senna terazosin valproic acid . Medications on transfer from OSH: propofol gtt heparin 5000 unit subcut TID tylenol prn docusate combivent methylprednisolone 60mg QID Timentin Valproic Acid 250mg TID, 750mg HS folic acid fluoxetine diltiazem 240mg [**Hospital1 **] Buspirone 10mg [**Hospital1 **] terazosin 2mg [**Hospital1 **] metoprolol 150mg [**Hospital1 **] Iron 325mg aspirin 81 senna insulin gtt Discharge Medications: 1. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Five (5) mL PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO DAILY (Daily). 4. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO DAILY (Daily). 5. Senna 8.8 mg/5 mL Syrup Sig: Five (5) mL PO BID (2 times a day). 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Diltiazem HCl 60 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day): per PEG. 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day). 9. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). 10. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 11. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation QID (4 times a day). 12. Metoprolol Tartrate 50 mg Tablet Sig: 3.5 Tablets PO BID (2 times a day): per PEG. 13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for rash. 14. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): per PEG. 15. Insulin Glargine 100 unit/mL Solution Sig: Twenty Four (24) units Subcutaneous at bedtime. 16. Insulin Lispro (Human) 100 unit/mL Solution Sig: as dir Subcutaneous every six (6) hours: per sliding scale. 17. Propylthiouracil 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours): per PEG. 18. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical Q6H (every 6 hours) as needed. 19. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): per PEG. 20. Furosemide 40 mg Tablet Sig: Four (4) Tablet PO BID (2 times a day). 21. Valproate Sodium 250 mg/5 mL Syrup Sig: Twenty (20) mL PO Q6H (every 6 hours): checking levels daily x 1 week. 22. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. 23. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 24. Acetaminophen 160 mg/5 mL Solution Sig: [**9-27**] PO Q4H (every 4 hours) as needed for fever/pain. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Aspiration pneumonia Prolonged intubation, tracheostomy Secondary: Diabetes type I, history of stroke with residual hemiparesis, volume overload, hypothyroidism, depression, anemia, possible seizure disorder Discharge Condition: afebrile, vital signs stable Discharge Instructions: Patient was admitted with pneumonia that was complicated by prolonged intubation and eventual tracheostomy placement. Additionally she had fevers that resulted in extensive workup and were determined to eventually be secondary to medications. She should return to the ER if she has chest pain, shortness of breath, persistent fevers, chills, hypoxia or any other concerning symptoms. Followup Instructions: Patient should follow up with both neurology and endocrinology as an outpatient. She should follow up with Dr. [**Last Name (STitle) **] in endocrinology when able to go to the appointment (with thyroid function tests checked prior the appointment). This should be scheduled by calling [**Telephone/Fax (1) 2384**]. She should also have neurology follow up with previous neurologist or by calling ([**Telephone/Fax (1) 2528**] to see a [**Hospital1 18**] neurologist.

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icd9cm

[ [ [] ] ]

[ "96.56", "96.72", "31.1", "96.04", "99.04", "38.93", "03.31", "33.22", "96.6" ]

icd9pcs

[ [ [] ] ]

20526, 20605

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327, 381

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171,267

8340

Discharge summary

report

Admission Date: [**2163-6-5**] Discharge Date: [**2163-6-12**] Date of Birth: [**2086-11-28**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5552**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: EGD showed an ulcerated mass in the duodenum Colonoscopy showed diverticulosis, but was not able to be fully completed History of Present Illness: Ms. [**Known lastname **] is a 76 yo woman with metastatic colon cancer s/p right partial-colectomy who presents with bright red blood per rectum. Patient was admitted on the [**1-5**] with BRBPR. She reported that she has been having intermittent ongoing diarrhea secondary to her colon cancer/partial colectomy and one day prior to admission noticed bright red blood on the tissue paper. Associated abdominal pain for two days, diffuse, worst in the epigastrum. No nausea, vomiting, hematemesis. In the ICU, the pt did not receive any blood products as her Hct remained stable. An EGD showed a single ulcerated mass in the third part of the duodenum. Cold forceps biopsies were performed for histology at the third part of the duodenum. Also gastritis was found. A colonoscopy was discontinued due to the following complications: poor prep (blood); diverticulosis with sharp angulation. The pt was also found to have a tachycardia of unclear etiology. Her BB had been stopped on admission and was restarted this am. Her HR has markedly improved since then. Pt currently does not have any complaints. She denies any more abdominal pain. ROS: No chest pain, shortness of breath. She reports that she has been having intermittent shortness of breath at home at rest. Past Medical History: 1. Metastatic colon cancer-Patient has known Stage III adenocarcinoma of the cecum with metastatic disease to lung. She received CPT and her last treatment was given on [**2163-5-2**]. No treatment planned for this admission; plan as per outpatient oncologist. As per prior notes "Oncologic History: She was in her usual state of health until about 3 months prior to diagnosis when she saw her PCP for [**Name Initial (PRE) **] regularly scheduled appointment. She had no gastrointestinal symptoms and never had a colonoscopy. However, her stool was positive for occult blood. This led to a colonoscopy on [**2161-5-14**]. A cecal mass was found which on biopsy proved to be an invasive adenocarcinoma. Subsequently she underwent surgery on [**2161-6-19**]. The pathology revealed a 2.5 X 1.5 X 0.8 cm tumor in the Cecum. The tumor invaded through the muscularis propria and 6 of 25 nodes contained metastatic disease. The proximal and distal margins were negative but the radial margin was involved with tumor. LVI was present as was perineural invasion. Mrs. [**Known lastname **] completed adjuvant chemotherapy with the FLOX regimen on [**2162-1-13**]. Because of recurrent disease she began chemotherapy with Irinotecan. She has completed two cycles of Irinotecan chemotherapy for metastatic disease. This has been well tolerated with easily controlled diarrhea." 2. Hyperlipidemia 3. Hypertension 4. Glaucoma 5. Osteoporosis Social History: Patient lives alone in [**Location (un) 86**] area. She has a neice who lives in the area and is her primary support system. Denies tobacco, alcohol, or IVDA. Family History: NC Physical Exam: vitals T 96.3 BP 183/73 HR 89 RR 16 General: NAD, AA0x3, pleasant HEENT: left eye cateract, MMM, oropharynx clear Lungs: CTA bilat, port-a-cath on R chest Heart: RRR Abdomen: NT/ND, BS normoactive, soft Extremities: no edema Skin/nails: no rashes/no jaundice, diffuse SK Pertinent Results: Laboratory results: [**2163-6-4**] 09:30PM BLOOD WBC-10.3# RBC-4.29 Hgb-12.4 Hct-37.0 MCV-86 MCH-28.9 MCHC-33.6 RDW-16.7* Plt Ct-430 [**2163-6-12**] 12:00AM BLOOD WBC-12.5* RBC-3.93* Hgb-11.5* Hct-33.6* MCV-86 MCH-29.2 MCHC-34.2 RDW-15.6* Plt Ct-433 [**2163-6-4**] 09:30PM BLOOD Plt Ct-430 [**2163-6-5**] 07:15AM BLOOD PT-13.0 PTT-150* INR(PT)-1.1 [**2163-6-4**] 09:30PM BLOOD Glucose-147* UreaN-26* Creat-0.8 Na-134 K-3.3 Cl-103 HCO3-19* AnGap-15 [**2163-6-4**] 09:30PM BLOOD ALT-11 AST-14 AlkPhos-71 Amylase-72 TotBili-0.1 [**2163-6-4**] 09:30PM BLOOD Lipase-38 [**2163-6-4**] 09:30PM BLOOD Calcium-9.6 Phos-3.6 Mg-1.8 [**2163-6-8**] 12:04AM BLOOD CEA-38* Relevant Imaging: 1)CT abdomen/pelvis ([**6-5**]): 1. No evidence of bowel obstruction or free air within the abdomen. 2. Progression of disease with marked increase in pulmonary nodules and slight increase in mesenteric lymph node masses. 3. Unchanged left ovarian calcified mass and right adnexal/mesenteric mass which continue to be concerning for Krukenburg tumors, or mucinous tumors of the ovaries. 4. Stable nodular appearing left adrenal gland. 5. Increased ascites and inflammatory stranding within the abdomen as well as anasarca. 2)Endoscopy ([**6-7**]): A single ulcerated mass was found in the third part of the duodenum. Cold forceps biopsies were performed for histology at the third part of the duodenum. 3)Colonoscopy ([**6-7**]): Multiple diverticula were seen in the sigmoid.Diverticulosis appeared to be severe Brief Hospital Course: Ms. [**Known lastname **] is a 76 yo female with metastatic colon cancer presenting with BRBPR, hemodynamically stable. 1)GI bleeding: Patient presented with BRBPR. She was initially admitted to the ICU and her hematocrit remained stable and she did not require any blood transfusions. Patient was started on IV PPI. She underwent an EGD which showed an ulcerating mass in the 3rd part of the duodenum. Final pathology is consistent with adenocarcinoma. Colonoscopy showed severe diverticulosis. There was no clear source of bleeding identified but GI felt that mass was most likely source. Upon transfer to the oncology service, her Hct dropped to 27 and she required a total of 2 blood transfusions. She responded appropriately with an increase in her Hct. She had 1 episode of melanotic stools. GI was re-consulted and did not feel that she needed to be re-scoped since she was hemodynamically stable and there was no evidence of a brisk bleed. Angiography was an option but was deferred since patient was thought to have a slow bleed and this study would likely not be useful. Her hematocrit remained stable during the rest of her stay and she had no further bleeding. 2)Tachycardia: Patient's blood pressure medications were initially stopped in the setting of an acute bleed. She was restarted on beta-blocker with some improvement but her heart rate still remained high. Differential included dehydration, GI bleed and infection. She also found to have a UTI which may have contributed to her tachycardia. She was also hydrated agressively with IVFs. Lopressor was titrated up with an appropriate response. 3)UTI: Patient complained of dysuria and was found to have a U/A consistent with a UTI. She was started on Cipro for 7d course. 4)Metastatic colon cancer: Patient was not actively being treated. She is followed by Dr. [**Last Name (STitle) **] as an outpatient. CEA had increased to 38 during this admission. Patient would like to continue with further therapy which will be deferred as an outpatient. 5)Hypertension: Blood pressure medications were initially held in light of GI bleeding. Lopressor was restarted and then titrated up slowly. 6)Hypothyroidism: Continued on Levoxyl. 7)Glaucoma: Continued on outpatient regimen of Pilocarpine, Dipivefrin, and Erythromycin. 8)Osteoporosis: Fosamax was held given GI bleeding; patient was asked to re-start after discussing with primary oncologist. Medications on Admission: Medications at home: Acetazolamide 250 mg PO Q24H Alendronate 10 mg PO DAILY Atorvastatin 10 mg PO DAILY Dipivefrin 0.1 % Drops Q12H Levothyroxine 50 mcg PO DAILY Naproxen 250 mg Q12H Pilocarpine HCl 6 % Drops Q6H Erythromycin 5 mg/g Ointment QID Aspirin 81 mg Chewable PO DAILY Atenolol 25 mg Tablet [**Hospital1 **] Loperamide 2 mg PO QID (4 times a day) as needed for diarrhea. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL 15-30 MLs PO QID prn Lansoprazole 30 mg PO DAILY Medications on transfer: Heparin 2500 UNIT SC TID Metoprolol 12.5 mg PO TID Ondansetron 4 mg IV Q8H:PRN Acetaminophen (Liquid) 325 mg PO Q4-6H:PRN Erythromycin 0.5% Ophth Oint 0.5 in OU QID Pantoprazole 40 mg IV Q12H AcetaZOLamide 250 mg PO Q24H Levothyroxine Sodium 50 mcg PO DAILY Dipivefrin HCl 0.1% 1 DROP BOTH EYES Q12H Pilocarpine 6% 1 DROP BOTH EYES Q6H Atorvastatin 10 mg PO DAILY Discharge Medications: 1. Acetazolamide 250 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q24H (every 24 hours). 2. Atorvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 3. Dipivefrin 0.1 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic Q12H (every 12 hours). 4. Levothyroxine 50 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 5. Pilocarpine HCl 6 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic Q6H (every 6 hours). 6. Erythromycin Ophthalmic 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 8. Atenolol 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day. 9. Ciprofloxacin 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H (every 12 hours) for 3 days. Disp:*6 Tablet(s)* Refills:*0* Discharge Disposition: Home with Service Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: Lower GI bleed Duodenal Ulcer Metastatic colon cancer Hypertension Hyperlipidemia Tachycardia Osteoporosis UTI Discharge Condition: stable Discharge Instructions: You were admitted for bleeding in your intestinal tract. Please take your medications as prescribed. Your alendronate (fosamax) was stopped because this can cause some irritation of the GI tract. Please talk to your primary care doctor or Dr. [**Last Name (STitle) **] to discuss re-starting this medication. You should not take medications such as ibuprofen, advil, naproxen or aspirin (tylenol is ok). Please talk to your primary care doctor or Dr. [**Last Name (STitle) **] about when it might be ok to start taking your aspirin again. You were prescribed an antibiotic, ciprofloxacin, for a urinary tract infection. Please continue taking this medication for three more days. You were also prescribed a new medication, pantoprazole, which will help to decrease the irritation in your stomach. Please make sure to take this twice a day. Please call your doctor or return to the ER if you have further episodes of blood in your stool, black stools, worsening stomach pain, nausea, vomiting, chest pain or other concerning symptoms. Followup Instructions: Please follow-up with your primary care doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], in [**12-28**] weeks. His phone number is [**Telephone/Fax (1) 608**]. You also have the following appointments already scheduled: Provider: [**Name10 (NameIs) 17246**] [**Name11 (NameIs) **], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2163-6-16**] 9:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7167**], RD Phone:[**Telephone/Fax (1) 3681**] Date/Time:[**2163-6-21**] 2:00 Please call Dr.[**Name (NI) 8949**] office to make an appointment in the next 1-2 weeks. His phone number is ([**Telephone/Fax (1) 5562**]. You can speak to him about re-starting your alendronate (fosamax) and aspirin at that time.

[ "244.9", "285.1", "733.00", "562.10", "599.0", "196.2", "197.4", "707.03", "V10.05", "272.4", "578.9", "401.9", "197.0" ]

icd9cm

[ [ [] ] ]

[ "45.23", "45.16" ]

icd9pcs

[ [ [] ] ]

9424, 9501

5211, 7632

321, 442

9656, 9665

3695, 4354

10754, 11522

3385, 3389

8548, 9401

9522, 9635

7658, 7658

9689, 10731

7679, 8134

3404, 3676

276, 283

4372, 5188

470, 1737

8159, 8525

1760, 3192

3208, 3369

23,652

153,469

19131+19192

Discharge summary

report+report

Admission Date: [**2133-8-30**] Discharge Date: [**2133-10-15**] Date of Birth: [**2056-1-3**] Sex: F Service: NEUROSURGERY HISTORY OF THE PRESENT ILLNESS: The patient is a 77-year-old woman transferred from the [**Hospital 4415**] with a subarachnoid hemorrhage from a posterior communicating artery aneurysm. The patient was originally transferred from [**State 1727**]. She was awake, alert, and following limited commands. She was intubated in [**State 1727**] and transferred to [**Hospital 10908**]. A CT showed a diffuse subarachnoid hemorrhage in the basal cisterns and left sylvian fissure with hydrocephalus and no midline shift. The patient had a vent drain placed and reportedly had an arteriogram at the [**Hospital 10908**] that showed a small posterior communicating artery aneurysm. The patient was transferred to [**Hospital6 2018**] for treatment of this aneurysm endovascular fashion. PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2. GERD. 3. PVCs. 4. Multi-infarct disease. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 98.6, BP 136/55, heart rate 68, respiratory rate 16, saturations 100%, ICPs 9. HEENT: Pupils were equal, round, and reactive to light, 3 down to 2 mm. She was intubated. Lungs: Clear bilaterally. Cardiac: Regular rate and rhythm. No murmurs, rubs, or gallops. Abdomen: Soft, nontender, nondistended, positive bowel sounds. Extremities: No clubbing, cyanosis or edema. She was intubated, sedated, not opening her eyes, withdrawing all extremities to pain, following some simple commands with squeezing hand and moving feet. HOSPITAL COURSE: She was taken to arteriogram where she had a coil embolization of this posterior communicating artery aneurysm without complication. On [**2133-9-3**], she had repeat arteriogram to look for the presence of vasospasm. It did show some slight vasospasm in the A2 segment of the anterior cerebral artery with right greater than right. The patient was maintained on HHH therapy to prevent vasospasm and continued to be monitored closely in the Neuro ICU with close observation of her neurologic status. The patient also require reintubation for respiratory failure at that point. The patient continued to remain in the ICU. On [**2133-9-16**], the patient again went to arteriogram which showed resolution of the vasospasm. The patient was also intubated for this procedure without intraoperative complications and the procedure went without complication. Postoperatively, the patient was localizing briskly bilaterally, opening her eyes to voice, tracking, and attentive, but not following commands and moving her legs to stimuli. Her groin had no hematoma and she had good distal pulses. The patient spiked to 101.7 on [**2133-9-16**] and was currently receiving vanco, ceftazidime, Flagyl, and fluconazole for IV antibiotic coverage for 10,000 yeast in her urine and sparse MRSA in her sputum. On [**2133-9-19**], she was opening her eyes, attentive, nodding appropriately, localizing in the bilateral upper extremities, not following commands, withdrew her lower extremities, left greater than right. Her vent drain continued to be in place but was raised to 20 above the tragus. The sodium level remained stable at 141. On [**2133-9-24**], she spiked to 102.7. The ID Service was consulted. She was opening her eyes, localizing the upper extremities, not following commands. Her pupils were 3 down to 2.5. She withdrew her lower extremities but seemed somewhat more lethargic. She was also treated with Flagyl for C. difficile that was diagnosed on [**2133-9-6**]. All of the cultures except for her urine which came back positive for yeast have been negative. On [**2133-9-23**], the patient had her vent drain removed. She continued to open her eyes to voice, grimace to pain, tries to squeeze her hands bilaterally, localizes in her upper extremities. Temperature was down to 98.9. CT scan was negative with no changes. She continued to be intubated. On [**2133-9-24**], the patient had a lumbar puncture done due to a question of hydrocephalus. The patient's opening pressure was 19 and closing pressure 9, 20 cc of clear colorless CSF was sent off for culture which was negative. The patient tolerated the procedure well without complications. The patient required reintubation for a second time for respiratory distress. The patient remained intubated. On [**2133-9-26**], the patient again had a LP for a question of hydrocephalus and high ICP, opening pressure 10, closing pressure 8, 6-8 cc was removed. The patient was then transferred to the floor on [**2133-9-27**]. On [**2133-9-30**], the patient went into respiratory distress requiring intubation. The patient was transferred to the Medical Intensive Care Unit for respiratory failure. She had a chest x-ray. On [**2133-10-1**], she also underwent a repeat lumbar puncture, opening pressure 24, drained 23 cc of CSF, closing pressure 10. She tolerated the procedure well without complications. Her neurologic status prior to the LP fluctuated. At times, she would open her eyes to verbal stimuli. She had scant spontaneous movement of bilateral upper extremities and withdrew her lower extremities to painful stimulation. Occasionally, stronger tactile stimulation needed to arouse the patient to open her eyes. This all improved after intubation. The patient opened her eyes. She was attentive but not following commands and localized the left upper more than the right upper and slow localization on the lower extremities. She remained intubated. On [**2133-10-6**], the patient had a tracheostomy placed without complication due to inability to wean from the ventilator. She tolerated the procedure well without complications. On [**2133-10-7**], the patient neurologically was awake, alert, followed commands inconsistently, at times able to track to voice. The pupils were 4-5 mm and briskly reactive. She was able to lift bilateral lower extremities off the bed and move her upper extremities on the bed. She had no changes on the ventilator. Her PEG which had been placed previously from her first ICU stay was stable. She was tolerating her feedings. She again had a LP on [**2133-10-7**] with an opening pressure of 18, 15 cc of CSF was sent, closing pressure was 12. She remained stable and was weaned off the ventilator. She had a temperature again on [**2133-10-8**]. ID was again consulted. The patient had so far negative blood cultures, negative CSF, although on [**2133-10-1**], there was one positive Staphylococcus, coagulase-negative CSF which was thought to be a contaminant. A head CT on [**2133-10-7**] showed old infarct within the periventricular white matter. No new hemorrhages and just artifact from the aneurysm coiling. A chest x-ray showed bilateral small pleural effusions. On [**2133-10-2**], she also had Staphylococcus coagulase-positive sputum which came back and she was treated with vancomycin. The patient was weaned from the ventilator on [**2133-10-8**]. She tolerated that well. On [**2133-10-10**], the patient was transferred to the floor where she has remained neurologically stable, afebrile, awake, attentive, following simple commands intermittently, squeezing her hands, wiggling her toes. Pupils were 5 down to 4 mm and brisk. She has remained on a tracheostomy collar. She continues to improve neurologically. She was seen by Physical Therapy and Occupational Therapy and found to require acute rehabilitation prior to discharge home. DISCHARGE MEDICATIONS: 1. Insulin sliding scale. 2. Lorazepam 0.5 to 1 mg IV q. four hours p.r.n. 3. Heparin 5,000 units subcutaneously q. eight hours. 4. Zosyn 4.5 grams IV q. eight hours. 5. Folic acid 1 mg p.o. q.d. 6. Epoetin 40,000 units subcutaneously once a week on Fridays. 7. Ferrous sulfate 325 mg p.o. q.d. 8. Nystatin swish and swallow 5 cc p.o. q.i.d. p.r.n. 9. Miconazole powder 2% one application topically p.r.n. 10. Albuterol nebulizers one to two puffs q. four hours p.r.n. 11. Amiodarone 400 mg p.o. q.d. CONDITION ON DISCHARGE: Stable. FOLLOW-UP: The patient will follow-up with Dr. [**Last Name (STitle) 1132**] in one month with repeat head CT at that time. Her condition was stable at the time of discharge. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2133-10-15**] 12:45 T: [**2133-10-15**] 13:52 JOB#: [**Job Number 52216**] Admission Date: [**2133-8-30**] Discharge Date: [**2133-10-15**] Date of Birth: [**2056-1-3**] Sex: F Service: NEUROSURGERY HISTORY OF PRESENT ILLNESS: Patient is a 77-year-old woman, who was transferred from [**Hospital 4415**] with a subarachnoid hemorrhage and a posterior communicating artery aneurysm, which was coiled. The patient was transferred originally from [**State 1727**]. Was awake and alert, following commands, was intubated in [**State 1727**], and then transferred to [**Hospital 14852**]. A CT showed a diffuse subarachnoid hemorrhage in the basal cisterns and the left sylvian fissure with hydrocephalus and no midline shift. She had a vent drain placed and became more awake. Is now transferred here for coiling of the PCOM aneurysm. PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2. PVCs. 3. Multi-infarct disease. ALLERGIES: No known drug allergies. MEDICATIONS: Her only medication was Lipitor. VITAL SIGNS ON ADMISSION: Blood pressure is 136/55, heart rate 68, respiratory rate 16, and sats is 100%. ICP was 9. HEENT: Pupils are equal, round, and reactive to light 3 down to 2 mm. Lungs were clear, although the patient was intubated. Cardiac status: Regular, rate, and rhythm. Abdomen is soft, nontender, positive bowel sounds. Extremities: No edema. Neurologic: She was not opening her eyes, withdrew all extremities to pain. Follows some simple commands like squeezing hand and moving feet. She was admitted to the ICU for close monitoring. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2133-10-15**] 12:12 T: [**2133-10-15**] 12:21 JOB#: [**Job Number 52331**]

[ "280.0", "008.45", "518.81", "427.31", "482.41", "430", "428.0", "331.4", "V46.1" ]

icd9cm

[ [ [] ] ]

[ "31.1", "96.6", "88.41", "37.92", "96.71", "96.04", "44.32", "96.72", "03.31", "02.43" ]

icd9pcs

[ [ [] ] ]

7634, 8145

1695, 7611

8788, 9398

9594, 10387

9420, 9579

8170, 8759

62,512

160,010

21380+57242

Discharge summary

report+addendum

Admission Date: [**2140-5-31**] Discharge Date: [**2140-6-10**] Date of Birth: [**2078-2-16**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: unstable angina Major Surgical or Invasive Procedure: [**2140-6-3**] Coronary artery bypass graft x3 (Left internal mammary artery > left anterior descending, saphenous vein graft > obtuse marginal, saphenous vein graft > posterior descending artery) History of Present Illness: 62 year old male with knownmultivessel coronary artery disease,s/p multiple PCI(DES in [**6-4**] to the mid LCX (3.5 x 16mm Taxus stent) and the proximal RCA stenosis was successfully treated with a 3.5 x 12mm Taxus stent), Diabetes Mellitus, dyslipidemia, hypertension, and Aortic insufficiency presents to OSH with unstable angina. On [**2133-12-11**] he underwent another cardiac catheterization for an abnormal stress test which revealed his LAD had mild disease. The previously placed LCx stent had a 20% ISR. The previously placed RCA stent had a 70% ISR. The distal RCA had a 70% denovo stenosis. The ISR was treated with a 3.5 x 8 mm Cypher DES and the distal RCA were treated with a 3.5 x 8 mm Cypher DES. Post procedure, the RFA was angiosealed. He underwent cardiac catheterization again on [**2134-7-16**] for recurrent angina and an abnormal nuclear stress test. He was found to have an 80% stenosis of the OM for which he has been medically managed since that time. The patient presents to OSH reporting 10 days of crescendo angina, substernal chest pain with minimal exertion, and at rest.He underwent cardiac cath which revealed ostial and mid LAD with significant stenosis. He was transferred to [**Hospital1 18**] for evaluation of revascularization. Past Medical History: multivessel coronary artery disease,s/p multiple PCI(DES in [**6-4**] to the mid LCX (3.5 x 16mm Taxus stent) and the proximal RCA stenosis was successfully treated with a 3.5 x 12mm Taxus stent) Diabetes Mellitus dyslipidemia hypertension chronic anemia colonic adenoma gastric ulcer [**6-4**]:DES to the mid LCX (3.5 x 16mm Taxus stent) and the proximal RCA stenosis was successfully treated with a 3.5 x 12mm Taxus stent), [**2133-12-11**] RCA stent had a 70% ISR. The distal RCA had a 70% denovo stenosis. The ISR was treated with a 3.5 x 8 mm Cypher DES and the distal RCA were treated with a 3.5 x 8 mm Cypher DES. Social History: Lives with: married with 2 children Occupation:owns pizzaria Tobacco:quit 20yo ETOH:1-2 drinks daily(beer/hard liquor) Family History: His brother s/p MI at age 47. Mother with a [**Last Name **] problem, a valve problem, and HTN. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Pulse:84 NSR Resp: O2 sat: B/P Right: Left: Height:5'5" Weight:165Lb General: Skin: Dry [x] intact [x] HEENT: PERRLA [] 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: Left: DP Right: 2+ Left:2+ PT [**Name (NI) 167**]: Left: Radial Right: 2+ Left:2+ Carotid Bruit-none appreciated, pulses 2+(B) Pertinent Results: [**2140-6-10**] 05:35AM BLOOD WBC-12.0* RBC-3.90* Hgb-8.7* Hct-26.5* MCV-68* MCH-22.3* MCHC-32.8 RDW-19.6* Plt Ct-218 [**2140-5-31**] 08:00PM BLOOD WBC-7.0 RBC-5.15 Hgb-10.5* Hct-33.4* MCV-65* MCH-20.4* MCHC-31.5 RDW-15.6* Plt Ct-218 [**2140-6-7**] 02:49AM BLOOD PT-17.5* INR(PT)-1.6* [**2140-5-31**] 08:00PM BLOOD PT-12.5 PTT-25.0 INR(PT)-1.1 [**2140-5-31**] 08:00PM BLOOD Glucose-209* UreaN-23* Creat-1.0 Na-136 K-4.5 Cl-99 HCO3-24 AnGap-18 [**2140-6-10**] 05:35AM BLOOD ALT-926* AST-118* AlkPhos-98 Amylase-21 TotBili-0.9 [**2140-5-31**] 08:00PM BLOOD ALT-20 AST-20 LD(LDH)-124 AlkPhos-79 TotBili-0.2 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 56481**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 56482**]Portable TTE (Complete) Done [**2140-6-6**] at 10:00:00 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. [**Hospital1 18**], Division of Cardiothorac [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2078-2-16**] Age (years): 62 M Hgt (in): 65 BP (mm Hg): 122/46 Wgt (lb): 160 HR (bpm): 80 BSA (m2): 1.80 m2 Indication: Recent CABG. ?Pericardial effusion/tamponade. Left ventricular function. ICD-9 Codes: 423.9, 414.8, 424.1, 424.0, 424.2 Test Information Date/Time: [**2140-6-6**] at 10:00 Interpret MD: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) 4134**] [**Last Name (NamePattern1) 4135**], RDCS Doppler: Full Doppler and color Doppler Test Location: [**Location 13333**]/[**Hospital Ward Name 121**] 6 Contrast: None Tech Quality: Adequate Tape #: 2011W000-: Machine: Vivid i-2 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *4.6 cm <= 4.0 cm Left Atrium - Four Chamber Length: *6.2 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.6 m/s Left Atrium - Peak Pulm Vein D: 0.6 m/s Right Atrium - Four Chamber Length: *5.7 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: 4.7 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 2.1 cm Left Ventricle - Fractional Shortening: 0.55 >= 0.29 Left Ventricle - Ejection Fraction: >= 60% >= 55% Left Ventricle - Lateral Peak E': *0.06 m/s > 0.08 m/s Left Ventricle - Septal Peak E': *0.06 m/s > 0.08 m/s Left Ventricle - Ratio E/E': *18 < 15 Aorta - Sinus Level: 3.5 cm <= 3.6 cm Aortic Valve - Peak Velocity: 2.0 m/sec <= 2.0 m/sec Mitral Valve - E Wave: 1.1 m/sec Mitral Valve - A Wave: 1.1 m/sec Mitral Valve - E/A ratio: 1.00 Mitral Valve - E Wave deceleration time: 193 ms 140-250 ms TR Gradient (+ RA = PASP): *30 to 36 mm Hg <= 25 mm Hg Findings This study was compared to the prior study of [**2140-6-2**]. LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic function (LVEF>55%). TDI E/e' >15, suggesting PCWP>18mmHg. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTIC VALVE: Mildly thickened aortic valve leaflets. Mild (1+) AR. MITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild mitral annular calcification. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA systolic hypertension. PERICARDIUM: No pericardial effusion. Conclusions The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild mitral regurgitation with normal valve morphology. No pericardial effusion. Increased PCWP. Compared with the prior study (images reviewed) of [**2140-6-2**], the overall findings are similar. CLINICAL IMPLICATIONS: Based on [**2136**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2140-6-6**] 14:16 ?????? [**2132**] CareGroup IS. All rights reserved. Brief Hospital Course: Transferred from outside hospital for surgical evaluation. Underwent preoperative workup and plavix washout. On [**6-3**] he was brought to the operating room for coronary artery bypass grafting x3, (left internal mammary artery graft, left anterior descending, reverse saphenous vein graft to the marginal branch of the posterior descending artery) with Dr.[**Last Name (STitle) **]. See operative report for further surgical details. He received cefazolin and vancomycin for perioperative antibiotics and transferred to the intensive care unit for post operative managment. That evening he was weaned from sedation, awoke neurologically intact and was extubated without complications. He was started on diuretics and betablockers on post operative day one and transferred to the floor. Physical therapy worked with him on strength and mobility. He continued to progress and antihypertensives were titrated for blood pressure management. On post operative day three he had increased creatinine with hyperkalemia treated with kayexalate, insulin/dextrose, and intravenous fluids. All nephrotoxic medications were stopped and he was transferred to the intensive care unit for monitoring. Hyperkalemia resolved with treatment but creatinine continued to increase with peak 3.2 on [**6-7**] and then trended down. An echo was done on [**6-8**] to rule out tamponade and when compared with the prior study, per cardiology, the overall findings were similar and no tamponade. Mr [**Known lastname **] was transferred back to the step down unit on [**6-8**]. The remainder of his postoperative course was essentially uneventful. By POD# 7 his creatnine decreased to 1.7 and he was cleared for discharge to home with VNA services. All follow up appointments were advised. Medications on Admission: Simvastatin 80mg daily Amlodipine 10 mg daily Metformin 1000 twice a day Lisinopril 10 daily Ranitidine 300 at HS Imdur 120 Q AM Toprol XL 100 mg daily Glipizide ER 10 Q AM Plavix 75 mg daily ASA 325 mg daily 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. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 4. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 5. glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO DAILY (Daily). Disp:*30 Tablet Extended Rel 24 hr(s)* Refills:*2* 6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 7. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*2* 8. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO DAILY (Daily). Disp:*10 Tablet Extended Release(s)* Refills:*0* 9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Coronary artery disease s/p cabg Acute kidney injury Diabetes Mellitus Dyslipidemia Hypertension Chronic anemia Colonic adenoma Gastric ulcer Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesia Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) 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) **] on [**6-30**] at 1:45pm Cardiologist: Dr [**Last Name (STitle) 46008**] on [**6-29**] at 4:00pm Please call to schedule appointments with your Primary Care Dr [**Last Name (STitle) 56483**] in [**4-5**] 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:[**2140-6-10**] Name: [**Known lastname 10581**],[**Known firstname 10582**] Unit No: [**Numeric Identifier 10583**] Admission Date: [**2140-5-31**] Discharge Date: [**2140-6-10**] Date of Birth: [**2078-2-16**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 741**] Addendum: Pt advised to have follow up CXR to evaluate right pleural effusion. Outpt labs: potassium, BUN/Creatnine are to be drawn just prior to his scheduled wound check on Wed [**2140-6-15**] at 10:30Am Discharge Disposition: Home With Service Facility: [**Location (un) 437**] VNA [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2140-6-10**]

[ "411.1", "424.1", "416.8", "285.1", "414.01", "250.00", "V45.82", "584.9", "401.9", "276.7", "272.4" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

14162, 14343

8573, 10346

327, 526

11961, 12175

3468, 8055

13063, 14139

2625, 2839

10605, 11693

11796, 11940

10372, 10582

12199, 13040

2854, 3449

8078, 8550

271, 289

554, 1827

1849, 2472

2488, 2609

17,486

130,761

23690

Discharge summary

report

Admission Date: [**2155-5-1**] Discharge Date: [**2155-5-3**] Date of Birth: [**2076-2-17**] Sex: F Service: MEDICINE Allergies: Demerol Attending:[**First Name3 (LF) 7055**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: 79 yo female, h/o CAD s/p CABG, HTN, hyperlipidemia, HTN, presenting from [**Hospital6 **] s/p catheterization. She presented to [**Hospital3 **] today for a scheduled outpatient cath; prior to this, she had been experiencing recurrent exertional anginal symptoms. She states that since [**Month (only) 1096**], she had been experiencing exertional angina, described as pressure on her chest, worse with walking/exertion, better with rest/SL NTG. This was associated with SOB but she denied n/v/palpitations/diaphoresis. She had a MIBI at [**Hospital3 **] that revealed a defect, and she was scheduled for an outpatient elective catheterization. Cardiac Enzymes checked prior to catheterization were negative. Her cath at [**Hospital3 **] on day of admission revealed in-stent restenosis of her SVG-OM1-OM2 (jump). She was transferred here for brachytherapy; catheterization here revealed in-stent restenosis in SVG-OMI-OM2, and angioplasty with brachytherapy was performed. At the end of the procedure, she had some nausea/vomiting, and when the sheath was pulled, she threw up a small amount of tarry emesis. Her hematocrit was checked and found to be 29.6 (repeat 30.3; had been 40 at OSH on [**4-29**]). She denies any abdominal pain, h/o ulcers, NSAID use, or history of bloody/melanotic stools. She was transferred to CCU for hemodynamic monitoring. Past Medical History: PMH: 1. 1V CABG [**2123**], redo 2V in [**2141**]. Stenting of SVG-OM in [**2149**], ISR with restent in [**2154**], catheterization on [**5-1**] with angioplasty and brachytherapy of stenosed SVG-OM1-OM2. 2. Hyperlipidemia 3. HTN 4. Kidney stones Social History: Lives alone, former smoker Family History: NC Physical Exam: VS: 95.8 122/72 77 22 100% 2L NC Gen: pleasant female, A&Ox3, mentating well, slightly pale HEENT: PERRL, OP clear Lungs: CTA bilat, no w/r/r CV: RRR, distant HS, nl s1/s2, no m/r/g ABd: soft, nt/nd, nabs, no tenderness Extr: no c/c/e, PT 2+ bilaterally Neuro: grossly intact Pertinent Results: [**2155-5-1**] 07:52PM HCT-30.3* [**2155-5-1**] 05:54PM HCT-29.6* [**2155-5-1**] 10:50PM CALCIUM-8.2* PHOSPHATE-3.0 MAGNESIUM-1.9 [**2155-5-1**] 10:50PM GLUCOSE-96 UREA N-22* CREAT-0.6 SODIUM-145 POTASSIUM-4.4 CHLORIDE-113* TOTAL CO2-25 ANION GAP-11 [**2155-5-1**] 10:50PM CK(CPK)-56 [**2155-5-1**] 10:50PM WBC-9.4 RBC-4.09* HGB-11.9* HCT-34.7* MCV-85 MCH-29.1 MCHC-34.3 RDW-14.2 [**2155-5-1**] 10:50PM PLT COUNT-156 [**2155-5-1**] 10:50PM PT-13.1 PTT-24.5 INR(PT)-1.1 [**2155-5-2**]: US right groin without evidence of pseudoaneurysm or fistula Brief Hospital Course: 1. GI bleed: Pt had a ?10 pt hematocrit drop after procedure. Hct of 40 on [**4-29**] was likely hemoconcentrated (unlikely to have such high hct in female of age 79). She had hematoma prior to sheath pull and a small amount of bloody emesis. She was given 2 U PRBC upon transfer to the CCU with good hematocrit response. She was seen by GI who felt that no EGD was necessary. Her hematocrit remained stable while in-house, and she was instructed to be look out for tarry stools (given will need to be on ASA/Plavix). NG lavage was initially deferred (needed to lay flat after sheath pull) and not performed given hct stability and no further emesis. She will continue on protonix. Her coumadin was not restarted upon discharge (unclear indication) and can be restarted at the discretion of her PCP/cardiologist. She will follow up with her PCP who will decide if endoscopy is necessary in the future. 2. CAD: s/p CABG with multiple episodes of ISR, s/p angioplasty with brachytherapy to SVG-OM1-OM2. She was continued on ASA/Plavix. ACEI/BB were initially held due to ?GI bleed but restarted prior to discharge. She had no EKG changes with drop in hematocrit, and she was also continued on her Lipitor. She had no further episodes of chest pain while in-house. She had a small bruit at site of catheterization without hematoma, but US showed no evidence of pseudoaneurysm or fistula. 3. CHF: EF unknown, takes Lasix at home. This was initially held in setting of ?GI bleed but restarted prior to discharge. 4. Rhythm: She had some sinus bradycardia while in-house that resolved prior to discharge. 5. Dispo: She was discharged to follow up with her PCP and Cardiologist. Medications on Admission: ASA 325 Atenolol 25 mg Norvasc 5 mg Lasix 20 mg Lisinopril 5 mg Lipitor 10 mg Plavix 75 Coumadin (stopped prior to cath) ALL: Demerol-dystonic reaction Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*3* 3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual Q5MIN () as needed for chest pain. Disp:*100 Tablet, Sublingual(s)* Refills:*0* 4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lisinopril 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. 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* 8. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 9. Norvasc 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 10. Cardiac Rehab Please have your outpatient cardiologist arrange for cardiac rehabilitation. Discharge Disposition: Home Discharge Diagnosis: Primary: Coronary Artery Disease with in stent re-stenosis of SVG-OM-OM. Secondary: HTN, Hyperlipidemia Discharge Condition: Good. Discharge Instructions: Please follow up with all of your doctors. Please take all of your medications as indicated. Please make sure you take your aspirin and plavix daily, if you miss a dose of either medication, you may suffer another heart attack. The only medication change is a discontinuation of your coumadin which was stopped due to a decrease in your blood count. Please discuss the matter with your cardiologist and only re-start the coumadin if this is necessary. Please discuss this recent decrease in blood count and neccisity for an EGD with your PCP. Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 7178**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 7175**] Follow-up appointment should be in 2 weeks. At the time, please have him arrange from an outpatient EGD to evaluate for possible GI bleedds. Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) 870**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 5985**] Follow-up appointment should be in 3 weeks. At the appointment please discuss the necessity of coumadin anticoagulation. Please have your cholesterol panel and liver function tests performed in six weeks after discharge.

[ "428.0", "427.89", "V45.82", "285.1", "413.9", "414.00", "V13.01", "V45.81", "996.72", "998.12", "272.4", "401.9", "578.0" ]

icd9cm

[ [ [] ] ]

[ "36.01", "92.27", "88.55", "99.04" ]

icd9pcs

[ [ [] ] ]

6035, 6041

2942, 4637

275, 300

6190, 6197

2355, 2919

6793, 7447

2032, 2036

4840, 6012

6062, 6169

4663, 4817

6221, 6770

2051, 2336

227, 237

328, 1695

1717, 1972

1988, 2016

74,039

149,667

41945

Discharge summary

report

Admission Date: [**2161-11-14**] Discharge Date: [**2161-11-25**] Date of Birth: [**2111-1-20**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 3290**] Chief Complaint: unresponsiveness Major Surgical or Invasive Procedure: none History of Present Illness: 50 y/o w/ congenital hydrocephalus and [**Last Name (un) 62109**] syndrome with multiple VP shunt placements/revisions, who was transferred from an OSH where he presented with unresponsiveness, hypoxemia and hypernatremia. On the day of admission, his caregivers at [**Name (NI) **] [**Name (NI) 731**] noted him to be lethargic and thus called EMS. During transport in the ambulance, he has 3 focal seizures. OSH ED vitals were 98.7F rectal, HR 72, RR 10, BP 89/49, 89% on oxygen (unknown amount). CXR was completed which did not show acute intrathoracic process. CT head showed severe hydrocephalus with shunt in place, no change compared to prior CT from 1/[**2161**]. ABG on NRB was 7.33/50/82/95%. Labs notable for WBC 6.6 w/ 89% PMN, HCT 36.2, Na 149 (baseline 135-140), BUN 41, Cr 1.2 (baseline 0.8). Sputum culture showed GPC and GPR. UA suggestive for UTI. He received Zosyn. ECG without ischemic changes. Dilantin level was elevated at 27.5, phenobarbital was therapeutic 28.9. BNP and LFTs normal. Patient is DNR. . On arrival to the MICU, he was unresponsive and not withdrawing to pain. He was breathing spontaneously on a NRB which was tapered to a 50% face mask. Neurology was consulted. He was started on vancomycin and meropenum given report of GPC/GPR in sputum and ESBL in urine. Past Medical History: Congenital hydrocephalus Shato syndrome Dysphagia History of recurrent hypothermia Metabolic encephalopathy Seizure disorder H/o LLL pneumonia Developmental delay Ataxia with falls Recent UTI with possible UTI ESBL Acute renal failure Dysphagia Social History: lives at [**Location **] [**Location 731**], single, no children. Bedbound, [**Doctor Last Name 2598**] lift transfer to chair. No h/o of tob/ETOH/IVDA. Family History: 2 parents alive in their 70s. Physical Exam: ADMISSION EXAM General: not sedated, not responsive, not responding reliable to painful stimuli HEENT: Sclera anicteric, MM dry Neck: supple, no LAD CV: RRR, normal S1 + S2, no M/R/G Lungs: CTAB, no wheezes, rales, ronchi Abdomen: soft, NT/ND, no HSM Ext: warm, well perfused, 2+ pulses, no edema . At the time of discharge, the patients vital signs were stable though he required 2L of oxygen. He was interactive with staff though at times slow to respond - approaching baseline per his family. His heart, lungs, abdomen exam were [**Last Name (un) 2677**]. He had continued 2+ edema in the lower extremities and 1+ edema in the upper extremities. Pertinent Results: ADMISSION LABS [**2161-11-14**] 02:33PM BLOOD WBC-8.1 RBC-3.77* Hgb-12.0* Hct-36.7* MCV-98 MCH-31.9 MCHC-32.7 RDW-15.5 Plt Ct-96* [**2161-11-15**] 03:59AM BLOOD Neuts-88.6* Lymphs-6.3* Monos-4.6 Eos-0.4 Baso-0.1 [**2161-11-14**] 02:33PM BLOOD PT-14.3* PTT-30.0 INR(PT)-1.2* [**2161-11-14**] 02:33PM BLOOD Glucose-95 UreaN-45* Creat-1.4* Na-155* K-3.7 Cl-119* HCO3-25 AnGap-15 [**2161-11-14**] 02:33PM BLOOD ALT-43* AST-35 LD(LDH)-226 AlkPhos-124 Amylase-373* TotBili-0.4 [**2161-11-14**] 02:33PM BLOOD Albumin-3.7 Calcium-8.5 Phos-4.5 Mg-2.0 [**2161-11-14**] 02:33PM BLOOD Phenyto-25.2* [**2161-11-15**] 07:37PM BLOOD Vanco-21.0* [**2161-11-14**] 02:33PM BLOOD Triglyc-83 [**2161-11-14**] 02:53PM BLOOD Type-CENTRAL VE Temp-36.7 pO2-50* pCO2-64* pH-7.23* calTCO2-28 Base XS--2 [**2161-11-14**] 02:53PM BLOOD freeCa-1.24 . Imaging: . Cardiac 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 low normal (LVEF 50%). The right ventricular free wall thickness is normal. The right ventricular cavity is dilated with borderline normal free wall function. There is abnormal septal motion/position. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. Significant pulmonic regurgitation is seen. There is no pericardial effusion. . [**2161-11-18**] CXR: Widespread pulmonary opacification is most readily explained by pulmonary edema, but particularly since there is at least small-to-moderate bilateral pleural effusion, there is no way to exclude pneumonia, particularly in the right upper lobe. If the clinical situation is uncertain, CT scanning might be helpful in clarification. Heart is moderately enlarged. Right subclavian line ends in the low SVC. A segment of tubing projected over the right lower hemithorax could be a remnant of a previous shunt, but is really indeterminate. The left-sided cerebral shunt traverses the neck, chest and upper abdomen. No pneumothorax. . Negative Urine, Sputum, and Blood cultures. . LABS AT DISCHARGE [**2161-11-23**] 05:17AM BLOOD WBC-4.4 RBC-3.05* Hgb-9.8* Hct-29.4* MCV-96 MCH-31.9 MCHC-33.2 RDW-15.7* Plt Ct-232 [**2161-11-23**] 05:17AM BLOOD Glucose-79 UreaN-16 Creat-0.7 Na-143 K-3.8 Cl-108 HCO3-28 AnGap-11 [**2161-11-21**] 05:14AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.1 [**2161-11-22**] 04:20PM BLOOD Phenyto-8.5* [**2161-11-23**] 05:28AM BLOOD Vanco-22.1* Brief Hospital Course: 50 y/o w/ congenital hydrocephalus and [**Last Name (un) **] syndrome with multiple VP shunt placements/revisions, who was transferred from an OSH where he presented with unresponsiveness, hypoxemia and hypernatremia. . # Unresponsiveness: Likely multifactorial and per transfer notes, appears to be recurrent. We suspect this episode of unresponsiveness could be due to seizure activity which may have been precipitated by hypernatremia and/or hypothermia. Alternatively, indolent infection (UTI/recent ESBL or PNA considering GPC/GPR in sputum both likely considering culture data from transfer notes). The diffuse opacity on CXR is concerning for possible consolidation. His hydrocephalus is unlikely to be playing a role in his current acute mental status decompensation considering ventricles stable in size and shunt inplace/intact. The patient was continued on phenobarbital, and the phenytoin was initially held since the patient was supratherapeutic. Phenytoin was restarted at a lower dose of 100 [**Hospital1 **]. Per OSH record, sputum culture grew MRSA and urine culture grew ESBL. Blood, urine, and sputum cultures and urine legionella here were all negative to date on transfer to the floor. Empiric antibotics were started since admission with vancomycin and meopenem- which covered OSH ESBL and MRSA growth; this course was completed on the day of discharge. For hyponatremia, patient was started on D5W and slowly corrected to within a normal range. After 2 days in the MICU the patient returned to his normal baseline mental status and was transfered to the floor. . # Bilateral opacities lung: Differential included pulmonary edema from fluid resuscitation or multifocal pneumonia per CXR. Sputum cultures at OSH grew MRSA. Chest x-ray shows worsening pulmonary edema. Vancomycin and Meropenem were given for a total of a 10d course. A Legionella was negative. Blood and sputum culture were negative. Agressive pulmonary toilet was performed. The patient was diuresed with 20 mg IV lasix as necessary with continued monitoring of electrolytes. At the time of discharge the patient was on 2L NC of oxygen and the lung exam was stable. He should continue with PO or IV diuresis and pulmonary PT at rehab until he has returned to dry weight. . # UTI: OSH reports indicate ESBL, had recently been started on ertapenem [**11-12**]. Urine from the OSH grew >100,000 colonies of ESBL E.coli susceptible to gentamicin, ertapenem, nitrofurantoin; resistant to levofloxacin, ceftriaxone, cefazolin. Meropenem was continued for a total of 10 days . #. Hypotension - likely a distributive picture, given warm edematous extremities. The patient was started on vanco and [**Last Name (un) 2830**]. He was given multiple fluid bolus. He did not require pressors. The patient became normotensive after the first day of hospitalization and remained with SBPs greater than 100 until the day of discharge. . # Hypothermia - the patient became hypothermic on the day after tranfer to the floor with rectal temperatures <96 and oral temperatures of 90.0F. He was mentating at baseline throughout these episodes. On further investigation, it was noted that he had previously been admitted at [**Hospital1 112**] for hypothermia. Neurological evaluations suggested that this may be due to a mixed picture of hypothalamic dysfunction and infection. A cortisol stimulation test and morning cortisol were reportedly normal at the time of this workup. Based on the persistence of this problem and the known infection, it was decided that further workup was not necessary at this time. The patient was warmed with warming blankets and his temperatures returned to >96F within 48 hours. . INACTIVE ISSUES: . # Congenital hydrocephalus: Stable on CT head at OSH and VP shunt seried end within the lung cavity. Neurosurgery at [**Hospital1 756**] confirm that the VP shunt ended in the proper location. . # Seizure disorder: The patient reportedly had partial seizures upon transfer to ED. Neurology was consulted and recommended to hold phenytoin given the supratherapeutic level. Phenytoin was restarted at 100 mg [**Hospital1 **] and eventually increased to 100 mg QAM and 150 QPM. He was continued on his home dose of phenobarb and zonisamide. An EEG was performed and the findings were indicative of a moderate diffuse encephalopathy which is etiologically non-specific. . # Thrombocytopenia. The patient presented with throbmocytopenia. Platlets were stable throughout the hospitalization. There is no history of known HIT. . TRANSITIONAL ISSUES: The patient should resume home medications with the exception noted below. He should follow up with his neurologist and neurosurgery given the changes to his medication and his recent pnemonia (with V-pleural shunt). He should also follow-up with his PCP upon discharge. . REDUCE Dilantin 100 mg three times daily to dilantin 100 mg in the AM and 150 mg in the PM START Furosemide 40 mg by mouth every day until you have returned to your dry weight (112 kg was admission weight here); please monitor electrolytes while on furosemide. Medications on Admission: Risperdal 1.5mg daily and 2mg qHS Risperdal 0.5mg [**Hospital1 **] PRN agitation Phenobarbital 100mg daily Dilantin 100mg TID Colace 100mg [**Hospital1 **] Vitamin D3 1000 units [**Hospital1 **] Zonisamide 200mg qHS Miralax 17 gm PO QD Colace 100 mg PO BID Fondiparinox 2.5mg SQ daily Discharge Medications: 1. phenobarbital 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. zonisamide 100 mg Capsule Sig: Two (2) Capsule PO QHS (once a day (at bedtime)). 3. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. Risperidone M-Tab 0.5 mg Tablet, Rapid Dissolve Sig: Three (3) Tablet, Rapid Dissolve PO QAM (once a day (in the morning)). 5. risperidone 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. risperidone 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for agitation. 7. meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours) for 4 days. 8. vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q 12H (Every 12 Hours): 500 mg Q12H until [**11-24**]. Recon Soln(s) 9. phenytoin 125 mg/5 mL Suspension Sig: Four (4) ml PO QAM (once a day (in the morning)). 10. phenytoin 125 mg/5 mL Suspension Sig: Six (6) ml PO HS (at bedtime). 11. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. 12. Miralax 17 gram/dose Powder Sig: One (1) packet PO once a day. 13. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 14. Arixtra 2.5 mg/0.5 mL Syringe Sig: One (1) injection Subcutaneous once a day. Discharge Disposition: Extended Care Facility: [**Location (un) **] [**Location (un) 731**] - [**Location (un) **] Discharge Diagnosis: Pneumonia, UTI Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Dear Mr. [**Known lastname 91052**], It was a pleasure participating in your care during your hospital stay. You were tranferred to the [**Hospital1 18**] due to altered mental status. At the time of your admission you were on oxygen and not interactive with the staff here. You reportedly had three seizures in transit from your facility to the hospital where you first went. A chest x-ray showed that you likely had a pneumonia and a urine test showed that you likely had a urinary tract infection. You were treated with IV antibiotics. Your dilantin level was noted to be high and this dose was decreased. By day 4 of your stay, you were back to your normal mental status. It was thought that your change in mental status could have been due to the seizures, or either of the infections. You were transfered to the medical floor. You were noticed to have a really low body temperature. This appears to have happened in the past and you were warmed with warming blankets. by the time of your discharge your mental status had returned to [**Location 213**] and your body temperatures were also normal. You were noticed to have a high degree of edema after your ICU stay. This was likely due to high amounts of fluids received in the ICU. You were given lasix to help remove the fluids. A cardiac echo was done which showed some mild signs of heart failure. You should follow this up with your PCP. [**Name10 (NameIs) **] the time of your discharge, you continued to require oxygen though in decreasing amounts. This was likely due to both the excess fluid and the pneumonia, both of which were treated throughout your stay. At your extended care facility, you should continue with pulmonary physical therapy to try to increase your lung capacity. You should resume taking your home medications with the following changes: . REDUCE Dilantin 100 mg three times daily to dilantin 100 mg in the AM and 150 mg in the PM START Meropenem 500 mg every six hours until [**2161-11-24**] START Vancomycin 750 mg every twelve hours until [**2161-11-24**] START Furosemide 40 mg by mouth every day until you have returned to your dry weight; your electrolytes should be monitored periodically on this medication START Lovenox sub-cutaneous three times daily Followup Instructions: In addition to continuing with your primary care that you receive at Please follow with up the following appointments after your discharge: . Name: [**Last Name (LF) **],[**Name6 (MD) **] [**Name8 (MD) **] MD Location: [**Hospital1 112**] - NEUROLOGY/EPILEPSY Address: [**Doctor First Name **], [**Location (un) **],[**Numeric Identifier 6425**] Phone: [**Telephone/Fax (1) 68966**] Appt: [**11-24**] at 1pm . Department: Radiology --CT Scan Address: [**Doctor First Name 91053**] ([**Location (un) **]), [**Location (un) **],[**Numeric Identifier 6425**] Appt: [**11-30**] at 1pm . Name: [**Last Name (LF) **], [**Name8 (MD) **] MD Location: [**Hospital1 112**] - Dept of Neurosurgery Address: [**Doctor First Name **], [**Location (un) **],[**Numeric Identifier 6425**] Phone: [**Telephone/Fax (1) 78908**] Appt: [**11-30**] at 2pm Completed by:[**2161-11-27**]

[ "E936.1", "996.64", "584.9", "428.0", "V45.2", "482.40", "V49.86", "348.31", "428.31", "041.49", "742.3", "E879.6", "345.90", "995.29", "276.0", "799.02" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12279, 12373

5605, 9305

324, 330

12432, 12432

2829, 5582

14844, 15713

2114, 2145

11045, 12256

12394, 12411

10735, 11022

12571, 14821

2160, 2810

10172, 10709

268, 286

358, 1659

9322, 10151

12447, 12547

1681, 1928

1944, 2098

12,411

138,791

1020

Discharge summary

report

Admission Date: [**2188-12-23**] Discharge Date: [**2189-2-9**] Date of Birth: [**2141-5-14**] Sex: F Service: SURGERY Allergies: Sulfonamides / Biaxin / Vancomycin / Haldol / Heparin Agents / Flagyl Attending:[**First Name3 (LF) 3127**] Chief Complaint: Fever, leg edema, and fatigue Major Surgical or Invasive Procedure: Biopsy [**2189-1-7**] EGD [**2189-1-15**]: GI Bleed Drain removal [**2189-1-21**] History of Present Illness: 47 y.o. female s/p LRRT from sister [**10-10**] with complicated postop course including rejection, perinephric collection/hematoma, TTP/HUS,HTN with 2 drains placed in abd p/w fever x 1 day. Also, c/o productive cough with yellow phlegm. Complained of decreased po intake and fatigue. Denied diarrhea, nausea, vomiting, abd pain, CP/SOB. Of note VRE grew out from JP fluid on [**2188-12-15**]. Past Medical History: Living related renal transplant from sister [**2188-9-24**], Lupus, HTN, osteopenia, drug induced DM, Avascular necrosis of hips Social History: Lives alone Family History: NC Physical Exam: 101.4 115 165/84 18 100% RA NAD aniceric sclerae supple CTA RRR, tachy No cvat, lower abd drain-bloody fluid, soft, NT, ND\ Ext no cce L arm avf-+bruit/thrill wbc 4.4, hct 18.7, plt 28, creat 2.3, lactate 1.4, inr 1.0 Pertinent Results: [**2188-12-23**] 06:20PM FIBRINOGE-440* [**2188-12-23**] 06:20PM PT-11.8 PTT-28.9 INR(PT)-1.0 [**2188-12-23**] 06:20PM PLT SMR-LOW PLT COUNT-51* [**2188-12-23**] 06:20PM WBC-4.4 RBC-2.12*# HGB-6.6*# HCT-18.7*# MCV-88 MCH-30.8 MCHC-35.0 RDW-15.4 [**2188-12-23**] 06:20PM CALCIUM-8.6 PHOSPHATE-2.8 MAGNESIUM-2.0 [**2188-12-23**] 06:20PM GLUCOSE-126* UREA N-55* CREAT-2.3* SODIUM-143 POTASSIUM-3.8 CHLORIDE-112* TOTAL CO2-18* ANION GAP-17 [**2188-12-23**] 06:30PM LACTATE-1.4 Brief Hospital Course: On admission, an ABD CT was unchanged in appearance of the heterogeneous hematoma surrounding the superiorly located pigtail catheter with perinephric fluid and free fluid in deep pelvis. The fluid collection surrounding the inferiorly located catheter was unchanged. There was no intraperitoneal hemorrhage or other finding to account for the profound anemia. A transplant u/s revealed a perinephric fluid collection as seen on prior CT scan. Mild hydronephrosis of the transplanted kidney, increased since [**2188-12-8**]. Vascularity to the transplanted kidney had appropriate waveforms. A CXR revealed cardiomegaly, increased edema and L effusion. A cline was inserted and she received 2 PRBCs. GI was consulted for concern for GI bleed. PPI was increased. EGD was performed after DDAVP and plt transfusion. Red and clotted blood was seen in the stomach. An erosion or ulcer was found in the stomach antrum partially obscured by edematous folds. Epi and electrocautery were successful in obtaining hemostasis. IV Vanco and Zosyn were started. Blood cultures from [**12-23**] were negative. The JP fluid had 4+ PMN with STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH. PROBABLE ENTEROCOCCUS. MODERATE GROWTH. ANAEROBIC CULTURE (Final [**2188-12-28**]): NO ANAEROBES ISOLATED. FUNGAL CULTURE (Final [**2189-1-6**]): [**Female First Name (un) **] ALBICANS. SPARSE GROWTH. ID was consulted and recommendations included starting flu for thrush, dap to for re, po vanco for c.diff and discontinuation of IV vanco. These recs were followed. Stool was negative for c.diff and other pathogens. She continued to have melena. Creat was elevated from baseline of 1.7 up to 2.3. Nephrology was consulted. Elevated creatinine was felt to be due to ATN and decreased intravascular volume. She received IV Lasix for volume overload which exacerbated her respiratory status. A Bx was deferred until [**1-7**]. This showed mild interstitial fibrosis and tubular atrophy. Mild chronic inflammation accompanied the scarring. No endothelialitis was noted. C4d stain was negative. Diagnostic Category: Thrombotic microangiopathy. Urine output continued to be ~ 700cc/day. Creatinine increased and hemodialysis was initiated during the week of [**1-18**]. Urology had been consulted for cytoscopy with stent placement for hydronephrosis of L kidney. A MR urogram was recommended to trace transplant ureter to r/o obstruction and help with stent placement. This showed diffusely narrow appearance of the distal 4 cm of the ureter, without focal stricture. No hydronephrosis. Patent arterial supply and venous drainage of the renal transplant Cardiology was consulted for sob and pulmonary edema. An echo demonstrated mild symmetric LVH with normal cavity size and systolic function (LVEF>55%), [**1-6**]+ MR and a small pericardial effusion. Recs included more aggressive diuresis and decreasing BB dose. ON [**12-25**], she became very dyspneic requiring NRB O2 transfer to SICU. She was intubate and diuresed . A repeat echo was done without change. A chest CT was done to eval infiltrates. Diffuse ground glass opacities with septal thickening and bibasilar consolidation were noted. These findings were most consistent with atypical viral or mycoplasma infection given the widespread distribution, but a component of hydrostatic pulmonary edema was also likely, and interstitial pneumonitis related to lupus, as well as pulmonary hemorrhage was suggested. Moderate bilateral pleural effusions were noted. IV Caspo was started on [**12-25**] for expanded coverage for fever. ID recs included Bronch. Dapto was changed to vanco and levo was added. A bronchoscopy with lavage was done on [**12-27**]. Cultures were negative.Dapto was stopped and ampicillin was started. She continued to require plt and prbc transfusions for plt counts in 41-51. Hematology was consulted. A peripheral smear showed mild-moderate schistos. TTP was not felt to be the cause of low plt. DIC was also not felt to be a diagnosis as fibrinogen and coags were ok. An antiplt antibody was done to r/o ITP.This result was found to be positive as of [**2189-1-9**]. It was felt that she had ITP, thrombotic microangiopathy and AIHA. Recommendations included increasing steroids, but this was not done due to h/o AVN of hips and Gastric ulcer. She continued to receive prbc and plt for hcts in 25 range and plts in 30 range. A repeat HIT was negative. Epogen was started for anemia. Respiratory status improved with diuresis and empiric antibiotics. she was extubated on [**12-29**]. On [**1-1**] hct decreased to 19.7 and plt 51 for which she was transfused. She c/o distention and abd pain. A repeat abd ct showed slight decrease in size of previously noted hyperdense peri-transplant fluid collection consistent with hematoma with larger decrease in size of more inferior medially located simple fluid collection when compared to [**12-23**]. Bilateral increase in previously noted pleural effusions with new patchy airspace consolidation most marked in the left lower lobe, consistent with underlying pneumonia. Stable appearance to mild fullness of the transplant kidney collecting system with no frank hydronephrosis identified. Myfortic and [**Last Name (un) **] were stopped given septic appearance and [**Last Name (un) 500**] marrow suppression. Prednisone continued. There was concern for infiltrates secondary to rapamune. On [**1-4**], flagyl was added for fever and persistent diarrhea which was c.diff neg. She experienced hemolysis and had a +DAT. There was concern that rapamune could cause TMS. This was stopped on [**2189-1-9**]. Pheresis with IVIG was started for thrombocytopenia and hemolysis. Pheresis was done x 6 sessions without much improvement of plt. LDH decreased somewhat. There was no evidence of TTP. HUS was considered given bx. On [**2189-1-8**], a rpt EGD was done for decreased hct. An ulcer in the pre-pyloric region was noted. There were multiple oozing areas in the antrum of the stomach and a site of active oozing of blood in the duodenal bulb.Cautery was performed. DDAVP was given. She required intermittent plt/prbc transfusions. She continued to intermittent fevers while on antbx. Respiratory status slowly improved. On [**1-11**] urine was + for >100,000 yeast. She continued on IV Caspo. On [**1-12**] a rectal swab for screening was VRE +. She remained on Dapto/Caspo for drain cultures. On [**1-6**] she had a urine positive for BK virus with 20,000 copies. Recs included decreasing immunosuppression. Sidofovir was deferred due to the nephrotoxicity. Persistent fevers were felt to be due to known abd hematoma/fluid collections. On [**1-10**] Cefepime IV was added for empiric coverage and concern for hosp acquired pna. A LLL retro cardiac infiltrate was noted. She experienced persistent diarrhea. Flagyl continued for empiric treatment despite neg c.diff cx. E.coli H0157:H7 was check as this can cause TTP. This was negative. On [**1-14**] she transferred out of the sicu. But returned to the SICU on [**1-15**] for hct to 17, melena and hct drop. A repeat EGD was done on [**1-15**] Again blood was noted in the stomach with no definitive sites seen. Electrocautery was applied for hemostasis. A small ulcer was seen in the superior wall of the antrum and a 6-7 mm ulcer was found in the posterior wall of the duodenal bulb. On [**1-16**] an ABD CT revealed new intraperitoneal hemorrhage, with largest amount of blood seen anterior to the transplanted kidney, tracking down to the pelvis. There was slight decrease in size of previously noted peri-transplant fluid collections, with draining catheters again noted. Persistent bilateral pleural effusions with associated atelectasis. On [**1-19**] she was transferred out of the SICU. On [**1-21**] repeat abd CT was essentially unchanged. The drains were removed. HD was held x 6 days during which time she received IV Lasix and Diuril with low urine outputs and creatinine increase to 4. On [**1-26**] she became hypoxic, tachycardic, hypertensive and volume overloaded. She required emergent intubation for respiratory failure. She was transferred back to the SICU on [**1-5**] where HD was done with removal of 5 liters. She was extubated later that day. Subsequently, she was dialyzed each day with improvement in fluid overload and goal dry weight of 56 kg. Cardiology was re-consulted for echo findings of an EF of 30% and global LV hypokinesis. Recommendations included volume reduction, BB, ace, statin,correction of anemia, low Na diet,avoidance of nifedipine and repeat TTE once euvolemic. Concern was given for possible PE given SLE. On [**1-31**] a chest CT without contrast revealed Moderate amount of ascites tracking down the paracolic gutters into the pelvis, not significantly changed compared to the prior study. Mild interval decrease in size of well organized superior peri-transplant fluid collection containing multiple foci of air. The inferior collection was not well appreciated. 3. No change in appearance of two hypodense foci within the transplanted kidney. A linear consolidation within the right upper, right middle, left upper, and left lower lobes were noted as well as a dense consolidation/atelectasis in the right lower lobe. Moderate-sized right-sided pleural effusion and small sized left-sided pleural effusion. Moderate sized stable pericardial effusion. A sputum culture was sent on [**1-31**], but was contaminated. She continued dialysis daily achieving dry weight of 56kg and was seen regularly by ID and the Transplant Medicine service. Hematology felt thrombocytopenia was related to ITP and drugs (cefepime/valcyte). Should plt <20 then would consider IVIG or steroids. For discharge the plan was to administer dapto q 48 hours at HD, Dapto/fluc/cipro were to continue for 3 weeks then re image abd. New Eng Home therapies will supply Dapto. Gentiva VNA was arranged for PT/Nsg and HHA. Medications on Admission: Tums Oscal, Nystatin, Lopressor, Lasix, Myfortic, Nifedipine, Rapamune, fosamax, Prednisone, Valcyte, Discharge Medications: 1. Daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous 3 times/week at dialysis: Continue until notifies otherwise. Disp:*15 Recon Soln(s)* Refills:*5* 2. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection Q Tues, Thurs Sat at hemodialysis. 3. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 6. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours): Take following hemodialysis. Disp:*15 Tablet(s)* Refills:*2* 7. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*30 Tablet(s)* Refills:*2* 8. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO once a day. Disp:*90 Tablet(s)* Refills:*2* 9. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). Disp:*30 Tablet Sustained Release(s)* Refills:*2* 10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO every [**4-10**] hours. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Gentiva Discharge Diagnosis: BK virus VRE Perinephric hematoma/fluid collections + Yeast/VRE/coag neg staph Pneumonia gastric/duodenal ulcer-GI bleed renal transplant failure [**2-6**] thrombotic microangiopathy ?HUS?TTP Lupus [**Female First Name (un) 564**] UTI anemia Thrombotic microangiopathy, biopsy [**2189-1-7**] GI bleed ESRD: now on hemodialysis Discharge Condition: Good Discharge Instructions: Please call your doctor or return to the ER for any of the following: * Fever, chills * 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 if you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Any serious change in your symptoms, or any new symptoms that concern you. *Continue labwork weekly and have faxed to [**Hospital 1326**] clinic at [**Telephone/Fax (1) 697**] CBC, Chem 7, Ca, Phos, CK, AST, T Bili [**Location (un) 511**] Home therapies will provide Daptomycin for infusion at hemodialysis. Duration will be determined at [**Hospital 1326**] clinic appointment Hemodialysis q Tues,Thurs, Sat. You will receive Epogen at the dialysis unit Check finger stick blood sugars daily and record. Bring this record with you to Dr [**Last Name (STitle) 6729**] appointment. If you get readings greater than 160 with a fasting blood sugar in the morning please call your primary care physician. Followup Instructions: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2189-3-3**] 8:30 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2189-3-3**] 9:00 [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 2310**], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2189-3-12**] 4:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6730**], MD Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2189-3-13**] 1:00 [**Year/Month/Day 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2189-12-10**] 8:30 Completed by:[**2189-2-9**]

[ "584.5", "517.8", "425.4", "079.89", "998.12", "996.81", "251.8", "283.0", "518.81", "553.3", "789.5", "244.9", "591", "518.0", "280.0", "273.8", "E932.0", "787.91", "112.2", "428.0", "710.0", "112.0", "733.42", "511.9", "276.52", "531.00", "287.31", "403.91" ]

icd9cm

[ [ [] ] ]

[ "96.04", "38.93", "99.14", "44.43", "96.6", "38.91", "99.15", "55.23", "39.95", "54.91", "33.24", "99.71", "99.05", "45.13", "99.04", "96.71" ]

icd9pcs

[ [ [] ] ]

13343, 13381

1838, 11803

359, 443

13752, 13759

1327, 1815

15018, 15706

1064, 1068

11955, 13320

13402, 13731

11829, 11932

13783, 14995

1083, 1308

290, 321

471, 867

889, 1019

1035, 1048

42,486

124,461

53655

Discharge summary

report

Admission Date: [**2201-4-7**] Discharge Date: [**2201-4-14**] Date of Birth: [**2116-1-7**] Sex: F Service: CARDIOTHORACIC Allergies: Cider Vinegar Attending:[**First Name3 (LF) 1406**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Aortic valve, replacement with a 21-mm St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 4041**] tissue valve, Reference number [**Serial Number 79828**], serial number [**Numeric Identifier 110186**]. History of Present Illness: 85 year oll female with significant progressive worsening dyspnea on exertion. She also has a history of emphysematous COPD. She was evaluated for consideration in the [**Company 1543**] CoreValve trial, and she was felt to be high risk and was randomized to the surgical arm for aortic valve replacement. She underwent a cardiac catheterization which demonstrated no significant coronary artery disease. She was see by Dr. [**Last Name (STitle) **] and accepted for aortic valve replacement. Past Medical History: Aortic Stenosis valve area 1.0 cm2 [**2201-1-30**] COPD Anxiety Hypertension Hyperlipidemia Anemia Hypoparathyroidism Social History: -Tobacco history: [**11-17**] ppd >50 years -EtOH: occasional -Illicit drugs: The patient is divorced, 2 children, 1 grandchild. She lives in [**Location 38**] with her ex husband. Family History: Sister at age 45 had an MI prompting CABG. Brother died while sleeping, patient attributes this to his known heart block. Mother with permanent pacemaker for unknown indication. Physical Exam: Pulse: 71 Resp:18 O2 sat: 99& RA B/P Right:102/62 Left: Height:5'3" Weight:39.2 kg General: A&Ox 3 in NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [x] grade III/VI SEM at LSB 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 [x] Pulses: Femoral Right: Left: DP Right: Left: PT [**Name (NI) 167**]: Left: Radial Right: Left: Carotid Bruit - Right/Left: transmitted murmur b/l Discharge Exam: VS: T: 98.6 HR: 77 SR BP:105/60 Sats:100 2L NC Wt: 45.1 Kg (40.1) General: 85 year-old female in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple no lymphadenopathy Card: RRR Resp: clear breath sounds throughout GI: benign Extr: warm, trace edema Wound: sternal clean dry intact no erythema or click Neuro: awake, alert oriented to place, and self. CN II-XII intact, strengths Upper extremities 4-4/4, Lower extremities 3-3/4. movement and sensation intact. Pertinent Results: [**4-10**] TEE: LEFT VENTRICLE: Moderately depressed LVEF. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR well seated, normal leaflet/disc motion and transvalvular gradients. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Mild thickening of mitral valve chordae. Calcified tips of papillary muscles. No MS. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Normal tricuspid valve supporting structures. No TS. Mild to moderate [[**11-17**]+] TR. Moderate PA systolic hypertension. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Conclusions Image quality is limited. Overall left ventricular systolic function appears moderately depressed (LVEF = 35 %) with regional variation. The interventricular septum appears severely hypokinetic (the basal anterior septum appears akinetic) although postoperative septal wall motion abnormality may also be present. Right ventricular chamber size and free wall motion are normal. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. CXR: [**2201-4-10**]: No pneumothorax status post chest tube removal. Bibasilar hazy opacities may reflect new minimal pleural effusions or artifact secondary to semi-erect patient positiong. [**2201-4-9**]: CT Head: 1. Minimally increased MTT with decreased cerebral blood flow and volume within the left frontal lobe. 2. No flow-limiting stenosis, aneurysm, or vascular malformation detected on the CT angiogram. 3. No acute intracranial hemorrhage detected on the non-contrast head CT. 4. Multinodular goiter, including a dominant 2-cm right lobe lesion, warranting further evaluation with ultrasound on an outpatient basis, if prior imaging was not performed. 5. Moderate emphysema with a linear right upper lobe opacity, described in detail on the [**2201-2-26**], examination. 6. Mild pneumomediastinum and overlying anterior subcutaneous emphysema within recent-post-mediasternotomy limits. 7. Deg. spine changes with foraminal stenosis. [**2201-4-14**] WBC-6.1 RBC-3.13* Hgb-9.5* Hct-29.9* MCV-96 MCH-30.3 MCHC-31.7 RDW-13.4 Plt Ct-80* [**2201-4-7**] WBC-7.3 RBC-4.09* Hgb-12.6 Hct-39.9 MCV-97 MCH-30.7 MCHC-31.6 RDW-13.4 Plt Ct-208 [**2201-4-14**] Glucose-102* UreaN-14 Creat-0.6 Na-135 K-4.3 Cl-100 HCO3-30 [**2201-4-7**] Glucose-85 UreaN-21* Creat-0.8 Na-139 K-4.7 Cl-100 HCO3-29 [**2201-4-14**] Mg-2.0 Cultures: [**2201-4-10**]: Catheter tip: no growth [**2201-4-9**]: Urine no growth [**2201-4-10**]: MRSA no growth Brief Hospital Course: 85 yr old female with history of aortic stenosis who was randomized to surgical arm of corevalve study. She underwent AVR #21 tissue valve on [**4-8**] the surgery was performed by Dr [**Last Name (STitle) **]. Overall the patient tolerated the procedure well please see intraop note for further details. She arrived from the OR fully vented, AV paced over SB 50's, lower CI on Milrinime and neo. History of COPD had mild exp wheezing but extubated wihtout difficulty. Pressors weaned off then hypertensive once extubated started on Nitro and betablocker. Once extubated patient was noted to have right sided weakness. Neuro was consulted and stat head CTA was obtained which showed subltle area of hypoperfusion in the left frontal lobe. Her neuro status returned to [**Location 213**] within 24hrs therefore the head MRI was cancelled. It was felt her symptoms were suggestive of spasm. Of note she was weak and deconditioned preoperatively and continued to be so post-operatively. Her appetite was poor and she needed a great deal of ecouragement to eat. She remained hemodynamcially stable tolerated low dose lasix and betablocker. Pacing wires and Ct were removed in timely fashion. She was evaluated by the physical therapy service who recommended discharge to rehab. By the time of discharge on POD 6 the patient was stable, her wound was healing and her pain was controlled with Ultram. The patient was discharged to [**Hospital 38**] Rehabilitation in stable condition with appropriate follow up instructions advised. Medications on Admission: advair 1puff [**Hospital1 **] multivitamin Lasix 20 mg a day Prinivil 5 mg daily. Advair 250/50 one puff b.i.d. Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 4. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six (6) hours as needed for pain. 7. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) mL Inhalation Q6H (every 6 hours) as needed for dyspnea. 9. ipratropium bromide 0.02 % Solution Sig: Three (3) mL Inhalation Q6H (every 6 hours) as needed for dyspnea. 10. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. 11. potassium chloride 10 mEq Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day for 5 days. 12. Regular Insulin Sliding Scale Breakfast, Lunch, Dinner & Bedtime 71-119 mg/dL 0 Units 0 Units 0 Units 0 Units 120-159 mg/dL 1 Units 1 Units 1 Units 0 Units 160-199 mg/dL 2 Units 2 Units 2 Units 1 Units 200-239 mg/dL 3 Units 3 Units 3 Units 2 Units 240-280 mg/dL 4 Units 4 Units 4 Units 3 Units Discharge Disposition: Extended Care Facility: [**Hospital 38**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Aortic valve stenosis Congestive Heart Failure Anxiety Hypertension Hyperlipidemia Anemia Type 2 Diabetes Mellitus Hypothyroidism Discharge Condition: Alert and oriented x3 nonfocal OOB to chair with 2 assist, gait unsteady Sternal pain managed with oral analgesics Sternal wound: CDI Edema:+1 lower Discharge Instructions: Shower Daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions NO lotions, cream, powder, or ointments to incisions Daily weights: keep a log No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Wear a bra to reduce pulling on incision, avoid rubbing on lower edge **Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Please call to schedule appointments Surgeon Dr. [**Last Name (STitle) **] #[**Telephone/Fax (1) 170**] on [**2201-5-21**] at 1:00p PCP: [**Last Name (NamePattern4) **].[**Last Name (STitle) 31187**] [**2201-4-30**] at 12:30p Please call cardiac surgery if need arises for evaluation or readmission to hospital [**Telephone/Fax (1) 170**] Completed by:[**2201-4-14**]

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icd9cm

[ [ [] ] ]

[ "39.61", "35.21" ]

icd9pcs

[ [ [] ] ]

8974, 9068

5739, 7270

298, 521

9242, 9393

2795, 4485

9890, 10263

1402, 1581

7433, 8951

9089, 9221

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2282, 2776

239, 260

549, 1046

4494, 5716

1068, 1187

1203, 1386

605

145,576

3966

Discharge summary

report

Admission Date: [**2195-4-5**] Discharge Date: [**2195-4-8**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1055**] Chief Complaint: altered mental status, fevers Major Surgical or Invasive Procedure: central line placement History of Present Illness: Ms. [**Known lastname **] is an 85 year old nursing home resident, chinese speaking, s/p hospitalization [**Date range (1) 17569**] at [**Hospital1 2025**] for influenza a, has been on O2 since with baseline RA sats 88% and 92% on 2l NC. She presented to the [**Hospital1 18**] with altered mental status and fevers. She is very demented at baseline but is verbal. On the morning of admission, she had a small amount of her usual breakfast but was very lethargic and according to her nurses, may have aspirated some of her meal. VS there were T 103.8. BP 141/94 HR 99 O2 Sat 87% on 2LNC. When EMS arrived, her VS were 92/68 HR 95 (irregular) RR 42 Sat 94% on BVM 100%. . In the ED, she was noted to also be febrile so code sepsis was initiated. Her code status was confirmed to be full code. A left subclavian line was placed, and IV normal saline were administered. Intravenous ceftriaxone, vancomycin, levaquin and clindamycin were administered. Levophed was also started. Prior to transfer to the floor her SVO2 was 71%. . In the MICU, the levophed was weaned. The patient was maintained on vanco and zosyn. CXR showed a flourishing RUL PNA. Her mental status improved on time of transfer. Past Medical History: Alzheimer's Depression Hypernatremia Paroxymal Afib h/o Urinary tract infections Cholelithiasis h/o Influenza A/b Social History: Permanent resident of [**Hospital3 **] Manor. Chinese speaking only, Son and daughter active in her life and visit daily Family History: N/A Physical Exam: VS: Tm 103.9 Tc BP 117/49 (88-121/34-49) HR 84 RR 30 Sat 100% NC GEN: Elderly asian woman in bed sedate and difficult to arouse, breathing comfortably. Daughters at bedside. HEENT: Dry MM, eyes closed, no scleral icterus. NECK: Supple, no masses CV: Irregular, normal s1/s2 PUL: Coarse upper airway sounds ABD: Diffuse ttp, +BS, no rebound or guarding. EXT: No edema NEURO: Sedated, arousable, but non-verbal with eyes closed. Pertinent Results: EKG: normal axis, 1st degree a-v block, LVH, qV1-2, lateral j-point depression . Initial CBC: [**2195-4-5**] 11:38AM WBC-13.1*# RBC-4.56 HGB-14.7 HCT-45.4 MCV-100* MCH-32.1* MCHC-32.3 RDW-15.3 [**2195-4-5**] 11:38AM NEUTS-80.7* LYMPHS-9.9* MONOS-6.4 EOS-0.5 BASOS-2.5* [**2195-4-5**] 11:38AM PLT COUNT-402# . Lactate: 4.8 ([**2195-4-5**]) . UA negative. . CXR [**2195-4-5**]: Again seen is mild cardiomegaly, unchanged from prior study. Mediastinal and hilar contours appear unchanged with calcification again seen within the aorta. Pulmonary vasculature appears within normal limits. There is no evidence of focal consolidations. Diffuse opacity over the right upper lobe could be consistent with aspiration. Again noted are healed rib fractures on the right side. IMPRESSION: Diffuse increased opacity over the right upper lobe which could be consistent with aspiration. No focal consolidations seen. . Micro [**2195-4-7**] BLOOD CULTURE x 2 sets: NGTD [**2195-4-5**] URINE URINE CULTURE-FINAL {YEAST} [**2195-4-5**] BLOOD CULTURE AEROBIC BOTTLE & ANAEROBIC BOTTLE-PRELIMINARY {STAPHYLOCOCCUS, COAGULASE NEGATIVE) [**2195-4-5**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE: NGTD Brief Hospital Course: 86F with history of severe dementia, presents with fever and altered mental status, code sepsis in ED. The patient was resuscitated and admitted to the MICU. She was diagnosed with pneumonia and treated with Zosyn and Vancomycin for broad coverage. After she was stabilized and weaned off of pressors, she was transferred to the regular medical floor where she remained stable. She was discharged back to her NH in stable condition. . # AMS/infection: The patient is severely demented at baseline. A head CT completed in the ED was negative, and she did not have any focal neurological deficits on exam (although it was limited by the language barrier). On admission to the ICU, she had a clean UA but a RUL consolidation consistent with aspiration pneumonia. She was also hypernatremic which would also account for AMS. She was repleted with free water to correct her sodium, and she was continued on both Vanc and Zosyn for antibiotics. Given that she was recently hospitalized for influenza earlier in the month, it was thought she was at high risk for a nosocomial pneumonia, (also staph a. pneumonia post influenza). She had a repeat CXR the following day, which showed a more definitive infiltrate to suggest pneumonia. [**2-7**] bottles from her blood cultures grew coag negative staph. On the morning following admission, she became much more alert and talkative, demonstrating echolalia. Her family confirmed that her mental status was close to baseline on discharge. A PICC line was placed by IR on [**4-8**] without complication. She was discharged on 10 days of vancomycin and zosyn therapy. Her home medications for Alzheimer's were intially held while she was NPO but were restarted on transfer to the floor. . # F/E/N: She was initially kept NPO out of concern for sepsis and altered mental status. She had recently undergone a speech and swallow eval at [**Hospital1 2025**]; these results were obtained, which recommended the patient be kept on a pureed diet with honey thickened liquids. She was fed under aspiration precautions. Medications on Admission: Aricept 10mg daily Vitamin E 80u qPM Zyprexa 5mg qPM Namenda 5mg qPM Tylenol 650 supp q6: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. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 3. Memantine 5 mg Tablet Sig: One (1) Tablet PO Qpm (). 4. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 5. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg Intravenous twice a day for 10 days. 6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Discharge Disposition: Extended Care Facility: [**Hospital3 **] Manor - [**Location (un) 86**] Discharge Diagnosis: pneumonia hypernatremia sepsis bacteremia severe dementia paroxysmal AFib Discharge Condition: stable, back to baseline mental status. afebrile and normotensive. Discharge Instructions: Please return if you experience shortness of breath, fever >101.5, loow blood pressure, chest pain, lethargy, or any other worrisome symptoms. Please take all medications as directed. You have been prescribed 2 antibiotics to take for your pneumonia. Followup Instructions: Please follow-up with Dr [**Last Name (STitle) 10145**] within 1-2 weeks at [**Telephone/Fax (1) **].

[ "584.9", "331.0", "294.10", "995.92", "038.11", "507.0", "276.0", "427.31", "785.52", "311" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

6302, 6376

3541, 5607

290, 314

6494, 6564

2310, 3518

6865, 6970

1841, 1846

5751, 6279

6397, 6473

5633, 5728

6588, 6842

1861, 2291

221, 252

342, 1549

1571, 1686

1702, 1825

31,556

132,342

2117

Discharge summary

report

Admission Date: [**2119-6-24**] Discharge Date: [**2119-6-28**] Date of Birth: [**2067-8-15**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 495**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: 51 y/o M w/IPF on home O2 who presented to the ED last night with worsening dyspnea. This has been slowly worsening for the past few weeks, but over 2 days severely worsened to the point where he was short of breath at rest. He also has had a cough productive of yellow blood-tinged sputum for 2 days (normally has a non-productive cough at baseline). According to his pulmonary rehab notes, he has been increasingly unable to exercise due to hypoxemia with exertion despite supplemental O2. He has also had anterior chest pain which he associates with coughing. The chest pain is not exertional. He denies orthopnea and LE edema. He has had chills over the past couple of days, but no fevers. In the ED, he was intermittently hypoxic to the 70s and 80s on 4L so was switched to a NRB. He was also tachycardic in the 110s. He was given levofloxacin for pna. Because of the tachycardia and hypoxia, he underwent a CTA which was negative for PE but showed multifocal airspace disease. He was admitted to the [**Hospital Unit Name 153**]. Past Medical History: 1. IPF: Diagnosed on VATS [**2116**], treated with gamma-interferon for one year around that time. Has also been on N-acetylcysteine but stopped last year. Not a candidate for BUILD3 due to FVC <50%. Has never been treated with steroids. Undergoing transplant w/u at [**Hospital1 112**] (per pt, currently contingent on weight loss but remainder of w/u done). In pulmonary rehab here, and at home is on 2L O2 continuous with 4L O2 for exertion. Most recent PFTs [**2-17**]: FEV1 1.58 (51%), FVC 1.84 (44%), FEV1/FVC 86%, TLC 2.61 (43% in [**12-17**]), DLCO 8.6 (32% in [**12-17**]). 2. OSA, on CPAP 3. GERD 4. HTN 5. DM 6. Depression [**Last Name (un) 1724**]: albuterol MDI prn, atenolol 50 mg daily, bupropion SR 200 mg qAM, celexa 40 mg daily, hctz 25 mg daily, lantus 14 U qhs, metformin 1000 mg [**Hospital1 **], trazodone 50 mg qhs:prn, aspirin 325 mg daily, amino acids, omeprazole 20 mg daily, flovent 220 mcg 2 puffs qAM (recently restarted at pulmonary rehab) Social History: Occupation: Currently unable to work but formerly worked for Merchant Marine Drugs: No Tobacco: Never Alcohol: No Other: No animals at home. No sick contacts. Family History: non-contributory. Physical Exam: General Appearance: Overweight / Obese, tachypneic, in mild respiratory distress Head, Ears, Nose, Throat: Normocephalic Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic), Unable to appreciate loud P2 Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse: Not assessed) Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : bilateral bases), (Breath Sounds: Crackles : [**1-11**] way on R, [**1-12**] way on L, No(t) Wheezes : ), egophony at bilateral bases Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t) Clubbing Skin: Warm, No(t) Rash: Neurologic: Attentive, Responds to: Verbal stimuli, Movement: Not assessed, Tone: Not assessed Pertinent Results: patient expired Brief Hospital Course: 51 yoM w/ a h/o of IPF presented with a significant worsening of his IPF. Moving in bed would cause his O2 sat to drop to 60% while on FiO2 100%. Patient was DNR / DNI. Not on the transplant list due to BMI > 30 and evaluated at the [**Hospital1 112**]. [**Hospital6 **] was contact[**Name (NI) **] who confirmed the fact that the patient was not on the list and there was no way to place him on a list for an urgent lung transplant. Discussion with the family led to the decision to make the patient comfort measures only. Patient Died on [**2119-6-28**]. Medications on Admission: patient expired Discharge Medications: patient expired Discharge Disposition: Expired Discharge Diagnosis: patient expired Discharge Condition: patient expired Discharge Instructions: patient expired Followup Instructions: patient expired

[ "401.9", "786.3", "786.50", "327.23", "V66.7", "518.81", "V46.2", "486", "516.3", "250.00" ]

icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

4250, 4259

3580, 4144

330, 336

4318, 4335

3540, 3557

4399, 4417

2613, 2632

4210, 4227

4280, 4297

4170, 4187

4359, 4376

2647, 3521

283, 292

364, 1413

1435, 2420

2436, 2597

45,099

124,881

35772

Discharge summary

report

Admission Date: [**2185-3-9**] Discharge Date: [**2185-3-22**] Date of Birth: [**2115-10-24**] Sex: M Service: CARDIOTHORACIC Allergies: Vancomycin Attending:[**First Name3 (LF) 922**] Chief Complaint: Angina Major Surgical or Invasive Procedure: Coronary artery bypass grafts (LIMA-LAD,SVG-OM,SVG-RI,SVG-PDA) [**2185-3-16**] left heart catheterization, coronary angiogram History of Present Illness: This 69 year old white male with medical history as noted has previously undergone coronary intervention. He developed recurrent angina ans was admitted for catheterization. This revealed triple vessel disease with well preserved ventricular function. He was referred for revascularization. Past Medical History: Hyperlipidemia hypertension s/p right total knee replacement left leg claudication insulin dependent diabetes mellitus obstructive sleep apnea (w/o BiPAP) Chronic obstructive pulmonary disease Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 81356**]TTE (Complete) Done [**2185-3-10**] at 11:17:22 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 18**] - Cardiac Services [**Location (un) 830**], [**Hospital Ward Name 23**] 7 [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2115-10-24**] Age (years): 69 M Hgt (in): 66 BP (mm Hg): 151/78 Wgt (lb): 200 HR (bpm): 68 BSA (m2): 2.00 m2 Indication: Coronary artery disease. Preoperative assessment ICD-9 Codes: 414.8, 424.0, 424.2 Test Information Date/Time: [**2185-3-10**] at 11:17 Interpret MD: [**Known firstname 449**] [**Last Name (NamePattern4) **], MD Test Type: TTE (Complete) Son[**Name (NI) 930**]: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 18401**] Doppler: Full Doppler and color Doppler Test Location: West Echo Lab Contrast: None Tech Quality: Adequate Tape #: 2009W008-0:19 Machine: Vivid [**6-28**] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *4.1 cm <= 4.0 cm Left Atrium - Four Chamber Length: 5.2 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.6 m/s Left Atrium - Peak Pulm Vein D: 0.4 m/s Left Atrium - Peak Pulm Vein A: 0.2 m/s < 0.4 m/s Right Atrium - Four Chamber Length: 4.5 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.4 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 2.8 cm Left Ventricle - Fractional Shortening: 0.36 >= 0.29 Left Ventricle - Ejection Fraction: 70% >= 55% Left Ventricle - Lateral Peak E': *0.04 m/s > 0.08 m/s Left Ventricle - Septal Peak E': *0.06 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 14 < 15 Aorta - Sinus Level: 3.3 cm <= 3.6 cm Aorta - Ascending: 3.2 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.3 m/sec <= 2.0 m/sec Mitral Valve - E Wave: 0.7 m/sec Mitral Valve - A Wave: 0.9 m/sec Mitral Valve - E/A ratio: 0.78 Mitral Valve - E Wave deceleration time: 227 ms 140-250 ms TR Gradient (+ RA = PASP): 24 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global systolic function (LVEF >55%). No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Focal calcifications in ascending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral annular calcification. Mild thickening of mitral valve chordae. Calcified tips of papillary muscles. No MS. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal tricuspid valve supporting structures. No TS. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. Normal main PA. No Doppler evidence for PDA PERICARDIUM: No pericardial effusion. Conclusions The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. 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 no pericardial effusion. Electronically signed by [**Known firstname 449**] [**Last Name (NamePattern4) **], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2185-3-10**] 13:10 [**Hospital 93**] MEDICAL CONDITION: 69 year old man with LM and 3VD, preop CABG tomorrow REASON FOR THIS EXAMINATION: Please evaluate for carotid stenosis Final Report There are no prior studies for comparison. CLINICAL HISTORY: Preop CABG surgery. TECHNIQUE: Grayscale imaging supplemented by duplex ultrasonography was performed. FINDINGS: There is evidence of atherosclerotic plaque formation, which is partially calcified. However, this does not result in a significant ICA stenosis on either side. There is antegrade flow in both vertebral arteries. The following peak systolic flow velocities were obtained in m/sec. RIGHT SIDE: CCA 0.94, proximal ICA 0.79, mid ICA 0.81 and distal ICA 0.71. LEFT SIDE: CCA 1.06, proximal ICA 0.87, mid ICA 1.06 and distal ICA 0.98. The ICA/CCA ratios are 0.86 on the right and 1.0 on the left. IMPRESSION: 1. No significant ICA stenosis on either side. 2. Antegrade flow in both vertebral arteries. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Approved: [**Doctor First Name **] [**2185-3-17**] 12:03 PM WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2185-3-20**] 05:51AM 7.0 2.98* 9.2* 26.0* 87 30.8 35.3* 14.9 220 Source: Line-PICC DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas [**2185-3-16**] 02:05PM 77.5* 16.4* 4.2 1.4 0.5 [**2185-3-16**] 06:15AM 58.0 27.1 7.1 7.0* 0.9 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [**2185-3-20**] 05:51AM 220 Source: Line-PICC BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino [**2185-3-16**] 02:05PM 166 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2185-3-21**] 05:40AM 107* 27* 1.3* 134 5.0 97 28 14 Brief Hospital Course: This 69 year old man has a history of hypertension, hyperlipidemia, diabetes, LE claudication, sleep apnea and known CAD, s/p Cx and OM stenting at [**Hospital1 2025**] in [**2179**]. The patient reports that he has had stable exertional angina but that over the past month he has noticed an escalation in his symptoms. He describes shortness of breath and mid chest pressure after carrying bundles approximately 100 feet, resolving with relaxation. Because of these complaints he was evaluated by Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] on [**2185-3-8**] and underwent a persantine ETT (74% of predicted heart rate). He had no anginal symptoms but did have inferolateral ST depression. Imaging revealed a dilated LV cavity with stress. A large reversible lateral and apical wall defect was noted. LVEF was noted at 57%. He is now referred for cardiac catheterization to further evaluate. Cardiac catherization was done on [**3-9**] which revealed LM 60%, 90% proximal ramus, serial LAD- 70% diagonal branch, D2 100% occluded, proximal LCX disease 70-80%, RCA 100% occluded. Mr [**Known lastname 61836**] was evaluated for Coronary artery bypass graft and was taken to the OR on [**3-16**] once he completed his plavix washout and his creatinine which had elevated after his cath dye load had returned to baseline. On [**3-16**] 09 Mr. [**Known lastname 61836**] had a CABg x 4- LIMA-LAD, SVgrafts to Om, Ramus, PDA. Immediately post operatively Mr. [**Known lastname 61836**] was admitted to the cardiac surgical ICU intubated and on neosynephrine and insulin drips. Extubated on POD#1. Given his history of sleep apnea Bipap was used overnight while in hospital. He was weaned [**Last Name (un) 5720**] his pressor but remained in the ICU until POD#3 on an insulin drip due to elevated blood glucoses. He was started on betablockers and diuresis and was transferred from the ICU once glucoses were stable off the insulin drip. [**Last Name (un) **] was consulted for glucose management. Mr. [**Known lastname 61836**] developed post op Afib and converted with IV amioarone and lopressor. Chest tubes and wires were removed per cardiac surgery protocol. Mr. [**Known lastname 61836**] was seen by physical therapy and rehab was recommended upon discharge from the hospital. Patient was discharged to rehab on [**2185-3-22**]. Medications on Admission: reglan -? dose Lisinopril20mg/D lipitor 80mg/D Toprol XL 50 mg/D Humalog 75/25mg 114U AM, 74 u supper advair diskus Combivent MDI ASA 325mg/D Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): please follow creatinine weekly or more frequently if elevated. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days. 6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 7 days. 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours): 2 tabs [**Hospital1 **] x5days then 2 tabs daily x7 days then one tab daily. 9. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) puff Inhalation twice a day. 10. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1) puffs Inhalation twice a day. 11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. insulin 75/25 35 units Sq qam 15 units Sq with dinner 13. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day. 14. Outpatient Lab Work monitor BUN/Creat weekly or more frequently- newly on metformin. Discharge Disposition: Extended Care Facility: southeast rehab Discharge Diagnosis: coronary artery disease insulin dependent diabets mellitus hypertension obesity chronic renal insufficiency hypercholesterolemia peripheral vascular disease obstructive sleep apnea s/p right total knee replacement s/p coronary angioplasty Discharge Condition: good Discharge Instructions: shower daily, no baths or swimming no lotions, creams or powders to incisions no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks report any redness of, or drainage from incisions report any fever greater than 100.5 report any weight gain greater than 2 pounds a day or 5 pounds a week take all medications as directed Call the office with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]) Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 41710**] in [**12-24**] weeks ([**Telephone/Fax (1) 81357**]) Dr. [**First Name11 (Name Pattern1) 122**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] in [**1-25**] weeks ([**Telephone/Fax (1) 8725**]) [**Hospital Ward Name 121**] 6 wound clinic in 2 weeks please call for appointment Completed by:[**2185-3-22**]

[ "414.01", "403.90", "584.9", "272.4", "250.00", "427.31", "496", "440.21", "585.9", "327.23", "997.1", "V43.65", "411.1" ]

icd9cm

[ [ [] ] ]

[ "37.22", "88.56", "39.61", "36.13", "88.53", "36.15", "38.93" ]

icd9pcs

[ [ [] ] ]

10733, 10775

6831, 9196

283, 411

11058, 11065

970, 5082

11544, 12048

9388, 10710

5122, 5175

10796, 11037

9222, 9365

11089, 11521

237, 245

5207, 6808

439, 734

756, 951

32,410

129,228

34673

Discharge summary

report

Admission Date: [**2131-7-13**] Discharge Date: [**2131-8-8**] Date of Birth: [**2058-1-7**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: VRE endocarditis of prosthetic AV, AO-[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **], Annular abscess Major Surgical or Invasive Procedure: Redo sternotomy/AVR, MVR, closure Aortic-LV fistula [**7-18**] CVVH and HD History of Present Illness: This 73M is s/p AVR in [**8-5**]. He recently presented to his PCP with LE edema and was found to have a creat. of 3. He was admitted to a hospital in [**State 108**] for diuresis and was found to have VRE endocarditis of the MV and AV. He was turned down for surgery there and was flown here for surgery. Past Medical History: s/p AVR [**8-5**] HTN cardiomyopathy CRI (baseline creat. 2.5) orthostatic hypotension [**1-30**]+ MR AAA sleep apnea BPH- s/p TURP obesity ^chol. chronic enterococcal UTI, s/p suprapubic tube s/p bil. cataract surgery Social History: Lives with wife in Fla. Retired engineer Cigs: 70 pk. yr., quit 20 yrs. ago ETOH: occ. Family History: Unremarkable Physical Exam: Alert, oriented. Lungs- sl. diminished sounds at bases. Cor- SR 72. BP 153/64. Abd- benign Exts- warm, well perfused with trace edema.Double lumen PICC RT antecubital fossa. Wounds- Lower end sternum with wound vac in place. sternum stable. Pertinent Results: [**Known lastname **],[**Known firstname **] [**Medical Record Number 79514**] M 73 [**2058-1-7**] Radiology Report CHEST (PORTABLE AP) Study Date of [**2131-8-2**] 7:21 AM [**Last Name (LF) **],[**First Name7 (NamePattern1) 1112**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2131-8-2**] SCHED CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 79515**] Reason: check R effusion [**Hospital 93**] MEDICAL CONDITION: 73 year old man with REASON FOR THIS EXAMINATION: check R effusion Final Report HISTORY: Right effusion, to evaluate for change. FINDINGS: In comparison with the study of [**8-1**], the right chest tube remains in place. Again there is a small pneumothorax in the axillary region and stable right pleural effusion with atelectatic change at the base. The remainder of the study is unchanged. DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**] Approved: [**Doctor First Name **] [**2131-8-2**] 10:49 AM [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 79516**] (Complete) Done [**2131-7-18**] at 10:05:01 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 1112**] W. [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2058-1-7**] Age (years): 73 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: MVR/Re-do AVR with endocarditis ICD-9 Codes: 424.90, 786.05, 786.51, 799.02, 440.0, V43.3, 424.1, 424.0 Test Information Date/Time: [**2131-7-18**] at 10:05 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 #: 2008AW1-: Machine: aw1 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 25% to 30% >= 55% Aorta - Ascending: 3.4 cm <= 3.4 cm Aorta - Descending Thoracic: 2.4 cm <= 2.5 cm Aortic Valve - Peak Gradient: *42 mm Hg < 20 mm Hg Aortic Valve - Valve Area: *0.8 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. RIGHT VENTRICLE: Mild global RV free wall hypokinesis. AORTA: Simple atheroma in ascending aorta. Simple atheroma in descending aorta. AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). MITRAL VALVE: Severely thickened/deformed mitral valve leaflets. Severe (4+) MR. TRICUSPID VALVE: Moderate [2+] 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: There is a fistula between the aorta and the LA. It arises from the sinus of Valsalva at the left cusp, tracks by the non-coronary cusp and enters the LA. No spontaneous echo contrast is seen in the left atrial appendage. RV shows mild global free wall hypokinesis. There are simple atheroma in the ascending aorta. There are simple atheroma in the descending thoracic aorta. A bioprosthetic aortic valve prosthesis is present. The leaflets all move but are thickened. There is a peak gradient of 42 mmHg across it. The mitral valve leaflets are severely thickened/deformed. Severe (4+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is no pericardial effusion. Post-CPB: The patient is on an epinephrine infusion. There is a well-seated and functioning mitral valve prosthesis. No leak, no MR. There is a prothetic aortic valve, also well-seated and with no leak or AI. The residual aortic valve mean gradient is 9 mmHg. RV systolic fxn is mildly depressed. LV systolic fxn is moderately depressed. EF remains 30 - 35%. Ascending and descending aorta intact. 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) **] [**2131-7-18**] 15:00 ?????? [**2125**] CareGroup IS. All rights reserved Brief Hospital Course: The pt. was admitted to the CVICU and was fully cultured. He was continued on his Daptomycin and cardiology and ID were consulted. He had a TEE which revealed 4+MR, vegetations on the AV and MV, a paravalvular leak, and an aortic-[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] with abscess. He had also had severe back pain and had a spine MRI which showed possible discitis at T4-T5 and a question of discitis osteomyelitis at L3-L4 and possible L1-L2. On [**7-18**] he underwent Redo sternotomy, AVR(23 mm porcine)/MVR(29 mm porcine)/closure of aorto-[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]. The cross clamp time was 170 mins. and total bypass 215 mins. He tolerated the procedure well and was transferred to the CV ICU on Nitro and Epi in stable condition. His renal function deteriorated and he became oliguric. CVVH was begun on POD 3 after a renal consultation. He was extubated, then re intubated on POD #1 after only 11 minutes extubated. He went into A Fib with hypotension on POD #2 and was cardioverted to SR. Bronchoscopy done POD #2 for secretions and RLL collapse. Chest tubes also removed. Cardioverted again unsuccessfully on POD #4 but was not hypotensive. Cardiology consulted. Repeat bronch done POD #5. He remained stable and off pressors. He was making some urine and CVVH was converted to HD. After the treatment the dialysis catheter was removed and dialysis not required subsequently He was cultured for sternal drainage on POD #6 and ID re consulted. He was extubated again on POD #7. Haldol was given for agitation. The lower end of the sternal incision was opened and cultured negative on POD #8. A PICC line was also placed. Meropenem was started for pseudomonas in the urine. Postoperatively he had severe confusion in the ICU which responded to Haldol and cleared over several days. He has remained intact and Haldol has been reduced. He was transferred to the floor on POD # 13, but transferred back to the CV ICU early on POD #14 for respiratory distress. A right chest tube was placed for a large effusion. IV heparin and low dose Coumadin were started. Continued diuresis for mild CHF was carried out. The CT was eventually removed. The sternal wound was sterile(on antibiotics for endocarditis)and a wound vac was placed on [**7-27**]. The wound has remained clean and the vac is changed every three days. He has continued to make adequate urine and the renal function has remained stable. At this point he is ready for rehabilitation and will complete a 6 week course of Daptomycin. Medications on Admission: Percocet PRN Ambien 5 mg PO qhs PRN Colace 100 mg PO BID Protonix 40 mg PO daily Daptomycin 600 mg IV QOD Vit B12 50 mg PO daily Fe Gluc 325 mg PO daily MVI 1 PO daily Amio 200 mg PO daily Zocor 20 mg PO daily Zetia 15 mg PO daily Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 2. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY (Daily): Target INR 1.5-2. 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 8. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 10. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Furosemide 10 mg/mL Solution Sig: Eighty (80) mg Injection Q12H (every 12 hours) for 1 weeks: The reassess volume status. 13. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed. Disp:*30 Capsule(s)* Refills:*0* 14. Sodium Chloride 0.9 % 0.9 % Syringe Sig: Three (3) ML Injection PRN (as needed) as needed for line flush. Disp:*50 ML(s)* Refills:*0* 15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. Disp:*30 Suppository(s)* Refills:*0* 16. Daptomycin 500 mg Recon Soln Sig: 800mg Recon Solns Intravenous Q48H (every 48 hours) for 3 weeks: Continue through [**2131-8-29**] for VRE. Disp:*6 Recon Soln(s)* Refills:*3* Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Prosthetic Aortic Valve endocarditis (VRE) mitral valve endocarditis Perivalvular leaks CRI s/p AVR ARF BPH s/p TURP w/chronic UTI HTN AAA Cardiomyopathy hypercholesterolemia Obstructive sleep apnea postop A Fib Discharge Condition: Stable 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) Daptomycin - 800mg Recon Solns Intravenous Q48H (every 48 hours) for 3 weeks: Continue through [**2131-8-29**] for VRE. 8) Lasix 80mg IV every 12 hours for 1 week, then reassess volume status. Please monitor and replete electrolytes (ie. Potassium) as needed. 9) Maintain PICC Line due to poor vascular access. Call with any questions or concerns. PICC is inserted to 50cm. 10) Continue VAC dressing to distal sternotomy. Change dressing every three days. 11) Coumadin for AF. INR goal 1.5-2.0. Discharge dose of coumadin is 1mg to be adjusted as needed. PT/INR checks initially daily then as needed. 12) Call with any questions. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] Follow up with Dr. [**Last Name (STitle) 79517**] in [**11-29**] weeks [**Telephone/Fax (1) 79518**] Follow up with Dr. [**Last Name (STitle) 976**] in [**12-31**] weeks Scheduled Appointments: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (Infectious Disease), Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2131-8-31**] 9:30 Completed by:[**2131-8-8**]

[ "486", "585.9", "421.0", "396.3", "584.9", "518.5", "998.6", "996.61", "997.1", "447.2", "403.90", "425.4", "997.5", "999.9", "599.0", "788.5", "427.31" ]

icd9cm

[ [ [] ] ]

[ "38.93", "35.21", "39.61", "39.95", "39.59", "34.04", "35.23", "88.72", "33.24", "96.6" ]

icd9pcs

[ [ [] ] ]

10688, 10767

6220, 8788

432, 509

11023, 11032

1503, 1926

12368, 12845

1209, 1223

9069, 10665

1966, 1987

10788, 11002

8814, 9046

11056, 12345

1238, 1480

280, 394

2019, 6197

537, 847

869, 1089

1105, 1193

31,842

157,527

33531

Discharge summary

report

Admission Date: [**2138-5-14**] Discharge Date: [**2138-6-6**] Date of Birth: [**2080-9-7**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8790**] Chief Complaint: renal cell carcinoma Major Surgical or Invasive Procedure: spinal emolization T5 vertebrectomy, T2-7 laminectomy and instrumented fusion History of Present Illness: This 58-year-old gentleman has a history of renal cell carcinoma. He experienced cerebral metastasis and a T5 metastasis with significant spinal cord compression and resultant instability of the thoracic spine. Past Medical History: renal cell carcinoma s/p L nephrectomy in [**2129**], no xrt/chemo Social History: lives with his daughter. Infrequent EtOH use. Quit smoking 25yrs ago. No IVDU Family History: negative for past malignancies Physical Exam: NAD, WDWN Ht: RRR, nl S1,S2 Lungs: CTA Abd: soft, nt ext: no cce neuro: aox3 motor full sensation intact dtr 2+ Pertinent Results: [**2138-5-14**] 03:41PM GLUCOSE-99 UREA N-14 CREAT-1.2 SODIUM-143 POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-27 ANION GAP-15 [**2138-5-14**] 03:41PM CALCIUM-9.7 PHOSPHATE-3.6 MAGNESIUM-2.0 [**2138-5-14**] 03:41PM PT-12.8 PTT-24.1 INR(PT)-1.1 Brief Hospital Course: Pt was admitted to the hospital [**5-14**] and underwent embolization to T5 lesion pre-op. He tolerated this well and was brought to OR [**5-15**] where under general anesthesia he underwent T5 vertebrectomy/reconstruction and T2-7 instrumented fusion. He had EBL of over 2 l, received 4uPRBC intraop but was hemodynamically stable, tolerated procedure was transferred to TICU and then extubated shortly thereafter. He was moving extremities but left quadriceps was slightly weak. MRI was obtained that showed no compression of nerve roots, good hardware placement. His strength improved. He received more transfusions for low hematocrit. His diet and acvtivity were increased. Drains that were placed intraop were removed on POD#2. He was transferred to the floor. His hematocrit was followed throughout the hospitalization. His was fit with TLSO brace. Incision was clean and dry with staples. He developed post op ileus and was seen in consultation by general surgery. rectal tube was placed with large output of air and relief of symptoms. His decadron which he came into the hospital on for brain mets s/p craniotomy were weaned. His dilantin level was followed and therapeutic. He developed abdominal distention and pain and KUB showed dilated loops of bowel. He was made NPO and seen by general surgery and GI. Rectal tube did help initially but pt was unable to tolerate and it was removed. Ambulation was encouraged - he did need TLSO brace whenever out of bed. He was seen by PT/OT who recommended rehab but was unable to go due to insurance reasons. He had lower extremity doplers for left leg pain which showed a left leg DVT. In discussion with Neurosurgery, he was started on lovenox, for which he will continue at least 6 months. He was reevaluated by PT who cleared the patient for home discharge. However just prior to discharge he developed a fever and subsequently became hypotensive. He was then transferred to the ICU for further care. ICU course: Patient was transferred to ICU service with fevers, hypotension and diarrhea. Cultures grew out GNRs initially. Patient was started on broad spectrum antibiotics including Vancomycin, Cefepime, flagyl. Patient remained normotensive while in the unit. His abdomen was soft but distended. CT scan was read as consistent with C diff infection. Surgery was consulted and felt his presentation was more consistent with his prior diagnosis of [**Last Name (un) 3696**] syndrome and that his distended bowel loops had decreased in size. Serial abdominal exams were performed with no change. Daily KUB's were performed and a rectal tube was place for decompression with initially good results. Team was concerned about perforation given degree of distention and that his course of steroids may mask his presentation. However, he became afebrile and normotensive, and was transferred back to the floor. Patient was also seen by neurosurgery as he was noted to have small wound at surgical site. Per neurosurgery, this was not consistent with wound infection, but only small serosanguinous drainage. He was evaluated by the wound nurse who recommended local wound care. After transfer back to the floor, his blood and urine cultures grew pan-sensitive E.coli. He was transitioned to PO cipro and remained afebrile and hemodynamically stable. His diarrhea resolved and c.diff was negative x 3 so flagyl and PO vancomycin were discontinued. He was evaluated again by GI who felt that since his symptoms were improving, there was no call for neostigmine or colonoscopy. His abdominal distension worsened with a rectal tube in place and after it was removed he had a large amount of stool and gas. His abdominal exam continued to improve and his diet was advanced. He was tolerating a full diet by discharge. He was given prescriptions for colace, senna, and dulcolax with instructions to contact his doctor or the [**Name (NI) **] if he does not have a BM in [**1-26**] with these medications. He began his cyberknife and radiation therapy treatments to his brain and spine while in house. He had received [**2-26**] of his cyberknife treatments prior to discharge. He will return next week to continue these treatments. He will follow up with his primary oncologist, his neuro-oncologist and his spinal surgeon. Medications on Admission: decadron dilantin ranitidine Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*2* 7. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H () as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 9. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas pain. 10. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). Disp:*14 Syringes* Refills:*0* 11. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. Disp:*20 Tablet(s)* Refills:*0* 12. Methocarbamol 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* 14. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*0* 15. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Metastatic renal cell carcinoma to T5 ileus anemia Discharge Condition: neurologically stable, all vital signs stable. Discharge Instructions: DISCHARGE INSTRUCTIONS FOR SPINE CASES ?????? Do not smoke ?????? Keep wound clean / No tub baths or pools until seen in follow up/take daily showers ?????? No pulling up, lifting> 10 lbs., excessive bending or twisting for two weeks. ?????? Limit your use of stairs to 2-3 times per day ?????? Have a family member check your incision daily for signs of infection ?????? You are required to wear a back brace whenever out of bed. ?????? You may shower briefly without the back brace unless instructed otherwise ?????? Take pain medication as instructed; you may find it best if taken in the a.m. when you wake for morning stiffness and before bed for sleeping discomfort ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc. for 3 months. ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine ?????? Any weakness, numbness, tingling in your extremities ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F ?????? Any change in your bowel or bladder habits You were also found to have a blood clot in your left leg. You were started on a blood thinning medication called Lovenox (enoxaparin) that you will continue for 3 months. You were also found have an infection in your bladder. This was treated with antibiotics called ciprofloxacin which you will continue at home. You have had difficulties having bowel movements. We will give you prescriptions for medications to help you have bowel movements, including suppositories. If you have not had a bowel movement in 2 days, even after taking your medications, you should call your doctor or return to the emergency room. If you have worsening abdominal pain, you should return to the emergency room Please take all your medications as prescribed. Please attend all of your follow up appointment Followup Instructions: You will need to return to [**Hospital Ward Name 332**] Building basement this Friday at 1pm to begin your radiation treatment. They will tell you the schedule for further treatments. PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR. [**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS. YOU WILL NEED XRAYS PRIOR TO YOUR APPOINMENT You have an appointment with Dr, [**Name6 (MD) 5005**] [**Last Name (NamePattern4) 5342**], MD Phone:[**Telephone/Fax (1) 44**] on [**2138-6-16**] at 4:00pm. You have an appointment with Dr. [**Last Name (STitle) **] on [**6-16**] at 3pm in the [**Hospital Ward Name 23**] building. ([**Telephone/Fax (1) 16668**] Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2138-7-14**] 9:15

[ "790.7", "401.9", "998.32", "560.89", "V10.53", "453.41", "198.3", "041.4", "336.3", "599.0", "198.5", "997.2", "E878.8" ]

icd9cm

[ [ [] ] ]

[ "81.63", "77.79", "80.99", "92.29", "99.15", "81.05", "84.51", "39.79" ]

icd9pcs

[ [ [] ] ]

7361, 7367

1305, 5597

334, 414

7462, 7511

1038, 1282

9639, 10416

858, 891

5676, 7338

7388, 7441

5623, 5653

7535, 9616

906, 1019

274, 296

442, 655

677, 746

762, 842

26,737

173,491

8965

Discharge summary

report

Admission Date: [**2138-6-14**] Discharge Date: [**2138-6-21**] Date of Birth: [**2053-12-3**] Sex: F Service: MEDICINE Allergies: Verapamil / Iodine-Iodine Containing / Zoloft / Atenolol / Toprol XL / Norvasc / Pindolol / Zestril / Clonidine / Keflex / Meclizine / Wellbutrin / Penicillins / Erythromycin Base Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Atrial fibrillation with rapid ventricular rate Major Surgical or Invasive Procedure: TEE Cardioversion History of Present Illness: 84F with paroxysmal atrial fibrillation s/p cardioversion x4 (last was <1 week ago), diastolic heart failure (EF >55% via echo in [**2134**]) admitted to the CCU for management of atrial fibrillation with rapid ventricular rate earlier last week. She was recently discharged on [**6-12**] and is s/p cardio-version on [**6-11**]. Pt noted HR in 120's at home starting at 2pm today. Describes fatigue, dizziness, weakness and SOB. Pt also states she had "indigestion" and tried tums, without relief, discomfort now resolved. Pt. was instructed by cardiologist to take an extra dose of nadolol 10mg, no effect noted by pt. Pt was refusing medication until Cardiologist called. She denies N/V/D/F/C, SOB. ROS is positive for wt loss in context of upping dose of furosemide. . On last hospitalization, team had extensive discussion with patient regarding risks and benefits of anticoagulation with coumadin, pradexa, or lovenox. After lengthy discussion patient expressed reluctance to start any new medications and refused Coumadin due to bleed in the past and apprehension regarding monitoring of Coumadin. . ED Course: In the ED, initial VS 96.8 150 108/53 16 100%. She was initially triggered for tachycardia to 150s. EKG: rAF no ischemia. CXR: no acute process. ED resident called [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**] [**Telephone/Fax (1) 31130**], who told Metoprolol was fine to give and the pt received Metoprolol 5mg IV x2, alprazolam x1 with no improvement. ED resident then d/w cardiology, who recommended amiodarone load and heparin gtt. Exam notable for heart rate to 120-150, hypotension 80/40. Labs notable for proBNP: 2521 INR: 1.3. The pt underwent CXR as well. EKG was afib in 150's with no ST changes. VS on transfer were: BP 93/46, HR 130's, Pox 99 on 2L, RR 20's. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. . Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: - Diastolic congestive heart failure - Atrial fibrillation s/p cardioversion - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: None - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: - COPD - Obstructive sleep-disordered breathing, mild - not on CPAP - Diverticulosis - Benign paroxysmal positional vertigo - Anxiety - Anemia - Hyponatremia - MSSA sepsis in [**2134-7-18**] - Pneumonia (~[**2132**]) Social History: Occupation: Retired. Drugs: Denies. Tobacco: Quit smoking 16 years ago with 80 pack-year history. Alcohol: Social. Other: Lives alone; completes all ADLs, walks with a cane on left at baseline. Family History: - Father died of myocardial infarction in his 40s. - Mother died of congestive heart failure at 88. - Otherwise, no family history of arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ON ADMISSION: VS: T= 96.7...BP=98/73...HR=111...RR=20...O2 sat= 99%2L GENERAL: Alert, oriented, NAD. Oriented x3. Mood, affect appropriate; speaking in full sentences without problem [**Name (NI) 4459**]: [**Name (NI) 12476**]. Sclera anicteric. PERRL, EOMI. Conjunctiva are pink, no pallor or cyanosis of the oral mucosa. OP clear without exudates, lesions. NECK: at 45* JVD to mid-neck and upto earlobes with hepatic pressure, no LAD. CARDIAC: irregular RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4 LUNGS: bilateral crackels over lower-lung upto 3cm below scapulas, no wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c, pre-tibial edema trace to +1 bilateral . No femoral bruits. SKIN: no RASH PULSES: Right: Carotid 2+ RADIAL 2+ DP 1+ Left: Carotid 2+ RADIAL 2+ DP 1+ . ON DISCHARGE Pertinent Results: ADMISSION LABS: [**2138-6-14**] 07:55PM WBC-8.4 RBC-4.03* HGB-12.6 HCT-35.8* MCV-89 MCH-31.2 MCHC-35.1* RDW-13.7 [**2138-6-14**] 07:55PM PLT COUNT-257 [**2138-6-14**] 07:55PM NEUTS-65.4 LYMPHS-24.6 MONOS-6.5 EOS-2.5 BASOS-0.9 [**2138-6-14**] 07:55PM GLUCOSE-118* UREA N-20 CREAT-1.1 SODIUM-133 POTASSIUM-4.7 CHLORIDE-95* TOTAL CO2-29 ANION GAP-14 [**2138-6-14**] 07:55PM CALCIUM-9.5 PHOSPHATE-4.2 MAGNESIUM-2.2 [**2138-6-14**] 07:55PM proBNP-2521* [**2138-6-14**] 08:53PM PT-14.5* PTT-28.0 INR(PT)-1.3* STUDIES: [**2138-6-14**] ECG: Atrial fibrillation with ventricular rate 140-160, left axis wnl (-[**11-1**]*), normal intervals, rate dependent ST depressions V4-V6 as well minimal depressions in II, III, AVF which are not seen in previous tracing in sinus rythm. [**2138-6-14**] CXR: Cardiomegaly with mild volume overload. [**2138-6-18**] TEE: 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. Right atrial appendage ejection velocity is good (>20 cm/s). No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). There are simple atheroma in the ascending aorta. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. IMPRESSION: No spontaneous echo contrast or thrombus in left atrium, left atrial appendage, right atrium, or right atrial appendage. Mild aortic regurgitation. Mild mitral regurgitation. Mild tricuspid regurgitation. Aortic atheromatous disease. Brief Hospital Course: Ms. [**Known lastname 31125**] is a 84 yo female with history of PAF s/p cardioversion x4, diastolic heart failure presenting with chest discomfort admitted to the CCU for evaluation and mgmt of Atrial Fibrillation with rapid ventricular rate . # Atrial Fibrillation with Rapid Ventricular Rate. No clear precipitator to reversion to irregular rate. Patient denies any history of insensible loss (decreased PO intake, n/v/d/fever). Patient denies infectious trigger - no fever, chills, or localizing complaints of infection (cough, n/v/d, dysuria). On admission, patient was afebrile, WBC wnl, CXR without infiltrate. Though patient does have h/o CHF does not appear in florid HF as precipitant to AF on this admission. TSH on last admission wnl. Patient is currently asymptomatic. She was loaded with amiodarone and started on a heparin drip. She was continued on her nadolol at her home dose. After discussion with the patient and her daughter, she was started on dabigatran and heparin gtt and aspirin was d/c-ed. Note that this medicine increases INR and PTT but these labs are not reliable indicators of anticoagulation status and should not be followed. She was amio loaded and continued on 200mg [**Hospital1 **] and will need 4 more days of twice daily dosing, then decrease to 200 mg daily therafter. She was scheduled for TEE cardioversion which she underwent on [**6-18**] with subsequent return to sinus rhythm. She will continue on amiodarone and dabigatran as an outpatient. Naldolol has been d/c'ed. Please note that dabigitran is contraindicated with creat clearance < 15, decrease to 75 mg [**Hospital1 **] for creatinine clearance 15-30. She has prior authorization for dabigitran through her pharmacy. . # Chronic Diastolic CHF. Slightly volume up. Patient with history of diastolic heart failure. LVEF~55%, no WMA. Patient without significant DOE and Os sat >95% on no O2 supplementation. On admission, gave patient 20 mg of lasix IV with goal of [**1-19**] L negative. Monitored strict I/Os, weights and fluid restriction 1500mL, low Na diet. She received prn lasix boluses. She was discharged on 40 mg Lasix which is increased from her home dose. Her weight at discharge is 73.5. Please note that pt is very concerned about her weight and concerned that it is up since admission. Labs indicate that pt is intravascularly dry and likely needs to increase PO intake and activity to mobilize fluid. . # HTN. Per patient history of labile blood pressures. Currently slightly hypotensive in setting of getting amiodarone load but asx. Held [**Last Name (un) **] in acute setting, please restart at low dose once creatinine is < 1.. . # COPD. No home oxygen requirement. Last PFTs with mild obstructive defect. Ipratroprium nebs prn. She has been complaining of a mild productive and spastic cough that she has had for a few months that we believe is reactive airway disease. She has not tolerated fluticasone type inhalers in the past. There is no evidence of infection. Her Ipratroprium and Albuterol nebs have been somewhat helpful and should be continued. Would change to Combivent inhaler once she goes home. . # Anxiety: Home Alprazolam prn . CODE: Full, HCP: [**Name (NI) 22917**] [**Name (NI) 13469**] Medications on Admission: 1. furosemide 20 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily). 2. nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. alprazolam 0.25 mg Tablet Sig: 0.5 Tablet PO at bedtime as needed for insomnia. 4. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. 5. benzonatate 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for cough. 6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO four times a day as needed for pain. 7. ipratropium bromide 0.02 % Solution Sig: One (1) vial Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 8. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Medications: 1. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 4. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 4 days: then decrease to 200 mg once a day thereafter. 5. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Contraindicated with creat clearance < 15, decrease to 75 mg [**Hospital1 **] for creatinine clearance 15-30. 6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath. 8. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath. 9. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. 10. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough. 11. Outpatient Lab Work Please check Chem-7 on Monday [**2138-6-23**] Discharge Disposition: Extended Care Facility: [**Hospital 4542**] Rehabilitation and Nursing of [**Location (un) 38**] Discharge Diagnosis: Atrial Fibrillation Acute on Chronic Diastolic congestive heart failure Anxiety Chronic Obstructive pulmonary disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mrs. [**Known lastname 31125**], It was a pleasure participating in your care. You were admitted for atrial fibrillation. You were started on medications to thin your blood as well as medications to help control your heart rate and rhythm. You underwent a transesophageal echocardiogram which showed no clot in your atrium. You then had an electrical cardioversion which changed your heart into normal sinus rhythm. You will continue on blood thinners (Dabigatran) and Amiodarone to help prevent you from developing clots or returning to an abnormal rhythm. Please call or return to the hospital if you develop chest pain, palpitations, shortness of breath, lightheadedness, or any other symptoms that concern you. We have made the following changes to your medicines: 1. START Dabigatran to prevent a blood clot and stroke 2. START Amiodarone, to keep you in a regular sinus rhythm 3. INCREASE the lasix to 40 mg daily 4. START Albuterol to be used with Ipratroprium for your wheezing and coughing 5. START Robitussin DM for your cough 6. START Colace as needed to prevent constipation . Please STOP the following medications: Nadolol, aspirin and valsartan Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. Followup Instructions: Department: MEDICAL SPECIALTIES When: MONDAY [**2138-6-23**] at 2:30 PM With: DR. [**First Name8 (NamePattern2) 3688**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: MONDAY [**2138-6-30**] at 10:40 AM With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2138-6-22**]

[ "428.33", "493.20", "458.29", "300.00", "428.0", "401.9", "E942.0", "780.2", "427.31" ]

icd9cm

[ [ [] ] ]

[ "88.72", "99.62" ]

icd9pcs

[ [ [] ] ]

11863, 11962

6618, 9847

496, 515

12124, 12124

4675, 4675

13633, 14285

3528, 3746

10628, 11840

11983, 12103

9873, 10605

12307, 13610

3761, 3761

2897, 3050

409, 458

543, 2789

4692, 6595

3775, 4656

12139, 12283

3081, 3300

2811, 2877

3316, 3512

64,671

159,894

37057

Discharge summary

report

Admission Date: [**2117-8-20**] Discharge Date: [**2117-9-12**] Date of Birth: [**2080-8-28**] Sex: M Service: MEDICINE Allergies: Dilantin Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: slurred speech, headache Major Surgical or Invasive Procedure: endotracheal intubation History of Present Illness: Mr. [**Known lastname 48422**] is a 36-year-old man with a history of metastatic, dedifferentiated thyroid cancer on doxarubucin (C1D18) and celiac disease, presenting with one day of headache and altered mental status. Patient developed a headache after using a suppository for constipation yesterday. He has had several weeks of low grade temperatures to 99.5 and night sweats. This morning, he was noted by his family to not be making any sense when they were speaking with him. He states he was having difficulty word finding, following commands, and writing sentences at that time. It resolved, but re-occured during his appointment with his oncologist later that day. He was referred to the ED where his symptoms resolved again, but then re-occurred in the ED where he was noted to be having difficulty finding words, making paraphrasic errors, and appearing overall globally confused. He has been on dexamethasone daily and his last chemotherapy was cycle 1 day 1 of doxorubicin on [**2117-8-3**]. . In ED VS were 98.9 103 123/82 14 100% on RA. Labs sig for Na of 123, Hct of 22.7, WBC of 9.9 with 15% bands. Lactate 0.8 He received IV Vancomycin, CFTX, and Acylovir (meningitis dosing) and 3 L NS. Neurology and neurosurgery were both consulted. Neurosurgery did not recommend any intervention for the SDH noted on Head CT, stating it was subacute. Neurology recommended LP for rule out meningitis which was performed in the ED and demonstrated WBC of 8, normal protein and glucose, and RBCS that did not clear from tube 1->tube 4. . Review of systems: (+) overall weakness (-) 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: Past Oncologic History (Per Dr.[**Initials (NamePattern4) 11574**] [**Last Name (NamePattern4) **] note): -[**2103**]: Nodule felt on physical examination, biopsy revealed papillary thyroid cancer and patient underwent a total thyroidectomy. Per reports, patient had 1.1 cm tumor with lymph node involvement. This was done in [**Location (un) 36413**]. He underwent radioactive iodine therapy, and was followed frequently with lab tests and scans. Abnormalities were detected in [**2107**] with evidence of possible remnant thyroid tissue, and he underwent repeat radioactive iodine ablation with good result. Was followed closely for a time, had last been seen in [**2113**] when he lived in [**Location 18296**], and was lost to follow up until move to [**State 350**] in [**2115**]. -As part of initial evaluation, he had an ultrasound done of his neck. The ultrasound demonstrated three enlarged morphologically abnormal lymph nodes on the left at level IV and further evaluation was recommended. The largest lymph node was 1.9 x 1.7 x 1.0 cm. He then underwent a Thyrogen radioactive iodine uptake scan, which was negative for residual thyroid uptake and had no evidence of metastatic disease. He subsequently went on to an ultrasound-guided biopsy and cytology from this procedure was positive for malignant cells consistent with carcinoma. The malignant cells had a large nuclei with prominent nucleoli and high nuclear to cytoplasmic ratios. The tumor cells were positive for CK7 and CK20, and negative for TTF-1 and thyroglobulin. These findings were consistent with dedifferentiated papillary carcinoma of the thyroid, but second primary could not be entirely excluded. As a result of this pathology, the patient underwent PET-CT scan, which demonstrated FDG avid nodal disease in the left neck at levels IV and IIa within the right thyroidectomy bed. There was atypical diffuse FDG avid nodal disease within the thorax along the periaortic and paraesophageal chain. The findings were consistent suggestive of dedifferentiated metastatic thyroid cancer; however, the pattern was atypical. There were no other sites of abnormal FDG uptake to suggest a secondary malignancy. Biopsy of the paraesophageal mass on [**2-17**] with pathology consistent with his previously diagnosed, dedifferentiated papillary thyroid carcinoma. Lastly, his PET/CT scan in [**2117-5-20**] revealed stable disease. . Other Past Medical History: Celiac disease Social History: The patient works as a consultant. His girlfriend and mother are present at the bedside. He does not smoke. Occasional EtOH use, none in last 5 weeks. Denies any illicit drug use. Family History: Mother had papillary carcinoma of the thyroid. Father died of colon cancer at age 63, was diagnosed at age 57. He has a brother and a sister who are healthy. His family history is significant for heart disease, specifically CHF. Physical Exam: Vitals: T: 98.7, BP: 123/74, P: 130, R: 24, O2: 91% 6L NC General: tachypnic, anxious, alert, oriented x 3 HEENT: NC/AT, mild scleral icterus Neck: supple, JVP 6 cm, no LAD Lungs: decreased BS at right base, dull to purcussion, occasional crackles R > L CV: tachycardic, 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: Labs on Admission: [**2117-8-20**] 07:50PM CEREBROSPINAL FLUID (CSF) PROTEIN-107* GLUCOSE-102 [**2117-8-20**] 07:50PM CEREBROSPINAL FLUID (CSF) WBC-8 RBC-26* POLYS-82 LYMPHS-2 MONOS-14 EOS-1 MACROPHAG-1 [**2117-8-20**] 07:50PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-295* POLYS-13 LYMPHS-23 MONOS-62 NUC RBCS-1 OTHER-1 [**2117-8-20**] 05:40PM COMMENTS-GREEN TOP [**2117-8-20**] 05:40PM LACTATE-0.8 [**2117-8-20**] 03:30PM URINE HOURS-RANDOM [**2117-8-20**] 03:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2117-8-20**] 03:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009 [**2117-8-20**] 03:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2117-8-20**] 02:30PM GLUCOSE-113* UREA N-16 CREAT-0.9 SODIUM-123* POTASSIUM-4.6 CHLORIDE-83* TOTAL CO2-30 ANION GAP-15 [**2117-8-20**] 02:30PM CALCIUM-9.8 PHOSPHATE-6.5* MAGNESIUM-1.7 [**2117-8-20**] 02:30PM WBC-9.9 RBC-2.97* HGB-7.9* HCT-22.7* MCV-76* MCH-26.5* MCHC-34.7 RDW-20.6* [**2117-8-20**] 02:30PM NEUTS-50 BANDS-13* LYMPHS-14* MONOS-8 EOS-0 BASOS-0 ATYPS-0 METAS-5* MYELOS-9* PROMYELO-1* NUC RBCS-8* [**2117-8-20**] 02:30PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-3+ POLYCHROM-1+ SCHISTOCY-OCCASIONAL [**2117-8-20**] 02:30PM PLT SMR-VERY LOW PLT COUNT-34* [**2117-8-20**] 02:30PM PT-13.6* PTT-22.1 INR(PT)-1.2* [**2117-8-20**] 12:44PM UREA N-17 CREAT-1.0 [**2117-8-20**] 12:44PM ALT(SGPT)-80* AST(SGOT)-38 LD(LDH)-828* ALK PHOS-510* TOT BILI-1.2 [**2117-8-20**] 12:44PM ALBUMIN-2.9* [**2117-8-20**] 12:44PM WBC-9.6 RBC-3.18* HGB-8.1* HCT-24.1* MCV-76* MCH-25.5* MCHC-33.7 RDW-20.0* [**2117-8-20**] 12:44PM NEUTS-52 BANDS-11* LYMPHS-12* MONOS-5 EOS-0 BASOS-0 ATYPS-2* METAS-9* MYELOS-9* NUC RBCS-10* [**2117-8-20**] 12:44PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-2+ MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-1+ SPHEROCYT-2+ SCHISTOCY-2+ TEARDROP-2+ BITE-2+ [**2117-8-20**] 12:44PM PLT SMR-VERY LOW PLT COUNT-34* [**2117-8-20**] 12:44PM GRAN CT-7808 Brief Hospital Course: 36 y/o male with metastatic de-differentiated papillary thyroid carcinoma, previously managed in [**Hospital Unit Name 153**] for altered mental status, transferred back to ICU for hypoxia, tachycardia, and acute hematocrit drop, with concern for hemolysis. . # Hypoxic respiratory failure: likely multifactorial. DDx is broad and includes pulmonary embolism (possible given tachycardia, hypercoagulable state in setting of neoplasm, and additional oxygen requirement), pulmonary infection (favor atypical infection such as PCP as opposed to acute bacterial pneumonia given lack of fever and leukocytosis), or, more likely rapidly rising tumor burden (favored diagnosis after reviewing his progressive disease on CT scan and discussing with radiology). Of note, patient has been on pentamidine prophylaxis, making PCP somewhat less likely. Also on DDx is TRALI given his recent pRBC transfusion. ABG on 6L NC: 7.53/26/73. Upon arrival to the ICU, patient demonstrated tachypnea, increased work of breathing on NRB, and required intubation. ETT was in appropriate position. He was started on PCP coverage and IV steroids (for presumed TTP, see below). . # Hct drop/anemia/thrombocytopenia: DDx includes bleeding (possible given hematuria, hematochezia, and now hemoptysis), DIC (possible though unlikely given normal coagulation parameters and fibrinogen > 300), TTP-HUS (possible given thrombocytopenia and evidence of schistocytes on peripheral smear). Evidence for hemolysis includes elevated direct bilirubin, and marked drop in haptoglobin to 6. Per oncology recommendations and given schistocytes, thrombocytopenia, and review of peripheral smear, there was overall concern for TTP-HUS, for which oncology initiated IV steroids. . # Subdural hematoma: known subdural hematoma with thrombocytopenia. NSGY following and patient on keppra. . # Suspected seizures: He had a negative EEG for seizure activity and unremarkable LP on the OMED floor. Remains on keppra per neurology recommendations. . # Metastatic Thyroid cancer: He received a dose of chemotherapy with Carboplatin and Paclitaxel on [**8-25**] and has been on decadron, calcitriol and levothyroxine. Suspect markedly advanced, rapidly progressive disease given abrupt rise in AST, ALT, bilirubin, and LDH. . # Altered mental status: now resolved. Previously with delirium likely secondary to infection, pain meds & lack of sleep [**12-22**] ICU environment. The cause of his severe agitation and AMS that led to intubation & transfer to the [**Hospital Unit Name 153**] is unclear, but there was concern for seizure with AMS [**12-22**] post-ictal state. Patient was loaded with empiric Keppra 1g and has since been changed to 1.5g [**Hospital1 **]. EEG was negative for seizure activity, but patient was placed on keppra for generalized slowing on EEG without epileptiform activity. Chronic subdural hematoma was stable. Patient was intially on standing haldol for agitation, which was changed to PRN when mental status improved; QTc were followed daily. In the unit, patient was started on and completed course of acyclovir for presumed HSV, which was negative when CSF HSV PCR came back. The patient continued keppra . # Hypoxia: Patient was intubated from [**Date range (1) 16628**] secondary to inability to protect his airway due to sedation that was required to control his agitation and altered mental status. Also being treated for HCAP (vanc/cefepime/flagyl for HCAP (d1=[**8-28**] for 8 days). Successfully extubated and supplemental O2 weaned. Had one episode of dyspnea requiring non-rebreather secondary to volume overload. . # Pancytopenia: Likely [**12-22**] recent chemotherapy. NSG recommended platelets >100 before any procedure. Filgrastim was stopped on [**8-30**]. Platelets were transfused with goal >30. PRBCs were transfused with hct goal >21 or if symptomatic. . ------------- MICU course: patient was transferred to ICU for hypoxia, tachycardia, and acute hematocrit drop, with concern for hemolysis. He was intubated upon arrival for tachypnea (RR 40s) and increased work of breathing despite NRB mask. A L IJ was placed. ETT and IJ CVL were in appropriate position. Patient underwent cardiac arrest with rhythm of ventricular fibrillation. CPR was initiated. He was resuscitated with epinephrine and shock x 2. Less than one hour later, patient went into cardiac arrest with rhythm of PEA. CPR was initiated with epinephrine and atropine. Patient was unable to be successfully resuscitated and time of death was 01:25 hours. Primary cause of death was felt to be underlying, rapidly progressive thyroid cancer. Medications on Admission: CALCITRIOL - 0.5 mcg Capsule - 1 Capsule(s) by mouth three times a day CYCLOBENZAPRINE - 10 mg Tablet - 1 Tablet(s) by mouth three times a day as needed for muscle spasm DEXAMETHASONE - 4 mg Tablet - 1 Tablet(s) by mouth DAILY FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth DAILY LACTULOSE - 10 gram/15 mL Solution - [**11-21**] Solution(s) by mouth three times a day as needed for constipation LEVOTHYROXINE - 150 mcg Tablet - 3 Tablet(s) by mouth once a day LORAZEPAM - 0.5 mg Tablet - [**11-21**] Tablet(s) by mouth every six (6) hours as needed for nausea/anxiety (takes rarely with no recent doses) ONDANSETRON - 8 mg Tablet, Rapid Dissolve - 1 Tablet(s) by mouth every eight (8) hours as needed for nausea OXYCODONE - 20 mg Tablet Sustained Release 12 hr - [**1-21**] Tablet(s) by mouth every eight (8) hours please take 60mg once daily (3 tabs) and 80mg twice daily (4 tabs) as needed for pain OXYCODONE - 5 mg Tablet - [**11-21**] Tablet(s) by mouth every four (4) hours as needed for pain PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth every twenty-four(24) hours PENTAMIDINE [NEBUPENT] - 300 mg Recon Soln - 300 mg inhaled Monthly POLYETHYLENE GLYCOL 3350 - 17 gram/dose Powder - 1 Powder(s) by mouth DAILY as needed for constipation Medications - OTC ACETAMINOPHEN - (Prescribed by Other Provider) - Dosage uncertain BISACODYL - (Prescribed by Other Provider) - 5 mg Tablet, Delayed Release (E.C.) - 2 Tablet(s) by mouth DAILY (Daily) as needed for constipation CALCIUM CARBONATE - (Prescribed by Other Provider) - 500 mg (1,250 mg) Tablet - 2 Tablet(s) by mouth three times a day CALCIUM [CALCIO [**Doctor First Name 15**] [**Month (only) 16**]] - (Prescribed by Other Provider) - 500 mg Tablet - 2 Tablet(s) by mouth three times a day 1000 mg DOCUSATE SODIUM - (Prescribed by Other Provider) - 100 mg Capsule - 1 Capsule(s) by mouth twice a day SENNA - (Prescribed by Other Provider) - 8.6 mg Tablet - 1 Tablet(s) by mouth twice a day Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: 1. metastatic, de-differentiated thyroid cancer Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2117-9-13**]

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icd9cm

[ [ [] ] ]

[ "38.93", "96.04", "99.25", "96.71", "03.31" ]

icd9pcs

[ [ [] ] ]

14442, 14451

7774, 10057

301, 326

14542, 14551

5662, 5667

14607, 14781

4863, 5093

14410, 14419

14472, 14521

12408, 14387

14575, 14584

5108, 5643

1915, 2178

237, 263

354, 1896

5681, 7751

10072, 12382

4633, 4649

4665, 4847

13,301

183,200

19723

Discharge summary

report

Admission Date: [**2198-2-28**] Discharge Date: [**2198-3-8**] Date of Birth: [**2121-7-5**] Sex: M Service: MICU CHIEF COMPLAINT: Transfer from outside hospital for evaluation for TIPS / Esophagogastroduodenoscopy. HISTORY OF PRESENT ILLNESS: The patient is a 76 year old very pleasant gentleman with a past medical history significant for invasive adenocarcinoma of the stomach status post near total gastrectomy in [**2197-10-11**], with Roux-en-Y anastomosis and partial jejunal pouch, cirrhosis, coronary artery disease and orthostatic hypotension who was admitted to [**Hospital6 2910**] on [**2198-2-15**] with complaints of nausea and dysphagia. At the [**Hospital6 2910**] Mr. [**Known lastname 14859**] [**Last Name (Titles) 1834**] an esophagogastroduodenoscopy which showed esophageal varices and stricture. He has had three esophageal dilatations in the past for stricture at anastomotic site. Dilation could not be performed at this time given his report of large varices. He was therefore transferred for evaluation. In addition, at [**Hospital6 2910**], Mr. [**Known lastname 14859**] had a transthoracic echocardiogram for evaluation of orthostatic hypotension which was unremarkable. He was noted to have significant orthostatic changes which was felt secondary to autonomic dysfunction after his Florinef was discontinued. He instead was transferred to Midodrine with some improvement in his blood pressure. Other work-up at [**Hospital6 2910**] included paracentesis with albumin which showed SAAG greater than 1.1. Cytology was negative for malignancy and there was no evidence of SVP. He was unable to tolerate more than liquids while at the hospital secondary to coughing which was felt secondary to aspiration. On admission to [**Hospital1 69**], he was initially managed on the Medicine Floor. However, on hospital day number two, he was noted to have desaturations and tachypnea and was complaining of a feeling of an obstruction in his throat. He had been n.p.o. prior to this event. He was transferred to the Medical Intensive Care Unit and was maintained on 100% nonrebreather face mask for the first two days in the Intensive Care Unit. He was slowly weaned off oxygen, however, had a respiratory event on hospital day number five, at which time he was intubated. The following morning, an esophagogastroduodenoscopy was performed and the remainder of hospital course will follow. PAST MEDICAL HISTORY: 1. History of pancytopenia. 2. Invasive gastric adenocarcinoma status post near total gastrectomy in [**2197-10-11**]. He had an esophageal to jejunal anastomosis within a Roux-en-Y procedure. 3. He is status post three esophageal dilatations by esophagogastroduodenoscopy secondary to strictures at the anastomotic sites. 4. History of cirrhosis which was diagnosed in the 70s thought secondary to alcohol use. He has not had any alcohol use since time of diagnosis. 5. Anastomotic site ulcer. 6. Coronary artery disease status post angioplasty and stent. 7. Autonomic dysfunction / orthostatic hypotension. 8. Depression. 9. History of syncope. 10. Transverse colectomy secondary to invasive gastric adenocarcinoma in [**2197-10-11**]. 11. Vitamin D deficiency. MEDICATIONS AT HOME: 1. Zoloft 50 q. day. 2. Folate. 3. Florinef. 4. Colace. 5. Megace. 6. Carafate. 7. Lipitor. ALLERGIES: No known drug allergies. MEDICATIONS ON TRANSFER: 1. Inderal 20 twice a day. 2. Protonix 40 twice a day. 3. Midodrine 10 three times a day. 4. Colace 100 twice a day. 5. Aldactone 50 twice a day. 6. Zoloft 50 q. day. 7. Lasix 40 q. day. 8. Milk of Magnesia p.r.n. SOCIAL HISTORY: Alcohol use: Heavy drinking for approximately 24 years, quit 29 years ago. The patient is very active in Alcoholics Anonymous and has not had any alcohol since diagnosis of cirrhosis. Tobacco use: Twenty-four years, also quit 29 years ago; approximately one pack per day. No history of illicit drug use. The patient lives alone in [**Location (un) 2624**], [**State 350**]. He has no close relatives. His point of contact is his friend, [**Name (NI) 53327**] Chief [**Name (NI) **] [**Name (NI) 53328**] whose phone number is [**Telephone/Fax (1) 53329**]. PHYSICAL EXAMINATION: On presentation to the Medicine Floor is temperature 95.1 F.; blood pressure 120/70; heart rate 82; respiratory rate 22; 97% on four liters oxygen by nasal cannula. In general, the patient appeared comfortable in no apparent distress. His pupils were equal, round and reactive. Extraocular muscles are intact. Mucous membranes were dry. Oropharynx was clear. He had poor dentition. His heart was regular rate. No murmurs, rubs or gallops were appreciated. He had bilateral basilar crackles, right greater than left. On abdominal examination, he had hypoactive bowel sounds, soft, nontender, nondistended; a very large horizontal abdominal scar was present and he was dull to percussion throughout with a positive fluid wave. On extremities: No lower extremity edema. He had [**Male First Name (un) **] stockings on. His skin was dry with some ecchymoses over his chest and right upper extremity. He had some spider angiomas. On neurological examination he was alert and oriented times four. Cranial nerves II through XII were intact. He had four over five bilateral upper extremity strength, four over five lower extremities bilateral strength and sensation was intact. LABORATORY: On transfer white blood cell count 9.6, hematocrit 31.7 at his baseline; platelets 122. Sodium 141, potassium 3.5, chloride 110, bicarbonate 22, BUN 14, creatinine 0.7, glucose 108, albumin 2.1; total protein 4.7. LDH 196, total bilirubin 1.7, alkaline phosphatase 82. ALT 5, AST 20, INR 1.4, uric acid 4.7. IMPRESSION: This is a 76 year old gentleman with a history of gastric cancer status post near total gastrectomy with an esophageal duodenal Roux-en-Y procedure who has had three esophageal dilatations secondary to stricture at the anastomotic site, who was transferred from outside hospital for complaints of dysphagia and nausea. He was transferred for evaluation of TIPS procedure and repeat EGD for evaluation of swallowing complaints which was thought secondary to aspiration. HOSPITAL COURSE: 1. GASTROENTEROLOGY: As stated above, Mr. [**Known lastname 53330**] main complaint included dysphagia which was thought secondary to mechanical obstruction at his anastomotic site from a history of gastric cancer treated in 10/[**2197**]. After intubation on hospital day number five, Mr. [**Known lastname 14859**] [**Last Name (Titles) 1834**] an esophagogastroduodenoscopy which showed no stricture and a wide open anastomosis with visible aspiration of secretions. General Surgery was consulted as well as Gastroenterology for possible interventions as it was felt that the reason he was intubated was secondary to recurrent aspiration. The conclusions from both consultations obtained was that there was no surgical or endoscopic intervention. 2. RESPIRATORY DISTRESS: He was intubated on hospital day number five for respiratory distress secondary to persistent aspiration through his esophageal duodenal anastomosis. Mr. [**Known lastname 14859**] was not able to be weaned from the ventilator given the development of metabolic acidosis which will be described below. He was finally [**Known lastname 53331**] on [**2198-3-8**], and expired within a few hours. 3. ENTEROCOCCUS BACTEREMIA: On [**2198-3-1**], Mr. [**Known lastname 14859**] had a one out of four blood culture bottles growing enterococcus which was sensitive to Vancomycin. He had a subclavian line at that time which was discontinued and the catheter tip sent for culture which did not have any growth. He was continued on Vancomycin intravenously for his bacteremia and remained afebrile. 4. LEUKOCYTOSIS: On hospital day number six and seven, the patient had significant and acute increase in his white blood cell count from 11 to 41. A differential at that time showed 7% bands. There was no clear source of infection, however, given the rapid and very high increase in his white count, Clostridium difficile colitis was suspected. In addition, other diagnoses which were entertained were sepsis and mesenteric ischemia. A CT scan of the abdomen was performed which showed no evidence of abscess with some colonic thickening which was nonspecific. Also of note, he had significant ascites which was tapped and showed 85 white cells and a SAAG of less than 1; therefore it was not felt that the patient had peritonitis as an explanation for his leukocytosis. He was placed on p.o. Vancomycin and continued on intravenous Flagyl and Levaquin which were started on hospital day number two for presumed aspiration pneumonia. 5. ALTERED MENTAL STATUS: Mr. [**Known lastname 53330**] mental status was clear until the time of aspiration event on hospital day number five when he was intubated. He was continued on Propofol and was taken off it on a number of occasions at which time Mr. [**Known lastname 53330**] delirium did not recover. He was not oriented for the remainder of his hospital course. It was felt that this was mostly toxic metabolic in nature given his significant leukocytosis and likely hepatic encephalopathy. 6. HYPOTENSION: The patient was started on Neo-Synephrine at the time of his intubation on hospital day number five and was never able to be weaned off pressors. He responded well to intravenous fluid boluses at times, however, his pressors were continued. He had a number of reasons for his hypotension including acute issues such as sepsis, leukocytosis, sedating medications, nutritional deficiency as well as chronic issues which included baseline autonomic dysfunction. 7. LEGAL ISSUES: Prior to intubation, Mr. [**Known lastname 14859**] elected his friend, [**Name (NI) 53327**] Chief [**First Name8 (NamePattern2) **] [**Name (NI) 53328**], to serve as his health care proxy and durable power of attorney. Mr. [**Known lastname 14859**] has no relatives in the area. On [**2198-3-8**], as Mr. [**Known lastname 53330**] condition continue to deteriorate despite full effort and full life sustaining support measures. In accordance to the patient's wishes, [**Known lastname 53327**] Chief [**Doctor Last Name 53328**] elected to have Mr. [**Known lastname 14859**] [**Last Name (Titles) 53331**] on [**2198-3-8**] and he expired within a few hours. An autopsy was requested, however, due to the fact that Mr. [**Name13 (STitle) 53328**] is not a family member, this could not be performed under [**State 350**] Law. Multiple attempts were made to contact any living family members, however, these were not successful. DISCHARGE DIAGNOSES: 1. Invasive gastric carcinoma status post total gastrectomy in [**2197-10-11**] with a transverse colectomy. 2. Respiratory failure secondary to recurrent aspiration. 3. Bacteremia. 4. Leukocytosis which was likely secondary to Clostridium difficile colitis, possible mesenteric ischemia. 5. Hypotension. 6. Aspiration pneumonia. 7. Coagulopathy, acquired. 8. Cirrhosis secondary to alcohol use. 9. Ascites. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Known firstname **], M.D. [**MD Number(1) 2691**] Dictated By:[**Last Name (NamePattern1) 18697**] MEDQUIST36 D: [**2198-3-9**] 11:50 T: [**2198-3-10**] 23:13 JOB#: [**Job Number 53332**]

[ "572.2", "789.5", "276.2", "284.8", "571.2", "507.0", "518.81", "008.45", "790.7" ]

icd9cm

[ [ [] ] ]

[ "54.91", "38.93", "96.71", "99.15", "96.04", "45.13" ]

icd9pcs

[ [ [] ] ]

10771, 11484

6277, 8813

3268, 3407

4262, 6260

150, 236

266, 2449

8829, 10750

3432, 3655

2471, 3247

3673, 4238

74,626

133,518

43821

Discharge summary

report

Admission Date: [**2137-5-6**] Discharge Date: [**2137-5-30**] Date of Birth: [**2067-6-30**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 38277**] Chief Complaint: Hypoxic respiratory failure Major Surgical or Invasive Procedure: Coronary catheterization [**2137-5-6**] History of Present Illness: 69 yo male with PMH of HTN, DM II, HLD s/p MI s/p 2 PTCA [**2121**] who presented to OSH with cough, exertional dyspnea and icnreased edema x2 days and was found to have NSTEMI and was transferred to [**Hospital1 18**] for cardiac catheterization. Patient initially presented to [**Hospital1 882**] on [**5-5**] Sun early am with 2 days of SOB, diaphoresis and an inconsistent history of chest pain. According to his discharge summary a number of possible diagnoses were entertained and a variety of therapeutic interventions were implemented. Intially he was felt to be hypervolemic, As a result he he was placed on BiPap, nitro-paste and diuresed with partial resolution of his symptoms. His diuresis was apparently discontinued secondary to rising Cr. He also had a CXR which showed a questionable infiltrate and fever to 102 on [**5-5**] and was started on empiric treatment for CAP with ceftriaxone and azithromycin. He was also noted to have an EKG showing ST depressions 1-2mm in V5 and V6. Trop on [**5-5**] at 2200 was 0.524 He was started on ASA, Metoprolol and aotrvastatin and a heparin GTT and transferred to [**Hospital1 18**] for LHC. . Patient was taken to the Cath lab at [**Hospital1 18**] on the evening of CCU transfer. He underwent R and L heart cath which demonstrated a mildly elevated wedge ~16, mildly elevated PAP, diffuse dis--90% mid LCX, 90% mid RCA, 50-60% os/LM, LAD diffuse disease, EF 45%, septal hypokinesis, 1+MR. . A [**Hospital1 **] was reccomenced and he was transferred to the floor for evaluation by CT [**Doctor First Name **]. Shirtly after arrival to the floor he became hypertenvie and tachycardic and quite agitated with concern for flash pulmonary edema. His oxygen saturations dropped to the mid 60's despite being on NRB. He was diaphoretic and agitated with notable agonal breathing. He was intubated and sedated on the floor and transferred to MICU 6 under the care of the CCU team. . On arrival to the MICU he was hypertensive on a nitro gtt, intubated and sedated with fentayl and propofol. His EKG on arrial demonstrated worseing ST depressions in the lateral leads as well as 1mm elevation in aVR. . He became hypotensive shortly after arrival to the ICU with MAPs in the 50's and diaphoretic. His propofol and nitro gtt were discontinued and dopamine was initiated to maontin cardiac perfusion. EKG during hypotensive episode showed worsening elevation in AVR and continued ST depressions in lateral leads. His MAPs quickly rebounded to 70's and repeat EKG showed resolving changes. . He is currently intubated on fentanyl and midazolam. And off pressors. All told he was on dopamine for 30 min total. . Unable to participate in ROS secondary to intubation and sedation. . Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: - [**Doctor First Name **]: none - PERCUTANEOUS CORONARY INTERVENTIONS: angioplasty x2 in [**2121**] - PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: COPD Social History: - Tobacco history: Smoked 2.5 PPD x 36 years quit smoking in [**2121**] - ETOH: denies (per OSH dc summary) - Illicit drugs: denies (per OSH DC summary) Family History: - Limited and obtained from OSH records. - Mother: CAD - Father: brain cancer Physical Exam: Admission Physical Examination: General Appearance: Well nourished, Diaphoretic Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube placed Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: diffuse crackles) Chest: Coarse symmetric breath sounds BL Abdominal: Soft, Distended Extremities: Right lower extremity edema: Trace, Left lower extremity edema: Trace Skin: Not assessed Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated, Tone: Not assessed . DISCHARGE EXAM: General Appearance: Well nourished, on nasal cannula Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Poor dentition Cardiovascular: (S1: Normal), (S2: Normal), no clear murmur Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ), (Breath Sounds: Rhonchorous: right > left), crackles bilaterally Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent Skin: Not assessed Neurologic: attentive, not oriented (oriented x1), poor attention Pertinent Results: ADMISSION LABS: [**2137-5-7**] 03:06AM BLOOD WBC-8.8 RBC-3.53* Hgb-11.1* Hct-34.0* MCV-96 MCH-31.4 MCHC-32.7 RDW-13.8 Plt Ct-215 [**2137-5-7**] 03:06AM BLOOD PT-13.1* PTT-50.0* INR(PT)-1.2* [**2137-5-6**] 05:30PM BLOOD Glucose-166* UreaN-26* Creat-1.4* Na-137 K-3.3 Cl-101 HCO3-25 AnGap-14 [**2137-5-6**] 05:30PM BLOOD ALT-30 AST-63* AlkPhos-38* Amylase-46 TotBili-0.4 [**2137-5-7**] 03:06AM BLOOD cTropnT-1.34* [**2137-5-7**] 02:39PM BLOOD cTropnT-1.56* [**2137-5-8**] 04:13AM BLOOD CK-MB-12* MB Indx-1.3 cTropnT-1.32* [**2137-5-6**] 05:30PM BLOOD Albumin-3.2* Cholest-117 [**2137-5-6**] 05:30PM BLOOD %HbA1c-8.7* eAG-203* [**2137-5-6**] 05:30PM BLOOD Triglyc-112 HDL-46 CHOL/HD-2.5 LDLcalc-49 [**2137-5-6**] 10:43PM BLOOD Lactate-1.3 K-4.3 . Relevant Labs: [**2137-5-10**] 11:36PM BLOOD ALT-30 AST-53* LD(LDH)-382* CK(CPK)-690* AlkPhos-40 TotBili-0.3 [**2137-5-26**] 04:24AM BLOOD ALT-28 AST-37 AlkPhos-92 TotBili-0.2 [**2137-5-7**] 11:04AM BLOOD CK-MB-24* MB Indx-1.5 [**2137-5-7**] 02:39PM BLOOD cTropnT-1.56* [**2137-5-8**] 04:13AM BLOOD CK-MB-12* MB Indx-1.3 cTropnT-1.32* [**2137-5-9**] 08:13AM BLOOD CK-MB-7 [**2137-5-10**] 06:16PM BLOOD CK-MB-13* MB Indx-1.4 cTropnT-1.51* [**2137-5-10**] 11:36PM BLOOD CK-MB-8 cTropnT-1.50* [**2137-5-6**] 05:30PM BLOOD %HbA1c-8.7* eAG-203* [**2137-5-6**] 05:30PM BLOOD Triglyc-112 HDL-46 CHOL/HD-2.5 LDLcalc-49 . Microbiology: Blood culture [**5-7**], [**5-11**], [**5-13**], [**5-20**]: negative Mycolytic/AFB cultures: pending Urine culture [**5-7**], [**5-11**], [**5-13**], [**5-18**], [**5-20**], [**5-22**]: negative C. diff [**5-15**], [**5-24**]: negative Urine legionella [**5-11**], [**5-22**]: negative Cryptococcal ag [**5-22**]: negative [**2137-5-21**] 2:37 am STOOL CONSISTENCY: SOFT Source: Stool. FECAL CULTURE (Final [**2137-5-23**]): NO SALMONELLA OR SHIGELLA FOUND. NO ENTERIC GRAM NEGATIVE RODS FOUND. CAMPYLOBACTER CULTURE (Final [**2137-5-23**]): NO CAMPYLOBACTER FOUND. VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED. [**2137-5-21**] 3:24 pm BRONCHOALVEOLAR LAVAGE RUL POST SEGMENT. **FINAL REPORT [**2137-5-23**]** GRAM STAIN (Final [**2137-5-21**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. RESPIRATORY CULTURE (Final [**2137-5-23**]): Commensal Respiratory Flora Absent. YEAST. >100,000 ORGANISMS/ML.. Viral culture of bronchial washings: negative IMAGING: [**5-6**] Cardiac Cath: COMMENTS: 1. Selective coronary angiography of this right dominant system revealed left main and triple vessel coronary artery disease. The LMCA had a 50% ostial stenosis with partial ventricularization of the catheter pressure with engagement and a 50% distal LMCA stenosis. The mid LAD had a 50% stenosis. The LCX had 60% high rising OM1, 90% tubular mid, and 50% OM2 stenoses in addition to 95% diffuse disase in both branches of a large bifurcating OM3. The RCA had a 95% mid vessel and 40% distal stenosis. 2. Resting hemodynamics demonstrated mildly elevated biventricular filling pressures with mean PCW 16mm Hg and RVEDP 12mm Hg. Mild pulmonary hypertension with mean PA 28mm Hg. Preserved cardiac index of 2.08 L/min/m2. Mild systemic arterial hypertension with central pressure of 149/65 mm Hg. FINAL DIAGNOSIS: 1. Left main and triple vessel CAD. 2. Mildly elevated biventricular filling pressures. 3. Mild pulmarony hypertension. . [**5-7**] Carotid series: IMPRESSION: 1. 40-59% stenosis of the right internal carotid artery. 2. 60-69% stenosis of the left internal carotid artery. [**2137-5-14**] Echo: The left atrium and right atrium are normal in cavity size. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with mild hypokinesis of the basal inferior and inferolateral segments. The remaining segments contract normally (LVEF = 45-50%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD. No clinically-significant valvular disease seen. Mild pulmonary hypertension. [**2137-5-18**] CT Head non-con: IMPRESSION: No evidence of intracranial hemorrhage. [**2137-5-18**] CT torso non-con: IMPRESSION: 1. Consolidation in the posterior segment of the right upper lobe, compatible with pneumonia. Additional bibasilar atelectasis and/or consolidation and small pleural effusions. 2. Two 9-mm perifissural nodules in the right upper and right middle lobes, possibly infectious in etiology. 3. Nonspecific small lymph nodes of the mediastinum and bilateral axilla; none meet pathologic size criteria; of unclear clinical significance. A follow-up chest CT is recommended after treatment to document resolution of the above findings. 4. Calcified atherosclerotic disease of the aorta, coronary arteries, renal arteries, and splenic arteries. 5. Diverticulosis. [**2137-5-21**] RUQ U/S: CONCLUSION: No evidence of liver or biliary disease. Small right effusion noted. [**2137-5-29**] Video Swallow:Trace aspiration with thin liquids and pureed solids. DISCHARGE LABS: [**2137-5-29**]: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 12.4* 3.05* 9.7* 31.1* 102* 31.8 31.2 17.2* 330 Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos 64.7 20.7 6.5 7.5* 0.5 RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy Polychr BASIC COAGULATION PT PTT INR(PT) 13.2* 31.3 1.2* RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap 209*1 49* 1.1 145 4.1 106 29 14 ENZYMES & BILIRUBIN ALT AST LD(LDH) AlkPhos TotBili 31 39 218 102 0.3 CHEMISTRY Calcium Phos Mg 8.6 4.6* 2.2 Brief Hospital Course: 69 YOM with h/o HTN, DM, HLD, COPD, initially p/w dyspnea and NSTEMI to OSH, s/p cath at [**Hospital1 18**] showing 3V CAD, admitted to CCU while intubated for acute onset hypertension and tachycardia resulting in flash pulmonary edema. Initial plan was for [**Hospital1 **]. Course was complicated by VAP and delerium. # Respiratory status: Patient was initially transferred from the floor to the CCU secondary to respiratory distress in the setting of flash pulmonary edema/hypertention/tachycardia as well as agitation. He was intubated on the floor prior to transfer to CCU. He was diuresed with IV Lasix and responded well. He was extubated transiently but then, 2 days later, became agitated, hypertensive and had another episode of flash pulmonary edema. Given tenuous respiratory status and extreme agitation, patient was re-intubated. Barriers to extubation included ventilator associated pneumonia (see below) leading to V/Q mismatch as well as delerium/agitation. Pulmonary c/s was obtained, who recommended control of agitation and aggressive diuresis and then to attempt extubation. Once SBPs and delerium were better controlled (see below for more details), Mr. [**Known lastname 1356**] was extubated successfully. Due to concern that his episodes of flash pulm edema were due to ischemia, he was reintubated and taken to cath where stent was placed in the right coronary and the circumflex was angioplastied. LAD was not as stenosed as previously thought so no action taken there. He was successfully extubated s/p cath but he continued to have poor respiratory status and seemed to be in a pattern where any activity or agitation (even just moving from bed to chair) caused hypertension and flash pulm edema. During these episodes he was placed on Bipap and aggressive diuresis as well as nebulizer treatments were provided. He would subsequently stabilize to his baseline, though this was also poor and characterized by tachypnea and paradoxical abdominal wall movements with breathing. He had copious secretions so also did chest PT and deep suctioning. He was aggressively diuresed several liters daily and his respiratory status improved. He was satting well on 2-3L NC at the time of discharge to rehab. # Mental status/delirium: Patient significant delerium/agitation during the admission. Worsened mental status, likely secondary to his respiratory distress in addition to underlying delirium. Patient was treated with Seroquel and responded well initially. However, when attempting to d/c propafol to assess mental status, patient remained sedated despite being off medications. Patient was evaluated by neurology who said he likely needed more time for propafol to wear off. Seroquel was stopped to limit sedation. Since patient was on a heparin drip and with quite labile blood pressures, there was some concern for ICH, so head CT was obtained. CT head was neg, with small areas of ischemia or watershed ischemia can be missed on CT. Once propafol wore off, patient was awake, responsive, following commands. Oriented to self, but not place or date. He improved to the point of being conversant, making jokes, and answering questions appropriately, but was still not oriented to place or time at the time of d/c to rehab. He failed a speech and swallow evaluation so required NG tube placement for feeding. If his mental status continues to improve, he should be evaluated again by speech and swallow at rehab and NG tube discontinued as early as possible to aid in recovery of mental status. # CAD: Patient was transferred from [**Hospital 882**] hospital with NSTEMI. He was taken to the Cath lab at [**Hospital1 18**] on the evening of CCU transfer. He underwent R and L heart cath which demonstrated a mildly elevated wedge ~16, mildly elevated PAP, diffuse dis--90% mid LCX, 90% mid RCA, 50-60% os/LM, LAD diffuse disease, EF 45%, septal hypokinesis, 1+MR. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] was reccomenced and he was transferred to the floor for evaluation by CT [**Doctor First Name **]. However, in the setting of complicated hospital course, CT [**Doctor First Name **] declined operative intervention due to high mortality in patients with such poor mental status prior to intervention. Decision was made after discussion with health care proxy and patient to proceed with a high risk PCI. On [**5-23**], patient was taken to the cath lab. During the procedure, stented right coronary, angioplastied left circumflex, no action on left main (not as stenosed as previously appeared). Prior to intervention, patient was on heparin drip and was plavix loaded. [**Hospital **] medical regimen currently includes plavix, aspirin 81mg, statin, beta blocker, abd ACE-I. Also started on lasix 60mg PO qd once was adequately diuresed with goal of euvolemia. # Ventilator associated pneumonia: Patient was spiking fevers and with leukocytosis during the admission. CXR on [**5-12**] suggests progression of infiltrate. No decubitus ulcer reported, urine cx neg, C.dif neg, so ruled those out as source of infection. Patient was treated with vancomycin/cefepime for 14 days. He was also treated with flagyl given high risk and suspicion for aspiration. He remained febrile and with leukocytosis, thus infectious disease was consulted. They recommended to continue with current antibiotic regimen as well as a bronchoscopy. Pulmonary was already following and performed a bronch which showed 1+ budding yeast. However, this was thought to be colonization and thus antifungal coverage was not initiated after discussion with ID. Bglucan was weakly positive at 81 (upper limit of normal is 80), did not treat. Cryptococcal ag and urine legionella were negative. Sputum cultures did not grow out any organism. He completed a 14 day course of abx coverage for HCAP (chose 14 days due to long period of intubation and persistent fevers early in on hospital course). After completion of abx he did well and had no recurrence of fevrs and WBC count remained normal. He did continue to have a junky cough and chest PT was performed to help pt cough up secretions. Would continue chest PT at rehab. # HTN: Patient had extremely labile and difficult to control blood pressures, with SBPs rising to the 200s. He was transiently controlled on a nitro drip and then transitioned to high dose, multi drug oral regimen (doses attached) including hydralazine, carvedilol, isosorbide dinitrate, lisinopril and lasix. Blood pressures were then well controlled. # Aspiration risk: Patient failed speech and swallow and video swallow on [**5-29**] showed silent aspiration. NG tube kept in, nothing by mouth except small amount of ice chips. Will need to be re-evaluated at rehab within 2-3 days and hopefully get NG tube out. # Hypernatremia: Patient was intermittently hypernatremic throughout the admission, likely in the setting of dehydration. Gave free water flushes w/ meds through NG tube, responded well, and these were continued to maintain normal electrolyte status while on tube feeds. # [**Last Name (un) **]: Baseline 1.1. Cr increased to peak of 1.9 during the admission. This wqas likely pre-renal from aggressive diuresis during flash pulmonary edema episodes and trended down when diuresis was held. Monitored closely after dye load for cardiac cath, but Cr did not trend up. His creatinine was 1.1 at the time of discharge. # DM: HbA1C 8.7 on admission. Placed on insulin SS and lantus, adjusted as needed throught the hospitalization. Had large insulin requirement while on tube feeds. # HLD: Triglyc-112 HDL-46 CHOL/HD-2.5 LDLcalc-49. Initiated Atorvastatin 80mg. TRANSITIONS OF CARE: - Chest CT in [**4-12**] months to followup the following incidental findings which were attributed to his pneumonia 1.) Two 9-mm perifissural nodules in the right upper and right middle lobes (thought to be infectious in etiology 2.) Nonspecific small lymph nodes of the mediastinum and bilateral axilla; none meet pathologic size criteria; of unclear clinical significance but assumed to be infectious. - Cardiology follow up: [**Hospital **] medical assistant will arrange - Will need to be weighed daily, [**Name8 (MD) 138**] MD if weight increases by 3 lbs in 1 day - repeat speech and swallow eval in [**2-8**] days at rehab to see if pt can have NG tube removed Medications on Admission: Fenofibrate 160mg QD Lipitro 40mg QD Diovan/HCTZ 160/25 daily Advair 250/50 [**Hospital1 **] Metformin 850 [**Hospital1 **] Lopressor 25mg QID Lasix 40mg Qdaily Amlodipine 5mg QD Lantus 10u SC daily Discharge Medications: 1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y (650) mg PO Q6H (every 6 hours) as needed for pain/fever. 5. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheeze, dyspnea. 7. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 8. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. isosorbide dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 10. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for Rash. 11. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 14. furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 15. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous at bedtime. 16. regular insulin sliding scale FINGERSTICK Q6H: 0-70mg/dL - Proceed with hypoglycemia protocol, 71-100mg/dL - 0 Units, 101-150mg/dL - 0 Units, 151-200mg/dL - 4 Units, 201-250mg/dL - 6 Units, 251-300mg/dL - 8 Units, 301-350mg/dL - 10 Units, 351-400mg/dL - 12 Units, >400mg/dL Notify M.D. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Non ST-elevation myocardial infarction Hypertension Diabetes Dyslipidemia Discharge Condition: mental status: occasionally coherent level of consciousness: alert and interactive at most times activity status: out of bed with assistance Discharge Instructions: Dear Mr. [**Known lastname 1356**], It was a privilege to provide care for you here at the [**Hospital1 **] Hospital. You were admitted because you were short of breath, and were found to have a pneumonia and a heart attack. You received a coronary cath procedure, which found that you have narrowings in some of the blood vessels on your heart. You had a stent placed in one area and a balloon used to prop open a second area. You were intubated temporarily to help you breathe, and then successfully extubated. Your medications were optimized and you were discharged to rehab. While you were here you had delirium, but this improved after you were extubated and your medications adjusted. Multiple changes were made to your medications. Please see the attached list for your new medication regimen. You do not need to take any other medications in addition to this unless your doctor tells you. Followup Instructions: Cardiology follow up in [**4-12**] weeks. Attending will arrange and pt will be notified.

[ "V45.82", "276.0", "780.09", "V15.82", "416.8", "412", "250.00", "V17.49", "V58.83", "272.4", "799.02", "V58.67", "410.71", "433.30", "518.4", "518.81", "V64.1", "496", "458.29", "112.4", "401.9", "414.01", "599.0", "433.10", "785.0", "307.9", "997.31", "584.9" ]

icd9cm

[ [ [] ] ]

[ "93.90", "36.07", "37.23", "00.45", "96.6", "33.24", "38.93", "00.41", "88.56", "38.91", "96.04", "00.66", "96.71", "96.72" ]

icd9pcs

[ [ [] ] ]

21220, 21286

11047, 18713

332, 374

21404, 21404

5025, 5025

22493, 22586

3581, 3660

19657, 21197

21307, 21383

19434, 19634

8404, 10504

21570, 22470

10520, 11024

3675, 3685

3238, 3358

4383, 5006

19167, 19408

3707, 4367

265, 294

402, 3134

5041, 8387

21419, 21546

18734, 19156

3389, 3395

3156, 3218

3411, 3565

76,420

160,159

35708

Discharge summary

report

Admission Date: [**2102-12-24**] Discharge Date: [**2103-1-12**] Date of Birth: [**2043-5-10**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: emergency salvage replacement ascending aorta/resusp. aortic valve [**2102-12-24**] tracheostomy and PEG placement [**2103-1-8**] History of Present Illness: 59 yo male admitted to ER at Addison-[**Doctor Last Name **] for chest and back pain.CT scan there showed acute aortic dissection from ascending to left common iliac. Transferred by [**Location (un) **] to [**Hospital1 18**] ED where he subsequently suffered cardiac arrest. CPR started and taken emergently to OR. Past Medical History: benign prostatic hypertrophy Social History: lives with wife Family History: unknown Physical Exam: CPR being performed in ER; no assessment done est. 95 kg 185 cm Pertinent Results: Conclusions PRE-BYPASS: A very limited Transgastric imaging showed a massive pericardial effusion and a dissection extending all the way in the thoracic aorta. Patient was having CPR done at that time. POST-BYPASS: The patient is AV paced and on an infusion of epinephrine and norepinephrine. Mild to moderate global RV hypokinesis. Trivial MR [**First Name (Titles) **] [**Last Name (Titles) **]. Aortic valve leaflets appear normal. LV funtion intact, EF 45%. The aortic dissection is again visualized in the arch and descending aorta, with flow into the true lumen. No pericardial effusion. Post bypass examination of all the valves and regional wall motions did not reveal any abnormalities. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2102-12-26**] 15 FINDINGS: MRI: The previously identified diffusion abnormalities in the left frontal and parietal lobes are less apparent on the current study indicating evolution of the previously seen infarcts. There is no evidence of acute hemorrhage or major vascular territory infarction, mass, or mass effect. The ventricles and sulci are normal in size and configuration. Inspissated material is again seen in the left maxillary sinus as well as mucosal thickening in the sphenoid sinus and fluid opacification of the bilateral mastoid air cells. MRA: The major intracranial arteries of the anterior and posterior circulation are patent without flow-limiting stenosis, occlusion, or aneurysm greater than 2 mm within the resolution of MR angiogram. IMPRESSION: 1. Expected evolution of left frontal and parietal subcortical infarcts. No evidence of acute hemorrhage or major vascular territory infarction. 2. Patent major intracranial arteries without flow-limiting stenosis, significant mural irregularity, or aneurysm greater than 2 mm. 3. Persistent fluid and/or mucosal thickening in the paranasal sinuses and mastoid air cells. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**] Approved: FRI [**2103-1-5**] 8:48 AM Imaging Lab [**2103-1-11**] 07:40AM BLOOD WBC-12.3* RBC-2.95* Hgb-8.7* Hct-26.3* MCV-89 MCH-29.5 MCHC-33.2 RDW-14.9 Plt Ct-512* [**2102-12-24**] 03:40PM BLOOD WBC-14.0* RBC-4.44* Hgb-13.4* Hct-37.1* MCV-84 MCH-30.1 MCHC-36.1* RDW-13.7 Plt Ct-220 [**2103-1-9**] 03:24AM BLOOD PT-14.1* PTT-25.9 INR(PT)-1.2* [**2102-12-24**] 03:40PM BLOOD PT-13.6* PTT-26.6 INR(PT)-1.2* [**2103-1-11**] 07:40AM BLOOD Glucose-115* UreaN-37* Creat-0.8 Na-147* K-4.5 Cl-105 HCO3-32 AnGap-15 [**2102-12-24**] 03:40PM BLOOD Glucose-145* UreaN-23* Creat-1.1 Na-141 K-4.1 Cl-108 HCO3-24 AnGap-13 [**2103-1-9**] 03:24AM BLOOD ALT-248* AST-122* LD(LDH)-361* AlkPhos-433* Amylase-58 TotBili-0.5 [**Known lastname **],[**Known firstname **] [**Medical Record Number 81233**] M 59 [**2043-5-10**] Radiology Report CHEST (PORTABLE AP) Study Date of [**2103-1-11**] 10:55 AM [**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2103-1-11**] 10:55 AM CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 81234**] Reason: eval for pleural effusions [**Hospital 93**] MEDICAL CONDITION: 59 year old man s/p type A dissection repair REASON FOR THIS EXAMINATION: eval for pleural effusions Final Report INDICATION: Status post dissection repair. FINDINGS: There are small bilateral pleural effusions, left greater than right with small atelectasis, roughly unchanged from the prior. The cardiomediastinal contours, notable for cardiomegaly are stable. A tracheostomy tube terminates 5.1 cm above the carina. There is mild pulmonary vasculature engorgement, but no acute pulmonary edema. IMPRESSION: Stable small bilateral pleural effusions. The study and the report were reviewed by the staff radiologist. DR. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 16277**] DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16278**]Approved: [**Doctor First Name **] [**2103-1-11**] 3:22 PM Imaging Lab [**Known lastname **],[**Known firstname **] [**Medical Record Number 81233**] M 59 [**2043-5-10**] Radiology Report MR HEAD W/O CONTRAST Study Date of [**2103-1-4**] 11:56 AM [**Last Name (LF) **],[**First Name3 (LF) **] CSURG CSRU [**2103-1-4**] 11:56 AM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # [**Clip Number (Radiology) 81235**] Reason: r/o new CVA [**Hospital 93**] MEDICAL CONDITION: 59 year old man with REASON FOR THIS EXAMINATION: r/o new CVA CONTRAINDICATIONS FOR IV CONTRAST: None. Provisional Findings Impression: [**First Name9 (NamePattern2) **] [**Doctor First Name **] [**2103-1-4**] 7:01 PM Interval decrease in diffusion-weighted signal intensity in the left frontal and parietal subcortical white matter consistent with expected evolution of small infarcts. Unremarkable MRA. Final Report INDICATION: 59-year-old male with status post aortic dissection repair, cardiopulmonary arrest, assess for anoxic injury or CVA. TECHNIQUE: Sagittal T1 images were obtained. Axial T2, gradient-echo, FLAIR, and diffusion technique was performed. Three-dimensional time-of-flight MR arteriography was performed and reformats were displayed. COMPARISON: [**2102-12-26**]. FINDINGS: MRI: The previously identified diffusion abnormalities in the left frontal and parietal lobes are less apparent on the current study indicating evolution of the previously seen infarcts. There is no evidence of acute hemorrhage or major vascular territory infarction, mass, or mass effect. The ventricles and sulci are normal in size and configuration. Inspissated material is again seen in the left maxillary sinus as well as mucosal thickening in the sphenoid sinus and fluid opacification of the bilateral mastoid air cells. MRA: The major intracranial arteries of the anterior and posterior circulation are patent without flow-limiting stenosis, occlusion, or aneurysm greater than 2 mm within the resolution of MR angiogram. IMPRESSION: 1. Expected evolution of left frontal and parietal subcortical infarcts. No evidence of acute hemorrhage or major vascular territory infarction. 2. Patent major intracranial arteries without flow-limiting stenosis, significant mural irregularity, or aneurysm greater than 2 mm. 3. Persistent fluid and/or mucosal thickening in the paranasal sinuses and mastoid air cells. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**] Approved: FRI [**2103-1-5**] 8:48 AM Imaging Lab Brief Hospital Course: Admitted via the ED [**12-24**], Medflighted in from outside hospital, and had a cardiac arrest while being admitted. CPR begun immediately and Mr.[**Known lastname 6330**] was transferred emergently to OR. There he underwent emergency salvage operation for ruptured ascending aorta with a Replacement # 24mm Gelweave Graft (8mm sidearm)with Dr. [**Name (NI) **]. Cross clamp time: 94minutes,Cardiopulmonary bypass time:134minutes. Please refer to Dr[**Doctor Last Name 14333**] operative report for further details. Mr.[**Known lastname 6330**] was transferred to the CVICU in critical condition on levophed, epinephrine, insulin and propofol drips. Sedation was weaned to off 12 hours later with minimal response neurologically. Neurology was consulted and continued to follow him closely. Over the course of the next 2 weeks, there was no significant neurologic recovery. Two brain scans were done during his hospital admission with the last showing expected evolution of left frontal and parietal subcortical infarcts. A family meeting was held [**1-5**] with the intensivist, the neurologist and the surgeon all in attendance. Decision was made by the family to proceed with trach/PEG to allow him further time for possible neurologic recovery, despite poor prognosis. POD#15 Trach (#8Portex)/PEG placement done ([**1-8**]) by the thoracic team. Per thoracic, tubefeedings were cleared to start the following day. Mr.[**Known lastname 6330**] [**Last Name (Titles) 81236**] to trach collar. [**1-10**] He was transferred to the stepdown unit for further monitoring and continued physical therapy consultation and medical care. Of note: There have many lengthy discussions with patient's wife and daughter regarding patient's quality of life and chance for meaningful recovery post cardiac surgery. They wish to give him some period of time yet to be determined for him to recover but if and when the time comes that he does not appear to be able to make a meaningful recovery, they wish to be able to make decisions regarding cessation of care. They will need ongoing support and counseling regarding this process. The remainder of his postoperative course was uneventful. Mr [**Known lastname 6330**] remained unresponsive, moving extremities spontaneously-without purpose and grimaces to deep pain stimulus. On POD# 19/4, Mr.[**Known lastname 6330**] was ready to be discharged to a neurologic rehab for further care and possible neurologic recovery. All follow up appointments have been advised. Medications on Admission: finasteride 5 mg daily Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO DAILY (Daily). 3. Ascorbic Acid 90 mg/mL Drops Sig: Five (5) PO DAILY (Daily). 4. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig: One (1) PO DAILY (Daily). 5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID (3 times a day). 6. Ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) PO DAILY (Daily). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily). 11. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2 times a day). 12. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 13. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1) Subcutaneous every six (6) hours: per sliding scale. 14. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 15. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 16. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 17. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**] Discharge Diagnosis: ruptured ascending aortic aneurysm cardiac arrest benign prostatic hypertrophy Discharge Condition: stable Discharge Instructions: no lotions, creams or powders on any incisions bathe daily and pat incisions dry call for fever greater than 100.5, redness,new drainage, weight gain of 5 pounds in one week Followup Instructions: -Dr.[**Last Name (STitle) **] (Cardiac surgery) #[**Telephone/Fax (1) **]-Please call for follow up appointment -Dr.[**First Name (STitle) **] (Thoracic surgery) #[**Telephone/Fax (1) **] for follow up in 2 weeks. -Dr.[**Last Name (STitle) **] (Neurology) #[**Telephone/Fax (1) **] for follow up in 4 weeks- if sooner if the family would like Neurology input for long term prognosis [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2103-1-12**]

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icd9cm

[ [ [] ] ]

[ "38.45", "39.61", "96.05", "34.04", "96.72", "33.24", "31.1", "43.11", "35.11", "39.64", "96.6" ]

icd9pcs

[ [ [] ] ]

11998, 12098

7965, 10475

332, 464

12221, 12230

1020, 4404

12453, 12958

911, 920

10548, 11975

5716, 5737

12119, 12200

10501, 10525

12254, 12430

935, 1001

282, 294

5769, 7942

492, 809

831, 861

877, 895

30,038

106,026

43029

Discharge summary

report

Admission Date: [**2193-11-24**] Discharge Date: [**2193-12-3**] Date of Birth: [**2143-4-3**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1990**] Chief Complaint: N/V, fever Major Surgical or Invasive Procedure: right subclavian line History of Present Illness: Pt is 50 yo f with no significant PMH, who had the acute onset of N/V 2 days prior to admission. 2 days PTA, pt had dinner which included cooked ground beef and "moldy cheddar cheese". 4 hours later, the pt had "indigestion", took Tums, and then had the onset of N/V with vague abdominal discomfort. She had several additional episodes of non-bloody emesis over the next 48 hours. Yesterday, the pt also noted a diffuse, erythematous rash on her chest, back, arms, and legs (she is unsure where the rash started). She felt feverish and chilled, and reportedly had a temp of 99. She continued to have episodic N/V, called her PCP and was told to come to the ED. Denies any diarrhea, hematemesis, hematochezia, or dysuria. She has had decreased PO over the past 2 days. No recent travel. No new medications or herbal supplements. No sick contacts. [**Name (NI) **] ingestion of raw meat or seafood. Of note, pt's menstrual period started 3 days ago and she has been using tampons (currently has a tampon in place for last 12 hours). . In the [**Name (NI) **], pt had temp up to 104.2, BP down to 85/47, and HR up to 119. She was given 7 L IVF, a R SC central line was placed, and she was started on levophed. Her BP then improved to 112/61, and CVP was measured at 12. Her O2 sat also dropped to 81% on RA, and improved to 100% on 100% NRB. She was given zosyn, flagyl, tylenol, and zofran. She had an abdominal CT scan, which was negative. . Pt currently c/o mild, vague abdominal discomfort and mild SOB with cough (cough started in ED). Denies CP. Has a very mild headache, but no neck stiffness or photophobia. Past Medical History: h/o neck pain, buttock pain, and low back pain s/p MVC '[**86**] - s/p C-sectoin - s/p tonsillectomy Social History: Lives at home with female partner and 12 [**Name2 (NI) **] daughter. [**Name (NI) 1403**] as a social worker. Denies tobacco or drugs. Occasinoal EtOH. Family History: Mother with Parkinsons. Father with heart disease. Physical Exam: Vitals: T 103.5 BP 103/52 HR 113 RR 20 O2 100% on 100% NRB Gen: tired appearing, flushed, but able to speak in complete sentences HEENT: PERRL. MM dry. No OP lesions. Neck: Supple, full neck ROM. Non-tender. Cardio: regular, tachy, no m/r/g Resp: decreased BS bilaterally [**1-4**] poor insp effort Abd: soft, mildly distended, mild generalized tenderness, no rebound or guarding. + BS. Ext: no c/c/e Neuro: A&Ox3. Skin: diffuse erythroderma/flushing of abdomen, back, buttocks, neck. No petechiae. No rash on palms or soles. Rectal: guaiac negative brown stool Pertinent Results: [**2193-11-24**] 04:23AM WBC-3.9*# RBC-4.31 HGB-13.7 HCT-39.3 MCV-91 MCH-31.8 MCHC-34.9 RDW-13.8 [**2193-11-24**] 04:23AM NEUTS-80* BANDS-18* LYMPHS-2* MONOS-0 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2193-11-24**] 04:23AM PLT COUNT-237 [**2193-11-24**] 04:23AM PT-12.5 PTT-23.6 INR(PT)-1.1 [**2193-11-24**] 04:23AM ALT(SGPT)-21 AST(SGOT)-31 LD(LDH)-174 ALK PHOS-52 AMYLASE-50 TOT BILI-0.6 [**2193-11-24**] 04:23AM GLUCOSE-117* UREA N-16 CREAT-1.2* SODIUM-139 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-25 ANION GAP-14 [**2193-11-24**] 05:35AM LACTATE-1.9 [**2193-11-24**] 10:09AM WBC-12.8*# RBC-3.33* HGB-10.6*# HCT-30.6* MCV-92 MCH-31.9 MCHC-34.6 RDW-13.6 [**2193-11-24**] 10:09AM NEUTS-85* BANDS-10* LYMPHS-1* MONOS-2 EOS-2 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2193-11-24**] 10:09AM ALBUMIN-2.6* CALCIUM-6.2* PHOSPHATE-1.0* MAGNESIUM-1.3* [**2193-11-24**] 05:54PM WBC-18.2* RBC-3.36* HGB-10.5* HCT-30.8* MCV-92 MCH-31.2 MCHC-34.0 RDW-13.2 [**2193-11-24**] 05:54PM NEUTS-55 BANDS-39* LYMPHS-1* MONOS-2 EOS-1 BASOS-0 ATYPS-0 METAS-2* MYELOS-0 Brief Hospital Course: Note - this hospital course reflects the course as reflected in the chart and here summarized by Dr. [**Last Name (STitle) **] from [**Location (un) 1131**] through the medical record. I (Dr. [**Last Name (STitle) **] was the attending of record only from [**12-1**] through [**2192-12-3**]. . 50 yo generally healthy female, p/w N/V, fever, hypotension, erythroderma and sepsis on admission requiring pressor support and agressive hydration on presentation with ICU admission. . Sepsis: felt to be due to toxic shock associated with tampon use. Cervical cx. showed MSSA, all other cultures were negative. Pt. recieved Vancomycin, clindamycin, and zosyn initially. She improved hemodynamically and abx were tapered to clindamycin po and she was transferred to the medical [**Hospital1 **], at which time wbc again rose with eosinophilia, this was changed to cefalexin for one day. As WBC continued to rise, all abx were stopped. At this time a morbilliform drug erruption was noted truncally, and eosinophilia persisted. These began to resolve by d/c with discontinuation of all abx. At time of d/c, pt. had been afebrile for over 72 hours, all surveillance cx were negative, and she was feeling well. Her ICU course was complicated by mild acute renal failure that improved with fluids, as well as mild pulmonary edema, attributed to massive IV fluid resuscutation on presentation, which resolved over time with auto diuresis. Medications on Admission: Tums only. Discharge Medications: Benadryl prn for itching. Discharge Disposition: Home Discharge Diagnosis: Toxic shock syndrome with septic shock requiring vasopressors and aggressive IV volume repletion resuting in pulmonary edema . Beta lactam allergy (likely) with drug eruption (rash) Discharge Condition: Stable, mild, resolving, morbilliform drug rash, afebrile for 72 hours, all surveillance cx. negative, independently ambulating, voiding, and tolerating po nutrition and fluids. Discharge Instructions: No new medications were prescribed. You can resume TUMS as you were prior to coming to the hospital, and you can use over the counter benadryl for itching as needed, as we discussed. Return to the [**Hospital1 18**] Emergency Department for: Fevers Worsening Rash Abdominal pain, malaise Followup Instructions: With your primary doctor within two weeks. Call for appointment: [**Last Name (LF) **],[**First Name3 (LF) **] S. [**Telephone/Fax (1) 3393**]

[ "275.41", "584.9", "693.0", "E915", "785.52", "038.9", "939.2", "995.92", "276.8", "040.82", "E930.8", "276.6", "041.11" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

5588, 5594

4039, 5477

326, 349

5820, 6000

2953, 4016

6339, 6486

2303, 2355

5538, 5565

5615, 5799

5503, 5515

6024, 6316

2370, 2934

276, 288

377, 1992

2015, 2118

2134, 2287

68,676

123,854

38035

Discharge summary

report

Admission Date: [**2180-8-17**] Discharge Date: [**2180-8-26**] Date of Birth: [**2120-4-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor First Name 2080**] Chief Complaint: CC:[**CC Contact Info **] Major Surgical or Invasive Procedure: IVC filter placement History of Present Illness: This is a 60 year old man with lung cancer with brain metastases previously on anticoagulation for [**Hospital **] transferred to the MICU from the SICU in the setting of arrythmias, most prominently tachyarrythmias, who originally presented to medical care on [**8-17**] late morning after being found by his family, lying down on the sidewalk outside of his home, minimally responsive. He awoke at the scene complaining of headache and left shoulder pain. He was taken to [**Hospital 6136**] Hospital; and then taken by [**Location (un) **] to [**Hospital1 18**] after a CT showed extensive acute ICH. An EKG there showed sinus rhythm, with an S in I and a Q in III, with prominent upright T waves in precordial leads and no indication of ischemia. He reportedly started the flight being AOx3 and following commands and then deteriorated into lethargy and minimal responsiveness. He was intubated for airway protection. Of note, his INR was 3.7 on arrival to [**Hospital1 18**] consistent with coumadin taken regularly at home for known PE in [**2179-12-30**]. He received 2 units of FFP and vitamin K. . At [**Hospital1 18**] he was admitted to the SICU on the neurosurgical service. Ultimately, neurosurgery decided to observe the patient, start seizure prophylaxis, normalize INR (with a recommendation to avoid anticoagulation for one month) with no indication for neurosurgical intervention. He was diagnosed with a left humeral fracture for which orthopedics recommended splint. He was extubated on [**8-19**]. An IVC filter was placed on [**8-21**]. . Of note in terms of his functional status prior to the event, he had not had recent falls prior to this. However, prior to his diagnosis with brain mets, he had a persistent cough and had some prior episodes, unwitnessed by family and only uncovered in retrospect, in which he coughed violently and then fell down, perhaps similar to this presentation. He was until this admission able to perform basic ADLs, ambulating, toileting, eating, etc; though with low energy and slow mobility. Past Medical History: Stage IV lung cancer with brain metastases diagnosed [**9-5**] after episode of seizures, s/p R craniectomy [**9-5**] for tumor resection, s/p chemo/radiation; oncologist [**First Name8 (NamePattern2) 1528**] [**Last Name (NamePattern1) **] ([**Hospital1 6136**]), rad onc [**Location (un) **] ([**First Name8 (NamePattern2) **] [**Doctor First Name **]); per daughter, little effect of chemo/rads, oncologist said emphasis should be on quality of life at this point PE diagnosed in [**1-7**] (on coumadin), diagnosed by routine CT scan, was evidently asymptomatic at that time Hyperlipidemia NIDDM GERD Bipolar disorder diagnosed in [**2174**] after a psych hospitalization for mania, has been on several meds; stopped meds and was rehospitalized; since then has been on seroquel alone Seizure disorder secondary to brain mets only . Social History: Ran an auto detailing and used car sales business until his cancer diagnosis; was on disability thereafter. Two adult children who live ~half hour away from his home. Lives with wife. Portuguese-speaking only. 60 pack year cigarette history. No EtOH or drugs by report. Family History: non-contributory Physical Exam: PHYSICAL EXAM on admission: O: T:97.0 BP:129/6/ HR:102 RR:16 O2Sats 96% Gen: WD/WN, comfortable, NAD. HEENT:normocephalic, small superficial abrasion to left head. Pupils:PERRLA EOMs: UTA due to inattention/lethargy Neuro:Mental status: Lethargic, arousable to loud voice. No commands. Face appears to be symmetric. Spont mvmt observed in the RUE. Brisk w/drawl of LE(R>L). minimal mvmt of LUE observed, though also withdraws to nox. 5/5 strength throughout. [**12-31**]+ reflexes, equal BL. Normal coordination. Gait assessment deferred Discharge: O: T:97 BP:132/60 HR:84 RR:18 O2Sats 97%RA HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or gallops. LUNGS: high whistle-like wheeze heard throughout bilat lung fields ABDOMEN: NABS. Soft, NT, ND. EXTREMITIES: No edema or calf pain or cords, 2+ dorsalis pedis/posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. No ulcers. NEURO: Awake with eyes open, follows simple commands. A&O to name, [**Hospital 86**] hospital, [**Last Name (un) 2753**] president. Responds appropriately to questions (eg "how are you today?" "I'm OK." PERRL, EOMI, face symmetric. Able to squeeze hand with L and R hand, decreased strength on L. Unable to assess left arm due to orthopedic injury and L arm in sling. Moves RUE and RLE spontaneously. No spontaneous movement of LLE but withdraws from pain. Lines: bilateral SCDs, R PIV without erythema, cords, purulence, TTP. Pertinent Results: LEFT SHOULDER, THREE VIEWS [**2180-8-17**]: There is a fracture involving the proximal shaft of the left femur. There is displacement by approximately one shaft width with apex lateral angulation of the fracture site. CT OSH(1227 [**8-17**]): "extensive acute ICH identified which all appears to be extra-xial and is most prominent superficial to the anterior left frontal lobe, but there is less extensive acute ICH along the right anterolateral aspect of the suprasellar cistern, right side of the anterior cranial fossa, left ambient cistern, along the adjacent left tentorium cerebelli, and along the sulcus posterior right frontal lobe". CT/CTA([**Hospital1 18**]): Left frontal subarachnoid hemorrhage and subdural blood measuring up to 6mm and layering along the falx. No signficant mass effect. No intraventricular hemorrhage. 5 x 9 mm focus of hemorrhage in the right parietal lobe. No e/o aneurysm or vascular abnl. CTA: 1. Left frontal subarachnoid hemorrhage and subdural hematoma without evidence of significant mass effect. 2. Small focus of subarachnoid hemorrhage or intraparenchymal hemorrhage in the right parietal lobe. 3. Small amount of intraventricular hemorrhage in the left perimesencephalic cistern. 4. Unremarkable CTA of the head. Repeat CTA [**2180-8-19**]: IMPRESSION: 1. Previously noted left frontal hypodensity and subarachnoid hemorrhages as well as intraventricular hemorrhage are again seen. 2. Mild vasospasm is identified more predominantly in the left middle cerebral artery and the main divisions of middle cerebral artery. No vascular occlusion is seen. Echo ([**2180-8-25**]): Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 40-50 %) secondary to inferior posterior hypokinesis Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Video Oropharyngeal Swallow ([**2180-8-25**]): No gross aspiration or penetration. Labs: [**2180-8-17**] 05:51PM GLUCOSE-176* UREA N-10 CREAT-0.7 SODIUM-143 POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-29 ANION GAP-15 [**2180-8-17**] 05:51PM CALCIUM-9.3 PHOSPHATE-3.4 MAGNESIUM-1.9 [**2180-8-17**] 05:51PM WBC-9.7 RBC-3.67* HGB-9.4* HCT-30.7* MCV-84 MCH-25.7* MCHC-30.6* RDW-14.8 [**2180-8-17**] 05:51PM PLT COUNT-252 [**2180-8-17**] 05:51PM PT-16.5* PTT-20.4* INR(PT)-1.5* Brief Hospital Course: 60 year old Portugese speaking gentleman found down and taken to outside hospital where CT scan revealed left frontal tentorial cistern acute subarachnoid and subdural hemorrhage. He was transported by [**Location (un) **] to [**Hospital1 18**] when his mental status deteriorated in flight. He was intubated for a GCS of 7 at arrival and recieved profiline and FFP in ED. He also sustained a left humeral fracture that was splinted by ortho trauma. On [**8-18**] he was found to have a left lower lobe mass. He remained intubated becuase he did not tolerate CPAP. On [**8-19**], the patient was extubated and placed on nimodipine for subarachnoid hemorrhage. On physical exam, patient was awake, following commands, giving thumbs up and moving R>L. Pupils were equal and reactive. On [**8-20**], cardiology was consulted for arrthymias seen on telemetry and nimoedipine was discontinued, as no vasospasm was seen on CTA. On [**8-21**], a repeat head CT scan showed a stable intra-cranial bleed. Patient did not sustain any further injuries to the body per trauma. Family meeting was conducted to discuss goals of care and patient was made DNR/DNI. Patient was transferred out of the ICU to the medicine floor to coordinate recommendations of consult services and to initiate discharge planning. 1. Intracranial hemorrhage: The patient's intracranial bleed was stable on head CTs on [**8-21**] and [**8-23**]. Patient's mental status improved over the course of the admission, becoming more interactive, A&Ox2, able to state his address and birthday, following commands and moving all four extremities to command. It's still unclear why the patient fell initially--the differential includes seizure, arrythmia, hypoxia secondary to cigarette smoking/lung CA. The patient had cardiac enzymes negative x3. He had an echo with above results. Neurosurgery followed the patient while admitted, with recommendations to hold the patient's Coumadin for (at least) 1 month as well as to continue seizure prophylaxis with Keppra 1000 mg [**Hospital1 **]. Neurology and neurosurgery both felt the patient's prognosis was somewhat guarded, but may improve in time. As his coumadin had to be discontinued, the patient had an IVC filter placed while admitted. . 2. Arrhthymias: The patient had several episodes of atrial tachycardia while on telemetry, as well as one episode of bradycardia. This was likely atrial fibrillation secondary to the stress of acute event. Cardiology was consulted and recommended a low-dose beta blocker for rate control (metoprolol 12.5mg three times daily). TSH was normal. The patient remained hemodynamically stable throughout his admission, with normal blood pressure. Cardiology was also concerned that additional anti-arrythmic intervention would increase his risk for bradycardia, of which the patient had only one concerning episode but which would ultimately likely be more problem[**Name (NI) 115**] than his well-perfusing tachycardia. If the patient decompensates in the future, a pacemaker could be considered as a palliative measure if life expectancy sufficient. . 3. Lung cancer: Per report of family, the patient and his oncologist had decided to emphasize on quality of life for the last few months given failure to respond to chemo/rads. The patient had a chest CT, showing 8 cm mass of the left lower lobe growing into the left main stem bronchus and associated with complete collapse of the left lower lobe. This mass may contribute to future respiratory compromise via obstruction or subsequent pneumonia--however, the patient remained stable from a respiratory stand-point throughout his hospitalization, with 02 saturations >95% on room air and without respiratory distress. In the future, if the patient develops respiratory distress, intervention on the bronchial mass could be considered by interventional pulmonology with stenting or phototherapy. These procedures would require intubation with bronchoscopy. The patient with follow up with IP as an out-patient. . 4. Fever: the patient became febrile on the floor, spiking fevers of up to 101.3 (PO) on multiple occasions. Although he had no obvious source, with a negative UA and indeterminate CXR showing extensive left lung collapse and effusion, the patient was begun on coverage for ventilator associated pneumonia with IV Cefepime, Vanc, and Flagyl, given his increased risk from recent intubation. He will continue this regimen at rehab. Blood and urine cultures were pending at discharge. The patient had been afebrile for 24 hours at discharge after 3 days of antibiotics. . 5. Diabetes: While in the hospital, the patient had elevate CBGs into the 300s. He was started on a PM dose of Lantus (14 units) prior to discharge. His blood sugar control can be further titrated at rehab. However, intensive glucose control may create sharp swings in glucose, could precipitate arrythmias so aggressive glucose control should be avoided. . 6. Hypertension: The patient's systolic blood pressure should be kept <180 per neurosurgery recommedation. This was achieved with Metoprolol 12.5mg TID, with the patient's blood pressure ranging from 114-132/60-80 on day of discharge. . 7. Left humerus fracture: The patient is being discharged with his arm in a sling after splinting by ortho. He will need to follow up with ortho as an outpatient. . 8. Nutrition: The patient was evaluated by the speech and swallow with the recommendation to feed the patient thin liquids/soft solids with 1:1 supervision. He had a video swallow which showed no aspiration. Medications on Admission: Medications prior to admission: 1. Omeprazole 20mg 2. Tramadol 50mg [**12-31**] q 6h 3. Simvastatin 20mg daily 4. Seroquel 100mg HS 5. Glipizide ER 10mg daily 6. Coumadin 4mg daily 7. Keppra 500mg [**Hospital1 **] 8. IBU 800mg Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Nystatin 100,000 unit/mL Suspension [**Hospital1 **]: Five (5) ML PO QID (4 times a day) as needed for thrush. Disp:*1 bottle* Refills:*0* 3. Levetiracetam 500 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*0* 4. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO TID (3 times a day). Disp:*45 Tablet(s)* Refills:*0* 5. Simvastatin 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 6. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Two (2) doses PO BID (2 times a day). Disp:*120 doses* Refills:*0* 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*0* 8. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: [**5-7**] mL PO Q6H (every 6 hours) as needed for pain/fever. Disp:*1 bottle* Refills:*0* 9. Ipratropium Bromide 0.02 % Solution [**Month/Year (2) **]: One (1) neb Inhalation Q6H (every 6 hours) as needed for dyspnea. 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Month/Year (2) **]: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing. 11. Insulin Regular Human 100 unit/mL Solution [**Month/Year (2) **]: asdir unit Injection four times a day: See attached insulin sliding scale. 12. Insulin Glargine 100 unit/mL Solution [**Month/Year (2) **]: Fourteen (14) units Subcutaneous qa breakfast: See attached sliding scale. 13. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback [**Month/Year (2) **]: One (1) Intravenous Q8H (every 8 hours) for 5 days. Disp:*qs * Refills:*0* 14. Cefepime 2 gram Recon Soln [**Month/Year (2) **]: One (1) dose Intravenous twice a day for 5 days. Disp:*qs * Refills:*0* 15. Vancomycin in Dextrose 1 gram/250 mL Solution [**Month/Year (2) **]: One (1) dose Intravenous twice a day for 5 days. Disp:*10 dose* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital 5503**] Rehab Hospital Discharge Diagnosis: Primary: 1. intra-cranial hemorrhage 2. heart arrhythmias 3. left humerus fracture 4. Ventilator associated pneumonia Secondary: 1. stage 4 lung cancer with brain metastasis 2. pulmonary embolism s/p IVC filter placement 3. Diabetes, type 2 4. HTN Discharge Condition: stable. Discharge Instructions: General Instructions ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel) prior to your injury, you may safely resume taking this on XXXXXXXXXXX. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. If you haven been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. 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. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) 739**], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment.

[ "518.0", "198.3", "V12.51", "162.5", "997.31", "933.1", "272.4", "511.9", "296.80", "530.81", "250.00", "V58.61", "427.31", "852.02", "E915", "812.00", "345.90", "E885.9" ]

icd9cm

[ [ [] ] ]

[ "38.7", "96.04", "96.6", "88.51", "96.71", "33.24" ]

icd9pcs

[ [ [] ] ]

16055, 16116

8008, 13565

341, 364

16408, 16418

5242, 7985

17943, 18279

3604, 3622

13842, 16032

16137, 16387

13591, 13591

16442, 17920

3637, 3651

13623, 13819

277, 303

392, 2442

3665, 3865

3880, 5223

2464, 3301

3317, 3588

3,227

121,731

49394

Discharge summary

report

Admission Date: [**2111-8-19**] Discharge Date: [**2111-8-20**] Date of Birth: [**2033-8-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3326**] Chief Complaint: alcohol intoxication Major Surgical or Invasive Procedure: None. History of Present Illness: 77 year-old male with history alcoholism presents with alcohol intoxication and anion gap acidosis. Pt states that he underwent alcohol binge - 1 pint of whiskey, 1 6-pack of beer. Usually does this about every 3 months, denies particular increase in stress or precipitant. Does not recall calling ambulance. States that he lives alone since he was widowed and becomes visibly upset at mention of this. Last drink about 5PM the evening of admission. Feels sober at this point. Denies other ingestions. Denies shortness of breath over his baseline secondary to COPD, chest pain, nausea, vomiting, dysuria, abdominal pain, loss of consciousness, falling. Denies particularly poor po intake over last few days. Denies suicidal ideation, homicidal ideation, or auditory/visual hallucinations. Denies history of alcohol withdrawal seizures. Past Medical History: 1. alcoholism 2. depression, with h/o suicidal ideation 3. hypertension 4. lower back pain 5. peripheral vascular disease s/p bifem-[**Doctor Last Name **] bypass 6. hyperlipidemia 7. chronic obstructive pulmonary disease 8. h/o acute retinal necrosis of R eye 9. h/o syphilis Social History: Retired factory worker; used to work as presser of garments x35 years. First-generation American. Widowed, lives alone; 3 sons live close by. tob: 1 ppd x 50years, decreased to 1/2ppd, quit [**2108**]. EtOH: h/o binge drinking. Denies IVDU. Family History: noncontributory Physical Exam: Tm 99.4 148/64 104 18 98% RA Gen: NAD, appears somewhat jumpy with strange affect HEENT: R eye milky, MM somewhat dry, OP clear CV: RRR, nl S1/S2, no murmurs, heart sounds difficult to hear secondary to breathing Pulm: decreased breath sounds diffusely, no crackles or wheezes Abd: soft, nontender, mildly distended, +BS, no masses Ext: no edema, 2+ distal pulses Pertinent Results: Admission labs: CBC: 08:20PM WBC-13.8*# RBC-5.07 HGB-14.9 HCT-44.8 MCV-88 MCH-29.4 MCHC-33.3 RDW-14.6 NEUTS-75.7* LYMPHS-21.2 MONOS-2.4 EOS-0.5 BASOS-0.2 PLT COUNT-327 electrolytes: 08:20 PM GLUCOSE-93 UREA N-14 CREAT-1.1 SODIUM-141 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-14* ANION GAP-27* 08:20PM OSMOLAL-362* 12:35AM GLUCOSE-73 UREA N-16 CREAT-1.1 SODIUM-144 POTASSIUM-4.7 CHLORIDE-106 TOTAL CO2-15* ANION GAP-28* tox screens: serum: ASA-NEG ETHANOL-288* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG urine: bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG UA: BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0-2 lactate: 10:08PM LACTATE-7.3* 12:44AM LACTATE-7.2* EKG: 101 bpm, sinus tachycardia, nl axis and intervals, no ST depressions/elevations; TWI in V2, aVL CT head without contrast: no evidence of acute intracranial bleed CXR: no acute cardiopulmonary process Brief Hospital Course: A/P: 77 year-old male with alcohol intoxication and elevated anion gap, lactic acidosis. 1. Alcohol intoxication - The patient presented after ingesting a pint of vodka and a 6 pack of beer. He claims that he does this about once a month. He didn't not have any signs of withdrawal during the hospital stay. He was maintained thiamine, folate, and a multivitamin. Social work was consulted, but the patient refused referral to services. 2. Metabolic acidosis - His anion gap was attributed to ethanol ingestion given that his osmolar gap was normal. He also had an elevated lactate to 7.3 on admission, which was attributed to hypoperfusion in the setting of alcohol ingestion. The anion gap resolved and the lactate level decreased with aggressive fluid resuscitation. He never had any signs of infections given that he was afebrile, normal white count, negative CXR and UA. There was also an initial concern that he may have ischemic bowel; however, his abdomen was benign and he had non-bloody stool. 3. Hypertension - His blood pressure was generally elevated and typically ranged from 130-170's systolic. His outpatient lisinopril was increased from 20 to 40 mg on the day of discharge. 4. Emphysema - He oxygenated well on room air throughout the admission. He was maintained on his outpatient Atrovent MDI throughout the admission. 5. Hyperlipidemia - His Statin was initially held until his LFTs were normal. 6. Depression - Initially, there was concern for suicidal ideation; however, the patient repeatedly denied suicidal and homicidal ideation. 7. Anemia - His hematocrit dropped after he received aggressive fluid resuscitation. This was attributed to hemodilution. 8. FEN - He was maintained on a low sodium diet. He was aggressively fluid resuscitated and his potassium, magnesium, and phosphate were repleted. 9. Prophylaxis - He was maintained on subcutaneous heparin, PPI, and a bowel regimen. 10. Code - DNR/DNI Medications on Admission: 1. Lisinopril 20mg once a day 2. Atorvastatin 20mg once a day 3. MVI once a day 4. Aspirin 81mg once a day 5. Atrovent Discharge Medications: In-hospital medications: Diazepam 5 mg IV Q2HR:PRN CIWA > 10 Lisinopril 20 mg PO DAILY Aspirin 81 mg PO DAILY Thiamine HCl 100 mg PO DAILY Multivitamins 1 CAP PO DAILY Folic Acid 1 mg PO DAILY Ipratropium Bromide MDI 2 PUFF IH QID Pantoprazole 40 mg PO Q24H Heparin 5000 UNIT SC Q8H Docusate Sodium 100 mg PO BID Bisacodyl 10 mg PO/PR DAILY:PRN constipation Discharge Disposition: Home Discharge Diagnosis: Alcohol intoxication Metabolic acidosis Hypertension Discharge Condition: Good. Metabolic acidosis has resolved. Discharge Instructions: Please take all medications as prescribed. Please keep all follow-up appointments. Followup Instructions: Please follow-up with your primary care physician as follows: Provider: [**First Name8 (NamePattern2) 354**] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2111-9-29**] 1:30 . You also have the following appointments: Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Where: [**Hospital6 29**] [**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2111-9-17**] 1:15 Provider: [**Name10 (NameIs) 101785**] HMFP- EYE Where: [**Hospital6 29**] [**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2112-3-31**] 11:15 Completed by:[**2111-8-20**]

[ "303.91", "272.4", "285.9", "401.9", "492.8", "276.2", "443.9", "272.0", "311" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5793, 5799

3274, 5238

336, 343

5896, 5937

2231, 2231

6069, 6777

1806, 1823

5408, 5770

5820, 5875

5264, 5385

5961, 6046

1838, 2212

276, 298

371, 1218

2248, 3251

1240, 1527

1543, 1790

28,517

158,703

1319+55276

Discharge summary

report+addendum

Admission Date: [**2195-4-15**] Discharge Date: [**2195-5-1**] Date of Birth: [**2123-8-4**] Sex: M Service: OTOLARYNGOLOGY Allergies: Penicillins / Sulfonamides Attending:[**First Name3 (LF) 7729**] Chief Complaint: Metastatic Squamous Cell Carcinoma Major Surgical or Invasive Procedure: [**2195-4-15**] 1. Metastatic squamous cell carcinoma, right neck. 2. Metastatic squamous cell carcinoma subcutaneous tissue scalp. 3. Reconstruction of scalp defect with a split-thickness skin graft from the right leg. 4. Lymph node biopsy left posterior neck. [**2195-4-17**] Evacuation of hematoma and ligation of vessels. History of Present Illness: INDICATIONS: The patient is a 71-year-old male with a known history of poorly differentiated squamous cell carcinoma involving the central portion of the occipital parietal scalp which was excised using a Mohs technique. It was noted at the time of resection that he had lymphovascular invasion. He received postoperative radiation therapy. More recently, he noted a mass in the right neck and over the ensuing period of time, over the past several weeks, other masses became evident in the right posterior neck which seemed to enlarge. They also became quite painful. Clinically he was also found to have an additional lymph node on the contralateral side in the mid portion of level V. CT scan corroborated all of these findings. Findings consistent with metastatic squamous cell carcinoma of the right neck with deep invasion into the prevertebral musculature. The brachial plexus and phrenic nerve were preserved. Past Medical History: - HTN - Atrial Fibrillation, on coumadin - AAA s/p repair in [**2179**] - ESRD following AAA rupture. S/p renal transplant in [**2181**] (A 6 antigen matched cadaveric kidney) - h/o SBO [**2146**] - Moderate Aortic Stenosis: Aortic Valve - Valve Area: *1.1 cm2 [**8-27**] - Aortic regurgitation 2+ in [**8-27**] - h/o Endocarditis - s/p splenectomy - Gout - Glaucoma - Cataracts - Axonal polyneuropathy- bilateral LE peripheral neuropathy - Low back pain with radiculopathy to the lower extremities - GERD - Anemia - Negative exploration for pheochromocytoma in [**2153**] - Left leg osteomyelitis in distant past - Right simple orchiectomy s/p varicoceles, hydroceles [**2182**] - Repair of ventral incisional hernia with Marlex mesh. [**2182**] - Left ankle synovial osteochondromatosis. s/p excision - skin ca: SCC on the L elbow, SCC on the L arm, and BCC on the nose Social History: Patient lives with his wife in [**Name (NI) 8117**], [**Name (NI) **]. She is very involved in his care. He is a army vet. He smoked for > 30 years, but quit in [**2175**]. No alcohol or drug use. Family History: NC Physical Exam: General: Well, NAD, A&O CV: Irreg, 1-2/6 Systolic murmur RESP: CTAB ABD: Soft, NT, ND HEENT: Surgical skin graft donor site on head C/D/I with no sign of necrosis or breakdown at graft edges. Left neck surgical incision C/D/I with sutures removed. Right neck surgical incision with staples. Small area of skin retraction at trifurcation, JP drain tract weeping clear yellow serous fluid. Compression dressing with montcomery strap over surgical incisions. Anterior thigh skin graft donor site C/D/I with xeroform dressing covered with telfa and ABD pad. Pertinent Results: [**2195-4-22**] WOUND CULTURE (Final [**2195-4-24**]): SERRATIA MARCESCENS. HEAVY GROWTH. [**2195-4-22**] MRSA SCREEN Source: Nasal swab. (Final [**2195-4-25**]): No MRSA isolated. Pathology Examination SPECIMEN SUBMITTED: Left neck lymph node, Scalp lesion, Modified radical neck dissection w/ dissection of deep cervical musculature. Procedure date [**2195-4-15**] DIAGNOSIS: 1. Lymph node, left neck (A-B): Poorly differentiated carcinoma consistent with metastatic squamous cell carcinoma in one lymph node. See note and case comment. Note: There is extracapsular extension. Immunostain for P63, cytokeratin, and CK7 are positive, chromogranin and S-100 are negative. The immunostains and histology favor a diagnosis of a poorly differentiated squamous cell carcinoma. Synaptophysin stain is focally positive. This stain is not specific, however, neuroendocrine differentiation cannot be completely excluded. CK20 is negative speaking against [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5668**] cell carcinoma. LMP (EBV) is negative. 2. Skin, scalp, excision (C-K): -Dermal malignant neoplasm consistent with poorly differentiated squamous cell carcinoma, completely excised. See note. -Actinic keratosis, completely excised. -Medial calcinosis of vessels. Note: The lack of epidermal involvement favors a dermal metastasis. The histology is similar to that of the nodal carcinoma. 3. Modified radical neck dissection with dissection of deep cervical musculature (L-[**Doctor Last Name **]): -Level II: Twelve lymph nodes; no malignancy identified. -Level III: Eight out of fourteen lymph nodes with metastatic carcinoma. -Level IV: Five out of nine lymph nodes with metastatic carcinoma. -Level V: Ten out of eleven lymph nodes with metastatic carcinoma. Note: There is a total of 23 of 46 nodes positive for carcinoma. Some of the lymph nodes show extracapsular extension. Slides AB-AE, Level V, show tumor with necrosis involving muscle, fat, and possibly may completely involve a lymph node (included in lymph node count), however, no definitive lymphoid tissue is identified. This may represent a soft tissue metastasis. Case comment: The previous specimen (Mohs debulk - S07-[**Numeric Identifier 8118**]) is reviewed. The specimen shows a moderately differentiated squamous cell carcinoma extending from the epidermis and more poorly differentiated carcinoma which is predominantly dermal. The poorly differentiated carcinoma is similar to that observed in current lymph nodes and skin specimen. There is some transition which suggests this is the primary site of the carcinoma, however, the possibility that there are two separate tumors in that specimen cannot be completely excluded. The poorly differentiated histology and extensive nodal involvement are somewhat unusual for a cutaneous squamous cell carcinoma and raise consideration of a primary site from the head or neck region. Clinical-pathologic correlation is recommended. Brief Hospital Course: Pt was admitted on [**2195-4-15**] and underwent resection of scalp mass, STSG, and neck dissection. Two JP drains were left in place. Pt received perioperative clindamycin which was continued while the drains were in place. Coumadin was held while drains were in place. Foley catheter was removed on POD#1. JP output was serosanguinous with 75cc and 100cc over 24h in each drain. On POD#2 worsening swelling was noted in the neck dissection/resection bed site. JP output increased to approx 100cc per drain over 24h and remained serosanguinous. On POD#2 ([**4-17**]) pt was taken back to the operating room for R neck exploration and evacuation of hematoma/seroma and two new JP drains were placed. On [**4-17**] JP output was 35 and 80 serosanguinous with decreased edema. JP output increased to 250 and 170 on [**4-18**] though edema over Right neck was decreased. On [**4-19**] output continued to be elevated at 185 and 225, was serous in quality, and neck continued to be flat in contour. Drain output slowly declined during his post-operative course. On [**4-22**] (POD [**6-27**]) increasing erythema was noticed around the drain site and inferior staple line. Pt was empirically started on Vancomycin and Ciprofloxacin. Clindamycin was discontinued at this time. Gram stain of the JP bulb fluid revealed Gram-Negative rods. On [**4-24**] JP drain culture grew out pan-sensitive Serratia Marcescens. Vancomycin was discontinued. Erythema improved. The pt remained afebrile during this time. On [**4-25**] One of the JP drains was removed. The remaining JP drain continued to have high outputs on the order of 200-300 cc/day, though it was clear and serous in quality. On [**4-27**] a compression dressing was fashioned over the right neck region with [**Location (un) **] straps. On [**4-28**] JP bulb was replaced with gravity drainage bag. Drain output slowly declined to 100-200 cc/day. On [**4-29**] drain was inadvertently removed by the pt while changing his gown. The compression dressing was continued over the neck wound. On [**4-30**] Coumadin was restarted. Pt was discharged home on [**5-1**] with home VNA. Dressing changes PRN. Patient is being discharged: afebrile, tolerating regular diet without nausea/vomiting, pain well controlled on oral medication, voiding, and ambulating well. Patient will follow-up within 7 days. The nephrology transplant service was consulted upon admission and managed Mr.[**Known lastname 8119**] FK monitoring and daily dosing of his Prograf. Of note, Mr.[**Known lastname **] was agitated during awaking from anaesthesia both on [**4-15**] and [**4-17**]. On [**4-15**] the pt hit his arm on the side rail of his bed and was complaining of left wrist pain. On [**4-16**] a plain film revealed a Non-displaced fracture through the radial styloid as above. Orthopaedic surgery was consulted and managed his wrist injury conservatively without the need for casting or splinting. Medications on Admission: allopurinol 200", Lipitor 40', clinda 600 prior to procedures, Plendil 5', fluorouracil cream", Lasix 20', lisinopril 20', Protonix, prednisone 10', ranitidine, Prograf 1", timolol gtt', Coumdin 4' x 6/7 days, Tylenol prn, vit B12 1', Colace, MVI Discharge Medications: 1. Outpatient Lab Work Labs to be drawn on [**5-6**] or [**5-7**]. Please do not take your AM dose of Prograf until after labs drawn. Chem 10, CBC, INR, FK level 2. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Disp:*60 Capsule(s)* Refills:*2* 3. Vitamin A 10,000 unit Capsule Sig: Two (2) Capsule PO DAILY (Daily): Continue until surgical incesions well healed. Disp:*60 Capsule(s)* Refills:*2* 4. Ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 1 weeks. Disp:*14 Tablet(s)* Refills:*0* 5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: 2mg daily Tuesday - Sunday while taking Ciprofloxacin. Then resume 4mg daily Tuesday - Sunday. Disp:*30 Tablet(s)* Refills:*2* 6. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Felodipine 2.5 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 9. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical twice a day: Keep edges of skin graft site on head moist. 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain: Do not take extra Tylenol (acetaminophen) while taking this medication. Disp:*20 Tablet(s)* Refills:*0* 15. 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* 16. Timolol Maleate 0.25 % Drops Sig: Two (2) Drop Ophthalmic DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: Metastatic squamous cell carcimona. HTN, A-fib, ESRD s/p CRT, mod AS, gout, glaucoma, cataracts, axonal polyneuropathy, LBP, GERD, anemia Discharge Condition: Good Discharge Instructions: Seek immediate medical attention for fever >101.5, chills, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. OK to shower but do not soak incision until follow up appointment, at least. No strenuous exercise or heavy lifting until follow up appointment, at least. Do not drive or drink alcohol while taking narcotic pain medications. Narcotic pain medications may cause constipation, if this occurs take an over the counter stool softener. Resume all home medications. Call your surgeon to make follow up appointment. Followup Instructions: Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1837**] [**Telephone/Fax (1) 8120**] to schedule a follow-up appointment within one week. You are being discharged on an adjusted coumadin dose due to interaction with antibiotics. The VNA has been instructed to monitor your INR. Your PCP who has previously been adjusting and following your coumadin dosing should continue to do so. Please contact him upon discharge and tell the VNA to send him your daily INR in order to make adjustments. Please send INR to patient's PCP, [**Last Name (NamePattern4) **].[**First Name8 (NamePattern2) 1312**] [**Last Name (NamePattern1) 1313**] at [**Telephone/Fax (1) 7318**] Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2195-5-12**] 11:00 Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern1) 4961**], M.D. Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2195-5-12**] 1:45 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2195-5-20**] 1:40 Name: [**Known lastname 1063**],[**Known firstname **] Unit No: [**Numeric Identifier 1064**] Admission Date: [**2195-4-15**] Discharge Date: [**2195-5-1**] Date of Birth: [**2123-8-4**] Sex: M Service: OTOLARYNGOLOGY Allergies: Penicillins / Sulfonamides Attending:[**First Name3 (LF) 1065**] Addendum: During hospital admission from [**2195-4-15**] to [**2195-5-1**] the patient developed a stage II pressure ulcer on the left buttock. The ulcer was treated with barrier cream, turning and repositioning, use of a 4 inch foam cushion on the chair and duoderm dressing. Additional Disgnosis: stage II left buttock pressure ulcer. Discharge Disposition: Home With Service Facility: [**Last Name (LF) 1066**], [**First Name3 (LF) **] [**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1067**] MD [**MD Number(1) 1068**] Completed by:[**2195-5-15**]

[ "V42.0", "715.35", "272.4", "V10.52", "998.32", "496", "041.85", "998.13", "998.59", "998.12", "196.0", "707.05", "E917.3", "427.31", "293.9", "198.2", "355.8", "530.81", "E878.8", "813.42", "198.89", "424.1", "682.1" ]

icd9cm

[ [ [] ] ]

[ "40.11", "38.91", "86.69", "93.59", "86.04", "86.3", "40.41", "38.82" ]

icd9pcs

[ [ [] ] ]

14205, 14445

6333, 9268

326, 655

11685, 11692

3323, 6310

12337, 14182

2730, 2734

9565, 11397

11524, 11664

9294, 9542

11716, 12314

2749, 3304

252, 288

683, 1604

1626, 2499

2515, 2714

54,486

152,680

37294

Discharge summary

report

Admission Date: [**2173-12-21**] Discharge Date: [**2173-12-23**] Date of Birth: [**2107-1-1**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4365**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 66 yo F history COPD on 3L home O2 with 1 week history progressive SOB, worse this AM. She has had a chronic cough and has been [**Last Name (un) 33606**] up increasing sputum this past week. One week prior to admit she thought she had a sinusitis. She made an appointment to see her PCP but started feeling more short of breath and so went to the ED. She denies fevers, chills, chest pain except for intermittent axillary sharp pain that goes beneath both axilla. . She presented to [**Last Name (un) 883**] ED, where initial ABG notable for ABG 7.29/98/58; CTA negative for PE, troponin negative x1. She received steroids, antibiotics and BiPAP placement and sent to [**Hospital1 18**] because there were no more ICU beds at their facility. . In the ED, initial vitals were: 96.3, 97, 132/67 30 97% on BiPAP. Patient appeared comfortable on BiPAP. Repeat ABG noted to be 7.3/92/234/47. CXR showed no focal consolidation, flattened diaphragm. She was admitted to the ICU as she was requiring non-invasive ventilation. . In the ICU, transfer vitals were: 97, 101, 130/74, 21, 99% BiPAP. She was uncomfortable on the BiPAP mask and so was taken down to NC. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. She does complain of some constipation. Past Medical History: - COPD on 3L NC at home - h/o intubation in ICU 2 years ago Social History: - Tobacco: 40 pack year smoker and continues to smoke one pack a day - Alcohol: rare - Illicits: Denies Family History: Non-contributory Physical Exam: Vitals: T: 95.6 BP: 119/65 P: 95 R: 17 O2: 100% on 50% BiPAP General: Frail appearing 66 year old HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, JVP not elevated, no LAD Lungs: Decreased breath sounds bilaterally slight end-expiratory wheezes, slight bibasilar crackes also noted, no rhonchi CV: RRR no murmurs Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: No clubbing, cyanosis; 1+ radial pulses; moves all 4 extremities Pertinent Results: Labs on Admission: 139 | 90 | 9 ------------------< 146 4.3 | 40 | 0.3 Ca: 9.8 Mg: 1.7 P: 3.3 CBC: 10.5 > 13.1/40.6 < 208 Labs on Discharge: Micro: [**2173-12-23**] 07:55AM BLOOD WBC-7.7 RBC-4.03* Hgb-12.2 Hct-37.3 MCV-93 MCH-30.2 MCHC-32.6 RDW-12.4 Plt Ct-257 [**2173-12-23**] 07:55AM BLOOD Glucose-85 UreaN-12 Creat-0.5 Na-141 K-4.2 Cl-89* HCO3-48* AnGap-8 [**2173-12-23**] 07:55AM BLOOD Calcium-9.8 Phos-3.9 Mg-1.9 Studies: Chest X-ray: IMPRESSION: Emphysema. Bilateral upper lobe ill-defined airspace opacities worrisome for infectious process. Brief Hospital Course: 66 yo F history COPD on 3L home O2 with 1 week history progressive SOB worsening this AM likely secondary to COPD. . # COPD Exacerbation: Patient was transferred from [**Hospital 882**] hospital for a ABG of 7.29/98/58 and on BiPAP. She was transferred to the MICU for close monitoring. PE was ruled out in [**Hospital1 882**] by CTA. She was ruled out for MI. She was weaned off of BiPAP to 5 Liters nasal cannula and ultimately back to her baseline of 3 L NC. She was also given levofloxacin for possible CAP to be completed [**2173-12-25**]. She was started on prednisone 60 mg with plan for a fast 2 week taper. Given round the clock nebulizers. Her respiratory status improved and will be discharged to a rehab facility. Blood and Sputum cultures were pending at time of discharge. She will be followed Chest X-ray did not show any consolidation concerning for PNA. She did not have fevers or an elevated wbc. It was felt, however, her exacerbation was in the setting of a recent URI. Medications on Admission: - Spiriva with handihaler 18mcg - Albuterol sulfate HFA 90 mcg/actuation aerosol - Advair diskus unknown strength 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. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): DVT prophylaxis. 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever: Do not exceed more than 4 grams in 24 hours. 6. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 6 days: Start [**2173-12-24**]: 60 mg (3 pills) x 2 days, 40 mg (2 pills) x 2 days, 20 mg (1 pill)x 2 days then start second prednisone prescription. 7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 4 days: To be started after taking previous prednisone prescription). Start (one pill) 10 mg x 2 days then 5 mg (one-half pill) x 2 days then stop. 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 10. 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. 11. 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. 12. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for dyspepsia. 13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for indigestion. 14. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 15. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 16. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [**12-18**] Inhalation Q2H (every 2 hours) as needed for SOB. 17. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO at bedtime for 3 days. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary: COPD on Home oxygen Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: You were admitted due to a COPD exacerbation. You were given a Bipap to help you breath. You were ultimately weaned back down to your home oxygen requirement of 3 Liters Nasal Cannula. You were given steroids and antibiotics to help with your breathing. You improved and it was felt safe for you to go home. Your new medications include: 1. Prednisone 60 mg daily x 2 days then 40 mg x 2 days then 30 mg x 2 days then 20 mg x 2 days then 10 mg x 2 days then 5 mg x 2 days then stop. Followup Instructions: You are scheduled to see your primary care doctor Dr. [**First Name8 (NamePattern2) 30623**] [**Last Name (NamePattern1) **] on Friday [**1-7**] at 1:00 pm. His phone number is [**Telephone/Fax (1) 30837**]. You should call the office if you need to reschedule. I spoke with Dr.[**Name (NI) 83926**] office and they will set up a Lung doctor for you to follow up with at this appointment. It is important you go to this appointment.

[ "305.1", "V46.2", "276.4", "465.9", "518.81", "491.21" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6596, 6668

3258, 4251

324, 330

6741, 6741

2674, 2679

7426, 7863

2110, 2128

4415, 6573

6689, 6720

4277, 4392

6918, 7403

2143, 2655

1539, 1890

277, 286

2824, 3235

358, 1520

2693, 2804

6755, 6894

1912, 1973

1989, 2094

19,914

164,071

7985

Discharge summary

report

Admission Date: [**2116-12-22**] Discharge Date: [**2117-1-12**] Date of Birth: [**2046-3-5**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5644**] Chief Complaint: Transferred from OSH with thoracic aortic aneurysm by CT scan. Major Surgical or Invasive Procedure: 1. Endovascular thoracic aortic aneurysm repair 2. Transesophageal echocardiogram History of Present Illness: 70-year-old man w/ mult medical problems including DM2, HTN, CAD s/p CABG presented to OSH on [**2116-12-21**] w/ 1 week of epigastric pain radiating to the back. OSH CT revealed 4.5cm thoracic aortic aneurysm [**Company 5249**]-10 level, w/ possible dissection and leaking. He was transferred to [**Hospital1 18**] for further rx on [**2116-12-21**], received endovascular aortic aneurysm repair on [**12-22**]/5 during which he lost 2500cc blood and received 10units PRBCs. He was then admitted to [**Hospital1 18**] for further management. Past Medical History: PMH: 1. HTN 2. Hypercholesterolemia 3. DM2 4. PVD 5. CRI 6. CAD s/p CABG x 4 7. CHF: ECHO [**2115-12-30**] w/ severely depressed EF, basal akinesis, [**12-20**]+ MR 8. Colon CA s/p R colectomy 9. h/o Bell's palsy 10. h/o MRSA infection of L toe PSH: 1. CABG x 4: [**2107**] 2. L BKA [**10-22**] 3. AICD placement [**2-19**] 4. R hemicolectomy [**7-22**] 5. L fem-[**Doctor Last Name **] bypass [**2112**] 6. L CEA w/ patch [**2112**] 7. cholecystectomy [**2111**] 8. appendectomy 9. R fem-peroneal bypass Social History: smoked but quit 25 years ago, no alcohol or recreational drug use Family History: 1. DM: brother 2. Pancreatic CA: sister Physical Exam: VS T 99ax, BP 134/37, HR 73, RR 28, O2 sat 96% 4L/m Gen: awake, alert, sick appearing man in NAD HEENT: anicteric, EOMI, PERRL, OP clear w/ MMM, no LAD, neck supple, JVP to ear lobe w/ bed at 30 degrees elevation CV: faint reg s1/s2, 2/6 systolic murmur at LUSB, no s3/s4/r Pulm: dull to percussion in bases B, crackles to 1/2 up B, no wheezes Abd: obese, +BS, soft, NT, ND Ext: s/p L BKA, cool, DP dopplerable on R, L thigh w/ 1+ pitting edema, 2+ pitting edema to knee on R, no cyanosis Neuro: alert and oriented x 3, CN 2-12 intact, strength 4/5 throughout UE/LE B, sensation to fine touch intact throughout Pertinent Results: [**2116-12-30**] 03:14AM BLOOD WBC-13.9* RBC-4.35* Hgb-11.8* Hct-36.4* MCV-84 MCH-27.2 MCHC-32.5 RDW-15.5 Plt Ct-252 [**2116-12-30**] 03:14AM BLOOD Plt Ct-252 [**2116-12-30**] 12:07PM BLOOD PT-15.7* PTT-82.5* INR(PT)-1.6 [**2116-12-30**] 03:14AM BLOOD ALT-19 AST-25 LD(LDH)-238 CK(CPK)-49 AlkPhos-149* Amylase-51 TotBili-0.9 Lipase-45 [**2116-12-30**] 12:07PM BLOOD Glucose-294* UreaN-34* Creat-1.3* Na-133 K-3.8 Cl-94* HCO3-33* AnGap-10 [**2116-12-21**] 11:10PM BLOOD CK-MB-NotDone cTropnT-0.07* [**2116-12-22**] 05:00AM BLOOD CK-MB-NotDone cTropnT-0.08* [**2116-12-25**] 03:38PM BLOOD CK-MB-NotDone cTropnT-0.51* [**2116-12-26**] 06:00AM BLOOD CK-MB-NotDone cTropnT-0.55* [**2116-12-26**] 07:04PM BLOOD CK-MB-NotDone cTropnT-0.57* [**2116-12-27**] 12:35PM BLOOD CK-MB-3 cTropnT-0.58* [**2116-12-27**] 08:15PM BLOOD CK-MB-NotDone cTropnT-0.65* [**2116-12-28**] 05:00AM BLOOD CK-MB-3 cTropnT-0.63* [**2116-12-29**] 08:05AM BLOOD CK-MB-NotDone cTropnT-0.59* [**2116-12-29**] 06:29PM BLOOD CK-MB-NotDone cTropnT-0.51* [**2116-12-30**] 03:14AM BLOOD CK-MB-NotDone cTropnT-0.48* Stool ([**12-27**]): C diff positive Blood cx ([**12-29**]): MRSA 3/4 bottles Blood cx ([**12-30**]): MRSA Urine cx ([**12-29**]): no growth ECHO ([**2116-12-30**]): The left atrium is mildly dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed. Resting regional wall motion abnormalities include inferior, inferolateral and inferoseptal akinesis. Right ventricular chamber size and free wall motion are normal. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. CXR ([**2116-12-29**]): Mild CHF may be improved compared to [**2116-12-26**]. Otherwise, unchanged exam with stable cardiomegaly and retrocardiac opacity. UE doppler US: [**Doctor Last Name **] scale and color doppler son[**Name (NI) 493**] examination of the left upper extremity venous system was performed. Nonocclusive thrombus is seen within the left internal jugular vein and left subclavian vein. Normal compressibility, color flow and waveforms are seen within the left axillary vein. Normal color flow and waveforms are seen within the left cephalic, basilic, and brachial veins. TEE ([**2117-1-7**]): The left atrium is mildly dilated. The right ventricle is dilated and diffusely hypokinetic. The left ventricular systolic function is moderately to severely depressed.There is significant calcification in the aortic arch. The aortic valve leaflets are mildly thickened with no vegetations or abscess. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened with no vegetations or abscess. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. There is a graft in the descending thoracic aorta. No abscess is seen around the graft, however CT scan or MRI would be a more accurate test to rule out the diagnosis. No TEE evidence of endocarditis. CT abdomen ([**2117-1-8**]): 1) Small left inguinal fluid collection with surrounding fat stranding. This can be seen post-procedurally. However, a superimposed infection cannot be excluded radiographically. 2) Extensive vascular calcification with the endograft in the thoracic aorta. 3) Simple bilateral moderate pleural effusions. Brief Hospital Course: 1. Thoracic aortic aneurysm: he was transferred from OSH on [**2116-12-21**] for treatment of T10-level aortic aneurysm discovered on CT scan. He underwent endovascular aneurysm repair w/ stent placement on [**2116-12-22**], during which he lost 2500cc blood and received 10units PRBCs. There were no procedural complications. He was treated w/ heparin gtt after his surgery for anticoagulation; meanwhile, he was started on coumadin therapy for a goal INR of [**1-21**]. When goal INR was achieved, heparin gtt was d/c and he was continued on coumadin. His aortic stent was observed to be in the proper position by serial CXRs during his admission, w/ no signs or symptoms of bleeding. He does not require further anticoagulation for his vascular grafts after d/c, but must continue coumadin for treatment of DVT as below. He will require follow-up with Dr. [**Last Name (STitle) 28610**] in Vascular Surgery clinic in [**12-20**] weeks after d/c. 2. MRSA bacteremia: approximately 1 week after surgery, the pt became febrile. Blood cultures were drawn, and grew MRSA. The patient's left IJ central line was d/c on the 1st day of fever, and was noted to contain purulent fluid; the catheter tip was cultured and grew MRSA, making infected line the most likely source of bacteremia. A new right subclavian central line was placed, and treatment was begun w/ vancomyin on [**2116-12-30**]. The pt defervesced after 24 hours of vancomycin therapy, and was monitored w/ daily surveillance cultures. Surveillance cultures on [**12-14**], and [**1-5**] grew MRSA despite continuing vancomycin treatment, raising concern for possible bacterial seeding of cardiac valves or vascular graft. He was evaluated w/ TEE, which showed no evidence of endocarditis, and w/ abdominal CT, which showed no evidence of vascular graft infection. ID service was consulted, and believed that positive surveillance cultures were most likely [**1-20**] infected left IJ thrombus w/ intermittent bacterial showering. The pt was continued on vancomycin therapy, and gentamicin was added for synergy and to assist with clearance of bacteremia. After 2 days rifampin replaced gentamicin. Treatment was continued w/ vancomycin and rifampin until d/c. At d/c, there are no signs of active infection. The pt has been afebrile for nearly 2 weeks, and surveillance cultures from [**2117-1-5**] to [**2117-1-8**] show no growth. He will need to continue vancomycin and rifampin after d/c to complete a 6 week course of antibiotics. 3. Ventricular tachycardia: his post-op course was complicated by multiple episodes of NSVT, all asymptomatic, the longest episode lasting 10-15 minutes. Cardiology and EP services were consulted, and it was thought that NSVT was most likely [**1-20**] cardiac scarring from previous MI. His AICD was interrogated, and was found to have not fired during NSVT, presumably because the patient's heart rate never reached the AICD threshold of 150 bpm. The AICD was reprogrammed to fire above 140 bpm, and treatment was begun w/ amiodarone as an antiarrhythmic [**Doctor Last Name 360**]. He was loaded w/ IV amiodarone, and then transitioned to oral amiodarone, w/ no further episodes of NSVT observed during his admission. Cardiology has recommended a PMIBI to evaluate for ischemic disease, to be performed as an outpt when the pt's acute issues are resolved. At d/c, there is no evidence of cardiac arrhythmia. He will need close f/u w/ his Cardiologist to monitor for arrhythmia and schedule PMIBI. 4. C. diff colitis: he developed diarrhea after surgery, and stool studies were positive for C diff toxin. He was treated w/ a 14 day course of flagyl, and diarrhea resolved by the time of d/c. At d/c, there is no diarrhea and no evidence of active infection. He will need to closely for return of diarrhea or fever, which could represent return of C diff colitis in the setting of ongoing antibiotic therapy. 5. CAD: the pt has known CAD, s/p CABG in [**2107**]. He was noted to have elevated troponin after surgery, most likely [**1-20**] demand ischemia from V tach. Cardiology consultants thought there was a low likelihood of acute ischemia, and troponin trended down consistently after NSVT was controlled w/ amiodarone. He was treated w/ his outpt regimen of lopressor, ASA, simvastatin, and losartan during his admission, w/ no signs or symptoms of active ischemia. He will require PMIBI when active issues resolved to evaluate for ischemic disease. 6. CHF: he has ischemic heart failure w/ severely depressed LVEF of 25% by ECHO. Following surgery w/ aggressive fluid resuscitation, he had evidence of increased pulm congestion and LE edema on exam, together w/ O2 requirement of 4L/minute. The pt was diuresed w/ lasix, which was limited late in his hospital course by [**Doctor First Name 48**]. However, after a brief period of holding diuretic meds, renal function returned to baseline and lasix was reinstituted, achieving consistent diuresis w/ resolution of pulm crackles and improvement in LE edema by the time of d/c. At d/c, the pt is maintaining good O2 sat on room air, and has no objective evidence of pulm edema. He will need to continue diuretic therapy after d/c to treat persistent fluid overload and peripheral edema. 7. DM2: he has long-standing DM controlled at home w/ insulin. During his admission, treatment was continued w/ his usual outpt regimen, and he was covered for hyperglycemia w/ RISS. At d/c, he will need to continue NPH and regular insulin for glucose control. 8. Acute on chronic RI: he has CRI, w/ baseline creatinine around 1.2 from DM. Creatinine was elevated above baseline after surgery, likely [**1-20**] prerenal azotemia and worsening CHF, as supported by his low FEUrea of 14%. [**Doctor First Name 48**] was initially exacerbated by diuretic therapy. However, losartan and lasix were held to allow renal fxn to return to baseline, and then lasix was reinstituted and achieved consistent diuresis in the setting of stable creatinine at baseline. At d/c, creatinine remains stable at baseline despite ongoing diuretic therapy and reinstitution of losartan. He will require close follow-up of renal fxn as an outpt. 9. HTN: well controlled during admission on his outpt regimen lopressor, lasix, losartan. 10. DVT: after pulling left IJ central line, the pt was observed to have increased edema of the LUE, without pain or tenderness. LUE US showed non-occlussive DVT of L IJ and L subclavian veins, where infected central line was located. This thrombus had developed in the setting of heparin therapy after surgery, and was suspected to be the source of bacterial showering and positive surveillance cultures during this admission. At the time of discovery of the DVT, the pt was already being treated w/ coumadin and had therapeutic INR. Treatment was continued w/ coumadin for a goal INR of [**1-21**], and LUE edema showed some improvement by d/c. At d/c, the pt has persistent LUE edema, but no signs of inflammation in the LUE. He will require continued coumadin therapy for at least 6 months to prevent further thrombosis, and will need close f/u as an outpt to monitor coumadin dosing. 11. Pneumonia: given the pt's persistent O2 requirement and exam indicating LLL consolidation despite treatment for CHF, CXR was obtained and demonstrated LLL infiltrate concerning for PNA. Levaquin was started as empiric therapy. Sputum cx was obtained and grew MRSA. The pt received 8 days of levaquin therapy before sputum cx was finalized, at which time it was thought that MRSA in sputum would be adequately covered by vanco and rifampin. Thus, levaquin was d/c and the pt was continued on vanco/rifampin as above. By d/c, the pt's PNA was clinically resolved, w/ no O2 requirement and no persistent evidence of pulmonary consolidation on exam. The pt should have repeat CXR 6-8 weeks after d/c to ensure resolution of LLL infiltrate. Medications on Admission: vancomycin 1g q12 hours flagyl 500mg tid heparin gtt coumadin 10mg qhs losartan 12.5mg [**Hospital1 **] lasix 80mg po bid metalazone 5mg qhs and 5mg qod lopressor 100mg tid amiodarone 1mg/min ASA 325mg q day simvastatin 20mg q day NPH 35/44 regular insulin [**5-24**] protonix 40mg IV bid morphine 2-4mg IV Q4 hours prn tylenol prn Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Metolazone 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 7. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 8. Rifampin 300 mg Capsule Sig: Two (2) Capsule PO Q24H (every 24 hours) for 38 days. 9. Zolpidem Tartrate 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 10. Losartan Potassium 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 11. Warfarin Sodium 3 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. Vancomycin HCl 10 g Recon Soln Sig: One (1) gram Intravenous Q24H (every 24 hours) for 38 days. 13. Rifampin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) for 38 days. 14. Amiodarone HCl 400 mg Tablet Sig: One (1) Tablet PO twice a day for 8 days: to be taken on [**2117-1-13**] to [**2117-1-20**]. 15. Amiodarone HCl 400 mg Tablet Sig: One (1) Tablet PO once a day: to be started on [**2117-1-21**]. 16. Furosemide 80 mg Tablet Sig: One (1) Tablet PO QAM. 17. NPH insulin Take 44units before breakfast and 40 units before dinner 18. Regular insulin Take 6units before breakfast and 6units before dinner Discharge Disposition: Extended Care Facility: [**Hospital 8641**] Healthcare, NH Discharge Diagnosis: Primary: 1. Thoracic aortic aneurysm 2. MRSA bacteremia 3. Ventricular tachycardia 4. C diff colitis 5. Pneumonia 6. DVT 7. Acute on chronic renal insufficiency 8. CHF Secondary: 1. CAD 2. HTN Discharge Condition: Stable to go to rehab; no evidence of active infection, tolerating diet well, no O2 requirement. Discharge Instructions: You are being discharged after treatment for aortic aneurysm, NSVT, MRSA infection, pneumonia, and congestive heart failure. Please take all medications as prescribed. Weigh yourself daily, and call your doctor if you gain more than 2 pounds in any 24 hour period. You have been treated with antibiotics for infectious diarrhea. If you have increased diarrhea or fever after discharge, present to your doctor [**First Name (Titles) **] [**Last Name (Titles) 2742**] as you may have return of infectious diarrhea. Present to the ED or your doctor [**First Name (Titles) **] [**Last Name (Titles) 2742**] if you have chest pain, shortness of breath, repeated back pain, dizziness, fever, palpitations, or other concerning symptoms. Followup Instructions: Follow-up with your PCP (Dr. [**Last Name (STitle) 28611**] [**Telephone/Fax (1) 28612**]) in [**12-20**] weeks Follow-up with Dr. [**Last Name (STitle) **] in Vascular Surgery clinic ([**Telephone/Fax (1) 2625**]) in [**12-20**] weeks. You will need repeat CTA of the torso to evaluate your surgical graft in [**12-20**] weeks, to be ordered by Dr. [**Last Name (STitle) **]. Follow-up with your Cardiologist at [**Hospital 12017**] [**Hospital 12018**] Hospital in [**1-21**] weeks.

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icd9cm

[ [ [] ] ]

[ "39.79", "38.93", "38.18", "88.72" ]

icd9pcs

[ [ [] ] ]

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Discharge summary

report

Admission Date: [**2122-6-3**] Discharge Date: [**2122-6-5**] Date of Birth: [**2058-1-13**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3624**] Chief Complaint: Abnormal labs Major Surgical or Invasive Procedure: None History of Present Illness: 64y.o. male with Hx of sCHF (EF 50%), ESRD [**3-5**] glomerulonephritis s/p cadaveric renal transplant ([**2102**]), complicated by acute humoral rejection in [**12/2121**](s/p IVIg and plasmapharesis, rituximab x 1), DM, HTN, h/o MI presenting to the ED at the request of his PCP due to abnormal laboratory data. Patient has been in his usual state of health when he went for a follow up visit with his PCP. [**Name Initial (NameIs) 2094**] 2-3 weeks prior to presentation, he mentioned having some increased fatigue, which prompted his PCP to check [**Name Initial (PRE) **] CBC and basic electrolyte/liver tests. He had his lab draws today which showed an electrolyte abnormalities including hyperkalemia/hyperphosphatemia and elevated creatinine. He was contact[**Name (NI) **] by his PCP to report to the emergency room for further evaluation. Of note, patient mentions he took us usual long acting insulin the night prior to presentation, but the morning of presentation did not take his usual sliding scale insulin as his glucometer was broken. He did take his usual oral hypoglycemics. . In the ED, initial VS were: T 100.0 HR 70 BP 138/54 RR 18 satting 98% on RA. On presentation, fingersticks were critically high. ABG was performed which showed pH of 7.36/pCO2 34/pO2 78/ HCO3 20. UA showed glucosuria, some protein, but otherwise no signs of infection. Lactate was low at 1.4. CMP was abnormal with glucose of 652, sodium of 128 (corrected to 135), potassium of 5.9 (baseline [**5-7**]), phosphorus of 4.9, creatinine of 2.8 (has fluctuated 2.1 - 2.6 in last several months) Lipase of of 78 (fluctuates 60's to 150's), HCT of 27.5 (around baseline), WBC of 5.4 (baseline) and AST/ALT of 51 and 41 respectively (baseline in the teens to 20's). CXR was noncontributory, and renal ultrasound showed increase RI with compromised diastolic flow, most notable in the lower pole region, but stable compared to [**Month (only) 404**]. EKG was consistent with prior, with sinus rhythm of 67, first degree AV block, TWI in III/V1, and q waves in inferior leads c/w prior MI. He received 10 units of IV insulin and was started on an insulin gtt at 8u/hour. Vitals prior to transfer were afebrile/stable. . On arrival to the MICU, patient is AOX3, feels well without complaint. Past Medical History: Diabetes Dyslipidemia Hypertension CAD, history of MI s/p PCI with 5 stents in approx [**2115**] H/o ESRD [**3-5**] glomerulonephtritis s/p cadaveric renal transplant in [**2101**] at [**Hospital1 336**]. - Acute humoral rejection with biopsy and presence of both class I and II antibodies), treated with plasmapheresis and IVIg in [**12/2121**] History of colon cancer s/p resection [**2111**], currently in remission Pancreatitis GERD Anemia Squamous cell skin cancer, multiple on hands bilat s/p resections Social History: -Tobacco history: No smoking history. -ETOH: 1-2 times monthly. -Illicit drugs: Denies. Retired middle/high school math teacher. Lives at home with his wife. Married with one son. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Mother - addison's disease. Father - died of colon cancer in old age. Physical Exam: ADMISSION EXAM: vs: 98.5 T/ HR 70 / BP 113/62 RR 23 96% ON RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, conjunctiva with mild injection, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, [**3-9**] crescendo/decrescendo pansystolic murmur best auscultated in the aortic region. Otherwise no rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Scar in midline c/w colon cancer history. Obese but soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, MAE's. Skin: multiple areas of actinic keratoses and prior sites of skin cancer. . DISCHARGE EXAM: VS: 98.6 147/65 (130-147/60s) 71 98% RA BG: 338 (5H) 296 (26L, 2H) --> 152 GENERAL: Well appearing 64 yo M who appears stated age. Comfortable, appropriate and in good humor. HEENT: Sclera anicteric. PERRL, EOMI. NECK: Supple with low JVP CARDIAC: RRR, S1 S2 clear and of good quality, [**3-9**] crescendo/decrescendo pansystolic murmur best auscultated in the aortic region. LUNGS: Resp were unlabored, no accessory muscle use, moving air well and symmetrically. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender to palpation over his transplanted kidney, non-distended, bowel sounds present EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. trace pedal edema Pertinent Results: ADMISSION LABS [**2122-6-3**] 08:25PM BLOOD WBC-5.4 RBC-2.90* Hgb-8.1* Hct-27.5* MCV-95 MCH-27.9 MCHC-29.4* RDW-13.9 Plt Ct-195 [**2122-6-3**] 08:25PM BLOOD Neuts-74* Bands-6* Lymphs-13* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2122-6-3**] 08:25PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-1+ Stipple-1+ Tear Dr[**Last Name (STitle) **]1+ [**2122-6-3**] 08:25PM BLOOD PT-10.9 PTT-30.0 INR(PT)-1.0 [**2122-6-3**] 08:25PM BLOOD Glucose-652* UreaN-65* Creat-2.8* Na-128* K-5.9* Cl-98 HCO3-19* AnGap-17 [**2122-6-3**] 08:25PM BLOOD ALT-41* AST-51* AlkPhos-50 TotBili-0.2 [**2122-6-3**] 08:25PM BLOOD Lipase-78* [**2122-6-4**] 12:28AM BLOOD CK-MB-6 cTropnT-0.08* [**2122-6-4**] 03:00AM BLOOD cTropnT-0.08* [**2122-6-3**] 08:25PM BLOOD Albumin-4.1 Calcium-9.1 Phos-4.9* Mg-2.4 [**2122-6-3**] 08:25PM BLOOD Acetone-NEGATIVE Osmolal-319* [**2122-6-3**] 09:59PM BLOOD Type-ART pO2-78* pCO2-34* pH-7.36 calTCO2-20* Base XS--5 [**2122-6-3**] 08:33PM BLOOD Lactate-1.4 . DISCHARGE LABS: [**2122-6-5**] 06:00AM BLOOD WBC-4.5 RBC-2.90* Hgb-8.1* Hct-26.6* MCV-92 MCH-28.0 MCHC-30.4* RDW-14.0 Plt Ct-182 [**2122-6-5**] 06:00AM BLOOD Glucose-133* UreaN-53* Creat-2.0* Na-138 K-4.9 Cl-110* HCO3-21* AnGap-12 [**2122-6-5**] 06:00AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.3 . URINALYSIS: [**2122-6-3**] 08:50PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007 [**2122-6-3**] 08:50PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2122-6-3**] 08:50PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE Epi-<1 TransE-<1 . MICROBIOLOGY [**2122-6-3**] Blood Culture, Routine-PENDING [**2122-6-3**] Blood Culture, Routine-PENDING [**2122-6-3**] URINE CULTURE- no growth . IMAGING: # CHEST (PA & LAT) Study Date of [**2122-6-3**] PA AND LATERAL VIES OF THE CHEST: Lungs are clear. Cardiomediastinal silhouette is unremarkable. No pleural effusions or pneumothorax. IMPRESSION: No evidence of cardiopulmonary process. . # RENAL TRANSPLANT U.S. Study Date of [**2122-6-3**] FINDINGS: The right lower quadrant transplant kidney measures 14.1 cm. There is preserved corticomedullary differentiation with no hydronephrosis or perinephric fluid collection. A small echogenic focus is again seen in the upper pole. COLOR DOPPLER SPECTRAL ANALYSIS: The main renal artery and main renal vein are patent with normal waveforms. Resistive indices are mildly increased at 0.87 to 0.89 in the upper, mid and lower pole of the interlobar arteries. There again appears to be a lack of diastolic flow in the mid to lower pole, unchanged from the prior examination. IMPRESSION: Increased resistive index is with compromised diastolic flow most notably in the lower pole region but stable exam compared to the [**2122-2-1**]. Brief Hospital Course: 64 yo male with history of renal transplant, DM presenting with hyperglycemia and electrolyte abnormalities as well as acute on chronic kidney injury. . ACTIVE ISSUES: # Hyperglycemia: Pt has long history of diabetes requiring insulin and oral agents. He reports fasting sugars of 100-130 at home. On admission, his serum osms were not significantly elevated, and he was not spilling ketones in urine. He had no significant anion gap so did not meet diagnosis of HHS or DKA. No clear etiology of his hyperglycemia was noted, but differential included prednisone use, missed insulin doses, or silent MI. His cardiac enzymes appeared to be at baseline and he had no EKG changes. His urine culture was negative and he had no growth in blood cultures at time of discharge. He was briefly on an insulin drip but was quickly weaned off to subcutaneous insulin and PO diet. His electrolyte abnormalities resolved with correction of his glucose. He was discharged on his home insulin regimen and oral hyperglycemic agents with instructions to follow up with his PCP and titrate his insulin as needed. . #Hyponatremia: Pt hyponatremic on admission, likely pseudohyponatremia in the presence of hyperglycemia. This resolved s/p IVF and blood sugar control. His diuretics were initially held but resumed on discharge. . #[**Last Name (un) **] on CKD: Pt was admitted with creatinine elevated to 2.8 from baseline around 2.4, thought to be prerenal in the setting of osmotic diuresis from hyperglycemia. His creatinine returned to baseline with IVF. He was continued on home dose of tacrolimus. His diuretics were initially held but resumed prior to discharge. . CHRONIC ISSUES: #Renal Transplant: Pt is s/p renal transplant 21 years ago. His renal ultrasound showed stable decreased flow. He was continued on MMF, tacrolimus and prednisone. . #Elevated lipase: Pt has chronically elevated lipase, currently at baseline with no complaints. . #CAD: pt was continued on aspirin, statin, and beta blocker. . #Chronic sCHF: EF of 50% with no evidence of decompensation during this admission. He did receive 4 liters of IVF in the MICU and his diuretics were held, but pt continued to appear euvolemic. His diuretics were resumed prior to discharge and he was continued on his ace inhibitor and beta blocker. . TRANSITIONAL ISSUES: # Pt should follow up with his outpatient PCP for insulin regimen adjustment. His Lantus may need to be increased, as his ratio of long acting:short acting insulin appears skewed towards excessive short acting, which may have contributed to this episode of hyperglycemia. Medications on Admission: 1. acitretin 25 mg Capsule Sig: One (1) Capsule PO once a day. 2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO TIW. 5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Vitamin D2 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 7. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. furosemide 40 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 9. insulin glargine 100 unit/mL Solution Sig: Twenty Six (26) units Subcutaneous at bedtime. 10. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 11. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 12. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. tacrolimus 0.5 mg Capsule Sig: Five (5) Capsule PO Q12H (every 12 hours). 15. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 16. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Omega 3-6-9 Fatty Acids 400-400-200 mg Capsule Sig: One (1) Capsule PO once a day. 18. linagliptin 5 mg Tablet Sig: One (1) Tablet PO once a day. 19. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day. 20. insulin lispro 100 unit/mL Solution Sig: per sliding scale Subcutaneous with meals. Discharge Medications: 1. acitretin 25 mg Capsule Sig: One (1) Capsule PO once a day. 2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO TIW. 5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Vitamin D2 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 7. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. furosemide 40 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 9. insulin glargine 100 unit/mL Solution Sig: Twenty Six (26) units Subcutaneous at bedtime. 10. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 11. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 12. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. tacrolimus 0.5 mg Capsule Sig: Five (5) Capsule PO Q12H (every 12 hours). 15. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 16. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Omega 3-6-9 Fatty Acids 400-400-200 mg Capsule Sig: One (1) Capsule PO once a day. 18. linagliptin 5 mg Tablet Sig: One (1) Tablet PO once a day. 19. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day. 20. insulin lispro 100 unit/mL Solution Sig: per sliding scale Subcutaneous with meals. Discharge Disposition: Home Discharge Diagnosis: Hyperglycemia (primary) Insulin dependent diabetes (secondary) Renal transplant (secondary) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital for very elevated blood sugars in the setting of missing your insulin dose. After a short stay in the ICU and on the general wards, your sugars have resumed normal baseline levels and you are safe to be discharged home with close outpatient follow up with your primary care provider. No changes are made to your medications. Please discuss increasing your long acting insulin (lantus) dose with your primary care provider to reduce some of your sliding scale coverage. Please follow up with your providers as listed below. Followup Instructions: PCP [**Name Initial (PRE) **]: Tuesday, [**6-9**] at 11:15am With:[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 88387**],MD Location: [**Hospital1 **] HEALTHCARE - [**Hospital1 **] Address: ONE PEARL ST, [**Apartment Address(1) 12836**], [**Hospital1 **],[**Numeric Identifier 9647**] Phone: [**Telephone/Fax (1) 17919**] Department: TRANSPLANT CENTER When: FRIDAY [**2122-7-17**] at 9:20 AM With: [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: RADIOLOGY When: THURSDAY [**2122-8-6**] at 1:40 PM With: RADIOLOGY MRI [**Telephone/Fax (1) 590**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 861**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: GASTROENTEROLOGY When: FRIDAY [**2122-8-14**] at 12:50 PM With: [**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], 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 [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**] Completed by:[**2122-6-6**]

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Discharge summary

report

Admission Date: [**2111-8-3**] Discharge Date: [**2111-10-16**] Date of Birth: [**2038-7-7**] Sex: F Service: MEDICINE Allergies: Meperidine Attending:[**First Name3 (LF) 3984**] Chief Complaint: Diplopia. Major Surgical or Invasive Procedure: 1. tracheostomy 2. sinus biopsy 3. arterial line 4. PICC placement History of Present Illness: The patient is a 73 year-old right-handed female with a history of breast cancer, atrial fibrillation on coumadin, ulcerative colitis (on prednisone) who presented with chief complaint of diplopia. The patient noted double vision on the morning of admission. She noted that the false image appeared diagonal to the true image. Note was not made if the diplopia was worse in any one direction. The pt noted that she also developed numbness on the left half of her face below her eye, which she first noticed on the morning of admission. She also complained of feeling unsteady and fell to the left side on the morning of admission. In addition, she noted her voice was hoarse and weak. She denied headache, nausea, neck pain, parasthesiae, changes in hearing, dysphagia, weakness. No incontinence or back pain. She did admit to fever, nausea and vomiting for the past two days prior to admission. REVIEW OF SYSTEMS: denies chest pain, has shortness of breath upon exertion at baseline, denies dysuria, hematuria, or bright red blood per rectum. Past Medical History: -breast cancer, diagnosed in [**2102**]; bilateral with metastases to lymph nodes, s/p lumpectomy, local radiation and 5FU/adriamycin -osteoarthritis -s/p R-knee and L-hip replacement ([**2109**]) -Atrial fibrillation -rheumatoid arthritis -h/o adriamycin-induced cardiomyopathy -ulcerative colitis, s/p ileostomy -restrictive lung disease (related to radiation and/or amiodarone) -dilated cardiomyopathy Social History: The pt denied use of tobacco or illicit drugs. She admitted to occasional alcohol use. The pt lives alone, not married, no children, gets assistance from health aids. At baseline walks with a cane. Family History: No history of stroke or other neurologic disease. Physical Exam: Vitals: T100.5 Heart rate 82 Blood Pressure 148/72 RR 21, sO2 97 RA General: no acute distress, not dyspneic, pleasant Skin: no rash Head, ear, nose and throat: no bruits over the skull, moist mucous membranes Neck: no Carotid Bruits; palpation of the paraspinal soft tissues not painful, Brudzinski negative. Lungs: bronchial breathing sounds bilaterally Cardiovascular: Regular rate and rhythm, normal S1 and S2, I/VIsystolic murmur above the apex. Abdomen: normal bowel sounds, soft, nontender, nondistended. No organomegaly. Multiple scars form previous surgery. Ileostoma, site non-infected. Extremities: ecchymoses on both knees and L-arm, bilateral non- pitting edema lower extremities. NEUROLOGIC EXAMINATION: Mental Status: Awake and alert, cooperative with exam, pleasant affect. Oriented to person, place, month, day, date, and president Attention: Can say months of year backward; can perform serial subtractions. Language: Fluent with good comprehension and repetition. No paraphasic errors. Slight dysarthria. Naming is intact. [**Location (un) **] intact. Writing intact. Fund of knowledge normal. Able to calculate. Registration: [**2-12**] items, Recall [**1-12**] at 3 minutes No apraxia, No neglect (situation, space) Cranial Nerves: I: deferred II: Visual acuity 20/200 L and R. Visual fields are full to confrontation; Pupils equal, round and reactive to light both directly and consensually, 1 mm bilaterally. Fundoscopic exam: not able to see discs, no hemorrhages or exudates. III, IV, VI: Not able to move both eyes across the midline to the L. Able to move R eye laterally, but not sustained. Vertical eye movements intact. Ptosis on the L. V: Facial sensation intact in V1,V2, and V3 to light touch; not able to feel pinprick and temperature (cold) in V1, V2, and V3 on the right. Jaw opening with deviation to the R. VII: Facial paresis on L side both in upper and lower part of the face. VIII: Hearing intact to finger rub bilaterally. IX, X: Palate elevates in midline. [**Doctor First Name 81**]: Sternocleidomastoid [**4-14**] on left. Not able to keep head up in sitting position ([**2-14**]), pointing to neck extensor weakness. XII:Tongue protrudes to the right, able to move in both directions, no fasciculations or atrophy. Motor: Normal bulk and tone bilaterally. No fasciculations, no pronator drift; intermittent tremor in arms. No athethosis. No asterixis. Strength: D T B WF WE FiF [**Last Name (un) **] IP Gl Q H AF AE TF TE Right 5 5 4 4 4 4 4 4 5 5 5 5 5 5 5 Left 4 5 4 4 4 4 4 4 5 5 5 5 5 5 5 Sensory: Sensation was intact to light touch; pin prick was decreased in upper extremity and lower extremity; vibration decreased in feet only; proprioception intact in all extremities. No extinction to double, simultaneous stimulation. Reflexes: B T Br Pa Ach Right 1 1 1 1 - Left 1 1 1 1 - Brisk masseter reflex. Toes were equivocal bilaterally. Coordination: Finger-nose-finger slow and more difficult on L-side, possibly related to double vision, rapid alternating normal, heel to shin normal. Gait: not tested; when sitting up patient she was not able to hold her head up against gravity. Pertinent Results: Labs on admission: [**2111-8-2**] 08:25AM BLOOD WBC-8.8 RBC-3.02* Hgb-10.6* Hct-32.8* MCV-108* MCH-35.2* MCHC-32.4 RDW-15.3 Plt Ct-199 [**2111-8-2**] 08:25AM BLOOD Neuts-85* Bands-0 Lymphs-6* Monos-8 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* [**2111-8-2**] 08:45AM BLOOD PT-13.6* PTT-20.7* INR(PT)-1.2 [**2111-8-2**] 08:25AM BLOOD Glucose-143* UreaN-20 Creat-1.1 Na-138 K-3.6 Cl-102 HCO3-27 AnGap-13 [**2111-8-3**] 04:25AM BLOOD Calcium-7.3* Phos-2.3* Mg-1.7 Cholest-216* [**2111-8-3**] 04:25AM BLOOD Triglyc-68 HDL-117 CHOL/HD-1.8 LDLcalc-85 [**2111-8-3**] 04:25AM BLOOD %HbA1c-5.4 [Hgb]-DONE [A1c]-DONE . On discharge INR 2.9, HCT 27.4, WBC 5.2, PLT 150, Creat 0.6, K 4.8 . CSF: Hematology ANALYSIS WBC RBC Polys Lymphs Monos [**2111-8-3**] 10:30AM 631 16* 84 3 13 TUBE #4 [**2111-8-3**] 10:30AM 471 37* 79 5 16 TUBE #1 CHEMISTRY TotProt Glucose [**2111-8-3**] 10:30AM 110* 91 TUBE #2 . Imaging: [**2111-7-17**]: Chest CT (oupt): Bilateral apical consolidation with traction bronchiectasis consistent with post-radiation changes. Bilateral patchy ground-glass opacities in both upper lobes and right lower lobe, which may be due to infectious or inflammatory etiology. A followup CT scan is recommended in 3 months. Stable right-sided septal thickening and right pleural thickening. . [**8-2**] MRI head: Small (4 x 7 mm), ring-enhancing mass within the left pontine tegmentum, with signal and enhancement characteristics of some concern for an abscess. Neoplastic disease would be a secondary consideration, in view of the history of prior breast cancer. Rim enhancement would be very atypical for an infarct. . [**8-4**]: Echo: Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal (LVEF>=60%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild to moderate ([**1-11**]+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. . [**8-4**]: CT chest: New moderate bilateral pleural effusions with bilateral basilar atelectasis. Bilateral apical consolidation with traction bronchiectasis. No evidence of lymphangitic spread of disease. . [**8-4**]: CT neck: No evidence of lymphadenopathy noted on this neck CT. Sinus disease. Bilateral pleural effusion. . [**8-6**]: CT sinuses: The left sphenoid cell is almost completely opacified. This may be secondary to inspissated secretions and mucosal thickening. However, the bony margins are intact. There is no evidence of bony disruption or erosion. The right sphenoid air cell appears to have a small air fluid level within it. There is ethmoid sinus mucosal thickening. The maxillary sinuses appear normal. The septum is midline. The cribriform plates are at the same level. There is a slight leftward septal deviation. . [**8-4**]: CT pelvis: There has been interval left total hip replacement, which is noted to cause a large amount of streak artifact in the pelvis, slightly limiting evaluation for signs of infection. Allowing for this, there are no bony destructive changes. There is no evidence of hardware loosening. No fluid collections are identified. A Foley catheter is present within the collapsed bladder as well as note of a small amount of air, which may be seen with recent manipulation. An ileostomy is noted in the right lower uadrant. There is diffuse stranding of the subcutaneous fat consistent with anasarca. Note is made of calcified injection granulomas in the posterior subcutaneous tissues. A cleft is noted along the midline of the posterior subcutaneous tissues overlying the sacrum, which is most consistent with a skinfold. IMPRESSION: 1. No definite signs of infection given limitations of technique and streak artifact. If there is strong clinical suspicion, a MRI or white blood cell scan would be helpful. 2. Findings consistent with anasarca in the subcutaneous tissues. . [**8-8**]- MRI lumbar spine: Moderate degenerative changes and two perineural cysts at the S2 level. . [**8-11**]- CXR: Left lower lobe atelectasis. Mild congestive heart failure with mild cardiomegaly. Small bilateral pleural effusions. . [**8-12**]: Head MRI: FINDINGS: Again, note is made of pontine abscess with ring enhancement, which has increased in size compared to the prior study and now spreading across the midline to the right side of the pons, with increased amount of surrounding edema. Note is made of high signal intensity on diffusion-weighted images corresponding to the area of abscess, which also spread across midline. Note is made of low signal intensities on gradient echo at the location of the abscess, which may represent hemorrhage content or free radicle. The rest of the brain appears unremarkable. Again, note is made of opacification of the left sphenoid sinus, representing sinus disease. Note is made of fluid within the bilateral mastoid cells. IMPRESSION: 1. Progression of the pontine abscess with ring enhancement, associated with increased edema and hemorrhage versus free radicle formation, which now crossing the midline and extending to the right side of the pons. 2. Chronic sinus disease in left sphenoid sinus. . [**8-15**]- MRI head: signal abnormality with hyperintensity to signal is seen involving the posterior portion of the pons along the floor of the fourth ventricle. In this region, rim-enhancing areas are identified concerning for infectious etiology. Mild brain atrophy. . [**8-13**]: CT sinuses: Again, note is made of fluid within the left sphenoid sinus with multiple small collections of air probably epresenting sinusitis. The septum of the sphenoid sinus inserts at right carotid groove. Note is made of mucosal thickening of bilateral ethmoid sinuses, unchanged compared to the prior study. Bilateral maxillary sinuses are clear. Again, note is made of fluid within bilateral mastoid air cells. Anterior clinoid processes are not pneumatized. The patient is status post intubation. No intracranial air is noted. IMPRESSION: Continued left sphenoid fluid with air bubbles, representing sinusitis. Mucosal thickening of bilateral ethmoid sinuses. . [**8-21**]: MRI head: Decrease in size of the enhancing multi-cystic lesion in the pons, with decreased amount of edema, surrounded by high low signal intensity ring on T1-weighted images, probably representing improving pontine abscess. Unchanged appearance of opacification of the left sphenoid sinus. Bilateral mastoid air cell opacification. . [**8-30**]: MRI head: Compared to examinations performed at the beginning of [**Month (only) 216**], and even to the study of [**2111-8-21**], there is less edema in the dorsal pontine body, than on previous studies. The left paramedian abscess, which has susceptibility artifact along its rim, is slightly smaller in size. Enhancement in this area has also decreased. Diffusion signal hyperintensity persists, and may represent residual liquified material within the abscess. There continues to be opacification of the mastoid air cells and fluid or mucosal thickening within the sphenoid sinus. Overall, the appearance of the remainder of the brain is unchanged. The ventricles are not dilated. . [**9-4**]: GI bleeding study: Probably negative GI bleeding study, indicating no active bleeding at the time of study. The left upper quadrant accumulation of activity was not positively confirmed as free pertechnetate; however, were this to represent bleeding, the rate of bleeding was not brisk. . [**9-6**]: BILAT LOWER EXT VEIN: Limited study. No evidence of DVT, but the right distal SFV and left politeal could not be imaged. . [**9-9**]: MRI Head: No significant interval change seen involving the examination of the brain since [**2111-8-30**]. An area of residual enhancement is still present along the posterior aspect of the pons and upper medulla with some diffusion abnormality still present suggestive of a partially resolving posterior pontine abscess. Bilateral T2 hyperintensities within the mastoid and sphenoid sinuses. Followup is recommended and should be based on clinical grounds. . [**9-12**]: Portable CXR: A left-sided PICC line terminates at the junction of the left brachiocephalic vein, and upper superior vena cava. A tracheostomy tube is in unchanged position. A Dobhoff tube is seen extending towards the stomach antrum. When compared with prior study, there is no significant interval change in appearance of the lungs. The cardiac silhouette, mediastinal and hilar contours are normal and stable. There remains pulmonary vascular congestion and redistribution bilaterally, and there are stable bilateral pleural effusions. Again, noted are fibronodular opacities within bilateral lung apices, as previously described. These are stable in size and appearance. The surrounding soft tissue and osseous structures are unremarkable. IMPRESSION: 1. Stable interval appearance of pulmonary vascular congestion and bilateral pleural effusions, consistent with congestive heart failure. 2. Stable fibronodular opacities in bilateral lung apices, as previously described. 3. Lines and tubes as indicated above. EEG [**2111-9-30**] : Abnormal portable EEG due to the slow and disorganized background and bursts of generalized slowing. These findings indicate a widespred encephalopathic condition affecting both cortical and subcortical structures. Medications, metabolic disturbances, and infection are among the most common causes. There were no areas of persistent focal slowing, and there were no overtly epileptiform features. There was a large amount of movement artifact. Some artifact appeared due to tremor or other head movement. No electrographic seizures were recorded. [**2111-9-9**] 03:19AM BLOOD WBC-6.1 RBC-3.03* Hgb-9.3* Hct-29.3* MCV-97 MCH-30.8 MCHC-31.9 RDW-20.0* Plt Ct-51* [**2111-9-9**] 03:19AM BLOOD Plt Ct-51* [**2111-9-9**] 03:19AM BLOOD Glucose-80 UreaN-43* Creat-0.7 Na-144 K-4.1 Cl-109* HCO3-28 AnGap-11 [**2111-9-8**] 03:10AM BLOOD ALT-29 AST-35 LD(LDH)-387* AlkPhos-166* Amylase-291* TotBili-0.5 [**2111-9-8**] 03:10AM BLOOD Lipase-85* [**2111-9-9**] 03:19AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.0 [**2111-8-9**] 04:00AM BLOOD TSH-1.1 [**2111-8-9**] 04:00AM BLOOD Free T4-0.9* [**2111-9-2**] 01:35PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE [**2111-9-5**] 01:02PM BLOOD [**Doctor First Name **]-NEGATIVE Brief Hospital Course: The patient was admitted to the ICU where she remained until discharge. 1. Pontine abscess: It was originally thought that the symptoms could be related to a brainstem ischemic event, as the MRI performed on admission revealed an area of restricted diffusion in the left pontine tegmentum. Upon further review of the entire MRI study by the radiology service, it was felt that this lesion more likely represented an abscess given that it was ring-enhancing on T1 with gadolinium. In addition, the patient had a persistent fever, supporting this hypothesis. A lumbar puncture revealed pleocytosis and elevated protein; gram stain was negative; serologic and laboratory studies on CSF remained negative. An HIV antibody was sent and returned negative. In addition, the pt was ruled-out for tuberculosis with acid fast smear taken from endotracheal samplings. In addition, a TTE was performed that revealed no valvular lesions or vegetations. A dental consult, given a history of mandibular implants, provided no evidence of infection at the site of the implants. A CT scan of the left hip was performed which showed no evidence of infection of the replacement hip. CT of the sinuses were performed and showed evidence of mucosal thickening in the left sphenoid sinus. A biopsy of the left sphenoid sinus demonstated a group of cells that were suspicious for carcinoma. Further workup should take place once the patient is in better condition, i.e. as outpatient. Altogether, no pathogens could be identified that might have caused the abces. A biopsy would have been the only means to make the ultimated diagnosos, but this procedure was considered to be too dangerous (per Neurosurgery). The infectious disease consult team recommended treating for presumptive bacterial infection with intravenous ceftriaxone, ampicillin, vancomycin and metronidazole. On hospital day ten, a repeat MR of the head was performed to assess for response of the lesion to a course of antibiotics. Unfortunately, the MR revealed extension in the size of the lesion. The pt showed evidence of worsening clinically on hospital day twelve with a small (1mm) but reactive right pupil and sluggishly reactive (although normal-sized) left pupil as well as evidence of a left cranial nerve twelve palsy. Yet another MR of the head was performed which showed stable size of the lesion from the study of two days prior. Neurosurgical consultation was requested to assess whether the lesion would be amenable to drainage in light of the extension seen radiographically. It was felt that given the location of the lesion, biopsy or drainage would entail too great a likelihood of morbidity. The antibiotic regimen at this point was changed to meropenem (to cover gram positive and negative organisms as well as Nocardia) and ambisome to cover fungal pathogens. High-dose dexamethasone was also added and later tapered. A repeat MRI of the head was performed to reassess the lesion on hospital day 18. This demonstrated decreased size of the lesion and surrounding edema after treatment with antibiotics Given the high suspicion for Listeria as the etiologic [**Doctor Last Name 360**], with other possible pathogens including HSV, the antibiotic regimen was changed to high-dose penicillin and acyclovir at this time. She began to slowly improve clinically. Acyclovir was discontinued after 10 days. Further MRI studies ([**8-30**] and [**9-9**]) showed continued improvement. Upon discharge, the patient had regained slight horizontal eye movements. She is left with a significant L-facial paresis, is able to move her tongue, but with difficulties and remains unable to clear her secretions. Her way of communicating is through writing, although this is at times difficult due to a tremor. To evaluate an episode of altered mental status, an EEG was obtained that showed no epileptiform waves but did show patterns consistent with metabolic encephalopathy. Neurology was consulted and did not suggest that any of her altered mental status or tremors were due to seizures. Her mental status cleared as her hypoglycemia and infections resolved. In addition to the problems involving her cranial nerves, she has significant proximal muscle weakness in her upper and lower extremities, mostly secondary to her infection and high dose steroids. The steroids have been tapered down to prednisone 8 mg daily, on which she needs to remain (i.e. her home dose was 10). Follow up MRI was done on day if discharge. She will follow up with neurology and infectious disease to evaluate improvement. SHe completed course of penicillin G to treat the presumed Listeria abscess. . 2. Atrial fibrillation: On admission, the pt was in atrial fibrillation with rapid ventricular rate to the 130s. She was maintained on metoprolol and diltiazem was added to aid in rate-control. Amiodarone was discontinued per her cardiologist, Dr. [**Last Name (STitle) 1911**]. Anticoagulation was held early in the course of the admission over concern for hemorrhage into the pontine lesion, but was later restarted. The patient than developed a GI bleed, while her INR was supratherapeutic and her platelets were dropping. Coumadin was held until PLT had recovered (i.e. >150.000). She was reloaded on amiodarone as it seemed to be the only [**Doctor Last Name 360**] that adequately rate controlled her which was necessary to improve filling times forward flow but this was subsequently d/c. She is currently rate controlled on digoxin (last level 1.1 on [**10-8**]) and metoprolol 25 mg QID with hr ranging from 90-120. She is currently being reloaded on coumadin as she is subtherapeutic. . 3. Hypotension: the patient had several episodes of hypotension. These might have been related to her primary brainstem lesion in combination with sedation and blood loss (see below). For support she was started on neosynephrine gtt when needed. Most recently she again required pressors on [**10-6**] following a large volume thoracentesis. DDX included adrenal insufficiency, fluid shift, or new infection/early sepsis. She was able to be weaned off pressors w/o stress dose steroids and stabilized on vanc/meropenem. Cultures were only notable for MRSA in her sputum. Thus, plan for 10 day course of vancomycin to end on [**2111-10-17**]. Patient has now been stable off pressors x 7 days. She is fluid overloaded on exam. She should be started on diureses while at rehab, when her BP is stable. Her blood pressure has been lowish with SBP in the loww 100's. We opted not to start diuresis on discharge as we were titrating her metoprolol. We recommend a dose of Lasix 10 IV BID with goal negative fluid balance of 500-1000cc per day. . 4. Respiratory: Shortly after admission, the patient was intubated because she was not able to swallow and clear her secretion. A tracheostomy was performed on [**8-13**]. She was placed on ventilator support. During her stay, she developed worsening respiratory distress. Bronch specimen produced stenotrophomonas maltophilia and patient completed a 21 day course of bactrim for this. As described above, patient also being tx for MRSA PNA and is currently d9/10. Currently she is vent dependent. Her current settings are PS 15 w/ PEEP 5 and FiO2 40%. Of note, the patient has a poor pulmonary baseline secondary to radiation (breast ca). . 5. Ophthalmology: The patient has bilataral keratopathy (L>R) and evidence of corneal abrasion on left. Ophthalmology was consulted. Erythromycin gtt and artificial tearts should be continued. A patch over her left eye will help her manage her diplopia. The patch should be removed a few hours a day, this to train her eyes. She should be seen by an ophthalmologist in one week after discharge. . 6. Hematology: After the patient was restarted on coumadin, her Hct dropped. She was transfused with pRBC to keep Hct>30. Gasteroenterology was consulted to evaluated for GI bleed as her stools looked tarry, suggesting an upper GI bleed. Their workup remained negative (see below). In addition, her PLT trended down to the 50's. This drop might have been medication related. Bactrim was therefore discontinued but later restarted without further thrombocytopenia. Heparin Abs were negative and lab results did not suggest intravascular hemolysis. Another etiology might include pancytopenia secondary to her chronic disease. Currently, hct stable around 28 and plt 150's and have remained stable in the week prior to discharge. She is expected to improve slowly. . 7. Infectious disease: -Brainstem abcess: Responded well to penicillin G i.v. She has received a total of 8 week course with penicillin G. -MRSA in sputum/sinus/stool culture, representing colonization. She is due to finish course on [**2111-10-17**]. -stenotrophomonas in sputum, representing colonization. This was treated with bactrim. . 8. Gasteroenterology: The patient has a stoma. Following a drop in Hct and tarry stools, she was evaluated by GI. an EGD [**9-3**] showed no active bleed but an AVM that might have bled. A bleeding scan with tagged blood was negative for GI bleed as well. The patient was started on PPI iv q 12hrs, to be converted to PO BID upon discharge. In addition, elevated LFT's and lipase/amylase were noted. These abnormalities might be related to overall poor condition or sludge/stones. The patient did not complain of abdominal discomfort. Please continue to follow these enzymes. Further workup should be considered only once she has recovered. . 9. Endocrine: The patient's glucose levels were adjusted per RISS and FSBS were followed. This is to be continued after discharge. Please follow up on thyroid studies, i.e. monitor for hypothyroidism. The patient's home dose of 6 units NPH [**Hospital1 **] was discontinued since she had several hypoglycemic events as low as 30. FS during last week of hospitalization have been in 80-160. . 10. FEN: The patient has a NGT and received TF that she tolerates well. Consider to further improve her protein status with supplements. The patient is significantly fluid overloaded. This should be improved by ace-wraps, improvement of protein status and mobilization. She was gently diuresed as pressure allowed. . 11. PPX: pneumoboots, PPI, "ski-boots" for contractures, [**Male First Name (un) **] stockings or ace wraps for edema, OOB to chair. Please provide skin care to coccygeal area. Medications on Admission: ACETAMINOPHEN 325MG.--2 tabs by mouth q4 hours AMBIEN 5MG--One by mouth at bedtime as needed for sleep AMIODARONE HCL 200MG--One daily AQUAPHOR --Apply top as needed for -- to pruritic areas DIOVAN 80MG--One daily LASIX 20MG--One daily LIPITOR 10MG--One daily LOTRISONE .05%--Apply to foot twice a day MEGACE 20MG--One tabl twice daily, in the morning and the evening MULTIVITAMINS --One tablet by mouth every day OXAZEPAM 15 MG--One capsule by mouth as needed at bedtime insomnia PREDNISONE 5MG--Take 2-5mg tabs and 1-20mg tablet daily for 7 days; then, 3-5mg tabs daily for 7 days; then 2-5m tabs daily for 7 days; then 1-5mg tablet daily for 7 days, then call us. TAMOXIFEN 10 MG--One tablet by mouth three times a day TAMOXIFEN CITRATE 10MG--One by mouth twice a day. TOPROL XL 25MG--One twice daily WARFARIN SODIUM 3MG--One daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Albuterol 90 mcg/Actuation Aerosol Sig: 6-8 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. 3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-11**] Drops Ophthalmic Q3H (every 3 hours). 4. Erythromycin 5 mg/g Ointment Sig: One (1) drop Ophthalmic TID (3 times a day). 5. Erythromycin 5 mg/g Ointment Sig: One (1) drop Ophthalmic QHS (once a day (at bedtime)). 6. Folic Acid 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily). 7. Dolasetron Mesylate 12.5 mg IV Q8H:PRN 8. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 11. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO once a day. 12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 13. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 14. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 15. Prednisone 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 16. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous Q 36H () for 1 doses: last dose on [**2111-10-17**]. 17. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 18. Lorazepam 2 mg/mL Syringe Sig: 0.5 mg Injection every eight (8) hours as needed for agitation/anxiety. 19. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO QID (4 times a day): hold for SBP<95, HR<65. 20. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-11**] Drops Ophthalmic Q3H (every 3 hours). Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: 1. pontine abcess 2. MRSA sinusitis, atypical cells to be evaluated by oncology as outpatient 3. Atrial fibrillation with rapid ventricular response 4. gasterointestinal hemorrhage 5. thrombocytopenia 6. anemia 7. hypotension 8. steroid myopathy 9. sepsis Discharge Condition: Fair Discharge Instructions: Please continue medications as instructed. . Please provide care to the tracheostoma and colonostoma. . Please provide skin care to the coccygeal area. . Hold coumadin until INR<1.5 then have subclavian central line pulled. Then re-start coumadin. Start 5 mg once, then 2 mg daily, checking INR's 2x/week until on stable regimen . Re-start lasix at recommend dose of 10 IV BID when BP stable (SBP>105) Followup Instructions: Please follow up with your Primary Care Physician after discharge from rehab. . Please follow up at the [**Hospital 878**] Clinic: Provider: [**Name10 (NameIs) 5005**] [**Name Initial (NameIs) **] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2111-10-23**] 9:30AM, [**Hospital Ward Name 23**] [**Location (un) **]. . Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] OB/GYN PPS CC8 (SB) Where: OB/GYN PPS CC8 (SB) Date/Time:[**2111-10-7**] 1:00 . Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**] [**Hospital 2039**] CARE CENTER Phone:[**Telephone/Fax (1) 6733**] Date/Time:[**2111-12-10**] 11AM, [**Hospital Ward Name 23**] [**Location (un) 442**]. . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6719**], M.D. Where: [**Hospital6 29**] [**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2111-12-17**] 9:45 Have ophthalmology follow up with respect to the keratopathy every two weeks. You have follow up with Infectious Disease regarding your brain abscess, Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2111-11-12**] 8:30AM, [**Last Name (NamePattern1) **]. Basement, Suite G [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

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icd9cm

[ [ [] ] ]

[ "31.1", "99.07", "34.91", "96.04", "33.21", "22.11", "38.93", "96.6", "99.05", "99.04", "45.13", "96.72" ]

icd9pcs

[ [ [] ] ]

29306, 29378

16189, 26553

280, 348

29678, 29685

5319, 5324

30136, 31575

2091, 2142

27438, 29283

29399, 29657

26579, 27415

29709, 30113

2157, 2852

1297, 1427

231, 242

376, 1278

3412, 5300

5338, 16166

2891, 3396

2876, 2876

1449, 1856

1872, 2075

63,509

166,932

38931

Discharge summary

report

Admission Date: [**2121-2-13**] Discharge Date: [**2121-2-27**] Date of Birth: [**2086-1-23**] Sex: F Service: OME HISTORY OF PRESENT ILLNESS: The patient presented to [**Hospital **] Hospital on [**2121-2-10**] with back pain and shortness of breath and was found on chest x-ray and CT to have pulmonary nodules, liver, and renal masses. She underwent biopsy of a left groin nodule and the skin nodule revealing melanoma and was diagnosed with metastatic melanoma. She was subsequently transferred to [**Hospital1 69**] on [**2121-2-13**] for further management. On admission, her back pain was managed with MS Contin with p.r.n. morphine with good response. A CT was negative for brain metastasis. She underwent a spinal MRI to rule out cord compression which revealed multiple lytic lesions but no spinal cord compression. Treatment options were discussed and high-dose IL-2 therapy was recommended. She initiated high-dose IL-2 on [**2121-2-15**] after undergoing central line placement in interventional radiology. During this week, she received [**11-25**] doses of IL-2 with course complicated by pulmonary edema. She was managed with oxygen supplementation and aggressive Lasix diuresis as well as albuterol nebulizers. Her respiratory status worsened over the next 36 hours, requiring ICU transfer for aggressive diuresis and fluid management. She did not require intubation. She was treated with antibiotics for a possible pneumonia. She slowly improved with Lasix diuresis and was transferred out of the ICU on [**2121-2-26**] and was able to be discharged to home later that day when ambulating off O2 without noted hypoxia. Other side effects during this week included rigors improved with Demerol; nausea improved with antiemetic therapy; normal sinus tachycardia and development of an erythematous skin rash. During this week, she had no renal failure noted. She developed transaminitis with a peak ALT of 156 and a peak AST of 200, both improved at the time of discharge. She developed hyperbilirubinemia with a peak bilirubin of 4.7 improved to 3.2 at the time of discharge. She was anemic without need for packed red blood cell transfusion. She developed thrombocytopenia with a platelet count low of 85,000 without evidence of bleeding. She had no myocarditis or coagulopathy noted. By [**2121-2-27**], she had recovered from side effects to allow for discharge to home. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To home with her family. DISCHARGE DIAGNOSIS: Metastatic melanoma status post cycle 1 week one high-dose IL-2 therapy complicated by pulmonary edema. DISCHARGE MEDICATIONS: Tylenol 1-2 tablets q.i.d. p.r.n. pain, Zantac 150 mg p.o. b.i.d. p.r.n. indigestion, lorazepam 0.521 mg t.i.d. p.r.n. nausea/vomiting or anxiety, Benadryl 25-50 mg q.i.d. p.r.n. pruritus, Compazine 10 mg q.i.d. p.r.n. nausea/vomiting, Lomotil 1-2 tabs q.i.d. p.r.n. diarrhea, Eucerin cream topically, Sarna lotion topically, MS Contin 15 mg p.o. b.i.d., Senna tablets 1-2 tablets p.o. b.i.d. p.r.n. constipation, oxycodone 5-10 mg every 4 hours p.r.n. pain, guaifenesin [**4-21**] mL p.o. every 6 hours p.r.n. cough, nicotine patch 21 mg topically every 24 hours, levofloxacin 500 mg p.o. daily x3 days, MiraLax 17 grams p.o. daily p.r.n. constipation. FOLLOW-UP PLANS: The patient will return in 1 week for Week 2 of therapy assuming she recovers adequately. [**First Name11 (Name Pattern1) 449**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], [**MD Number(1) 21348**] Dictated By:[**Last Name (NamePattern1) 18853**] MEDQUIST36 D: [**2121-5-13**] 12:51:45 T: [**2121-5-14**] 12:05:12 Job#: [**Job Number 86375**]

[ "172.7", "196.5", "197.7", "305.1", "787.02", "427.89", "285.9", "E933.1", "275.2", "287.4", "518.4", "486", "198.5", "197.0", "198.0", "518.81", "300.00", "276.8", "693.0" ]

icd9cm

[ [ [] ] ]

[ "38.93", "00.15" ]

icd9pcs

[ [ [] ] ]

2645, 3300

2516, 2621

3318, 3712

165, 2415

2440, 2494

48,479

123,178

39789

Discharge summary

report

Admission Date: [**2180-7-17**] Discharge Date: [**2180-11-2**] Date of Birth: [**2153-3-30**] Sex: M Service: SURGERY Allergies: Adult Low Dose Aspirin / CellCept / Shellfish Attending:[**First Name3 (LF) 695**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Paracentesis, multiple [**2180-8-23**] Orthotopic deceased donor (brain dead) liver transplant (piggyback), portal vein anastomosis, Roux- en-Y hepaticojejunostomy, infrarenal aortic conduit to the common hepatic artery of the donor. [**2180-9-30**] Exploratory laparotomy, evacuation of intraabdominal clot, redo Roux-en-Y hepaticojejunostomy, and Tru-Cut biopsy of the liver [**2180-8-5**] Angiogram with embolization of IPDA [**2180-9-4**] Tunnelled line placement [**2180-9-11**] Percutaneous cholangiogram [**2180-10-26**]: Endoscopically placed post pylotic feeding tube History of Present Illness: The patient is a 27-year-old incarcerated male s/p cadaveric liver transplant in [**2169**] for autoimmune hepatitis and PSC complicated by graft failure secondary to recurrent disease/chronic rejection (now on transplant list again) transferred from OSH after being found obtunded. He was brought to OSH where he was intubated for protection of airway. Labs there notable for tbili of 35.2, INR of 3.6,and Cr 1.5 (baseline 1). Also had a lactate of 4.5. A CT scan of the head was done that showed no acute intracranial process. . Of note had recent admits to [**Hospital1 18**] for encepholopathy on ([**Date range (1) 17913**]) w/ confusion that improved after starting rifamixin & lactulose and episode of BRBPR for which he was transfused 1 unit prbc. He then had an additional admit for on [**4-24**] w/ encephalopathy, jaundice thought to be related to noncompliance w/ medication. Had third admission from [**2180-5-24**] to [**2180-5-30**] for back pain and found to have T10-L2 compression fractures and was sent home with TLSO brace. . He arrived to the ED on [**2180-7-17**] and was admitted to the SICU. A RUQ US was performed that showed patent vasculature. He had a chest x-ray that showed possible PNA in LLL so he was started on vancomycin and zosyn. A BAL performed on [**7-17**] showed 3+GNR/3+budding yeast/2+GPCs. He got 1 dose of fluconazole but this was discontinued due to lack of evidence supporting treating yeast from BAL and sputum specimens. He was extubated on [**7-17**] and has been doing well, weaned down to room air. A Right IJ was placed for access. He was given 1 u PRBC on [**7-18**] for a hct of 21.3 /w appropriate response. Past Medical History: Autoimmune hepatitis Primary sclerosing cholangitis s/p liver transplant [**2169**] ([**Doctor Last Name **]) h/o liver rejection [**2178**] pancreatitis [**2-24**] cellcept in [**2177**] SLE adrenal insufficiency DMII - since [**2177**] HTN h/o UGIB [**2-24**] gastritis [**2178**] h/o of GBS bacteremia panic attacks. . Past Surgical History: Liver transplant (UPenn, [**2169**]) Social History: 10.5 pack-year history. Ceased tobacco use 1.5 years ago. Denies alcohol and IV drug use. Has used marijuana. Has been in prison for last 8 months with a sentence of 3.5 more years. Family History: Father - DM, Grandmother - SLE, breast CA, No FH of liver or kidney disease. Physical Exam: ADMISSION PHYSICAL EXAM HEENT: PERRL, EOMI, scleral icterus, diffusely jaundiced CARDIOVASCULAR: Regular rhythm RESPIRATORY/CHEST: Symmetric expansion, CTA bilaterally ABDOMINAL: Distended, +fluid wave NEUROLOGIC: Responds to noxious stimuli, moves all extremities, sedated DISCHARGE PHYSICAL EXAM General: Cachectic and frail in appearance HEENT: No scleral icterus, has temporal wasting CV: RRR, no M/R/G Lungs: CTA bilaterally Abd: Wound Vac in place, Has capped Roux tube, Capped PTC, no ascites, c/o mild tenderness around VAC incision area Extr: No edema Pertinent Results: ADMISSION LABS [**2180-7-16**] 10:10PM URINE RBC-35* WBC-3 BACTERIA-NONE YEAST-NONE EPI-0 TRANS EPI-<1 [**2180-7-16**] 10:10PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-LG UROBILNGN-NEG PH-7.5 LEUK-NEG [**2180-7-16**] AMMONIA-157* [**2180-7-16**] ALT(SGPT)-71* AST(SGOT)-64* ALK PHOS-246* TOT BILI-30.7* DIR BILI-22.5* INDIR BIL-8.2 [**2180-7-16**] GLUCOSE-259* UREA N-22* CREAT-1.1 SODIUM-144 POTASSIUM-3.0* CHLORIDE-109* TOTAL CO2-20* ANION GAP-18 [**2180-7-16**] PT-53.2* PTT-51.9* INR(PT)-5.3* [**Hospital3 984**] [**2180-7-17**] 12:18PM BLOOD ALT-63* AST-56* LD(LDH)-250 AlkPhos-221* TotBili-30.1* [**2180-7-18**] 02:24AM BLOOD ALT-55* AST-44* LD(LDH)-212 AlkPhos-195* TotBili-28.3* [**2180-7-19**] 04:50AM BLOOD ALT-49* AST-43* LD(LDH)-231 AlkPhos-201* TotBili-28.2* [**2180-7-20**] 05:00AM BLOOD ALT-63* AST-54* LD(LDH)-292* AlkPhos-257* TotBili-38.1* DirBili-27.0* IndBili-11.1 [**2180-10-2**] 11:48AM HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HIV Ab-NEGATIVE HCV Ab-NEGATIVE IMAGING PRE TRANSPLANT: CXR [**2180-7-16**] FINDINGS: Endotracheal tube and NG tube are unchanged, end in standard position. Low lung volumes remain. There is unchanged dense consolidation of the left lung base, with a probable left pleural effusion. Developing opacity in the right lower lobe is new. The cardiac silhouette is top normal, the mediastinal contours are normal though remain shifted to the right. IMPRESSION: Increasing left greater than right basilar opacity likely reflecting atelectasis with moderate left pleural effusion, which are worsening and pneumonia with empyema should be considered. RUQ ULTRASOUND [**2180-7-18**] IMPRESSION: 1. Coarse liver echotexture without focal lesions. Hepatic vasculature is patent. 2. Splenomegaly. 3. Small-to-moderate amount of ascites. Head CT [**2180-7-22**]: No acute intracranial process CT Abd/Pelvis [**2180-7-26**]: 1. Acute hematoma in right paracolic gutter extending into the pelvis without evidence of active extravasation. 2. Large amount of ascites. 3. Findings consistent with cirrhosis with portal hypertension. 4. Right renal stone without evidence of obstruction. 5. Right pleural effusion with dependent atelectasis. .... Discharge Labs: [**2180-11-2**] WBC-3.4* RBC-3.30* Hgb-9.8* Hct-27.8* MCV-84 MCH-29.7 MCHC-35.2* RDW-17.4* Plt Ct-67* Glucose-161* UreaN-73* Creat-1.8* Na-129* K-4.8 Cl-95* HCO3-20* AnGap-19 ALT-9 AST-22 AlkPhos-121 TotBili-0.7 Calcium-9.4 Phos-4.4 Mg-1.7 [**2180-11-1**] 05:00AM BLOOD tacroFK-4.4* [**2180-11-2**] FK Pending: Will call if needs adjustment Brief Hospital Course: 27-year-old incarcerated male s/p cadaveric liver transplant in [**2169**] for autoimmune hepatitis and PSC complicated by graft failure secondary to recurrent disease/chronic rejection (re-listed for transplant) transferred from OSH after being found obtunded, found to have hepatic encephalopathy secondary to pneumonia. He was intubated to protect airway. Opacity and haziness in the LLL were seen on CXR, and treatment was begun for presumed pneumonia. Lactulose and Rifaximin were given. Respiratory and mental status improved after 1 day; he was weaned and extubated. BAL revealed GNRs, GPCs, and budding yeast. Vancomycin, Zosyn and Fluconazole were given. Fluconazole was stopped after discussion with ID. On [**7-20**], he was switched to levofloxacin and flagyl for treatment of presumed community acquired pneumonia and possible aspiration pneumonia. The final sputum culture found only rare commensal respiratory flora. Flagyl was stopped and Levo continued for 10 days for CAP. However, on [**7-21**] repeat chest x-ray showed a large left pleural effusion in addition to massive collapse of the alveoli of the RLL. Bilateral pleural effusions, L > R were noted. Effusions decreased in size after Lasix and Spironolactone. He was relisted for liver transplant after completing re-evaluation and sufficient treatment with antibiotics. Transaminases were stable throughout most of this admission. However, T bili continued to increase. Medical management continued. Hydrocortisone was given for adrenal insufficiency. Insulin was given for hyperglycemia secondary to steroids, infections and tube feeds. On [**7-22**], he had a generalized tonic-clonic < 1 minute seizure that self-resolved. Head CT was normal. Neuro thought seizure was secondary to metabolic disturbances. As this was his first seizure, anti-epileptic drug therapy was not started. With the seizure he had an aspiration event, requiring vanc/zosyn for a 8 day course after that event (Antibiotics stopped on [**2180-7-30**]). Paracentesis was performed several times. On [**7-25**] paracentesis was complicated by intraabdominal bleed which required 3 days in the SICU with multiple transfusions and blood products to keep hemodynamically stable. This bleed stopped after 24 hours. On [**8-6**], he had a massive GI bleed requiring scoping, massive transfusions, [**State **] tube and IR gelfoam of inf pancoduodenal Artery. On [**2180-8-23**], a liver donor offer was accepted. He underwent orthotopic deceased donor (brain dead)liver transplant (piggyback), portal vein anastomosis, Roux- en-Y hepaticojejunostomy, infrarenal aortic conduit to the common hepatic artery of the donor. Surgeon was Dr. [**First Name (STitle) **] W. [**Doctor Last Name **] assisted by Dr. [**First Name4 (NamePattern1) 3742**] [**Last Name (NamePattern1) **]. Postop, he remained in the SICU for management for 10 days during which time LFTs decreased with the exception of alk phos which slowly increased to the 200-300 range. JP drains (2)were serosanguinous. Roux tube was capped on postop day 8. He was extubated on postop day 9 ([**9-1**]). He required CVVHD then HD for [**Last Name (un) **]. [**2180-8-30**], he had multiple seizures likely from weaning propofol. Keppra was given IV bid. Head CT was negative. A left IJ tunnelled line was placed for HD. On [**9-5**], he was febrile to 101.3. He was pan cultured. Vanco and Cefepime were given. Blood and urine cultures remained negative. Atelectasis and small left effusion were seen on CXR. Bile was noted in the JP drain. Gravity cholangiogram via the Roux tube demonstrated contrast leak at the anastomosis. CT scan on [**9-9**] was done for fever, tachycardia and SOB. CT noted large gastrohepatic and hepato-IVC hematomas and left lower lobe and lingular consolidation and multifocal ground-glass opacities involving the right lung and left apex. A cholangiogram was performed on [**9-11**] noting a tiny contrast connection between the left side of the choledochojejunal anastomosis and the known leak. An 8 French modified nephrostomy pigtail with additional sideholes was placed. T. bili and alk phos decreased a little. Chevron incision leaked seroanguinous/bilious ascitic looking fluid. Incision was opened partially and a wound vac dressing was placed. Abdominal CT scan was done on [**9-12**] to evaluate hepatic artery given biliary anastomosis leak. This revealed heterogenous LLQ and perihepatic collections likely hematomas with large amount of intra abdominal ascites. At this time, he was experiencing a lot of left flank/LUQ pain. On [**9-15**] the LUQ collection was aspirated under U/S guidance for 900cc of greenish brown fluid. An 8 Fr drain was placed. This fluid was sent to micro and was negative. On [**9-20**], an abdominal CT scan was done to re-eval fluid collection. Persistent sub-hepatic fluid collections posterior to right and left hepatic lobes were seen. Drain fluid was sent for culture on [**9-23**]. Culture isolated VRE, Coag negative staph and [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 29361**]. Dapto, [**Last Name (un) **] and Micafungin were started. Tube cholangiogram on [**9-29**] showed persistent bile leak at biliary anastomosis. On [**9-30**], he was taken back to the OR for exploratory lap, evacuation of intra abdominal hematoma and fluid collections, redo of Roux en Y hepaticojejunostomy over 10 Fr silastic catheter, Tru cut bx of liver, and closure of wound with prolene mesh at trifurcation. Surgeon was Dr. [**First Name (STitle) **] W. [**Doctor Last Name **]. See operative note. Wound vac was placed across the entire Chevron incision. Two JP drains were in place with serosanguinous fluid. Roux tube was to gravity drainage with bile. This was later capped on [**10-13**] after tube cholangiogram demonstrated no leak on [**10-5**]. He was admitted to SICU following surgery. LFTs improved. Antibiotics continued until [**10-12**] (Dapto x 15 days, [**Last Name (un) **] x12 days). Micafungin was stopped on [**10-19**] (19days)when send out sensitivities showed [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 29361**] sensitive to Fluconazole. Fluconazole was started on [**10-20**]. He remained in the Sicu for 6 days transferring to med-[**Doctor First Name **] unit on [**10-6**] where he continued to receive nutrition from TPN which was later switched to tube feeds. He was extremely debilitated and was unable to lift legs off bed. PT worked with him and recommended rehab. He was very edematous and was given Lasix. Once diuresed, apparent cachexia was profound. Tube feeds were recommended, however, feeding tube was removed by patient. Appetite improved and kcals were documented. However, caloric intake (~1600 kcals/day) was not at goal despite supplements. JP drains were removed. Operative biliary drain was capped. VAC dressings were changed every 72 hours noting incision wound granulating (length 32 cm, width 2cm, depth 0.5 cm ). Sacral decub was noted (1cm stage 2)Mepilex was applied and appropriate mattress was in place. Renal function was notable for persistent alkalosis with C02 as low as 11. He was started on sodium bicarb as well as IV bicarb. Renal was consulted. He experienced abdominal distension and loose stools. Cellcept/bicarb and iron were stopped on [**10-11**]. Abdominal distension improved. CO2 improved with capping of Roux tube and biliary drain. Acute on chronic kidney failure noted to worsen again around POD 55/16. He was followed again by the renal service, but did not require further hemodialysis. Creatinine increased to as high as 2.4 with hyperkalemia on [**10-23**]. Prograf level was 16 at this time. Prograf dose was decreased and Kayexalate given. A renal u/s was done [**10-20**] noting mild to moderate right hydro with a couple non obstructing stones in renal pyramids. This finding was reviewed by radiology noting stable finding consistent with CT scan one month prior to US. UA and urine culture were sent. UA was negative except for hyaline casts. Culture was negative. A foley was attempted serveral time. Catheterization with a coude cath 12Fr was placed, but was subsequently removed for penile pain and urine leakage around catheter. A 14 Fr Coude catheter was placed on [**10-21**]. This was not well tolerated due to pain and urine leaking from around catheter. Foley was removed and left out. Urology was consulted and recommended PVRs and repeat renal US. Repeat renal US demonstrated stable hydronephrosis on right. No stone visualized. Post void residuals were negative. Mag/lasix renal scan done noting left kidney to be performing 26% of the total renal function and the right kidney performing 74%. No obstruction noted. Creatinine increased to 2.6 on [**10-25**] and [**10-26**]. The creatinine has slowly decreased again over the last few days of hospitalization. Medications remain renally dosed. With improving nutrition and prograf level management the creatinine appears to have stabilized around 1.8 with 1.5-2.5 liters urine daily. Edema is entirely resolved. Immunosuppression consisted of tapering steroids to 7.5 mg daily at time of discharge and Prograf. Mycophenylate which had been held from POD 49 - 70 for gastric distress was added back on [**2180-11-1**]. Prograf levels fluctuated and doses were adjusted. On [**10-27**], an EGD was done to place a nasojejeunal feeding tube. Stomach and esophagus appeared normal. Tube feeds ( Nepro) were started and tolerated over 24 hour period. He is now cycled for 16 hours at 60 cc, which is also well tolerated. Blood sugars have been labile requiring periodic adjustments, and patient being followed by [**Last Name (un) **]. He is being transferred to [**First Name4 (NamePattern1) 4115**] [**Last Name (NamePattern1) 11309**] Hospital in [**Doctor Last Name 13548**]as per request of the [**State 792**]D.O.C. and Dr [**Last Name (STitle) **] for continued rehabilitation. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Ondansetron 4 mg PO Q12H:PRN nausea 2. Hydrocortisone 20 mg PO QAM 3. Hydrocortisone 10 mg PO QPM 4. Lactulose 15 mL PO TID 5. Lidocaine 5% Patch 1 PTCH TD DAILY 6. Alendronate Sodium 70 mg PO QSAT 7. Ursodiol 300 mg PO BID 8. Tacrolimus 0.5 mg PO DAILY 9. HumaLOG *NF* (insulin lispro) 100 unit/mL Subcutaneous TID 8 UNITS BEFORE BREAKFAST, 12 UNITS BEFORE LUNCH, 20 UNITS BEFORE DINNER 10. NPH insulin human recomb *NF* 100 unit/mL Subcutaneous [**Hospital1 **] 50 UNITS QAM AND QPM 11. Furosemide 20 mg PO DAILY 12. Spironolactone 25 mg PO DAILY 13. Morphine Sulfate IR 30 mg PO BID 14. Calcitonin Salmon 200 UNIT NAS DAILY 15. Omeprazole 20 mg PO DAILY 16. Calcium Carbonate 500 mg PO BID 17. Rifaximin 550 mg PO BID 18. Vitamin D 50,000 UNIT PO 1X/WEEK (TU) Discharge Medications: 1. Pantoprazole 40 mg PO Q24H 2. Vitamin D 50,000 UNIT PO 1X/WEEK (TU) 3. ValGANCIclovir 450 mg PO EVERY OTHER DAY 4. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 5. Fluconazole 200 mg PO Q24H 6. HYDROmorphone (Dilaudid) 1 mg PO Q12H:PRN break thru pain hold for sedation/ respiratory depression 7. LeVETiracetam 500 mg PO BID 8. Methadone 2.5 mg PO BID monitor for sedation, respiratory depression 9. PredniSONE 7.5 mg PO DAILY 10. Sarna Lotion 1 Appl TP QID:PRN dry skin 11. Acetaminophen 650 mg PO Q8H Pain 12. Glargine 30 Units Breakfast Insulin SC Sliding Scale using REG Insulin 13. Metoprolol Tartrate 75 mg PO BID hold sbp<100, hr<60 14. Mycophenolate Mofetil 500 mg PO BID 15. Sodium Bicarbonate 650 mg PO BID 16. traZODONE 25 mg PO HS 17. Tacrolimus 2.5 mg PO Q12H 18. Ondansetron 4 mg PO Q12H:PRN nausea Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 4115**] [**Last Name (NamePattern1) 11309**] House Discharge Diagnosis: Hepatic encephalopathy now s/p liver transplant Community acquired pneumonia Seizure Cirrhosis from primary sclerosing cholangitis and autoimmune hepatitis GI bleed Bile leak Intra abdominal abscesses, VRE, staph coag negative and [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) **] HRS/[**Last Name (un) **] Malnutrition 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: [**Hospital1 18**] Transplant Service [**Telephone/Fax (1) 673**] should be called if patient develops any of the following: temperature of 101 or greater, chills, nausea, vomiting, inability to eat, drink or take medications, increased abdominal pain/distention, abdominal wound appears red or has purulent drainage, diarrhea or constipation, decreased urine output, or edema. - Please draw a Trough Prograf level only on Friday [**11-3**] with results to transplant clinic fax [**Telephone/Fax (1) 697**] Then resume twice weekly labs starting Monday [**11-6**] -Labs to be drawn every Monday and Thursday with results faxed to the transplant clinic at [**Telephone/Fax (1) 697**]. CBC, Chem 10, AST, ALT, Alk Phos, T Bili, Trough Prograf level. -wound vac will be changed every 3 days. Keep suction at 100 mm Hg continuous suction. Wound currently 32 cm wide, 4 cm at apex, and 2 cm at bilateral incision lines. very shallow but mesh with granulation tissue and prolene sutures below the black mesh Patient should be ambulating 4 times daily and participating in at least 1 hour of rehab activities daily. Followup Instructions: [**Hospital 1326**] Clinic, [**Hospital **] Medical Building, [**Last Name (NamePattern1) **], [**Location (un) 3971**], [**Location (un) 86**], MA Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14254**], [**Name12 (NameIs) 1046**] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2180-11-8**] 9:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2180-11-8**] 10:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2180-11-2**]

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icd9cm

[ [ [] ] ]

[ "51.37", "96.6", "39.95", "38.95", "51.98", "00.93", "50.59", "33.24", "88.47", "54.59", "50.11", "96.72", "45.13", "42.33", "99.29", "44.43", "87.54", "54.91" ]

icd9pcs

[ [ [] ] ]

18239, 18346

6519, 16490

326, 906

18729, 18729

3896, 6138

20038, 20690

3221, 3299

17403, 18216

18367, 18708

16516, 17380

18905, 20015

6154, 6496

2967, 3005

3314, 3877

265, 288

934, 2600

18744, 18881

2622, 2944

3021, 3205

21,122

184,528

7801

Discharge summary

report

Service: BLUE Date: [**2185-6-8**] Date of Birth: Sex: Surgeon: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4007**] DATE OF ADMISSION: [**2185-2-16**]. DATE OF DISCHARGE: [**2185-3-17**]. CHIEF COMPLAINT: Left upper quadrant abdominal mass. HISTORY OF THE PRESENT ILLNESS: The patient is a pleasant 70-year-old male who was referred from the [**Hospital 3340**] Clinic in [**State 108**] for management of a malignant peritoneal mesothelioma. He complained of early satiety and weight loss over a six-month period. He was evaluated in [**State 108**] to have a very large left upper quadrant mass. Percutaneous needle biopsy was done at that time, which showed it to be malignant mesothelioma of the peritoneal cavity. Metastatic workup revealed that the patient did not have any spread of disease. However, he continued to accumulate ascites requiring multiple paracenteses. The patient was referred to the Surgical Service here in conjunction with the oncology service for management of his malignant mesothelioma. PAST MEDICAL HISTORY: History is significant for a small hiatal hernia, and hypertension. MEDICATIONS ON ADMISSION: Zestril. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient is a retired food broker. He quite smoking cigarettes 35 years ago. He has no known asbestos exposure. He drinks occasional alcohol. PHYSICAL EXAMINATION: Examination revealed the following: The patient is a cachectic-appearing, thin male with a protuberant abdomen. Neurological examination was within normal limits. The HEENT exam was within normal limits. Sclerae were anicteric. The oropharynx was normal. NECK: Neck did not revealed any palpable lymphadenopathy. Chest was clear. HEART: Heart revealed regular rate and rhythm with no murmurs, gallops or rubs. ABDOMEN: Abdomen was soft, but distended, nontender. There was palpable left upper quadrant mass that was quite sizeable. He appeared to have ascites on physical examination. Groin did not reveal any palpable lymphadenopathy. EXTREMITIES: Extremities were normal without edema. He had palpable distal pulses. RECTAL: Examination was guaiac negative with no masses. LABORATORY DATA: Admission laboratory revealed the following: The patient's admission electrolytes were within normal limits. BUN and creatinine were 13 and 0.7. The white blood cell count was 14.4. Hematocrit was 33.7. Platelet count was 647,000. Admission PT was 13.8 and the PTT was 34.4. He had an ESR that was 122. The albumin of was 2.4. The EKG showed sinus tachycardia with borderline LVH and some minor T-wave abnormalities. Chest x-ray was within normal limits. HOSPITAL COURSE: Brief hospital course: The patient was admitted to the Surgical Service for preoperative evaluation for resection of his malignant mesothelioma. He had a central line placed by the Surgical House Staff and began total parenteral nutrition almost immediately. In addition, he was encouraged to eat until his operation was scheduled. He underwent a helical CAT scan, that revealed a large heterogenous mass that involved multiple loops of small bowel, stomach, spleen, left lobe of the liver. In addition, the patient was noted to have a moderate amount of ascites, as well as lymphadenopathy. During the preoperative period, the patient did require a radiologic guided paracentesis for symptomatic ascites. Once he was adequate rehydrated and received approximately a week of total parenteral nutrition, he went to the operating room and underwent an exploratory laparotomy with resection of this mass and debulking with Argon beam coagulation. The mass was noted to be adherent to the transverse colon, therefore, a transverse colectomy was performed. However, it was peeled off the stomach, small bowel, and the abdominal wall. The Argon beam was used to debulk some of the tumor. A peritonectomy was not performed. The immediate postoperative course of this patient was uneventful. On a postoperative-line change, access was lost and upon re-inserting a central-venous catheter, the patient's sustained a left pneumothorax. This was treated using a radiologically-placed left chest tube. This pneumothorax resolved spontaneously. The patient was transferred from the ICU to the floor, where he recovered fairly nicely. He began to resume bowel function. However, on postoperative day #8, when the patient was awaiting transfer to a rehabilitation facility, he became acutely shortness of breath, manifested signs of peritonitis and had a leukocytosis into the 40,000 range. He was urgently transferred to the ICU and re-intubated for respiratory failure. The patient had an abdominal CAT scan that revealed fluid in the abdomen, consistent with an anastomotic leak. Discussion was undertaken with the family whether or not to proceed with a re-operation. Initially, the family was reluctant, given the patient's advanced stage of disease. However, after approximately a week of managing this patient in the Intensive Care Unit using percutaneously placed drains and intraperitoneal antibiotic therapy, it was clear that the patient's sepsis was not going to resolve without laparotomy. During this time, the patient was placed on broad-spectrum antibiotic and antifungal therapy. However, the respiratory status continued to worse and it was clear that the patient was in septic shock. He was intermittently on pressors during this time. Due to the patient's critical condition, and the fact that he was not improving with an anastomotic leak on nonoperative therapy, the family was reapproached and the decision was made to take this patient back to the operating room for urgent diversion. On [**2185-3-7**] the patient was taken to the operating room and explored. The significant findings at the time of re-exploration were that the anastomosis had completely dehisced. The edges appeared pink, suggesting that there was too much tension on the anastomosis. The proximal end of the colon was simply brought up as a colostomy and matured to the skin. The distal end was stapled off as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] pouch. The belly was washed out with copious amounts of irrigation. The drainage catheters were exchanged for sterile catheters to continue antibiotic irrigation in the postoperative period. The patient's postoperative period was quite [**Male First Name (un) 3928**]. He continued to manifest signs of sepsis. Although, he did initially experience some improvement, he had continued respiratory failure with subsequent pneumonia while on the ventilator. He was extubated for a brief period of time, however, he required reintubation. Given the patient's significant state of critical illness, the fact that he had multiple nosocomial infections, and not improving, and especially in light of his advanced state of malignancy, discussion was entertained with the family to withdraw support. The family did not want to see Mr. [**Known lastname 8260**] suffer any further and, therefore, made the decision to make the patient comfort-measures only. The patient expired on [**2185-3-17**] after support was withdrawn. DISCHARGE DIAGNOSES: 1. Malignant peritoneal mesothelioma. 2. Status post exploratory laparotomy, debulking of tumor and transverse colectomy. 3. Anastomotic leak requiring re-exploration and urgent diverting colostomy. 4. Septic shock. 5. Nosocomial pneumonia. 6. Hypertension. 7. Pneumothorax status post central line placement, requiring temporary tube thoracostomy. CONDITION ON DISCHARGE: Deceased. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4007**] Dictated By:[**Last Name (NamePattern4) 28218**] MEDQUIST36 D: [**2185-6-8**] 14:04 T: [**2185-6-14**] 14:42 JOB#: [**Job Number 6678**]

[ "486", "197.5", "567.2", "518.5", "997.4", "262", "427.31", "158.8", "197.6" ]

icd9cm

[ [ [] ] ]

[ "46.11", "54.4", "54.12", "99.61", "54.91", "45.34", "96.04", "45.74", "45.94" ]

icd9pcs

[ [ [] ] ]

7671, 8045

1252, 2902

2920, 7650

273, 1225

8070, 8322

76,180

158,164

35510

Discharge summary

report

Admission Date: [**2199-1-16**] Discharge Date: [**2199-1-19**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1253**] Chief Complaint: Cholangitis, sepsis Major Surgical or Invasive Procedure: [**1-16**] ERCP with biliary stent History of Present Illness: This is a 89 year-old male who presented to OSH with abdominal and back pain that started this afternoon, there patient was given Unacyn and transferred to [**Hospital1 18**] for further evaluation and treatment. Patient had epigastric pain 2 weeks ago which resolved on its own. Patient reports sudden recurrent of symptomss this afternoon worse than prior, and w/o resolution. He denies any nausea, vomitting, diarrhea, constipation, fevers, or chills. Never had symtpoms like this. In the ED patient hypotensive with : T 98.5 SBP 80-90 HR 66 RR 14 O2 94%RA , CBC/LFTs were obtained suggesting cholecystitis/cholangitis. US confirmed diagnosis of cholangitis w/o cholecystitis. CxR also with pulm infiltrate. patient was given Vanc/Zosyn/Levo, fluids 4L, central line was placed for fluid and antibiotics, and admitted to [**Hospital Ward Name **] ICU for ERCP in am. ROS: The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, shortness of breath, orthopnea, PND, lower extremity oedema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: # emphysema # arthritis # hernia repair Social History: former smoker, quitt several years ago. lives with daughter. Family History: NC Physical Exam: Vitals: T: afebrile 107/83 p75 18 91 RA GEN: Well-appearing, no acute distress HEENT: no epistaxis or rhinorrhea, dry MM, OP Clear, poor dentition. L eye depressed/flattened. NECK: No JVD, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: decreased breath sounds throughout. Normal respiratory effort. ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E NEURO: alert, oriented to person, place, and time. Pertinent Results: Imaging: RUQ US: IMPRESSION: Dilated extrahepatic common bile duct to 1.4 cm near the hilum. Distal evaluation including evaluation of the pancreatic head could not be performed given overlying bowel gas. Recommend CT for further evaluation to exclude underlying mass lesion or obstructing stone. . CT Abd/Pelvis: IMPRESSION: 1. Choledocholithiasis causing biliary obstruction. ERCP is recommended. 2. Cholelithiasis without evidence for cholecystitis. 3. Large diaphragmatic hernia containing stomach, transverse colon and tail of the pancreas. 4. Multiple bladder diverticula. . . ERCP: Impression: Food mixed with liquid was found in the stomach Tortuous stomach was noted A single periampullary diverticulum was identified The major papilla was normal Successful deep cannulation of the common bile duct using a sphincterotome was performed Contrast medium was injected into the common bile duct resulting in complete opacification The common bile duct, common hepatic duct, and right and left hepatic ducts were filled with contrast and well visualized A 2 cm round-shaped stone was noted in the mid-common bile duct causing complete biliary obstruction Moderate biliary dilation was noted in the common bile duct proximal to the stone, as well as in the common hepatic ducts, and right and left hepatic ducts Successful placement of a 10Fr 9cm Cotton-[**Doctor Last Name **] biliary stent because of severe cholangitis was performed because of severe cholangitis. Adequate bile flow into the duodenum was noted following biliary stent placement. . Recommendations: Fluids when alert and awake Follow up for response and complications Continue IV antibiotics and supportive care Follow up ERCP in 8 weeks for repeat ERCP, sphincterotomy, lithotripsy and CBD stone extraction Follow up with Dr [**First Name (STitle) **] . . Admission: [**2199-1-16**] 12:00AM BLOOD WBC-16.9* RBC-3.65* Hgb-12.7* Hct-36.0* MCV-99* MCH-34.8* MCHC-35.3* RDW-14.1 Plt Ct-299 [**2199-1-16**] 12:00AM BLOOD Neuts-93.8* Lymphs-1.9* Monos-3.7 Eos-0.4 Baso-0.1 [**2199-1-16**] 12:00AM BLOOD Glucose-99 UreaN-9 Creat-0.7 Na-141 K-4.1 Cl-108 HCO3-26 AnGap-11 [**2199-1-16**] 12:00AM BLOOD ALT-148* AST-246* AlkPhos-156* TotBili-2.1* [**2199-1-16**] 12:00AM BLOOD Lipase-56 [**2199-1-16**] 12:00AM BLOOD Calcium-8.6 Phos-2.5* Mg-1.8 [**2199-1-17**] 04:19AM BLOOD Albumin-2.8* Calcium-8.0* Phos-2.3* Mg-1.7 [**2199-1-16**] 12:25AM BLOOD Lactate-1.4 . . Discharge: [**2199-1-19**] 06:15AM BLOOD WBC-5.2 RBC-3.81* Hgb-13.4* Hct-37.7* MCV-99* MCH-35.2* MCHC-35.5* RDW-13.4 Plt Ct-308 [**2199-1-19**] 06:15AM BLOOD PT-14.1* PTT-33.2 INR(PT)-1.2* [**2199-1-19**] 06:15AM BLOOD Glucose-73 UreaN-9 Creat-0.7 Na-140 K-4.0 Cl-107 HCO3-23 AnGap-14 [**2199-1-19**] 06:15AM BLOOD ALT-46* AST-25 AlkPhos-121* TotBili-1.0 [**2199-1-18**] 06:10AM BLOOD Albumin-3.1* Calcium-8.4 Phos-2.1* Mg-2.0 [**2199-1-19**] 06:15AM BLOOD VitB12-845 Folate-9.2 ** [**2199-1-19**] 06:15AM BLOOD TSH-11* Brief Hospital Course: 89 yo M without significant pmh who was transferred to [**Hospital1 18**] from OSH for cholangitis w/o cholecystitis. He was admitted to the ICU and he had an ERCP done on [**1-16**] with removal of 2cm stone from the mid-common bile duct which had been causing complete biliary obstruction and was stented. He was initially on Vanc/Zosyn/Levo which was changed after ERCP to Levo/Flagyl. . # Cholangitis: Pt underwent ERCP with 2 cm stone removal from CBD, and patient was treated with antibiotics which were converted to Levofloxacin and flagyl. LFT's continued to trend down, patient remained afebrile, WBC trended down. - cont Levo/Flagyl for a 10 day course, day 1 was [**1-16**]) - follow up ERCP in 8 weeks for sphincterotomy, lithotripsy, and CBD stone extraction - Follow up with Dr [**First Name (STitle) **] . # Coagulopathy: Patient was noted to have a coagulopathy with a peak INR of 1.5, likely d/t nutritional depletion/biliary obstruction. - rec'd 1 dose of 5mg Vit K IV [**1-17**] - coags improved to INR 1.2 . # Anemia: Patient??????s Hct decreased from 36 to 32.5. Was > 4 L positive on admission, so likely dilutional. H/H monitored, and remained stable. . # Pulmonary infiltrates/COPD: The pulmonary infiltrates on CXR were thought to be due to PNA vs. capillary leak in the setting of sepsis. No symptoms/signs of resp distress/hypoxia. Legionella urinary Ag negative. - Pt being treated with antibiotics for cholangitis anyway which would be adequate treatment for pneumonia. Pt remained afebrile. - cont nebs . # dementia Pt was noted to have memory defecits, depression, and anxiety. Geriatrics was consulted, and further lab workup revealed TSH 11. Unclear if this represented euthyroid sic vs true hypothyroidism. Due to pt's depressive symptoms, and general poor sense of well being prior to acute illness, it seems reasonable to start Synthroid and have pt follow up with PCP for [**Name9 (PRE) 21033**]'s with titration as appropriate. - B12/folate WNL - Synthroid 75 mcg po q day; f/u with PCP . # Depression Pt noted to be depressed; geriatrics consulted. TSH elevated as above. - contin Citalopram - contin Quetiapine hs . # Code: FULL CODE, discussed with patient . # Comm: with patient and daughter [**Telephone/Fax (1) 80875**] Medications on Admission: Records obtained from PCP: 1. Sucralfate 1 gm [**Hospital1 **] pre meals 2. Combivent 2 puffs QID 3. Celexa 40 mg daily 4. Vitamin B12 1000 mcg inj qmonth 5. Advair 500/50 one inh [**Hospital1 **] 6. Timolol eye drops 0.5% 1 gtt daily to the right eye 7. Predforte 8. Prilosec 20 mg [**Hospital1 **] 9. Alphagam drops 0.1% 1 gtt [**Hospital1 **] to the right eye 10. Prevision vitamins 11. Vitamin D 1000 units daily 12. Seroquel 25 mg QHS 13. Ultram 50 mg Q6H PRN PAIN 14. Ativan 0.5 mg Q6H PRN anxiety 15. Prednisolone eye dropps 1% 1 gtt to the left eye daily Discharge Medications: 1. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 2. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 4. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) INH Inhalation twice a day. 5. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic DAILY (Daily). 6. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 7. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 8. Levofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 5 days. Disp:*10 Tablet(s)* Refills:*0* 9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 5 days. Disp:*15 Tablet(s)* Refills:*0* 10. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: # Cholangitis # Biliary obstruction; 2 cm stone in CBD # Coagulopathy # Dementia # Depression # Possible lactose intolerance Discharge Condition: stable Discharge Instructions: Please take your medications as prescribed. Please seek medical attention if you develop worsened abdominal pain, fevers, chills, nausea, vomiting, or any other concerns Followup Instructions: Follow up ERCP in 8 weeks for repeat ERCP, sphincterotomy, lithotripsy and CBD stone extraction. - Follow up with Dr [**First Name (STitle) **] . Recommend follow up Thyroid function tests and titrate Synthroid as appropriate.

[ "562.00", "574.51", "311", "486", "501", "553.3", "496", "576.1" ]

icd9cm

[ [ [] ] ]

[ "38.93", "51.88", "51.87" ]

icd9pcs

[ [ [] ] ]

9177, 9226

5236, 7506

282, 319

9395, 9404

2258, 5213

9623, 9853

1739, 1743

8119, 9154

9247, 9374

7532, 8096

9428, 9600

1758, 2239

223, 244

347, 1581

1603, 1644

1660, 1723

15,894

176,382

16262

Discharge summary

report

Admission Date: [**2121-7-15**] Discharge Date: [**2121-7-21**] Service: [**Last Name (un) **] HISTORY OF PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname 46373**] is an 84- year-old male who presented to this institution for elective surgical treatment of bleeding 8-mm and 2.5-cm cecal polyps. The patient was recently hospitalized at this institution following a fall. At that time, he was noted to have guaiac- positive stool. The patient was on aspirin for chronic atrial fibrillation and spent a short course at rehabilitation before eventually being discharge to home. The patient is doing well at this time and denies blood in his stools. He has noted no change in his bowel pattern. He appetite has been good, and he has had no weight loss. PAST MEDICAL HISTORY: Coronary artery disease. Congestive heart failure (with an ejection fraction of 35 percent). Atrial fibrillation. Prostate cancer. Hypercholesterolemia. Hypothyroidism. Aortic stenosis. Hypertension. Gastritis. History of upper gastrointestinal bleed. Status post cerebrovascular accident. Diverticulosis. PAST SURGICAL HISTORY: Coronary artery bypass grafting. Cholecystectomy. Left knee surgery. Bilateral carotid endarterectomy. MEDICATIONS ON ADMISSION: 1. Aspirin 81 mg by mouth once per day. 2. Lasix 40 mg by mouth once per day. 3. Toprol-XL 25 mg by mouth once per day. 4. Lipitor 10 mg by mouth once per day. 5. Doxazosin 4 mg by mouth once per day. 6. Levoxyl 125 mcg by mouth every day. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION ON ADMISSION: Vital signs revealed his temperature was 98.5, his pulse was 83, his blood pressure was 113/57, his respiratory rate was 10, and his oxygen saturation was 96 percent on room air. In general, the patient is an elderly male who appeared his stated age. He was in no distress and was sitting comfortably in a stretcher. The oropharynx was clear. The mucous membranes were moist. The neck was supple without lymphadenopathy. The heart was regular in rate and rhythm. The lungs were clear to auscultation bilaterally. The abdomen was soft, nontender, and nondistended with one paramedian well-healed surgical scar. The extremities were warm with 2 plus distal pulses and no edema. SUMMARY OF HOSPITAL COURSE: On the day of admission, the patient was taken to the operating room where an elective laparoscopic-assisted right colectomy was performed. The patient tolerated this procedure well with an estimated blood loss of 100 cc. The patient did receive 2 unit of packed red blood cells intraoperatively. Approximately 4 liters of clear ascites were drained at the time of surgery from the abdomen. The patient remained intubated and was transferred to the Intensive Care Unit postoperatively for close monitoring. The patient was extubated postoperatively. He was treated with albumin intravenously for two days to elevate his oncotic pressure. The postoperative hematocrit was 35.6 percent. His INR was elevated at 2.1 despite the absence of Coumadin. The patient was treated with morphine as needed postoperatively for pain. He was given Levophed for approximately two days to maintain his systolic blood pressure at greater than 100. Cardiac enzymes were sent on postoperative day one as the patient was persistently tachycardic. The electrocardiogram revealed a right bundle branch block, but the enzymes were negative for ischemia or infarction. The patient was given Lasix 40 mg intravenously twice per day to alleviate his abdominal ascites. He was given perioperative doses of Kefzol and Flagyl. On postoperative day three, the patient was converted to his home medications. At this time, the patient had passed flatus and had a formed bowel movement, and he was started on clear liquid diet. Around this time, the patient self- removed his Foley catheter. It was not replaced as he was able to void independently. At this time, the patient was transferred to the regular hospital floor. He was on a regular diet with supplemental Boost shakes three times per day. He was given Haldol intermittently to prevent him from climbing out of bed as he was deemed unsafe and at risk for falls. On postoperative day six, after the patient had been tolerating a regular diet and was hemodynamically stable, he was discharged to a skilled nursing facility in good condition. His wound did not have any evidence of erythema or discharge. His staples are to be removed in approximately one week. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: The patient was discharged to a skilled nursing facility. DISCHARGE DIAGNOSES: Cecal adenoma times two. Status post laparoscopic-assisted right colectomy. Coronary artery disease. Congestive heart failure (with an ejection fraction of 35 percent). Atrial fibrillation. Prostate cancer. Hypercholesterolemia. Hypothyroidism. Aortic stenosis. Hypertension. Gastritis. History of an upper gastrointestinal bleed. Status post cerebrovascular accident. Status post coronary artery bypass grafting. Status post cholecystectomy. Status post left total knee arthroplasty. Status post bilateral carotid endarterectomy. Ascites. Diverticulosis. MEDICATIONS ON DISCHARGE: 1. Aspirin 81 mg by mouth once per day. 2. Lasix 40 mg by mouth once per day. 3. Toprol-XL 25 mg by mouth once per day. 4. Lipitor 10 mg by mouth once per day. 5. Doxazosin 4 mg by mouth once per day. 6. Levoxyl 125 mcg by mouth every day. 7. Tylenol No. 3 as needed for pain. 8. Colace 100 mg by mouth twice per day. DISCHARGE FOLLOW-UP PLANS: The patient was discharged on a regular diet with supplemental Boost shakes three times per day. He was instructed to follow up with Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **] in approximately two weeks. His staples should be removed from his abdominal wound in approximately one week. The patient was instructed to follow up sooner if he developed fevers greater than 101.5 degrees Fahrenheit, severe abdominal pain, vomiting, drainage from the abdominal wound, or if he had any other questions or concerns. [**First Name11 (Name Pattern1) 333**] [**Last Name (NamePattern4) 366**], [**MD Number(1) 367**] Dictated By:[**Last Name (NamePattern1) 22791**] MEDQUIST36 D: [**2121-7-21**] 09:58:12 T: [**2121-7-21**] 10:31:17 Job#: [**Job Number 46374**]

[ "211.3", "789.5", "414.00", "272.0", "244.9", "V45.81", "427.31", "997.1" ]

icd9cm

[ [ [] ] ]

[ "99.04", "45.73", "45.93" ]

icd9pcs

[ [ [] ] ]

4593, 4652

4674, 5249

5275, 5605

1280, 1597

1147, 1254

2327, 4537

5623, 6439

136, 782

1612, 2298

805, 1123

4562, 4569

22,491

195,157

51164

Discharge summary

report

Admission Date: [**2151-2-8**] Discharge Date: [**2151-2-22**] Date of Birth: [**2073-8-11**] Sex: M Service: Purple Surgery CHIEF COMPLAINT: Patient was admitted for an operative procedure to repair ventral hernia, radical excision of squamous cell carcinoma, an excision of sinus tract. HISTORY OF PRESENT ILLNESS: Patient is a 77-year-old gentleman with a history of left squamous cell carcinoma on his stomach and left flank, who underwent placement of tissue expanders on [**2150-10-26**]. The patient is returning for removal of the tissue expanders as well as excision of the left flank squamous cell carcinoma. PREVIOUS MEDICAL HISTORY: 1. Coronary artery disease. 2. Hypertension. 3. Melanoma of the stomach. 4. Necrotizing fasciitis. 5. Status post nephrectomy. 6. Myocardial infarction x2. 7. Angina. MEDICATIONS ON ADMISSION: 1. Cartia 100 mg p.o. q.d. 2. Lopressor 50 mg p.o. b.i.d. 3. Prazosin 5 mg p.o. b.i.d. 4. Percocet 1-2 tablets p.o. q.4-6h. prn pain. BRIEF SUMMARY OF HOSPITAL COURSE: The patient was admitted on [**2151-2-8**] and underwent the operative procedure performed by the Purple Surgery service with Dr. [**Last Name (STitle) **] and the Plastic Surgery service performed by Dr. [**First Name (STitle) **]. Patient tolerated the procedure without any difficulty and there were no complications. For full description, please see the operative notes dated [**2-8**]. Following the operation, the patient was transferred to the Trauma SICU for initial recovery. Patient was noted to have an increase in O2 requirement and tachycardia, and a chest x-ray at that time showed a right lower lobe collapse. Following the patient's extubation, the patient's O2 saturation was 85% on 3 liters nasal cannula prompting his transfer to the SICU. On postoperative day #3, the patient underwent acute pulmonary decompensation with severe hypoxia and patient had to be reintubated. Patient tolerated the reintubation without any difficulty. Following the patient's intubation, the patient underwent a bronchoscopy and a bronchoalveolar wash was done. Returning was blood tinged fluid from the left lobes. The fluid returned from the wash was cultured and grew out Serratia marcescens. Due to these cultures, the patient was placed on levofloxacin and Zosyn. Also on [**2-11**], the patient developed atrial fibrillation with his heart rate oscillating between the 90s to 160s. The patient was on a Cardizem drip, and was given Lopressor, which did not manage either his heart rate nor his rhythm. The patient was then started on amiodarone drip following 150 mg IV bolus. The patient had to be electrically cardioverted and then was able to maintain his rhythm on the amiodarone drip. Over the next couple days through [**2-16**], the patient remained intubated and continued to produce large quantities of thick sputum, which hampered his extubation. Patient did have one respiratory trial with decreased amount of PEEP, but this was not tolerated and the patient was maintained on the ventilator. Patient had to be continually suctioned every 2-3 hours for a thick tan yellow sputum. From a cardiovascular standpoint, the patient remained in normal sinus rhythm and had no further episodes of atrial fibrillation. On [**2-17**], the patient was seen and evaluated by Cardiology for an elevated troponin and a borderline MB index. Patient was complaining of slight amount of chest pain corresponding to the increase in troponin, which was worrisome for evolving myocardial ischemia. It was advised that the patient would be increased on his beta-blocker, placed on aspirin, and to have an echocardiogram performed. The patient underwent echocardiogram on the [**2-17**] and this showed the following: Severe global left ventricular systolic dysfunction of multivessel coronary artery disease, and moderate mitral valve regurgitation. Following the echocardiogram, the patient was placed on lisinopril 5 mg p.o. q.d. and increased up to 10 mg as he was able to tolerate that. It was also advised that the patient undergo a stress test with the resolution of his current acute illness either as an inpatient or following discharge. Patient's Toprol XL was also increased to 100 mg p.o. q.d. and the patient was continued on amiodarone 200 mg q.d. On [**2-18**], postoperative day #10, the patient was weaned down to pressure support, and was able to tolerate this well. Patient continued to have vast quantities of thick white secretions. His lungs were clear overall. Patient continued to be diuresed. Planned to get 1-2 liters off per day. On [**2-19**], the patient was extubated and was able to maintain his oxygen saturations on 50% FIO2 via face mask tent. Patient was started on clear liquids and his diet was advanced as tolerated. On [**2-21**], the patient was transferred out of the unit onto the surgical floor. While on the floor, the patient had an uneventful recovery and was able to be discharged to acute rehabilitation facility. DISCHARGE DISPOSITION: The patient will be discharged to acute care facility. FOLLOW-UP INSTRUCTIONS: The patient was instructed to followup with Dr. [**Last Name (STitle) **] in [**11-27**] weeks following discharge and Dr. [**First Name (STitle) **] during the same time period. Patient was advised to please call to make these appointments. DISCHARGE CONDITION: The patient was discharged in good condition: Afebrile, tolerating regular diet without difficulty, ambulating with assistance. Maintaining oxygen saturations with supplemental oxygen. DISCHARGE DIAGNOSES: 1. Status post resection of squamous cell carcinoma of the left flank. 2. Status post excision of sinus tract. 3. Status post removal of tissue expanders. 4. Status post ventral hernia repair. 5. Omental flap harvest. 6. Status post advancement of skin flaps. 7. Myocardial infarction x2. 8. Coronary artery disease. 9. Reintubation for hypoxia. 10. Prolonged intubation. 11. Atrial fibrillation. 12. Electrocardioversion. DISCHARGE MEDICATIONS: 1. Plavix 75 mg p.o. q.d. 2. Metoprolol 50 mg p.o. b.i.d. 3. Lisinopril 5 mg p.o. q.d. 4. Aspirin 325 mg p.o. q.d. 5. Timolol malleate 0.5% drops one drop b.i.d. in both eyes. 6. Amiodarone 200 mg tablets one tablet p.o. b.i.d. 7. Lasix 20 mg p.o. q.d. 8. Potassium chloride 20 mg p.o. q.d. while on Lasix. 9. Zosyn 4.5 grams IV q.6h. for 11 days. 10. Reglan 10 mg IV q.6h. 11. Lansoprazole 30 mg p.o. q.d. 12. Metoprolol 5 mg IV q.6-8h. prn systolic blood pressure greater than 160. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6066**] Dictated By:[**Name8 (MD) 846**] MEDQUIST36 D: [**2151-2-22**] 10:53 T: [**2151-2-22**] 11:10 JOB#: [**Job Number 106197**]

[ "428.0", "410.91", "427.31", "518.5", "998.6", "486", "997.3", "997.1", "998.89" ]

icd9cm

[ [ [] ] ]

[ "96.6", "54.74", "86.05", "33.24", "54.3", "96.04", "77.91", "86.74", "86.4", "86.69", "53.61", "96.72", "38.93" ]

icd9pcs

[ [ [] ] ]

5047, 5103

5394, 5582

5603, 6027

6050, 6793

865, 1006

1035, 5023

164, 312

341, 839

5128, 5372

4,240

155,428

29819+57666

Discharge summary

report+addendum

Admission Date: [**2179-4-8**] Discharge Date: [**2179-4-14**] Date of Birth: [**2101-1-18**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 922**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2179-4-8**] - CABG x 5 (SVG->LAD, SVG->Diag->OM, SVG->AM->PDA) History of Present Illness: 78 year old gentleman recently diagnosed with ischemic cardiomyopathy with symptoms of dyspnea on exertion. He has improved on medical therapy and currently denies symptoms. A cardiac catheterization was performed which revealed severe three vessel disease. He now presents for surgical management. Past Medical History: s/p appy prostate procedure Ischemic cardiomyopathy Glaucoma Social History: Retired plumber Plays hockey 3x week Currently non-etoh; however previous history of heavy drinking quit 25 years ago No drugs No tobacco Family History: Father had MI (died) age 67 Mother died of TB All children healthy Physical Exam: 62 SR 12 128/58 GEN: Energenic elderly male in NAD HEENT: Unremarkable NECK: FROM, supple. No carotid bruits. LUNGS: Clear HEART: RRR, Soft SEM ABD: BEnign EXTR 2+ Pulses, no edema NEURO: Nonfocal Pertinent Results: [**2179-4-8**] ECHO 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 theright atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. No left ventricular aneurysm is seen. There is moderate to severe global left ventricular hypokinesis. Overall left ventricular systolic function is severely depressed. Right ventricular systolic function is borderline normal. There are simple atheroma in the ascending aorta. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There are filamentous strands on the aortic leaflets consistent with Lambl's excresences (normal variant). The mitral valve leaflets are mildly thickened. The mitral annulus is 28mm and there is a central regurgitant jet c/w with Mild (1+) mitral regurgitation. There is no pericardial effusion. Post_Bypass: Normal RV systolic function. Patient is on epinephrine 0.02 mcg/kg/min with overall LVEF of 35 to 40%. Trivial to Mild MR. Preserved aortic contour. [**2179-4-14**] 06:35AM BLOOD Hct-28.8* [**2179-4-11**] 05:35AM BLOOD WBC-8.7 RBC-3.09* Hgb-9.7* Hct-27.1* MCV-88 MCH-31.3 MCHC-35.6* RDW-14.3 Plt Ct-104* [**2179-4-14**] 06:35AM BLOOD PT-12.0 INR(PT)-1.0 [**2179-4-11**] 05:35AM BLOOD Plt Ct-104* [**2179-4-10**] 02:29AM BLOOD PT-13.4* PTT-33.7 INR(PT)-1.2* [**2179-4-14**] 06:35AM BLOOD UreaN-14 Creat-1.1 K-4.3 [**2179-4-11**] 05:35AM BLOOD Glucose-111* UreaN-18 Creat-0.8 Na-135 K-3.9 Cl-98 HCO3-30 AnGap-11 Brief Hospital Course: Mr. [**Known lastname 1137**] was admitted to the [**Hospital1 18**] on [**2179-4-8**] for surgical management of his coronary artery disease. He was taken directly to the operating room where he underwent coronary artery bypass grafting to five vessels. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. By postoperative day one, Mr. [**Known lastname 1137**] had awoke neurologically intact and was extubated. Aspirin, a statin and beta blockade was resumed. On postoperative day two, he was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. He developed atrial fibrillation which was treated with amiodarone and increased beta blockade, and he converted to normal sinus rhythm. He was ready for discharge home on POD #6. Medications on Admission: Aspirin 325mg daily lipitor 40mg daily Aldactone 12.5mg daily Digoxin .125mg daily Lisinopril 20mg daily Coreg 12.5mg twice daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. 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* 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. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 weeks: please take twice a day for 7 days and then decrease to once daily and follow up with your cardiologist within 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 8. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Coronary Artery disease s/p CABG Atrial Fibrillation Ischemic Cardiomyopathy Prostatitis Glaucoma Discharge Condition: Good. Discharge Instructions: [**Month (only) 116**] shower, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns Followup Instructions: Dr [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment Dr [**Last Name (STitle) **] in 1 week ([**Telephone/Fax (1) 35783**]) please call for appointment Dr [**Last Name (STitle) 11493**] in [**2-13**] weeks ([**Telephone/Fax (1) 11650**]) please call for appointment Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse ([**Telephone/Fax (1) 3633**]) Completed by:[**2179-4-14**] Name: [**Known lastname 99**],[**Known firstname **] Unit No: [**Numeric Identifier 11980**] Admission Date: [**2179-4-8**] Discharge Date: [**2179-4-14**] Date of Birth: [**2101-1-18**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 1543**] Addendum: This is a clarification of CHF noted on previous discharge summary. Mr. [**Known lastname **] has severely depressed LV systolic function as noted on the echo of [**2179-4-8**]. Brief Hospital Course: Discharge Disposition: Home With Service Facility: [**Company 720**] [**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**] Completed by:[**2179-5-5**]

[ "427.31", "428.0", "414.01", "E878.2", "428.20", "365.9", "424.0", "997.1", "414.8" ]

icd9cm

[ [ [] ] ]

[ "39.61", "36.14" ]

icd9pcs

[ [ [] ] ]

6952, 7158

6929, 6929

319, 387

5425, 5433

1274, 3030

5898, 6904

971, 1039

4163, 5211

5304, 5404

4009, 4140

5457, 5875

1054, 1255

260, 281

415, 715

737, 799

815, 955

8,073

174,048

2366

Discharge summary

report

Admission Date: [**2151-7-22**] Discharge Date: [**2151-8-16**] Date of Birth: [**2099-5-5**] Sex: F Service: SURGERY Allergies: Penicillins / Percocet / Iodine; Iodine Containing Attending:[**First Name3 (LF) 4748**] Chief Complaint: Right lower extremity claudication. Major Surgical or Invasive Procedure: [**2151-7-22**] 1. Right superficial femoral artery to anterior tibial bypass graft with nonreversed left arm vein. 2. Angioscopy with valve lysis. 3. Thrombectomy of right superficial femoral artery. [**2151-7-26**] 1. Right leg graft disruption and thigh hematoma. 2. Thrombosed right superficial femoral artery to anterior tibial graft. [**2151-8-10**] R - BKA History of Present Illness: The patient is a 52-year-old female, with peripheral [**Month/Day/Year 1106**] disease, who has undergone several previous percutaneous procedures on her right lower extremity, including atherectomies and stents to her distal SFA and popliteal artery, which have occluded. Past Medical History: 1. Severe peripheral [**Month/Day/Year 1106**] disease status post right femoral-popliteal bypass in [**2149-11-1**], now found to be occluded. 2. Status post thoracic aortic replacement. 3. COPD. 4. CAD with 90% RCA and 60% LAD lesions by recent catheterization. 5. Severe hyperlipidemia, cholesterol level of about 600 and triglycerides of approximately 3,000. 6. Insulin dependent diabetes. 7. Hypothyroidism. 8. Hypertension. 9. Pancreatitis. 10. Degenerative joint disease status post laminectomy. 11. Status post cholecystectomy. 12. Status post right femoral embolectomy. 13. Obesity. Social History: She admits to a 45 pack year history of tobacco. She is still smoking. Pt lives alone. She has 3 children. Family History: noncontributory Physical Exam: Obese female, NAD NCAT / PERRL / EOMI neg lesions nares, oral pjharnyx, auditory Supple / FAROM neg lymphandopathy, supra - clavicular nodes RRR CTA b/l soft NTND, pos BS, neg CVA GU defered Right AKA - C/D/I Left triphasic AT, biphasic DP; 2+ radial Pertinent Results: [**2151-8-15**] WBC-7.0 RBC-3.21* Hgb-8.9* Hct-27.1* MCV-85 MCH-27.8 MCHC-32.9 RDW-15.5 Plt Ct-590* [**2151-8-10**] PT-17.3* PTT-27.3 INR(PT)-2.0 [**2151-8-14**] Glucose-59* UreaN-13 Creat-0.7 Na-140 K-4.3 Cl-103 HCO3-22 AnGap-19 [**2151-7-28**] ALT-17 AST-26 AlkPhos-87 Amylase-27 TotBili-0.2 [**2151-8-14**] Calcium-9.1 Phos-4.1 Mg-2.0 [**2151-7-26**] Type-ART pO2-179* pCO2-39 pH-7.36 calHCO3-23 Base XS--2 [**2151-7-26**] 10 Glucose-186* Lactate-1.1 Na-135 K-4.4 Cl-107 [**2151-7-26**] Hgb-10.2* calcHCT-31 [**2151-7-26**] freeCa-1.17 [**2151-8-12**] Urine: Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014 Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG RBC-0-2 WBC-[**3-6**] Bacteri-FEW Yeast-NONE Epi-0 [**2151-8-1**] Blood cx: **FINAL REPORT [**2151-8-7**]** AEROBIC BOTTLE (Final [**2151-8-7**]): NO GROWTH. ANAEROBIC BOTTLE (Final [**2151-8-7**]): NO GROWTH. [**2151-8-10**] EKG Sinus rhythm. Normal ECG. Compared to the previous tracing of [**2151-7-8**] no diagnostic interim change. Intervals Axes Rate PR QRS QT/QTc P QRS T 66 140 86 [**Telephone/Fax (2) 12298**] 31 [**2151-8-10**] CHEST (PRE-OP PA & LAT) INDICATION: Preoperative assessment prior to BKA procedure. The patient is status post prior median sternotomy. The heart is upper limits of normal in size and stable. Pulmonary vascularity is normal. The lungs are clear, and there are no pleural effusions. Mild degenerative changes are seen within the spine. Finally, note is made of a right PICC line, terminating in the superior vena cava. IMPRESSION: No evidence of acute cardiopulmonary process. [**2151-8-4**] CATH Study BRIEF HISTORY: 52 yo woman with a long well-documented history of peripheral arterial disease, s/p many percuateneous interventional procedures on her right lower extremity including, most recently, directed thrombolytic therapy and throbectomy for an occluded recent bypass graft to her RLE. She now returns to the lab with probable re-occlusion of her graft. INDICATIONS FOR CATHETERIZATION: Limb threatening peripharal arterial disease PTCA COMMENTS: Initial angiography demonstrated a total occlusion of the SFA at just proximal to the proximal graft anastamosis. Heparin was started prophylactically. A stiff angled Glidewire was advanced though the native SFA into the distal popliteal artery were angiography demonstrated the AT and PT to be totally occluded and the peroneal artery to be patent as the main blood suppy to the foot but with moderate diffuse disease. The Glide wire was exchanged for a Mircale Bros 6 wire and atherectomy of the distal SFA into the distal politeal artey was performed. A wire was passed into the AT and distal injection confirmed that there was no distal runoff via the AT and flow did not improve with atherectomy of the origin of the AT. We were unable to cross in to the PT with a wire. We then turned our attention to the peroneal artery where atherectomy was performed on the proximal and mid vessel with restoration of flow into a large distal collateral, however the PT never filled. A distuption was noted in the mid peroneal artery at this point with diminished flow into the distal artery. In spite of thrombectomy with an Excisor catheter and several balloon inflations with 2.0 mm balloons. The case was terminated due to excess flouro time and contrast load. Final angiography revealed no significant impprovement in blood flow to the foot. COMMENTS: 1. Arterial access was obtained in retrograde fashion via the LFA with a 6 French short sheath. 2. Selective angiography of the right lower extremity revealed the SFA to be totally occluded just proximal to the anatamosis of the graft. 3. Failed percutaneous intervention on the right lower extremity. Final angiography revealed no restoration of flow into the infrapapliteal vessels (see PTA comments). FINAL DIAGNOSIS: 1. Total occlusion of the right SFA. 2. Failed intervention on the right SFA and infrapopliteal vessels. [**2151-8-2**] PICC W/O PORT [**Hospital 93**] MEDICAL CONDITION: 52 year old woman with R SFA-AT bypass with L arm v. Graft reexploration and thrombectomy. REASON FOR THIS EXAMINATION: Please place a midline in RUE. Unable to get PIV on floor. Unable to get midline on floor. We want to d/c her R IJ. HISTORY: Status post right SFA-AT bypass with graft reexploration and thrombectomy. Needs IV access. PROCEDURE AND FINDINGS: The right upper arm was prepped and draped in the usual sterile fashion. Since no suitable superficial veins were visible, ultrasound was used for localization of a suitable vein. The basilic vein was patent and compressible. After local anesthesia with 2 cc of 1% lidocaine, the basilic vein was entered under ultrasonographic guidance with a 21 gauge needle. A 0.018 nitinol guidewire was advanced under fluoroscopy into the superior vena cava. It was determined that a length of 37 cm would be suitable. The PICC line was trimmed to length and advanced over a 4 French introducer sheath under fluoroscopic guidance in the superior vena cava. The sheath was removed. The catheter was flushed. Final chest x-ray was obtained demonstrating the tip to be in the superior vena cava. The line is ready for use. A Stat-Lock was applied and the line was heplocked. IMPRESSION: Successful placement of 37 cm long right basilic single lumen PICC line with tip in the superior vena cava. The line is ready for use Brief Hospital Course: PT had difficult hospital course. Chart thinned. Pt admitted on [**2151-7-22**] Pt underwent the below procedure. She tolerated the procedure well. There were no complications. Pt extubated in the OR, Tansfered to the PACU in stable condition. After recovery from the anesthesia. Pt transfered to the VICU in stable condition. PROCEDURES: 1. Right superficial femoral artery to anterior tibial bypass graft with nonreversed left arm vein. 2. Angioscopy with valve lysis. 3. Thrombectomy of right superficial femoral artery. [**7-23**]/-[**7-25**] Pt was doing well. She started to c/o pain in her right leg. It was decided that the pt had a clot in her graft. she was taken back to the OR immediatly. [**2151-7-26**] Pt underwent the below procedure. She tolerated the procedure well. There were no complications. Pt extubated in the OR, Tansfered to the PACU in stable condition. After recovery from the anesthesia. Pt transfered to the VICU in stable condition. PROCEDURE: 1. Re-exploration of right superficial femoral artery to anterior tibial graft and graft thrombectomy. 2. Evacuation of thigh hematoma. Pt started on heparin IV / coumadin started. [**7-27**] - [**2151-8-9**] Pt was doing well. Pt was ready for discharge. Pt recieved PCA / PICC line placement. INR / PTT monitered. Pt goal achieved. Pt again started to experience pain. Another angiogram was done. Showed occluded graft, despite being on anticogulation. Post PVR were done showed flat metatarsal b/l. At this time it was decided to amputate the leg, for failed graft x 2. [**2151-8-10**] Pt underwent the below procedure. She tolerated the procedure well. There were no complications. Pt extubated in the OR, Tansfered to the PACU in stable condition. After recovery from the anesthesia. Pt transfered to the VICU in stable condition. PROCEDURES: R-BKA. [**8-11**] - [**8-16**] Pt recooperated from the aforementioned surgery. Anticoagulation was DC'd post operatively. On discharge pt taking PO, OOB to [**Last Name (un) **], urinating without difficulty, pos BM. Medications on Admission: ASA 325', plavix 75', atenolol 50', lisinopril 10', atorvastatin 80', gemfibrozil 600'', niacin 250', roglitazone 4'', protonix 40', NTG prn, propoxyphene 65', lantus 90', RISS Discharge Medications: 1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Niacin 100 mg Tablet Sig: One (1) Tablet PO Q 24H (Every 24 Hours). 5. Rosiglitazone Maleate 4 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed. 8. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical DAILY (Daily) as needed. 10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Hydromorphone 4 mg Tablet Sig: 2-3 Tablets PO Q3-4H (Every 3 to 4 Hours) as needed for pain. 12. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for pruritis. 14. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety/racing thoughts. 15. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 16. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Gabapentin 400 mg Capsule Sig: Three (3) Capsule PO Q8H (every 8 hours). 18. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 19. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours): DC [**2151-8-30**]. 20. PICC LINE Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift 21. INSULIN CHANGE Insulin SC Sliding Scale & Fixed Dose Fingerstick QACHS Insulin SC Fixed Dose Orders Bedtime Glargine 90 Units Insulin SC Sliding Scale Q6H Regular Glucose Insulin Dose 0-60 mg/dL 1 amp D50 61-159 mg/dL 0 Units 160-199 mg/dL 4 Units 200-239 mg/dL 7 Units 240-279 mg/dL 10 Units 280-319 mg/dL 13 Units > 320 mg/dL Notify M.D. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Right lower extremity claudication. Discharge Condition: Stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOLLOWING BELOW OR ABOVE KNEE AMPUTATION This information is designed as a guideline to assist you in a speedy recovery from your surgery. Please follow these guidelines unless your physician has specifically instructed you otherwise. Please call our office nurse if you have any questions. Dial 911 if you have any medical emergency. ACTIVITY: There are restrictions on activity. On the side of your amputation you are non weight bearing until cleared by your Surgeon.You should keep this amputation site elevated when ever possible. You may use the other leg to assist in transferring and pivots. But try not to exert to much pressure on the amputation site when transferring and or pivoting. Please keep knee immobilizer on at all times to help keep the amputation site straight. No driving until cleared by your Surgeon. PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: Redness in or drainage from your leg wound(s) Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. EXERCISE: Limit strenuous activity for 6 weeks. Do not drive a car unless cleared by your Surgeon. Try to keep leg elevated when able. BATHING/SHOWERING: You may shower immediately upon coming home. No bathing. A dressing may cover you??????re amputation site and this should be left in place for three (3) days. Remove it after this time and wash your incision(s) gently with soap and water. You will have sutures, which are usually removed in 4 weeks. This will be done by the Surgeon on your follow-up appointment. WOUND CARE: Sutures / Staples may be removed before discharge. If they are not, an appointment will be made for you to return for staple removal. When the sutures are removed the doctor may or may not place pieces of tape called steri-strips over the incision. These will stay on about a week and you may shower with them on. If these do not fall off after 10 days, you may peel them off with warm water and soap in the shower. Avoid taking a tub bath, swimming, or soaking in a hot tub for four weeks after surgery. MEDICATIONS: Unless told otherwise you should resume taking all of the medications you were taking before surgery. You will be given a new prescription for pain medication, which can be taken every three (3) to four (4) hours only if necessary. Remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. (Check with your physician if you have fluid restrictions.) If you feel that you are constipated, do not strain at the toilet. You may use over the counter Metamucil or Milk of Magnesia. Appetite suppression may occur; this will improve with time. Eat small balanced meals throughout the day. CAUTIONS: NO SMOKING! We know you've heard this before, but it really is an important step to your recovery. Smoking causes narrowing of your blood vessels which in turn decreases circulation. If you smoke you will need to stop as soon as possible. Ask your nurse or doctor for information on smoking cessation. Avoid pressure to your amputation site. No strenuous activity for 6 weeks after surgery. DIET: There are no special restrictions on your diet postoperatively. Poor appetite is expected for several weeks and small, frequent meals may be preferred. For people with [**Location (un) 1106**] problems we would recommend a cholesterol lowering diet: Follow a diet low in total fat and low in saturated fat and in cholesterol to improve lipid profile in your blood. Additionally, some people see a reduction in serum cholesterol by reducing dietary cholesterol. Since a reduction in dietary cholesterol is not harmful, we suggest that most people reduce dietary fat, saturated fat and cholesterol to decrease total cholesterol and LDL (Low Density Lipoprotein-the bad cholesterol). Exercise will increase your HDL (High Density Lipoprotein-the good cholesterol) and with your doctor's permission, is typically recommended. You may be self-referred or get a referral from your doctor. If you are overweight, you need to think about starting a weight management program. Your health and its improvement depend on it. We know that making changes in your lifestyle will not be easy, and it will require a whole new set of habits and a new attitude. If interested you can may be self-referred or can get a referral from your doctor. If you have diabetes and would like additional guidance, you may request a referral from your doctor. FOLLOW-UP APPOINTMENT: Be sure to keep your medical appointments. The key to your improving health will be to keep a tight reign on any of the chronic medical conditions that you have. Things like high blood pressure, diabetes, and high cholesterol are major villains to the blood vessels. Don't let them go untreated! Please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. This should be scheduled on the calendar for seven to fourteen days after discharge. Normal office hours are 8:30-5:30 Monday through Friday. PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE Followup Instructions: Call Dr [**Last Name (STitle) 1391**] [**Name (STitle) 12299**] at [**Telephone/Fax (1) 1393**] and schedulae an appoiintment for 2 weeks. Call Dr [**First Name (STitle) **] at [**Telephone/Fax (1) 4023**] and schedule an appointment in four weeks. ( on an off clinic day ) Keep the following appointments: Provider: [**Name10 (NameIs) **] STUDY Where: CC CLINICAL CENTER RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2151-10-26**] 11:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2151-10-26**] 1:00 Completed by:[**2151-8-16**]

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icd9cm

[ [ [] ] ]

[ "84.15", "39.29", "99.04", "38.18", "39.49", "38.22", "99.07" ]

icd9pcs

[ [ [] ] ]

12242, 12339

7598, 9661

346, 717

12419, 12427

2081, 4152

17800, 18481

1777, 1794

9888, 12219

6201, 6293

12360, 12398

9687, 9865

6027, 6164

12451, 14180

1809, 2062

4185, 6010

270, 308

6322, 7575

14193, 17103

17127, 17777

745, 1019

1041, 1635

1651, 1761

43,725

116,863

49132

Discharge summary

report

Admission Date: [**2146-10-30**] Discharge Date: [**2146-11-1**] Date of Birth: [**2091-6-5**] Sex: F Service: NEUROLOGY Allergies: Penicillins / Ambien / Metronidazole Attending:[**First Name3 (LF) 2569**] Chief Complaint: Agitation/ speech disturbance Major Surgical or Invasive Procedure: Intubation/ extubation History of Present Illness: Patient is a 55 y/o female with a PMHx of DM complicated by neuropathy, HTN, hypercholesterolemia, hepatitis C and h/o polysubstance use who presents with concerns for a stroke. Patient was at her usual baseline yesterday evening and went to bed at her usual time of ~11pm. At 05:30 her son also spoke to her describing her as having normal speech. However at ~7am she was then noted to be aphasic and moaning in bed found by her son. EMS was contact[**Name (NI) **] and she was brought to [**Hospital1 18**]. Of note, she likely vomited en route. Here she was noted to follow simple comands but was combative prompting sedation and intubation. Past Medical History: CAD and question of history of old inferior MI based upon EKG, partially reversible defect on MIBI [**6-16**] Chronic dizziness and gait disorder Hearing loss L ear x past year Diabetes mellitus - on Lamictal for neuropathy HTN Cataract [**Doctor First Name **] Hepatitis C Hyperlipidemia GERD Atypical migraines - on Topamax Social History: -Tobacco: recently quit smoking; smoked since age 12, one ppd -ETOH: hx of alcohol abuse -IVDA: hx of heroin and cocaine abuse Family History: Alcoholism, diabetes Physical Exam: PE on admition HEENT: NCAT, mucous membranes moist and pink, sclera non-icteric, OP clear - Neck: Supple, no thyromegaly, no lymphadenopathy, no bruits - Lungs: Clear bilaterally, good aeration, no wheezing/crackles - Cardiac: Normal S1 and S2, no murmur - Abdomen: S/NT/obese, normoactive BS - Extremities: warm, no C/C/E Neurologic Examination: - MS: Unintelligible / dysarthric speech, per report able to say "no" but did not witness - Cranial Nerves: I: not tested II: Blinks to visual threat, pupils 3->1.5mm bilaterally III, IV, VI: eyes midline, no nystagmus, doesn't follow commands for VFFTC testing, turns whole head in direction of sounds / questions V: unable to assess VII: Facial movements grossly symmetric, unable to assess for subtle facial droop VIII: unable to assess IX, X: gag intact [**Doctor First Name 81**]: unable to assess XII: unable to assess - Motor: Normal bulk and tone, restrained, full grasp with both hands, attempts to pull out ETT symmetrically, withdrawals legs from restraints with good strenght - Coordination: unable to assess - Reflexes: No clonus, toes downgoing bilatrally [**Hospital1 **] Tri [**Last Name (un) 1035**] Pat Ach C5-6 C7-8 C5-6 L3-4 S1-2 Right 2 2 2 1 1 Left 2 2 2 1 1 Pertinent Results: [**2146-10-30**] 10:57PM ALT(SGPT)-64* AST(SGOT)-55* LD(LDH)-200 ALK PHOS-100 AMYLASE-136* TOT BILI-0.2 [**2146-10-30**] 10:57PM CK-MB-5 cTropnT-<0.01 [**2146-10-30**] 10:57PM %HbA1c-5.7 eAG-117 [**2146-10-30**] 10:57PM TRIGLYCER-166* HDL CHOL-43 CHOL/HDL-2.9 LDL(CALC)-49 [**2146-10-30**] 08:59PM LACTATE-1.5 NA+-140 K+-3.7 CL--106 ct head: IMPRESSION: 1. No evidence of hemorrhage or loss of [**Doctor Last Name 352**]-white matter differentiation or mass effect on CT head without contrast. 2. CT perfusion demonstrates no evidence of asymmetric perfusion to indicate acute ischemia or infarct. 3. CT angiography of the neck demonstrates 50% narrowing of the right and 25 to 50% narrowing on the left near the carotid bifurcation. 4. CT angiography of the head demonstrates no vascular occlusion, stenosis or aneurysm greater than 3 mm in size. Vascular calcifications are seen at cavernous carotids bilaterally. 5. Retained secretions in the nasopharynx likely due to intubation. MRI head: Wet read. No acute process Brief Hospital Course: Mrs [**Known lastname 6330**] was admitted as a code stroke. She was seen in the ED and was noted to be agitated and had a speech disturbance that was not described in detail. A complete neurologic examination was not completed in ED. The patient was intubated in the ED and had a STAT CT head done. This was negative. She then proceeded to get an MRI of the brain done. This was also negative. She was extubated the next day without problems. She was awake interactive, oriented and had not known what had occurred the day before. She denies any fever/chills/headache. She states she has never had a seizure and takes Lamictal for her peripheral neuropathy secondary to DM II. Medications on Admission: -Humalog 75-25 17U q am and 20U q pm -Lamictal 200mg [**Hospital1 **] -Lisinopril 5mg daily -Metformin 500mg [**Hospital1 **] -Omepraxole 20mg daily -Simvastatin 80mg daily -Sumatriptan 50mg daily -Tramadol 50mg q 8hrs prn headaches -ASA 81mg daily -IB 800mg prn -Aleve -Nicotine patch Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary - Acute/transient altered Mental status (etiology unknown) Secondary -DM, insulin dependent - followed at [**Last Name (un) **] in the past but has not been see recently -HTN -Hypercholesterolemia - last lipids checked in [**2141**] -Hep C - per notes in remission -Diabetic neuropathy -Atypical Meniere's disease x 5 years - characterized by imbalance and lightheadedness Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for workup of your speech disorder and altered mental status. You were intubated in the ER for tests to rule out stroke. You had a CT of your head and an MRI of your brain which did not show any evidence of stroke. You were extubated the next day. You had an EEG which did not show any seizure activity. We are not sure what had caused this but it could have been a seizure. Followup Instructions: Please follow up with your primary care physician in the next 2-3 weeks. Call [**Telephone/Fax (1) 250**] for an appointment. Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 275**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2146-12-21**] 3:50 Provider: [**Name10 (NameIs) 1382**] [**Name11 (NameIs) 1383**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2147-1-9**] 11:30 [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

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icd9cm

[ [ [] ] ]

[ "38.91", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

4991, 5049

3975, 4654

328, 352

5475, 5475

2918, 3262

6043, 6601

1540, 1562

5070, 5454

4680, 4968

5626, 6020

1577, 1907

259, 290

380, 1030

2041, 2899

3271, 3952

5490, 5602

1931, 2025

1052, 1379

1395, 1524

68,437

140,220

370

Discharge summary

report

Admission Date: [**2119-10-2**] Discharge Date: [**2119-10-13**] Date of Birth: [**2043-5-9**] Sex: M Service: CARDIOTHORACIC Allergies: Lasix Attending:[**First Name3 (LF) 1267**] Chief Complaint: Chest pain, shortness of breath Major Surgical or Invasive Procedure: [**2119-10-5**] Aortic Valve Replacement(21mm Porcine). Mitral Valve Replacement(29mm Porcine). Two Vessel Coronary Artery Bypass Grafting utilizing the LIMA to LAD, and vein graft to obtuse marginal. [**2119-10-2**] Cardiac Catheterization History of Present Illness: Mr. [**Known lastname 3315**] is a 76 year old male with chronic diastolic congestive heart failure(aortic stenosis, mitral regurgitation) and chronic atrial fibrillation who presented to outside hospital with progressive shortness of breath and chest pain for the last six months. He admits to occasional rest pain as well. During that admission, he was found to be anemic and transfused with several units of PRBC's. Endoscopy found a nonbleeding AV malformation in the proximal duodenum. Given his above cardiac status, he was transferred to the [**Hospital1 18**] for further evaluation and treatment. Past Medical History: -Coronary Artery Disease, prior PCI -Aortic Stenosis -Mitral Regurgitation -Chronic Diastolic Congestive Heart Failure -Cerebrovascular Disease, prior TIA's, s/p right carotid stent, s/p Right CEA -Hypertension -Dyslipidemia -Chronic Atrial Fibrillaton -Chronic Renal Insufficiency -COPD -Anemia -History of GIB, AV Malformation(duodenum) -BPH, s/p TURP Social History: Lives alone. Quit tobacco about one months ago, prior heavy tobacco use. He denies ETOH. Family History: Father died at age 36 from MI. Physical Exam: Admit PE: 5'[**22**]" 67.1 kg T afebrile, BP 169/90, HR 69, R 20, 93% on 2L thin male in NAD PERRL, EOMI, oropharynx benign neck supple, no JVD, no carotid bruits irreg, irreg, 3/6 systolic murmur at RUSB and LLSB lungs clear anteriorly abdomen soft, slightly distended, non tender with normoactive bowel sounds extremities cool, no edema, decreased distal pulses alert and oriented, cn2-12 grossly intact, no focal deficits noted Pertinent Results: [**2119-10-11**] 05:47AM BLOOD WBC-8.8 RBC-2.98* Hgb-9.5* Hct-27.1* MCV-91 MCH-32.0 MCHC-35.2* RDW-16.3* Plt Ct-189 [**2119-10-2**] 05:15PM BLOOD WBC-5.7 RBC-3.47* Hgb-10.6* Hct-29.8* MCV-86 MCH-30.7 MCHC-35.7* RDW-15.7* Plt Ct-214 [**2119-10-13**] 05:58AM BLOOD PT-18.6* PTT-33.5 INR(PT)-1.7* [**2119-10-11**] 05:47AM BLOOD Plt Ct-189 [**2119-10-2**] 05:15PM BLOOD Plt Ct-214 [**2119-10-2**] 05:15PM BLOOD PT-15.5* PTT-114.6* INR(PT)-1.4* [**2119-10-13**] 05:58AM BLOOD Glucose-90 UreaN-25* Creat-1.7* Na-136 K-4.2 Cl-104 HCO3-26 AnGap-10 [**2119-10-2**] 05:15PM BLOOD Glucose-134* UreaN-25* Creat-1.8* Na-135 K-3.5 Cl-100 HCO3-26 AnGap-13 [**2119-10-4**] 12:40PM BLOOD ALT-24 AST-29 LD(LDH)-243 AlkPhos-70 TotBili-0.5 [**2119-10-13**] 05:58AM BLOOD Calcium-8.6 Mg-1.9 [**2119-10-4**] 12:40PM BLOOD %HbA1c-5.6 [**Known lastname **],[**Known firstname **] [**Medical Record Number 3316**] M 76 [**2043-5-9**] Cardiology Report ECG Study Date of [**2119-10-10**] 10:16:10 AM Atrial fibrillation with controlled ventricular response. Diffuse non-specific ST-T wave changes. Compared to the previous tracing of [**2119-10-5**] the rhythm is now atrial fibrillation and the other findings are similar. Read by: [**Last Name (LF) **],[**First Name3 (LF) **] V. Intervals Axes Rate PR QRS QT/QTc P QRS T 59 0 90 470/468 0 71 -32 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 3317**] (Complete) Done [**2119-10-5**] at 9:40:48 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 1112**] W. [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2043-5-9**] Age (years): 76 M Hgt (in): 71 BP (mm Hg): 128/66 Wgt (lb): 136 HR (bpm): 68 BSA (m2): 1.79 m2 Indication: intraop management for AVR/MVR/CABG. ICD-9 Codes: 440.0, 424.1, 424.0, 786.05, 786.51, 799.02 Test Information Date/Time: [**2119-10-5**] at 09:40 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3319**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW2-: Machine: 2 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *5.1 cm <= 4.0 cm Left Ventricle - Septal Wall Thickness: *1.6 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.5 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.8 cm Left Ventricle - Fractional Shortening: *0.16 >= 0.29 Left Ventricle - Ejection Fraction: 45% to 50% >= 55% Aorta - Annulus: 2.2 cm <= 3.0 cm Aorta - Sinus Level: 3.0 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.6 cm <= 3.0 cm Aorta - Ascending: *3.5 cm <= 3.4 cm Aorta - Arch: 2.7 cm <= 3.0 cm Aorta - Descending Thoracic: *2.7 cm <= 2.5 cm Aortic Valve - Peak Velocity: 1.9 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 14 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 13 mm Hg Aortic Valve - LVOT pk vel: 0.50 m/sec Aortic Valve - LVOT diam: 2.1 cm Aortic Valve - Valve Area: *0.7 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: Moderate LA enlargement. Mild spontaneous echo contrast in the body of the LA. No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Mildly depressed LVEF. LV WALL MOTION: Regional left ventricular wall motion findings as shown below; remaining LV segments contract normally. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Normal aortic arch diameter. Simple atheroma in aortic arch. Mildly dilated descending aorta. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: ?# aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Severe AS (AoVA <0.8cm2). Moderate (2+) AR. Eccentric AR jet directed toward the anterior mitral leaflet. MITRAL VALVE: Moderately thickened mitral valve leaflets. Myxomatous mitral valve leaflets. Mild mitral annular calcification. MR vena contracta is >=0.7cm Severe (4+) MR. TRICUSPID VALVE: Tricuspid valve not well visualized. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. 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. Results were personally reviewed with the MD caring for the patient. Conclusions PREBYPASS 1. The left atrium is moderately dilated. Mild spontaneous echo contrast is seen in the body of the left atrium. No mass/thrombus is seen in the left atrium or left atrial appendage. No atrial septal defect of PFO is seen by 2D or color Doppler. 2. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 45-50 %). The remaining left ventricular segments contract normally. 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. There are complex (>4mm) atheroma in the descending thoracic aorta. 5. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (area <0.8cm2). Moderate (2+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. 6. The mitral valve leaflets are moderately thickened. The mitral valve leaflets are myxomatous. The mitral regurgitation vena contracta is >=0.7cm. Severe (4+) mitral regurgitation is seen. 7. There is no pericardial effusion. 8. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2119-10-5**] at 827. POSTBYPASS 1. Patient is on phenylephrine infusion 2. A well seated, well functioning valve is seen in the mitral position. No perivalvular leak is noted. Mean gradient 3.1 mmHg. 3. A well seated, well functioning valve is seen in the aortic position. No perivalvular leak is noted. Mean gradient is 5.4 mmHg. 4. Aortic contour is smooth after decannulation 5. EF is 50%. 6. All other portions of the exam remain unchange. 7. Dr. [**Last Name (STitle) **] notified at 1227 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) **] [**2119-10-5**] 13:45 Brief Hospital Course: Mr. [**Known lastname 3315**] was admitted to the cardiology service with chronic diastolic heart failure and unstable angina. Cardiac catheterization revealed severe three vessel coronary artery disease. It was also notable for moderate-severe aortic stenosis, severe pulmonary arterial hypertension and mild biventricular diastolic dysfunction. LV gram was deferred secondary to his renal dysfunction. Cardiac surgery was therefore consulted and further evaluation was performed. Echocardiogram confirmed aortic stenosis but also revealed severe mitral and tricuspid regurgitation. Additional workup included a carotid ultrasound which found a totally occluded left internal carotid artery with a patent right internal carotid artery stent. He otherwise remained pain free on medical therapy and was eventually cleared for surgery. On [**10-5**], Dr. [**Last Name (STitle) **] performed aortic and mitral valve replacements along with coronary artery bypass grafting surgery. For surgical details, please see separate dictated operative note. Following the operation, he was brought to the CVICU for invasive monitoring. Extubated on POD #1 and developed melanotic stools, has pre existing AVM in the duodeum, hematocrit remained stable was started on protonix with no further issues. Beta blockade and amiodarone started postoperatively when he was in normal sinus rhythm but atrial fibrillation returned was treated with cardizem. He developed bradycardia and all av nodal blocking agents were discontinued, coumadin started and electrophysiology consult. Plan to hold av nodal blocking agents and monitor rhythm that is atrial fibrillation 50-60 and follow up with cardiologist as outpatient. Antihypertensives were titrated for blood pressure management. His foley catheter was removed twice with failure to void and urinary retention, remains in place at discharge and plan to follow up with outpatient urologist. He was ready for discharge to rehab on post op day 8. Medications on Admission: Transfer Meds: Protonix 40 qd, Cardizem 240 qd, Metoprolol 12.5 tid, Finasteride 5 qd, Fexofenadine 60 [**Hospital1 **], MVI, Ferrous Sulfate 300 [**Hospital1 **], Sulcralfate 1 tid, Flomax 0.4 qd, Lovenox 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. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 7. Diuril 250 mg/5 mL Suspension Sig: One (1) PO once a day for 7 days. 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 9. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO twice a day. 10. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: please dose based on INR - goal 2.0-2.5 for atrial fibrillation . 11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: Life Care Center - [**Location (un) 3320**] Discharge Diagnosis: Coronary Artery Disease s/p CABG Aortic Stenosis s/p AVR Mitral Regurgitation s/p MVR Bradycardia Urinary retention Cardiomyopathy Cerebrovascular Disease, prior TIA's, prior carotid stent, s/p RCEA Hypertension Dyslipidemia Chronic Atrial Fibrillaton Discharge Condition: Good. Discharge Instructions: 1) Shower daily. Wash incisions with soap and water. No creams, lotions, or ointments to incisions. 2) No driving for at least one month. 3) No lifting more than 10 lbs for at least 10 weeks. 4) Please call cardiac surgeon office if there is concern for sternal wound infection or fever greater than 100. 5) Please follow up with PCP for radiographic follow up on sclerotic lesion right clavicle 6) Sternal staples may be removed at rehab on [**10-17**] or call [**Telephone/Fax (1) 3071**] if questions or concerns 7) Hold all betablockers and ca channel blockers until follow up with cardiologist due to bradycardia Followup Instructions: Please call to schedule all appointments Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] Dr. [**Last Name (STitle) 3321**] after discharge from rehab Dr. [**First Name (STitle) 3322**] after discharge from rehab Dr [**Last Name (STitle) 3323**] (Urologist) on [**2119-10-25**] at 1:50 PM. ([**Telephone/Fax (1) 3324**] Completed by:[**2119-10-13**]

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icd9cm

[ [ [] ] ]

[ "99.04", "39.61", "35.23", "38.93", "37.23", "36.15", "36.11", "35.21", "88.56" ]

icd9pcs

[ [ [] ] ]

12546, 12616

9348, 11332

304, 547

12912, 12920

2182, 9325

13586, 13958

1682, 1714

11588, 12523

12637, 12891

11358, 11565

12944, 13563

1729, 2163

233, 266

575, 1182

1204, 1560

1576, 1666

9,815

127,504

30920

Discharge summary

report

Admission Date: [**2184-5-27**] Discharge Date: [**2184-6-2**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1973**] Chief Complaint: hypotension into 90s/40s Major Surgical or Invasive Procedure: None. History of Present Illness: 87 year-old M with CHF and HTN who presents with hypotension into 90s/40s. He underwent massive L inguinal hernia repair [**5-26**] at OSH, referred to [**Location (un) **] by VNA this am for hypotension into 90s/40s. He vomited twice overnight and presented with weankess to OSH ED today. He reports dizziness with movement and nausea; no abdominal pain, diarrhea, or constipation. He denies sick contacts. [**Name (NI) **] was started on pain medications post-operatively and recalls only taking one tablet. He does not think he took his diuretics. . Studies at OSH remarkable for CT abd with ascites, L pleural effusion, and nephrolithiasis. BNP 1480, WBC 11.2 with 83% neutrophils, INR 1.6, and Cr 1.7. He received 250cc IVF and was transferred to [**Hospital1 18**]. In ED he was given levoflox and metronidazole to cover GI and urinary pathology. He was given 750cc bolus with resultant SBP 90s. General surgery evaluated the patient and recommended scrotal elevation for swelling, but otherwise felt that there were no acute surgical issues. A 3-way foley was placed for BRB in foley from OSH. It cleared temporarily with 250 cc NS. UA with high specific gravity, large blood, 20-50 WBC. . ROS: He is legally blind. Pt denies fever or chills. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. No orthopnea or PND. No dysuria or hematuria is past. Past Medical History: CHF EF 25%, MR/TR HTN baseline BP 120s-130s 3rd degree AV block s/p Pacemaker s/p L inguinal hernia repair Back pain Social History: He lives alone in senior housing. No tobacco x 40 years, very occ EtOH. Family History: n/c Physical Exam: 97.8 96/80 60 18 95 on RA General: A&O x 3, NAD, sitting up in bed HEENT: EOMI, sclera anicteric. MMM, OP without lesions Pulm: decresed breath sounds to b/t bases, without crackles Cardiac: RRR, nl S1/S2, no M/R/G appreciated Abdomen: soft, NT/ND, + BS, ascites. surgical site in LLQ C/D/I Rectal: guaiac negative per OSH ED notes GU: large swelling and ecchymosis to scrotum, foley draining bloody urine Ext: cool distal LE, LLE 2+ edema, RLE trace. 1+ dp pulses b/t. Skin: xerosis, flaking, chronic venous changes. Neurologic: Alert & Oriented x 3. Unable to relate history fully due to poor memory. Pertinent Results: [**2184-5-27**] 07:00PM BLOOD WBC-11.5* RBC-4.60 Hgb-12.5* Hct-38.2* MCV-83 MCH-27.2 MCHC-32.9 RDW-17.6* Plt Ct-133* [**2184-6-2**] 06:45AM BLOOD WBC-8.8 RBC-4.62 Hgb-12.6* Hct-38.9* MCV-84 MCH-27.2 MCHC-32.3 RDW-18.3* Plt Ct-226 [**2184-5-27**] 07:00PM BLOOD Neuts-85.6* Lymphs-7.5* Monos-6.5 Eos-0 Baso-0.3 [**2184-6-2**] 06:45AM BLOOD Neuts-79.9* Lymphs-10.6* Monos-7.4 Eos-1.8 Baso-0.2 [**2184-5-27**] 10:50PM BLOOD Hypochr-1+ Anisocy-OCCASIONAL Poiklo-NORMAL Macrocy-NORMAL Microcy-OCCASIONAL Polychr-NORMAL Ovalocy-NORMAL Schisto-NORMAL [**2184-5-28**] 04:40AM BLOOD PT-17.6* PTT-35.2* INR(PT)-1.6* [**2184-6-1**] 06:30AM BLOOD PT-16.6* PTT-34.3 INR(PT)-1.5* [**2184-5-27**] 07:00PM BLOOD Glucose-95 UreaN-39* Creat-1.4* Na-139 K-4.6 Cl-107 HCO3-24 AnGap-13 [**2184-6-2**] 06:45AM BLOOD Glucose-95 UreaN-37* Creat-0.9 Na-138 K-4.0 Cl-105 HCO3-27 AnGap-10 [**2184-5-27**] 10:50PM BLOOD ALT-11 AST-22 CK(CPK)-64 AlkPhos-173* Amylase-47 TotBili-1.5 [**2184-5-31**] 12:57PM BLOOD ALT-14 AST-26 LD(LDH)-146 AlkPhos-140* TotBili-2.0* [**2184-5-31**] 12:57PM BLOOD GGT-23 [**2184-5-27**] 10:50PM BLOOD cTropnT-0.07* [**2184-5-28**] 04:40AM BLOOD CK-MB-NotDone cTropnT-0.07* [**2184-5-29**] 07:30AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.6 [**2184-6-2**] 06:45AM BLOOD Calcium-8.7 Phos-2.8 Mg-2.6 [**2184-5-29**] 07:30AM BLOOD TSH-3.1 [**2184-5-29**] 07:30AM BLOOD Free T4-1.2 [**2184-5-27**] 11:08PM BLOOD Lactate-1.6 . CHEST (PORTABLE AP) [**2184-5-27**] 7:37 PM 1. Bilateral pleural effusions, left greater than right. 2. Retrocardiac opacity which could be the combination of pleural effusion and atelectases, however, cannot rule out consolidation. 3. Left-sided dual chamber pacemaker. . ECG Study Date of [**2184-5-27**] 6:37:22 PM Ventricularly paced rhythm at 60 beats per minute with probable underlying atrial fibrillation. No previous tracing available for comparison. . UNILAT LOWER EXT VEINS LEFT [**2184-5-28**] 3:39 PM No DVT in the left lower extremity. . ABDOMEN U.S. (COMPLETE STUDY) [**2184-5-31**] 4:01 PM DUPLEX DOPP ABD/PEL [**2184-5-31**] 4:01 PM 1. Coarse echotexture of the liver, which may represent a component of fatty infiltration, although underlying cirrhosis/fibrosis cannot be excluded. 2. Patent Vascularity within the liver- specifically, patent hepatic veins, portal veins and hepatic artery. 3. Moderate amount of ascites in the right upper and right lower quadrants. 4. 4-cm seroma underlying the incision site. No significant ascites seen within the left lower quadrant. . ECHO Study Date of [**2184-5-31**] Biventricular cavity enlargement with severe systolic dysfunction c/w multivessel CAD or other diffuse process. Moderate-severe aortic valve stenosis. Moderate to severe pulmonary artery systolic hypertension. At least moderate mitral regurgitaiton. Brief Hospital Course: 87 year-old M with CHF and HTN who presents with post-operative hypotension, now stable, with serosanguinous discharge from abdominal surgical incision site. . * Post-Operative Wound Hemorage: Pt with new onset bleeding from surgical site. Concerning for new hematoma after he worked with PT vs worsening ascites either from hepatic or cardiac etiology exsanguination of seroma. CT abd without contrast at OSH showed marked anasarca, minimal ascites. Abdominal ultrasound with ascites in right side of abdomen, seroma around surigical site in LLQ, without hematoma. Liver without cirrhotic changes. Provide daily wound care with dressing changes and followup with outpatient surgery at [**Hospital **]Hospital for further management. . * Septicemia due to UTI: Sepsis, medication-related, nausea/vomiting, PE, post-operative volume depletion, hypothyroidism. Cardiac enzymes stable. Urine cultures no growth. Lactate within normal. LENIs negative for DVT. Thyroid panel normal. CT at OSH showed small pericardial effusion. Echo revealed biventricular cavity enlargement with severe systolic dysfunction c/w multivessel CAD or other diffuse process. Once BP stable, resumed on lasix, aldactone, and started low-dose ACE inhibitor. . * Systolic CHF with pleural effusions and ascites: Mild hypoxia. EF not known. V-paced on EKG. Biventricular cavity enlargement with severe systolic dysfunction c/w multivessel CAD or other diffuse process. Moderate-severe aortic valve stenosis. Moderate to severe pulmonary artery systolic hypertension. At least moderate mitral regurgitaiton. Resumed lasix, aldactone, started ACE inhibitor. BP remained normotensive on discharge. . * Elevated INR: No risk factors for liver disease. Low albumin. Most likely from CHF with hepatic congestion. Will need outpatient monitoring. No evidence of active bleeding, Hct stable. . * UTI: UA noted to be moderately positive for infection. WBC normal, pt without fevers. Completed 7 day course of ciprofloxacin on [**2184-6-2**]. Pt asymptomatic. . * Scrotal edema: Surgery consulted, recommended scrotal elevation, should resorb on its own. . *Prophylaxis: sc heparin, bowel regimen *FEN: low Na, cardiac diet *Access: PIVs *Code Status: FULL . *Dispo: PT cleared pt for DC. Discharge to rehab. . *Communication: [**Name (NI) **] (son) [**Telephone/Fax (1) 73114**] [**Name (NI) **] [**Name (NI) 110**] (daughter-in-law) [**Telephone/Fax (1) 73115**] Medications on Admission: Atenolol 25mg qd Lasix 60mg qd Aldactone 25mg qd Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Percocet 2.5-325 mg Tablet Sig: 1-2 Tablets PO every [**4-23**] hours as needed for pain for 10 days. Disp:*30 Tablet(s)* Refills:*0* 4. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 7. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 25759**] & Rehab Center - [**Location (un) **] Discharge Diagnosis: Congestive heart failure (EF 25%, MR/TR, moderate-severe AS) Pericardial effusion Hypotension Scrotal edema Ascites Urinary tract infection Serosanguinous discharge from hernia surgical site Discharge Condition: Stable, normal blood pressures, cleared by physical therapy for home. Discharge Instructions: You were admitted after your hernia repair surgery for low blood pressure. Your BP medications were held and your pressure remained stable. You had some bleeding from your hernia repair site that is still oozing and will need daily wound care. . You were restarted on your lasix, spironolactone, and a new medication, lisinopril, was added for your heart failure. . Please contact your PCP if you experience lightheadedness, dizziness, note bleeding or fluid discharge from your hernia surgical site, or have worsening swelling/pain from your scrotum. Followup Instructions: Please followup with your PCP: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 73116**] (Phone [**Telephone/Fax (1) 71880**]) on [**Last Name (LF) 766**], [**6-6**] at 2:30pm. . Your staples from the hernia repair site should be removed in 10 days by your PCP or at an emergency department.

[ "608.86", "599.0", "416.8", "V15.81", "458.29", "V15.82", "998.13", "V45.01", "398.91", "401.9", "369.4", "V13.01", "038.9", "599.7", "995.91", "396.2", "293.0", "423.9", "789.5" ]

icd9cm

[ [ [] ] ]

[ "99.07", "99.21" ]

icd9pcs

[ [ [] ] ]

8583, 8669

5418, 7844

286, 294

8904, 8976

2598, 5395

9576, 9875

1953, 1958

7944, 8560

8690, 8883

7870, 7921

9000, 9553

1973, 2579

222, 248

322, 1708

1730, 1848

1864, 1937

10,635

107,175

50071

Discharge summary

report

Admission Date: [**2125-4-23**] Discharge Date: [**2125-4-27**] Date of Birth: [**2068-11-10**] Sex: F Service: MEDICINE Allergies: Azmacort / Clindamycin / Versed / Fentanyl / Morphine / Optiray 300 / Ceftriaxone Attending:[**First Name3 (LF) 5644**] Chief Complaint: transfered from MICU Major Surgical or Invasive Procedure: a-line History of Present Illness: 56 y/o F w/ hx of chronic demyelinating disease, ? of restrictive/COPD lung disease, adrenal insufficiency, and asthma nwo being evaluated in the ED for increased shortness of breath and presumed allergic/?anaphylactic reaction in setting o fceftriaxone. [**Name (NI) 1094**] husband reports increased fatigue/weakness over past 2 weeks in setting of URI [**Last Name (un) **] mptoms x 2 weeks. No fevers, + chills, + mod HA, + soer throat. Progressive productive cough of yellow-green sputum with increased DOE/SOB at rest. She usually doesn't use her nebs but over the past [**1-18**] days has been using it continuously. ? decreased po intake and abdominal pain (hypogastric) with po's, no urinary symptoms, did have increased diarrhea. Has several [**Month/Day (3) **] contacts at home including daughter who works at a daycare. * In the ED, she was afebrile, HDS, but hypoxic to 88% on RA, improved to mid 90s on NC. Labs unremarkable and CXR without infiltrate, but concerned about pna. She was wheezing, given nebs, and then given ceftriaxone. Approximately 5 minutes into ceftriaxone infusion, she became erythematous, difficulty breathing, ? throat swelling, and hypotensive to 70s. She was given solumedrol, benadryl, pepcid, and aggressive IVF with improved SBP's adn the ceftriaxone was discontinued. Loevofloxacin was given instead. . MICU course: The patient respiratory stablized and was on room air on [**2125-4-25**]. His initial metabolic /resp acidosis, w/ increasing late to 6.3 of unclear etiology. His lactate has improved to 4.4 on [**4-24**] PM. Her last ABG 7.34/48/87. WBC normalized from 11.9 to 9.3 and increased to 19 after IV solumedrol started. Her cultures are pending on transfer. She was continued on levo for presumed pna. Past Medical History: Asthma. Restrictive lung disease. Unknown demyelinating syndrome (L leg paresis, bilateral arm weakness, demyelination on brain MRI, neurogenic bladder) Adrenal insufficiency. Osteoporosis. Hypothyroidism. History of chest nodules. Dyslipidemia. History of K breast papilloma with nipple discharge. Anxiety. Labile hypertension. History of right IJ thrombus in [**2112**]. IgG deficiency. Anemia. Status post cholecystectomy in [**2112**]. Dysfunctional uterine bleeding by history. Atypical pap smears. Common bile duct stenosis s/p sphincterotomy. Gastritis and prepyloric ulcers per EGD. Bilateral hearing loss. G-tube and self-catheterization Social History: The patient states she lives with her husband. Over 50 pack year smoking hx; quit in [**2109**]. Denies any recent alcohol or IV drug abuse. Family History: Family history is notable for coronary artery disease. Father had [**Name2 (NI) 499**] cancer, her mother had breast cancer, and her sister had brain cancer. Works with "special kids" group as coordinator and volunteer but has not been available for over one month secondary to frequent and severe ilees Physical Exam: Gen: NAD, talkative HEENT: PERRL CV: RRR, S1 and s2, 2/6 SEM Lung:mildly improving wheezing Abd: LLQ w/ PEG intact, + BS Ext: WWP, no edema Skin- intact Pertinent Results: .. CTA: no PE, no lung nodule previously noted CXR ([**4-25**]):?[**Month/Year (2) 25730**] opacity. Brief Hospital Course: A/P: 55 y/o F w/hx of demyelinating d/o, restrictive/obstructive lung disease, adrenal insufficiency, who presented to teh ED with resp distress and a question of an anaphylactic rxn to ceftriaxone. .. 1)Allergic/Anaphylactic rxn: timing and rash c/w drug rxn, after receiving PPI/solumedrol/benadryl was hemodynamically stable. SHe was continued on combination of PPR/prednisone/benadryl prn while she was in the floor and she did not have any recurrent episodes of allergic reaction .. 2)COPD flare: h/o [**Month/Year (2) 25730**] pna, CXR now without infiltrate, exam nonfocal. Increased sputum productive, known restrictive with component of COPD, increased O2 requirement but not in distress. CT chest w/o PE. -She was continued on levofloxacin and a combination of nebulizer and prednisone while she was here. SHe did well on room air as of [**4-27**] and was discharged on [**4-27**] on room air. .. 3) Hypotension: in setting of presumed allergic rxn. \ -She did not have any further episodes of hypotension today .. 4) Demyelinating disaes: rx with benzos. She had a total of 3 episodes of spasm while she was on the floor over the course of 2 days. Her usual baseline is 1 episodes per day. HEr COPD flare/pneumonia are the likely culprit of her increased frequency of spasm. She was continued on her muscle relaxant, clonazepam. Her ativan was increased as well .. 5) lipid- She was continued on lipitor .. 6) nutrition- She was continued on B12, folate, IVF and was getting nutrition via PEG tube while in hospital. .. 7). anemia -Her hct was stable at the time of discharge in the low 30s. .. 9) adrenal insuffiency SHe was continued on fludrocortisone and continued on slow prednisone taper (60 qd at the time of discharge) for total of 18 days as outpatient. .. Discharge Medications: 1. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days. Disp:*6 Tablet(s)* Refills:*0* 3. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). Disp:*90 Tablet, Chewable(s)* Refills:*2* 5. Lorazepam 1 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). Disp:*360 Tablet(s)* Refills:*2* 6. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 7. Fludrocortisone Acetate 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. 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* 9. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 12. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 14. Tizanidine HCl 4 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 15. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 16. Buspirone HCl 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 17. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q3-4H () as needed for SOB. 18. Prednisone 10 mg Tablet Sig: as directed Tablet PO as directed for 18 days: pls take 6 tabs for 3 days, 5 tabs for 3 days, 4 tabs for 3 days, 3 tabs for 3 days, 2 tabs for 3 days, 1 tab for 3 days. Disp:*63 Tablet(s)* Refills:*0* 19. Benadryl 25 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for allergy symptoms. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: COPD demyelinating nerve disease Discharge Condition: stable Discharge Instructions: please take your medications please take your levoquin for 6 more days please call your doctor if you experience chest pain or shortness of breath Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) **], MD Where: CC CLINICAL CENTER NEUROLOGY Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2125-5-10**] 3:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3031**], M.D. Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2125-6-25**] 10:20

[ "486", "276.5", "255.4", "584.9", "341.9", "493.20", "518.81", "244.9", "995.0", "401.9", "276.2", "272.0", "285.9", "E930.5" ]

icd9cm

[ [ [] ] ]

[ "93.90", "96.6" ]

icd9pcs

[ [ [] ] ]

7655, 7661

3628, 5408

364, 372

7738, 7746

3501, 3605

7943, 8360

3007, 3313

5431, 7632

7682, 7717

7770, 7920

3328, 3482

304, 326

400, 2159

2181, 2830

2846, 2991

72,113

192,251

54981

Discharge summary

report

Admission Date: [**2129-8-16**] Discharge Date: [**2129-8-21**] Date of Birth: [**2063-11-10**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Known firstname 32912**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: [**2129-8-16**]: EGD [**2129-8-17**]: Fistulogram [**2129-8-18**]: T-tube cholangiogram History of Present Illness: The patient is a 65-year-old man s/p subtotal cholecystectomy with CBDE and transduodenal sphincteroplasty with T-tube placement on [**2129-7-21**] for chronic cholecystitis and an intraoperative finding of a large cholecystoduodenal fistula and an impacted distal bile duct stone. An indwelling biliary tube was left in place and a postoperative cholangiogram demonstrated adequate emptying of the bile duct. He was discharged to rehab on [**2129-7-28**] and was readmitted with a subhepatic abscess, which was drained percutaneously by IR (Not bile, culture grew klebsiella and citrobacter). He was discharged back to rehab on antibiotics, with the IR drain in place and had been recovering well. Patient was feeling dizzy today at rehab while in the bathroom. He was found by staff to have a large amount of dark stools. The patient was transferred in the [**Hospital1 18**] for further evaluation. Past Medical History: Past Medical History: duodenal ulcer, bleed 30 years ago requiring surgery listed below, hepatitis C, s/p interferon ?history cirrhosis, normal liver fxn, anxiety, depression Past Surgical History: distal gastrectomy with Billroth II for bleeding duodenal ulcer 30 years ago, subtotal cholecystectomy with CBDE and transduodenal sphincteroplasty with T-tube placement on [**2129-7-21**] Social History: Lives alone on [**Social Security Number 112276**]social security. 240 pack year history of smoking but quit 10 years ago. 30 year history of heavy EtOH abuse (3 cases of beer daily + multiple shots of rum and vodka. Family History: Patient reports his father died of pancreatic cancer. He states his father's "entire" family died of different cancers (breast, ovarian, stomach and bladder). He states he has previously undergone genetic screening. Physical Exam: Upon Discharge: VSS, Afebrile GEN: Baseline anxious and confused, AAO x 3 CV: RRR RESP: CTAB Abd: T-tube in place draining bilious fluid, abscess drain in place draining scant amount of white/yellow opaque fluid, non-tender, well healing transverse incision c/d/i LE: WWP, no edema Pertinent Results: Fistulogram [**2129-8-17**] 50 cc of Optiray contrast was slowly hand injected into the abscess drainage catheter under fluoroscopic guidance. The contrast initially opacified a bilobed cavity surrounding the catheter tip. Further injection opacified two narrow tracts originating from the primary collection that were believed to be extraluminal. Contrast was also seen to track along the outside of the catheter retrogradely to the skin surface where it was seen to run dependently along the skin surface. Further injection of contrast showed communication between the main collection and the cystic duct which then lead to full opacification of the cystic duct and subsequent opacification of the common bile duct and the biliary tree. Contrast was then seen to fill the lower CBD and eventually the duodenum. IMPRESSION: Communication between the collection surrounding the catheter and the biliary tree via the cystic duct is c/w a cystic duct bile leak. TTube Cholangiogram [**2129-8-18**] FINDINGS: 50 cc of Optiray contrast was slowly hand injected into the biliary tube under fluoroscopic guidance. The contrast was seen entering the T-tube with subsequent opacification of the biliary tree and the duodenum. Shortly thereafter, opacification of what appears to be the cystic duct is seen. Further administration of contrast shows opacification of the cavity where the drainage catheter is located. It is not entirely clear whether biliary communication with the cavity is through the duodenum or the cystic duct as the duodenum comes into very close proximity to the cavity. However, on the previous study it appeared that the communication through the cystic duct was the more likely scenario. IMPRESSION: A communication exists between the cavity where the abscess drain is located and the biliary system. A cystic duct leak might be the culprit, however, communication with the duodenum and the cavity is not entirely excluded even though a fistula is not clearly seen. CTAP [**2129-8-19**] IMPRESSION: 1. Interval decrease in size of subhepatic fluid collection within which resides a drainage catheter. As no contrast was given through the catheter for this study, and there is no reflux of oral contrast of the duodenal limb in this patient status post Billroth II, persistent fistulous connection between the collection and bile duct or duodenum cannot be assessed. 2. Unchanged appearance of multiple liver lesions some of which are hypodense, and some of which enhance, compatible with hemangiomata and possibly cysts, which are unchanged from priors. 3. Multiple renal hypodensities, also unchanged from priors, some of which were previously demonstrated to be cystic in nature. Others are hyperdense by CT, and ultrasound is recommended on a non-emergent basis to exclude solid lesions. 4. Diverticulosis, without inflammatory change to suggest diverticulitis. 5. Unchanged appearance of Paget's disease. [**2129-8-19**] 06:15AM BLOOD WBC-9.1 RBC-3.06* Hgb-8.9* Hct-27.9* MCV-91 MCH-29.0 MCHC-31.9 RDW-17.0* Plt Ct-240 [**2129-8-18**] 10:20PM BLOOD Hct-25.7* [**2129-8-18**] 06:05AM BLOOD WBC-8.5 RBC-2.94* Hgb-8.7* Hct-26.4* MCV-90 MCH-29.6 MCHC-32.9 RDW-16.2* Plt Ct-283 [**2129-8-17**] 09:40PM BLOOD Hct-26.2* [**2129-8-17**] 01:50PM BLOOD Hct-27.2* [**2129-8-17**] 07:07AM BLOOD Hct-26.6* [**2129-8-16**] 11:59PM BLOOD WBC-11.0 RBC-2.83* Hgb-8.4*# Hct-25.0*# MCV-89 MCH-29.6 MCHC-33.4 RDW-16.4* Plt Ct-287 [**2129-8-16**] 09:15PM BLOOD Hct-18.2* [**2129-8-16**] 04:30PM BLOOD WBC-10.6 RBC-2.27*# Hgb-6.6*# Hct-20.8*# MCV-92 MCH-29.1 MCHC-31.8 RDW-16.1* Plt Ct-354# [**2129-8-16**] 04:30PM BLOOD Neuts-79.9* Lymphs-15.8* Monos-3.1 Eos-0.8 Baso-0.4 [**2129-8-19**] 06:15AM BLOOD Plt Ct-240 [**2129-8-18**] 06:05AM BLOOD Plt Ct-283 [**2129-8-16**] 11:59PM BLOOD Plt Ct-287 [**2129-8-16**] 11:59PM BLOOD PT-11.4 PTT-25.4 INR(PT)-1.1 [**2129-8-16**] 04:30PM BLOOD Plt Ct-354# [**2129-8-16**] 04:30PM BLOOD PT-11.2 PTT-26.2 INR(PT)-1.0 [**2129-8-16**] 11:59PM BLOOD Fibrino-283 [**2129-8-19**] 06:15AM BLOOD [**2129-8-18**] 06:05AM BLOOD [**2129-8-16**] 11:59PM BLOOD [**2129-8-21**] 05:54AM BLOOD Glucose-98 UreaN-8 Creat-0.6 Na-140 K-3.7 Cl-107 HCO3-25 AnGap-12 [**2129-8-18**] 06:05AM BLOOD Glucose-98 UreaN-7 Creat-0.6 Na-138 K-3.3 Cl-105 HCO3-30 AnGap-6* [**2129-8-16**] 11:59PM BLOOD Glucose-132* UreaN-21* Creat-0.6 Na-136 K-3.9 Cl-106 HCO3-25 AnGap-9 [**2129-8-16**] 04:30PM BLOOD Glucose-104* UreaN-29* Creat-0.6 Na-138 K-4.2 Cl-104 HCO3-24 AnGap-14 [**2129-8-19**] 06:15AM BLOOD ALT-12 AST-29 AlkPhos-138* TotBili-0.8 [**2129-8-18**] 06:05AM BLOOD ALT-9 AST-20 AlkPhos-117 TotBili-0.7 [**2129-8-16**] 11:59PM BLOOD ALT-11 AST-25 LD(LDH)-188 AlkPhos-108 TotBili-1.2 [**2129-8-16**] 04:30PM BLOOD ALT-11 AST-27 AlkPhos-117 TotBili-0.2 [**2129-8-21**] 05:54AM BLOOD Calcium-7.9* Phos-3.3 Mg-2.0 [**2129-8-19**] 06:15AM BLOOD Albumin-3.2* [**2129-8-18**] 06:05AM BLOOD Calcium-7.7* Phos-2.8 Mg-1.8 [**2129-8-16**] 11:59PM BLOOD Albumin-2.8* Calcium-7.4* Phos-2.3* Mg-1.9 [**2129-8-16**] 04:30PM BLOOD Albumin-2.9* [**2129-8-16**] 04:39PM BLOOD Type-[**Last Name (un) **] pO2-48* pCO2-41 pH-7.41 calTCO2-27 Base XS-0 [**2129-8-16**] 04:39PM BLOOD Lactate-1.6 Brief Hospital Course: The patient was admitted to Dr.[**Initials (NamePattern4) 111777**] [**Last Name (NamePattern4) 112276**] Sugery Service. He was admitted to the ICU on [**2129-8-16**] and was found to have a hematocrit as low as 18.2. He was transfused a total of 3 units of PRBC's. He also underwent an EGD. A single cratered 2 cm ulcer was found at the gastro-jejunal anastomosis (Billroth II anastomosis). A large clot was seen overlying the ulcer. The clot was removed using a snare. Two visible vessels were seen underneath the clot. Epinephrine 1/[**Numeric Identifier 961**] injections were applied for hemostasis with success in the edges and center of the ulcer. Three endoclips were successfully applied to the visible vessels. The visible vessels were cauterized with gold probe for hemostasis. The patient's hematocrit increased appropriately and remained stable in the range of 26 to 27. The patient was started on Epoiten and Ferrous Sulfate to augment his RBC production. His T-tube and Abscess drains were also studies. A communication between the collection surrounding the catheter and the biliary tree via the cystic duct is c/w a cystic duct bile leak was found. The decision was made to keep his T-tube and Abscess drain in place for his discharge. CV: See above. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. GI/GU/FEN: The patient was made NPO with IV fluids. Diet was advanced when appropriate, which was well tolerated. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. ID: The patient's white blood count and fever curves were closely watched for signs of infection. Endocrine: The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. Hematology: See above Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: 1. Acetaminophen PRN pain 2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 10 Days 3. Cyanocobalamin 50 mcg PO DAILY 4. DiphenhydrAMINE 25 mg PO Q6H:PRN itching 5. Pantoprazole 40 mg [**Hospital1 **] 6. FoLIC Acid 1 mg PO DAILY 7. MetRONIDAZOLE (FLagyl) 500 mg PO TID Duration: 2 Weeks 8. Mirtazapine 15 mg PO HS 9. OxycoDONE Liquid 5-15 mg PO Q4H:PRN pain 10. Risperidone 0.25 mg PO BID 11. Thiamine 100 mg PO DAILY 12. traZODONE 50 mg PO HS:PRN insomnia Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Epoetin Alfa 10,000 UNIT SC THREE TIMES PER WEEK 3. Ferrous Sulfate 325 mg PO DAILY 4. Mirtazapine 15 mg PO HS 5. Oxycodone-Acetaminophen (5mg-325mg) [**12-6**] TAB PO Q6H:PRN pain 6. Pantoprazole 40 mg PO Q12H 7. Potassium Chloride 40 mEq PO DAILY Hold for K > 5 8. Risperidone 0.25 mg PO BID 9. Risperidone 0.25 mg PO BID:PRN anxiety 10. Senna 1 TAB PO BID:PRN constipation 11. traZODONE 50 mg PO HS:PRN insomnia Discharge Disposition: Extended Care Facility: Nevins Nursing and Rehabilitaton Center Discharge Diagnosis: 1. Gastro-jejunal anastomosis ulcer 2. Cystic duct bile leak Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the surgery service at [**Hospital1 18**] with diagnosis of GJ anastomosis ulcer and cystic duct leak. You now safe to return home to Rehab your recovery with the following instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**4-14**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. . Right flank pigtail drain: To gravity drainage. *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *If the drain is connected to a collection container, please note color, consistency, and amount of fluid in the drain. Call the doctor, nurse practitioner, or VNA nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. *Wash the area gently with warm, soapy water or 1/2 strength hydrogen peroxide followed by saline rinse, pat dry, and place a drain sponge. Change daily and as needed. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation . Right T-tube: Capped Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in one week. Please assure to make an appointment by calling [**Telephone/Fax (1) **]. Please follow up with your PCP within one month.

[ "576.8", "305.01", "E878.8", "534.40", "311", "300.00", "V12.71", "997.49" ]

icd9cm

[ [ [] ] ]

[ "87.54", "88.47", "44.43" ]

icd9pcs

[ [ [] ] ]

11244, 11310

7763, 10264

313, 403

11414, 11414

2534, 7740

13308, 13499

1997, 2216

10768, 11221

11331, 11393

10290, 10745

11566, 13285

1555, 1746

2231, 2231

265, 275

2247, 2515

431, 1334

11429, 11542

1378, 1532

1762, 1981

22,905

180,604

27909

Discharge summary

report

Admission Date: [**2160-11-11**] Discharge Date: [**2160-11-19**] Date of Birth: [**2126-1-21**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Ciprofloxacin / Flagyl Attending:[**First Name3 (LF) 12135**] Chief Complaint: Pelvic organ prolapse Major Surgical or Invasive Procedure: total vaginal hysterectomy; combined anterior-posterior colporrhaphy with posterior mesh; subpubic urethral sling; sacrospinous colpopexy exploratory laparotomy Reexploration of vaginal surgical area pelvic angiography History of Present Illness: 34 yo G3P3 with pelvic organ prolapse after her second delivery; after her third delivery it became much worse. She feels like "everything is falling out." She urinates frequently, but occasionally the urine is very slow to start. She is unable to run without losing urine. The prolapse is especailly large and uncomfotable when she tries to move her bowels and it is easier for her to do sowhile standing rather than sitting. She has deep pain in intercourse. Past Medical History: Medical Chronic back pain: several discs and spondylolisthesis Surgical Left salpingo oophorectomy [**2156**] for torsion; coloposcopy and cryotherapy [**2155**]; appendectomy; T + A Ob 3 FTNDs Social History: Occasional EtOH 1ppd tobacco Family History: Mother had breast cancer Physical Exam: 112 # 138/94 Gen: NAD Heart: RRR, no murmurs Lungs: Clear to percussion and auscultation Breast: Negative Abdomen: Negative Pelvic Ext gen: negative Support: Anterior wall prolapses 3 cm past the hymen with loss of urine on valsalva; cervix 1cm above the hymen; posterior prolapse only to the hymen but 3.4 cm of perineal descent. Vagina: Negative Cervix: Negative Uterus: Anterior, tender on motion Adnexa: Right not palpable, left absent Rectal: Neg Pertinent Results: RADIOLABLED RED CELL STUDY [**11-12**] IMPRESSION: No evidence of acute bleed in the abdomen or pelvis. PELVIC ARTEROGRAM [**11-12**] FINDINGS: Images demonstrate diffusely small caliber vasculature consistent with shock. There is luminal irregularity seen in segments of both the left and right external iliac arteries consistent with spasm. Specifically, no extravasation of contrast, obstruction of blood flow, AV fistulization or intimal injury was observed. Thus, no embolotherapy was embarked upon. IMPRESSION: No active bleeding was observed. PATHOLOGY uterus, tubes, ovaries [**11-11**] 1. Uterus and cervix, hysterectomy (A-E): A. Secretory endometrium. B. Cervix with squamous metaplasia. C. Unremarkable myometrium. D. One intrauterine device, gross description. 2. Vaginal epithelium (F): Squamous mucosa and skin with no significant pathologic change. [**2160-11-11**] 06:37PM BLOOD WBC-20.0* RBC-3.31* Hgb-10.2*# Hct-31.2* MCV-95 MCH-30.9 MCHC-32.7 RDW-13.6 Plt Ct-297 [**2160-11-11**] 08:48PM BLOOD Hct-19.5*# [**2160-11-12**] 01:46AM BLOOD WBC-20.0* RBC-3.96* Hgb-12.5 Hct-34.4*# MCV-87# MCH-31.5 MCHC-36.4*# RDW-13.6 Plt Ct-89*# [**2160-11-12**] 09:45AM BLOOD WBC-12.7* RBC-3.17* Hgb-9.9* Hct-27.6* MCV-87 MCH-31.3 MCHC-35.9* RDW-14.2 Plt Ct-104* [**2160-11-13**] 04:09AM BLOOD WBC-12.1* RBC-3.73* Hgb-11.3* Hct-31.5* MCV-84 MCH-30.2 MCHC-35.8* RDW-15.4 Plt Ct-91* [**2160-11-14**] 12:15AM BLOOD Hct-28.7* [**2160-11-15**] 06:30AM BLOOD Hct-27.9* [**2160-11-17**] 04:45AM BLOOD WBC-12.6* RBC-3.53* Hgb-10.5* Hct-30.1* MCV-85 MCH-29.8 MCHC-35.0 RDW-14.6 Plt Ct-308# [**2160-11-11**] 06:37PM BLOOD PT-13.0 PTT-26.1 INR(PT)-1.1 [**2160-11-12**] 02:03PM BLOOD PT-13.2* PTT-24.2 INR(PT)-1.1 [**2160-11-13**] 04:09AM BLOOD PT-11.6 PTT-23.8 INR(PT)-1.0 [**2160-11-11**] 06:37PM BLOOD Glucose-146* UreaN-12 Creat-0.6 Na-140 K-4.1 Cl-108 HCO3-21* AnGap-15 [**2160-11-13**] 04:09AM BLOOD Glucose-96 UreaN-5* Creat-0.4 Na-139 K-3.1* Cl-108 HCO3-26 AnGap-8 [**2160-11-15**] 09:20PM BLOOD UreaN-4* Creat-0.3* Na-140 K-4.0 Cl-108 HCO3-27 AnGap-9 [**2160-11-11**] 06:37PM BLOOD Calcium-7.9* Phos-4.5 Mg-1.5* [**2160-11-13**] 01:03PM BLOOD Calcium-7.3* Phos-2.3* Mg-1.7 [**2160-11-14**] 06:30AM BLOOD Calcium-7.5* Mg-1.6 [**2160-11-15**] 09:20PM BLOOD Calcium-7.5* Phos-2.7 Mg-1.9 [**2160-11-11**] 10:53PM BLOOD Type-ART pO2-229* pCO2-44 pH-7.26* calTCO2-21 Base XS--6 Intubat-INTUBATED Vent-CONTROLLED [**2160-11-12**] 09:09AM BLOOD Type-ART Temp-37.2 Rates-/12 Tidal V-560 PEEP-5 FiO2-50 pO2-176* pCO2-42 pH-7.35 calTCO2-24 Base XS--2 Intubat-INTUBATED Vent-SPONTANEOU Brief Hospital Course: The patient was taken to the operating room on [**2160-11-11**] for TVH, sacrospinous fixation, SPARC, anterior and posterior repair with mesh, cystoscopy; for pelvic organ prolapse. There were no intraoperative complications and the surgical field was hemostatic at the conclusion of the case (see operative report for full description). The patient tolerated the procedure well and was stable in the PACU and admitted to the Gyn floor for routine care. At 1645 [**11-11**], the patient was noted to be hypotensive to 70/40 HR 84 with symptoms of lightheadedness while lying supine. There was no active bleeding noted at the surgical site on examination. A STAT HCT drawn at this time was 31.2. The patient was re-evalutated at [**2154**] and was found to be tacchycardic to 115 with BP 104/50 using a manual cuff. Urine output during the prior two hours had been 50cc and 24cc. A STAT HCT drawn at this time was 19.5. The clinical picture was concerning for a post-operative hematoma. The ICU was alerted to the patient's disposition and the operating room was activated for urgent re-exploration. The patient was taken to the OR on POD#0 for re-exploration with incision at 2243. Exploratory laparotomy revealed hemoperitonium and approximately 1 L of blood was evacuated. There was approximately 500cc of retroperitoneal clot. Despite laparotomy and re-exploration through the vaginal cuff, no source for the bleeding could be found. At the conclusion of the case, the patient continued to bleed, allbeit at a less brisk pace. The endotracheal tube was left in place. Intraoperatively, the patient recieved 5u PRBC. IR was consulted to identify the bleeding vessel with angiography, then perform embolization. Tagged cell and angiographic studies performed immediately after re-exploration on [**11-12**] did not indetify active bleeding and no emobolization was indicated. THe patient was stable and remained intubated. The patient was admitted to the ICU for further care. The patient's ICU course was uneventful. There was no evidence of continued bleeding and her HCT remained stable around 30. The pt self-extubated on POD #1. The patient developed a low grade fever to 100.1 on POD#1 which persisted to POD#2 and imperic treatment with gent/clinda was started. The patient was stable for transfer to the gyn floor on POD#3. Antibiotics were discontinued on POD#8 and pt remained afebrile thereafter. On POD#9, the patient was afebrile, tolerating a regular diet, ambultating without difficulty and voiding spontaneously. She was discharged home with follow-up in two weeks. Medications on Admission: Zoloft 100mg QD Ritalin 0.5mg [**Hospital1 **] Loraze3pam 0.5mg [**Hospital1 **] Percocet 5/325 QHS Allergies: Cipro, Flagyl Discharge Medications: 1. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*60 Tablets* Refills:*1* 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*60 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* Continue home meds. Discharge Disposition: Home Discharge Diagnosis: pelvic organ prolapse stress urinary incontinence retroperitoneal bleed hemoperitoneum Discharge Condition: stable Discharge Instructions: No heavy lifting for 6 weeks No abdominal exercises for 6 weeks Nothing in the vagina for 6 weeks Keep stools soft Followup Instructions: Please call Dr.[**Name (NI) 67989**] office for an appointment in 2 weeks. Completed by:[**2160-11-23**]

[ "287.5", "518.5", "998.89", "285.1", "998.11", "618.4", "788.30", "458.29" ]

icd9cm

[ [ [] ] ]

[ "70.77", "68.59", "54.12", "70.50", "59.79", "99.04", "88.47" ]

icd9pcs

[ [ [] ] ]

7636, 7642

4449, 7058

321, 542

7773, 7782

1835, 4426

7945, 8052

1319, 1345

7234, 7613

7663, 7752

7084, 7211

7806, 7922

1360, 1816

260, 283

570, 1037

1059, 1257

1273, 1303

65,537

148,062

41951

Discharge summary

report

Admission Date: [**2105-10-27**] Discharge Date: [**2105-11-4**] Service: MEDICINE Allergies: Bactrim Attending:[**Doctor First Name 3290**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname 91062**] is an 88 year-old female with PMHx of afib, dementia & hyperthyroidism who is transferred from [**Hospital1 **] [**Location (un) 620**] with septic shock most likely from a UTI. The patient is unable to give much history, but per her daughter, the patient has been having strong smelling urine x 1 week with associated confusion and generalized weakness. At baseline, the patient is able to perform her ADLs by herself and is A+O to self and place, but does not know date. Today the patient did not want get out of bed and daughter found pt was too weak to walk. No fever / chill, falls, no head injury, no CP no SOB, abdominal pain currently. Brought in by daughter to [**Hospital1 **] [**Name (NI) 620**] where she was febrile to 103.3, and had grossly infected urine and ?R sided lung infiltrate on CXR. Labs at BIDN were significant for WBC 25.5, Cr 1.8 and UA with 50-100 WBCs, troponin < 0.01, LFT 34/19/94/1.09, guiaic neg. There, the patient received vancomycin 1g IV, ceftriaxone 1g IV, tylenol 1g and 4L NS. BPs were in systolics 70s; RIJ CVL was placed and she was started on a neosynephrine drip at 1mcg/kg/min (of note, line had to be pulled back as it was initially in the R atrium). Per [**Location (un) **], during transfer systolic BPs were 100s-120s. In our ED, SBPs 80s-120s & pt has been in atrial fibrillation. Patient also received Zosyn 4.5mg IV for broaden coverage. Labs here notable for WBC 26.8 (no bands), Cr 1.1 and lactate 1.2. INR subtherapeutic at 1.2. UA again demonstrated UTI with <1 epis, large leuk, neg nitrite, many bacteria & >182 WBCs. VS on transfer were BP 123/71 HR 116, RR 19 98% RA, temp 98.9 (oral) and phenylephrine gtt at 1mcg/kg/min. On arrival to the MICU, Pt's VS are 100.5, 122, 64/50, 94% on RA Past Medical History: Dementia A-fib Hyperthyroidism CAD OA Social History: Unable to aquire due to altered mental status Family History: Unable to aquire due to altered mental status Physical Exam: Physical Exam on admission: General: Alert, following commands, oriented X0, no acute distress HEENT: PERRL, Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD CV: irregularly irregular, tachycardic, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Physical Exam on discharge: 98.8 (99.7) 124/70 (110's-130's/60's-70's) 56-84 18 98% RA General: Alert, following commands, oriented X 1.5, no acute distress HEENT: PERRL, Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD CV: irregularly irregular, tachycardic, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Labs on admission: [**2105-10-29**] 03:15AM BLOOD WBC-20.9* RBC-4.82 Hgb-10.5* Hct-32.4* MCV-67* MCH-21.8* MCHC-32.4 RDW-14.4 Plt Ct-232 [**2105-10-28**] 03:53AM BLOOD WBC-18.5* RBC-5.21 Hgb-11.1* Hct-36.4 MCV-70* MCH-21.4* MCHC-30.6* RDW-14.3 Plt Ct-218 [**2105-10-27**] 09:29AM BLOOD WBC-29.3* RBC-5.06 Hgb-11.1* Hct-33.9* MCV-67* MCH-22.0* MCHC-32.8 RDW-14.1 Plt Ct-242 [**2105-10-27**] 02:42AM BLOOD WBC-26.8* RBC-5.33 Hgb-11.3* Hct-36.7 MCV-69* MCH-21.1* MCHC-30.7* RDW-14.0 Plt Ct-245 [**2105-10-27**] 09:29AM BLOOD Neuts-53.5 Lymphs-44.9* Monos-1.3* Eos-0 Baso-0.3 [**2105-10-27**] 02:42AM BLOOD Neuts-42* Bands-0 Lymphs-55* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2105-10-29**] 03:15AM BLOOD Plt Ct-232 [**2105-10-29**] 03:15AM BLOOD PT-13.1 PTT-21.6* INR(PT)-1.1 [**2105-10-29**] 03:15AM BLOOD Glucose-127* UreaN-23* Creat-0.9 Na-141 K-4.5 Cl-110* HCO3-23 AnGap-13 [**2105-10-28**] 03:53AM BLOOD Glucose-148* UreaN-24* Creat-1.1 Na-139 K-3.7 Cl-105 HCO3-23 AnGap-15 [**2105-10-28**] 03:53AM BLOOD Calcium-8.5 Phos-2.6* Mg-2.1 [**2105-10-27**] 02:48AM BLOOD Glucose-166* Lactate-1.2 K-3.4 [**2105-10-27**] 02:42AM URINE Color-Straw Appear-Cloudy Sp [**Last Name (un) **]-1.009 [**2105-10-27**] 02:42AM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG [**2105-10-27**] 02:42AM URINE RBC-8* WBC->182* Bacteri-MANY Yeast-NONE Epi-<1 Lower extremity ultrasound: IMPRESSION: No evidence of deep vein thrombosis in either leg. Chest x-ray [**2105-10-27**]: IMPRESSION: 1. Bilateral lower lobe opacities concerning for infection. Probable mild volume overload. 2. Mild cardiomegaly. 3. Pleural plaques suggestive of prior asbestos exposure, correlate clinically Echocardiogram [**2105-10-27**]: Conclusions The patient is on a Neosynephrine drip @ 0.5 mcg/kg/min Left ventricular EF is 45-55% with no regional wall motion abnormalities.There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. [**Month/Day/Year **] [2+] tricuspid regurgitation is seen. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion [**2105-10-27**] 2:42 am URINE Site: CATHETER **FINAL REPORT [**2105-10-29**]** URINE CULTURE (Final [**2105-10-29**]): ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Labs on discharge: [**2105-11-4**] 06:25AM BLOOD WBC-21.2* RBC-5.25 Hgb-11.2* Hct-37.6 MCV-72* MCH-21.4* MCHC-29.8* RDW-14.1 Plt Ct-302 [**2105-11-4**] 06:25AM BLOOD Glucose-113* UreaN-18 Creat-0.9 Na-142 K-4.3 Cl-100 HCO3-35* AnGap-11 [**2105-11-4**] 06:25AM BLOOD Calcium-9.5 Phos-3.5 Mg-1.7 [**2105-10-27**] 2:50 am BLOOD CULTURE LEFT HAND. **FINAL REPORT [**2105-11-2**]** Blood Culture, Routine (Final [**2105-11-2**]): NO GROWTH [**2105-10-28**] 3:53 am STOOL CONSISTENCY: NOT APPLICABLE **FINAL REPORT [**2105-10-28**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2105-10-28**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). CT Abdomen and pelvis [**11-3**]: Preliminary Report !! WET READ !! Loss of L2 and L4 height of uncertain chronicity, correlate with pain (605b:40). [**Month/Year (2) **] lumbar spine djd. Hardware in the lower lumbar spine. Severe pleural calcifications suggesting asbestos exposure. Aterosclerotic disease. Severe left hydronephrosis. No definite stone seen. Concern for left UPJ narrowing/obstruction; cannot exclude crossing vessel (4:30). No hydroureter. [**Month/Year (2) **] artefact in the plevis from right hip prosthesis. Right renal cyst. Smaller right renal hypodensities. Diverticulosis. Renal Ultrasound [**11-3**]: IMPRESSION: 1. [**Month/Year (2) **]-to-severe hydronephrosis of the left kidney of unclear origin. An MR [**First Name (Titles) **] [**Last Name (Titles) **] is recommended for further evaluation. 2. Simple right renal cyst. No perinephric fluid collection is identified Brief Hospital Course: Ms. [**Known lastname 91062**] is an 88 year-old female with PMHx of afib (not on coumadin) and dementia & who is transferred from [**Hospital1 **] [**Location (un) 620**] with urosepsis complicated by a fib with RVR. # Urosepsis: Initial sepsis was thought to be from a urinary source given her grossly infected UA. Her CXR also showed a patchy opacity in RUL on CXR and ground glass opacity on LLL. At [**Hospital1 **] [**Location (un) 620**], she was started on vancomycin, ceftriaxone, zosyn, and placed on a neosynephrine drip. Upon arrival, her labs were notable for WBC 26.8 (no bands) and a repeat UA showed a UTI. She was continued on phenylephrine gtt. She was given IVF to a goal of UOP > 50 ml/hr and her phenylephrine was weaned off and finally stopped at 10am on [**10-27**]. An ECHO was obtained which showed "EF of 40%, [**Month/Year (2) 1192**] MR [**First Name (Titles) **] [**Last Name (Titles) 1192**] TR, Right ventricle pressure overload with septal flattening" and other findings as above. LENIs showed no DVTs. Her urine culture grew out pansensitive E.coli which was covered by ceftriaxone. Once the pt was stable and tranferred to the floor, she was switched to cefpodoxime and will complete a two week course of antibiotics (last day: [**11-9**]) # A-fib w/RVR: Pt has a documented history of A-fib. Her atenolol was initially held in the setting of septic shock. When she was adequately fluid resuscitated, she was started on metoprolol with holding parameters. Her BP was maintained with MAPs in 70s. However, her HR was elevated and she was placed on a diltiazem gtt. Her HR continued to be elevated and she was started on a loading dose of digoxin. On [**10-28**], her diltiazem gtt was made into a PO drip and she was continued on digoxin and metoprolol with good response. She continued to have rapid HR's into the 140's once she arrived on the floor. As her infection presumably improved, we were able to stop her digoxin and slowing wean off the diltiazem. On discharge her HR's were well controlled in the 80's and 90's on metoprolol 37.5 mg four times a day. #Leukocytosis: Pt had a WBC of 26.8 on admission. After treatment with antibiotics it slowly trended downward to the low 20's. However as the hospitalization continued we did not see a normalization of her WBC. Because of this we elected to perform a renal US to r/o abscess or another source of continued infection. Renal US showed [**Month/Year (2) 1192**] to severe hydronephrosis on the left side, confirmed by CT abdomen and pelvis. We conferred with urology and radiology who felt that the hydronephrosis was most likely secondary to an overlying vessel causing compression of the renal pelvis-uteral junction. Most likely, this is a chronic condition. She is scheduled for outpt urology follow up. # CHF: Pt has a relatively unknown underlying cardiac function. She received a TTE, the results of which showed an EF of 40%. On the floor the pt did not show any sign/symptoms of fluid overload. # [**Last Name (un) **]: Per OSH report, pt had Cr of 1.8, which downtrended to 1.1 after 4 liter fluid resuscitation. The likely etiology for [**Last Name (un) **] is prerenal in her case. Inactive Issues: # Hyperthyroidism: Pt's home dose of PTU was continued. # Chronic pain: Pt reports back and neck pain. She well controlled on RTC acetaminophen and gabapentin for her pain. # Dementia: Per report, pt has dementia at baseline, which most likely explains her AMS. She was closely monitored and written for prn haldol, which she did not require. Transitional Issues: -Pt will be transferred to a rehab facilty -Pt will need to follow up with her PCP one to two weeks after discharge from rehab -Pt will follow up with urology to monitor her left hydronephrosis and ensure that there is no further treatment needed -Pt should have her WBC checked at next PCP appointment to see if it has normalized or fallen to her baseline level. Medications on Admission: propylthiouracil 50mg 1 tablet PO TID lorazepam 0.5mg 1 tab PO BID PRN atenolol 25mg 1 tab PO BID aspirin 81mg PO daily trazodone 50mg tab PO qhs gabapentin 100mg 1 tab PO TID amiloride-hydrochlorothiazide 5mg-50mg 1 tab PO daily percocet 7.5mg-325mg tab 1 tab PO daily PRN Discharge Medications: 1. propylthiouracil 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 2. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 3. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for fever / pain. 5. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO QID (4 times a day). 6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 5 days. 8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed. Discharge Disposition: Extended Care Facility: [**Location (un) 582**] at [**Location (un) 620**] Discharge Diagnosis: Primary: Urosepsis Atrial Fibrillation with rapid ventricular response Secondary: Dementia Coronary Artery Disease Hyperthyroidism Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mrs. [**Known lastname 91062**], It was a pleasure taking care of you at [**Hospital1 771**]. You were admitted with a serious infection of urinary tract that spread into your bloodstream. We treated you with antibiotics through the vein until your condition had improved. We then switched you over to oral antibiotics. You will need to complete a two-week course of antibiotics for the infection. You also had a rapid heart rate from your atrial fibrillation. This can commonly happen when someone has an infection. We used a few medications to control your heart rate. As your infection improved we were able to decrease the amount of medications that you needed to slow your heart rate. Finally, we found on an ultrasound and CT scan that your left kidney was enlarged. However, your kidney function is normal and we consulted with urology who felt that this would not impair your kidney function or cause an infection. They recommended that you follow up with them as an outpatient, for which we have scheduled an appointment for you. You are now ready for discharge to a rehab facility. MEDICATION CHANGES: STARTED METOPROLOL 37.5 MG FOUR TIMES A DAY STARTED ACETAMINOPHEN 1000 MG THREE TIMES A DAY AS NEEDED FOR PAIN STARTED CEFPODOXIME 200 MG TWICE A DAY FOR THE NEXT FIVE DAYS STOPPED amiloride-hydrochlorothiazide 5mg-50mg 1 tab PO daily STOPPED PERCOCET 1 TAB DAILY AS NEEDED FOR PAIN STOPPED ATENOLOL 25 MG TWICE A DAY CHANGED ASPIRIN TO 325 MG DAILY Followup Instructions: Department: SURGICAL SPECIALTIES When: THURSDAY [**2105-11-19**] at 11:30 AM With: [**Name6 (MD) 161**] [**Name8 (MD) 6476**], MD [**Telephone/Fax (1) 921**] Building: [**Street Address(2) 3001**] ([**Location (un) 620**], MA) Ground Campus: OFF CAMPUS Best Parking: Parking on Site Please schedule a follow up appointment with your primary care doctor within one to two weeks of discharge from the rehab facility

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icd9cm

[ [ [] ] ]

[ "38.94" ]

icd9pcs

[ [ [] ] ]

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30276

Discharge summary

report

Admission Date: [**2162-4-1**] Discharge Date: [**2162-4-8**] Date of Birth: [**2081-5-6**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2387**] Chief Complaint: bilateral lower extremity edema Major Surgical or Invasive Procedure: none History of Present Illness: 80F w/ hx diastolic CHF, afib on coumadin, HTH, DMII, ILD p/w 4-5 days of worsening leg swelling. Patient had gradual increase in her lower extremity edema and subsequently developed significant erythema along the distal leg bilaterally. She reports that she has had lower extremity edema in the past with heart failure exacerbations, but she has never had this degree of erythema. She denies fever, chills, chest pain, dyspnea, PND, orthopnea. Admitted at end of [**Month (only) **] for hypertensive urgency, also has multiple admission over past year. Patient speaks Greek. . In the ED, initial VS: 97.6 72 194/62 20 96% ra. CXR with moderate pulmonary edema. LENIs without evidence of DVT. BNP found to be [**Numeric Identifier 72077**]. Troponin elevated at 0.06. INR: 2.2. Blood cultures sent and patient given Vancomycin 1gram IV x one with concern for cellulitis. Vitals prior to transfer: 97.5 hr 50's sb b/p 148/76 rr 20 o2. . Currently, she is alert, orientated, in no acute distress. No pain at rest but legs feel tender to palpation, and on mevement. She lives with her daugther who helps he rwith ADLs, is normally able to ambulate with a cane, but currently finds this too painful. She does report feeling cold, but no fevers, night sweats, dyspnea, orthopnea, chest pain. . ROS: Denies fever, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: Atrial fibrillation with progression to torsades during last admission-s/p dofetilide with DCCV ? [**6-9**] HTN DMII Mild COPD Interstitial lung disease Hyperlipidemia AR Social History: Lives with her daughter who is a nurse. [**First Name (Titles) **] [**Last Name (Titles) 5348**] a year or two ago she was able to walk [**4-15**] miles daily, however, she has recently been more restricted, able to walk around house with assistance of cane, however daughter helps her with most ADLs. Due to leg edema and dyspnea, which have been getting worse over the past few months, her activities have become increasingly more restricted. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: On admission: VS - 97.7, 186/60, 52, 16, 92% RA GENERAL - elderly female in no acute distress HEENT - NC/AT, Eyes asymmetric, patient has left-sided synechiae obscuring [**Doctor First Name 2281**]. Right sided cataract, blood clot. MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - Bilateral crackles to upper third of chest, diffuse wheezes. HEART - Harsh ejection systolic murmur loudest at the aortic area. ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - bilateral lower extremely pitting edema to mid thigh. Legs indurated, grossly edematous, warm and erythematous thickened skin over lower shins bilaterally. SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**5-15**] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait. Discharge exam Pertinent Results: Admission labs: [**2162-4-1**] 12:30PM BLOOD WBC-9.1 RBC-4.57 Hgb-12.4 Hct-40.2 MCV-88 MCH-27.1 MCHC-30.8* RDW-15.0 Plt Ct-175 [**2162-4-1**] 12:30PM BLOOD Neuts-76.9* Lymphs-14.8* Monos-4.5 Eos-3.2 Baso-0.6 [**2162-4-1**] 12:30PM BLOOD Plt Ct-175 [**2162-4-1**] 12:30PM BLOOD PT-23.3* PTT-36.3 INR(PT)-2.2* [**2162-4-1**] 12:30PM BLOOD Glucose-243* UreaN-77* Creat-3.0* Na-136 K-3.7 Cl-97 HCO3-26 AnGap-17 [**2162-4-1**] 12:30PM BLOOD CK(CPK)-25* [**2162-4-1**] 12:30PM BLOOD CK-MB-3 proBNP-[**Numeric Identifier 72077**]* [**2162-4-1**] 12:30PM BLOOD cTropnT-0.06* [**2162-4-1**] 07:14PM BLOOD CK-MB-3 cTropnT-0.05* [**2162-4-2**] 12:46AM BLOOD Calcium-9.1 Phos-4.4 Mg-2.5 [**2162-4-1**] 12:41PM BLOOD Lactate-1.6 Discharge labs Radiology: [**2162-4-1**] CXR Findings suggesting moderate interstitial pulmonary edema. . [**2162-4-1**] Bilateral LENI No evidence of deep venous thrombosis in the right or left legs, however, the calf veins could not be visualized due to overlying edema. . [**2162-4-2**] Echocardiogram Mild symmetric LVH with normal global and regional biventricular systolic function. Mild aortic stenosis. Moderate aortic regurgitation. Moderate mitral regurgitation. Moderate pulmonary hypertension. Compared with the prior study (images reviewed) of [**2160-11-11**], mitral regurgitation is slightly more prominent. Brief Hospital Course: 80 yo F Greek-speaking female with a history of afib on coumadin, torsades, chronic diastolic CHF, HTN, DM2, COPD, and ILD admitted with heart failure exacerbation and severe hypertension, transferred to the CCU with worsening kidney function. After family meeting, the decision was made to pursue comfort measurse only and she was discharged home with hospice. . # CHF: Patient was grossly fluid overloaded on admission, CXR shows pulmonary edema, BNP elevated>16,000. Unclear whether underlying trigger such as MI or medication non-compliance. Creatinine elevated from [**Year (4 digits) 5348**], likely [**2-11**] CHF exacerbation. Poor response to IV lasix boluses, necessitating transfer to the cardiology service for a lasix drip. An echocardiogram which showed slightly worse mitral regurgitation in comparison to prior echo. On the [**Hospital1 1516**] service, lasix ggt was initially started at 10mg/hr, but given poor UOP eventually increased to 20mg/hr, also with addition of metolazone 2.5mg [**Hospital1 **]. Her creatinine continued to increase, and UOP decreased. The renal team was consulted and she was transferred in the CCU. Her UOP continued to be poor on lasix drip as she continued to be more fluid overloaded. Only able to diurese about a liter during her CCU stay. Given her worsening kidney function and heart failure, a family meeting was held to discuss goals of care. The patient's wishes appeared to be stopping treatment and going home. Her son agreed with these goals and she was discharged home with hospice. She was discharged with olanzapine and ativan to use as needed for anxiety and agitation. . # Hypertensive urgency: BP elevated at around 220s systolic on the night of [**2162-4-1**], requiring total 50 mg IV hydralazine to bring SBP down to 180s. Patient was asymptomatic. We continue her clonidine and isosorbide and uptitrated isosorbide to 240 mg daily. HCTZ was discontinued since CrCl was approx 15 ml/min. Beta blocker not started due to heart failue and ACE inhibitor not started due to chronic renal failure. On [**4-2**] she again had SBP > 200, and a nitro ggt was started, as well as her home dose of clonidine, and hydralazine PO. This worked well for 24 hours, with SBP's around 150's. On [**4-3**], she became hypertensive again with SBP's 185-205. At this point she became confused and combative, and refused all PO meds and pulled her IV's out. IV's replaced and nitro gtt uptitrated to max, but she was no longer responsive to this. IV hydral given without sufficient response. She was thus transferred to the CCU for better control of her hypertension. In the CCU, she continued to refuse PO medications intermittently. Even when she was ablet to take them, her blood pressure would rarely go below 180. As her kidney function worsened, it was clear that her volume status was a large factor in her blood pressure. Renal consult felt she was not a candidate for dialysis given it was against her wishes. She was discharged home on hospice with clonidine, hydralazine and amlodipine. . # Chronic renal failure: Creatinine at 3.0 on admission, slightly elevated from recent discharge creatinine of around 2.7, may reflect poor forward flow in the setting of worsening CHF. We diuresed her with furosemide as above and avoided nephrotoxins, renally dosing all medications. Her creatinine continued to increase, and renal was consulted. Her volume overload likely contributed to her severe hypertension, and on lasix gtt was not diuresing sufficiently. . # Atrial fibrillation: INR therapeutic on coumadin. We continued warfarin and monitored her on telemetry. This was stopped prior to discharge. Medications on Admission: 1. levothyroxine 125 mcg Daily 2. hydrochlorothiazide 12.5 mg Daily 3. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: Four (4) Tablet Extended Release 24 hr PO DAILY 4. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO BID 5. docusate sodium 100 mg Capsule Sig: One Capsule PO BID as needed for constipation. 6. senna 8.6 mg Tablet Sig: One Tablet PO HS as needed for constipation. 7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) pkt PO DAILY (Daily) as needed for constipation. 8. pravastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 10. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day. 11. warfarin 1 mg Tablet Sig: 3-6 Tablets PO once a day: Start at 3mg. Adjust based on INR and doctor's orders after you see your PCP. Discharge Medications: 1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. [**Month/Year (2) **]:*30 Tablet(s)* Refills:*0* 2. hydralazine 50 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6 hours). [**Month/Year (2) **]:*180 Tablet(s)* Refills:*0* 3. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) patch Transdermal QSAT (every Saturday). [**Month/Year (2) **]:*4 patch* Refills:*0* 4. lorazepam 1 mg Tablet Sig: One (1) Tablet PO three times a day as needed for agitation. [**Month/Year (2) **]:*90 Tablet(s)* Refills:*0* 5. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO BID (2 times a day) as needed for agitation. [**Month/Year (2) **]:*60 Tablet, Rapid Dissolve(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 3005**] Hospice & Palliative Care Discharge Diagnosis: Congestive Heart Failure Renal failure Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital for heart and kidney failure. Your wishes were to go home with the goal being comfort. You will go home with hospice for comfort-focused care. Medications Start hydralazine 75mg every 6 hours for blood pressures Start amlodipine 10mg daily for blood pressure Start clonidine 0.3mg/24hr patch weekly for blood pressure Start lorazepam 1mg three times a day as needed for anxiety Start olanzapine 5mg twice daily as needed for anxiety Followup Instructions: Please discuss follow-up with hospice as needed.

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icd9cm

[ [ [] ] ]

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icd9pcs

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108,375

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Discharge summary

report

Admission Date: [**2140-2-2**] Discharge Date: [**2140-2-2**] Date of Birth: [**2117-8-7**] Sex: F Service: EMERGENCY Allergies: Penicillins / Morphine / Oxycodone Hcl/Acetaminophen Attending:[**First Name3 (LF) 2565**] Chief Complaint: dizziness Major Surgical or Invasive Procedure: none History of Present Illness: This is a 22F with a hx of lupus , ESRD on HD and malignant hypertension who presents today "feeling out of sorts." Following dialysis on Saturday the patient reports feeling weak. Her BP was 147/60. She also states that the pain from the uveitis in her L eye has gotten worse. . In the ED the patient's vitals were as follows: T 99, HR 71, BP 209/118, RR 16, O2 sat 98%RA. She was started on a labetolol gtt with marginal improvement in her pressures. The patient was tx to the ICU for further mgmt. . ROS is negative for any chest pain, SOB, and n/v. She reports that since she's started the nicardipine she has been having some urinary retention. Past Medical History: 1. Lupus - [**2134**]. Diagnosed after she began to have swolen fingers, a rash and painful joints. 2. ESRD secodary to SLE - [**2135**]. Was initially on cytoxan, 1 dose every 3 months for 2 years until began dialysis 3 times a week in [**2137**] (T, Th, Sat). Awaiting living donor transplant from mother. 3. HTN - [**2137**]. Normal BPs run 180's/120's. Has had 1 hypertensive crisis that precipitated seizures in the past. 4. Uveitis secondary to SLE - [**4-15**] 5. HOCM - per Echo in [**2137**] 6. Vaginal bleeding [**2139-9-20**] 7. Mulitple episodes of dialysis reactions 8. Anemia 9. Coag neg. Staph bacteremia and HD line infection - [**6-15**] 10. H/O UE clot, was on coumadin, but no longer Social History: Lives in [**Location 669**] with mother and 16 year old brother. Graduated [**Name2 (NI) **] School and then got sick so currently is not working or attending school. Denies any T/E/D. Family History: -No family history of SLE. -Grandfather has HTN. -Distant history of DM. -No history of clotting disorders -No other history of other autoimmune diseases Physical Exam: T 98.2 HR 75 BP 190/115 R 14 O2 sat 100% RA GEN: pleasant female in NAD, A & O X 3 HEENT: MMM, OP clear, no LAD HEART: nl rate, S1S2, iii/vi HSM along LLSB LUNGS: CTA b/l, no rrw ABD: benign EXT: dialysis line in L thigh, site c/d/i Pertinent Results: HEAD CT: no acute evidence of hemorrhage. CHEST PA and L: no acute cardiopulmonary process. Brief Hospital Course: 22F with hx of lupus and subsequent complications who presents today with hypertensive emergency. P: # Hypertensive emergency - Precipitant is unclear. [**Name2 (NI) **] reports that she is compliant with medications. Pain from uveitis may have been a precipitant. This may also reflect a progression of her disease. - Placed on labetalol gtt for SBP as high as 220 with fair BP control; transitioned back to po labetalol once BP was reasonably well controlled. Pt refused additional antihypertensives, saying, "You new doctors [**Name5 (PTitle) **] in here and think you can make my blood pressure perfect, but I have high blood pressure all the time and always have." - Will continue home medications - According to renal (Dr [**Last Name (STitle) 7143**], who follows pt), she insists that no volume be removed at HD, saying that when volume is removed, she feels "terrible." As a result, her volume status complicates her blood pressure management - After patient was informed that she would have to wait until 4pm for hemodialysis, she left against medical advice. . # ESRD - [**2-12**] to lupus nephritis. Patient will be receiving transplant kidney from mother. Cont [**Name2 (NI) 44537**]. Renal offered patient dialysis while in house . # Headache - Patient reported retro-orbital pain with uveitis. Head CT was negative for intracranial hemorrhage. . # Uveitis - Followed by outpatient optho specialist. Patient specifically refused evaulation by [**Hospital1 18**] ophtho consult despite retro-orbital pain. . # Anemia - Hct has fallen from 35 to 27 within the past month. Will repeat. Baseline anemia [**2-12**] renal disease. Receives EPO at HD. Medications on Admission: Clonidine 0.3mg Q24H Ativan 1mg q4-q6h Sevalamer 800mg TID Lisinopril 40mg [**Hospital1 **] Valsartan 320mg daily Labetalol 600mg TID Prednisone 40mg daily Moxifloxacin TID Nicardipine 30mg q8h Scopalamine Discharge Medications: same Discharge Disposition: Home Discharge Diagnosis: hypertensive urgency; end stage renal disease due to lupus nephritis Discharge Condition: fair Discharge Instructions: Follow up with your PCP within the next week. . Continue hemodialysis on your regular schedule.

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icd9cm

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icd9pcs

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321, 327

4560, 4566

2378, 2378

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272, 283

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1750, 1937

31,625

110,474

31452

Discharge summary

report

Admission Date: [**2119-8-18**] Discharge Date: [**2119-8-23**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2704**] Chief Complaint: Irregular Heart Rate Major Surgical or Invasive Procedure: TEE Intubation Cardioversion Temporary pacing wire placement Electrophysiology study Dual device pacemaker placement History of Present Illness: history limited by patient sedation/intubation. EVENTS / HISTORY OF PRESENTING ILLNESS: 84 year old male with atrial fibrillation on coumadin, HTN, history of angina who presented to [**Hospital **] Hospital complaining on light headedness, diaphoresis and presyncope and dizziness on the day of admission. No reports of chest pain. Had seen his PCP one week prior for low HR, unknown details. Stopped taking all of his medications a week ago for a few days because he wasn't feeling well per his son but then restarted. At OSH, his EKG showed wide complex tachycardia with right bundle branch block. His systolic blood pressures were hypotensive to systolic blood pressures in the 70's. He was given approximately 4L of iv fluids. He was intubated for unclear reasons although likely airway protection, sedated with versed drip and started on dopamine. He was given 10mg iv vitamin K and aspirin 325mg po x 1. He was then transferred to [**Hospital1 18**] ED. In [**Hospital1 18**] ED, he was continued on versed drip and Cardiology was consulted. Electrophysiology looked at patient's EKG: Irregular, HR 60's-140's, varying between right and left bundle branch block. At baseline, EKG with right bundle branch block. On review of symptoms, he was intubated and sedated and unable to answer questions. All of the other review of systems were negative. *** Cardiac review of systems was unable to be obtained secondary to intubation/sedation. Past Medical History: AFib on coumadin HTN Question of CAD with angina (20 years ago) Social History: Widowed, Lives with his son in a 2 family house (different floors), No tobacco, occasional EtOH. Family History: Non-contributory Physical Exam: VS: T 98.2F HR 68-150, BP 107/63, RR 20 , ?O2 % on ABG: pH 7.28 pCO2 39 pO2 170 on AC 500x14/FiO2%:100 ?PEEP ABG pH 7.37/32/112 on AC 500x14/60/5 . Gen: Well developed and well nourished elderly male, intubated, sedated, and responsive to stimuli moving all 4 extremitites HEENT: Normalcephalic/atraumatic. Sclera anicteric. PERRL, EOMI. MMM, intubated. CV: PMI located in 5th intercostal space, midclavicular line. Irreg irrgeular, occasional pauses and ectopy Chest: Coarse breath sounds bilaterally, faint bibasilar crackles. Abd: Obese, soft, non-tender and non-distended, No hepatosplenomegally or tenderness. No abdominal bruits. Ext: Trace bilateral lower extermity edema. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: 2+ DP Left: 2+ DP Pertinent Results: [**2119-8-18**] TEE IMPRESSION: No intracardiac thrombus identified. Moderate regional LV systolic dysfunction, c/w CAD. Moderate MR. Mild AS. Mild AR. . [**2119-8-18**] TTE IMPRESSION: Global and regional LV systolic dysfunction c/w diffuse process (multivessel CAD). Moderate mitral regurgitation. Pulmonary artery systolic hypertension. Mild aortic regurgitation. . [**2119-8-18**] CXR - moderate CHF, Small bilateral pleural effusion, left greater than right, Endotracheal tube in satisfactory position. . [**2119-8-23**] PA and Lateral CXR: Pacemaker lead placement in the right atrium and the right ventricle. . [**2119-8-18**] WBC-14.4* RBC-5.24 Hgb-15.8 Hct-48.3 MCV-92 MCH-30.1 MCHC-32.7 RDW-16.0* Plt Ct-190 Neuts-86.4* Bands-0 Lymphs-8.0* Monos-4.5 Eos-0.3 Baso-0.9 [**2119-8-23**] WBC-8.2 RBC-4.42* Hgb-13.7* Hct-38.7* MCV-87 MCH-30.9 MCHC-35.4* RDW-16.1* Plt Ct-139* . [**2119-8-18**] PT-22.8* PTT-28.8 INR(PT)-2.3* [**2119-8-23**] PT-15.3* PTT-26.4 INR(PT)-1.4* . [**2119-8-18**] Glucose-118* UreaN-19 Creat-1.0 Na-132* K-5.2* Cl-103 HCO3-12* Calcium-8.3* Phos-2.0* Mg-2.5 [**2119-8-23**] Glucose-105 UreaN-14 Creat-0.7 Na-142 K-3.9 Cl-108 HCO3-27 AnGap-11 . [**2119-8-18**] CK(CPK)-114 CK-MB-6 cTropnT-<0.01 [**2119-8-18**] CK(CPK)-122 CK-MB-19* MB Indx-15.6* cTropnT-0.18* [**2119-8-19**] CK(CPK)-20* CK-MB-NotDone cTropnT-0.18* . [**2119-8-18**] ALT-49* AST-48* LD(LDH)-273* AlkPhos-67 Amylase-41 TotBili-1.9* TSH-1.3 Free T4-1.4 Lactate-1.4 BTriglyc-54 HDL-38 CHOL/HD-3.3 LDLcalc-78 Brief Hospital Course: In summary, Mr. [**Known lastname 74063**] is an 84 year old male with AFib on coumadin, HTN who presnted to OSH with lightheadedness, presyncope and tachy-brady episodes. # Rhythm - On admission, the patient's rhythm was as follows: tachy-brady, occasional pauses 1.5 sec, underlying right bundle with intermittent left bundle and bigeminy with runs of VTach. The patient arrived to the unit intubated and while the patient was still sedated, a transesophegal echocardiogram was performed to evaluate for thrombus in the setting of chronic afib and rhythm abnormalities. No thrombus was appreciated and the patient then underwent synchronized cardioversion with 200J in syn mode. The patient was converted into normal sinus rhthymn. However, the patient continued to have runs of ventricular tachycardia that were mildly symptomatic. These episodes responded to a lidocaine drip and a temporary pacing wire was placed on [**2119-8-18**]. The patient was also loaded with a beta-blocker in an attempt to control the tachyarrythmia. However, the patient not only had episodes of ventricular tachycardia but also had episodes of bradycardia which made the dosing of the beta blocker difficult. Electrophysiology testing was performed on [**2119-8-21**] but revealed a trigger fascicular ventricular tachycardia which is not amenable to VT ablation. Therefore, on [**2119-8-22**], a dual device pacemaker was placed with leads in the right atrium and right ventricle. It is hoped that the pacemaker will control the patient's bradycardia so that a theraputic dose of beta blocker can be given. On [**2119-8-23**], the patient's metorolol was titrated up to 37.5mg PO TID. The pacemaker was interogated on [**2119-8-23**] and found to be working properly. PA and lateral chest films confirmed the pacemaker's lead placement in the right atrium and right venticle. The patient continued on 48 hours of antibiotics due to the pacemakder placement and will be followed in the device clinic on [**2119-9-1**] at 10:30am. # Pump - On admission, the patient appeared volume overloaded with bibasilar crackles and bilateral infiltrates and pleural effusions on chest x-ray. The patient was diuresed with prn lasix. An echocardiogram done on [**2119-8-18**] showed: EF 35% Global and regional LV systolic dysfunction c/w diffuse process. There was moderate mitral regurgitation. The patient was discharged on standing lasix due to poor left ventricular systolic function. #)CAD-Cardiac enzymes were cycled and an acute coronary process was ruled out. The patient does report a past history of chest pain and the echocardiogram did show regional left ventricular wall motion abnormalities suggestive of a past infarct. Therefore, the patient was started on an ACEinhibitor. The beta blocker was also continued. Additionally, it is recommended that the patient recieve a chemical stress test to evaluate for CAD as an outpatient. #)Anticoagulation: Heparin drip was initially started because patient received Vitamin K at the OSH. Additionally, the coumadin was held due to the temparary pacing wire placement, electrophysiology study, and pacemaker placement. The patient was anticoagulated with a heparin drip, and Coumadin restarted. On [**2119-8-23**], the patient was on coumadin 5mg PO Dialy with an INR of 1.4. The patient will follow up with Dr. [**Last Name (STitle) **] to have the INR checked. # HTN - Initially, the patient was hypotensive. The B-blocker and ACE inhibitor titrated to blood pressure. It is recommended that these continue to be titrated up as tolerated as an outpatient. # Metabolic Acidosis: On admission, a Gap acidosis was suggested by labs and ABG. However, the acidosis resolved. Lactate was found to be within normal limits. The patient is not diabetic or in renal failure. There was no know history of ingestions. The patient will be discharged home with services. The patient will follow up with Dr. [**Last Name (STitle) **] (PCP) on Monday [**2119-9-4**] at 2:45pm. Dr. [**Last Name (STitle) **] will check the INR. Additionally, the patient is scheduled with the device clinic ([**Telephone/Fax (1) 59**]) on [**2119-9-1**] at 10:30am. Finally, the paitient is scheduled with Dr. [**Last Name (STitle) **](cardiologist) on [**2119-9-14**] at 2:30pm at his office at [**Hospital1 18**]-[**Location (un) 620**]. Medications on Admission: coumadin isosorbide atenolol Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 5. Warfarin 1 mg Tablet Sig: 2-3 Tablets PO at bedtime: please resume your old dose of 3mg mon/wed/fri, and 2mg Tues/Thurs/Sat/Sun. Please have your INR checked frequently and adjust your dose accordingly. Disp:*180 Tablet(s)* Refills:*2* 6. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 7. Keflex 500 mg Capsule Sig: One (1) Capsule PO every eight (8) hours for 3 doses. Disp:*3 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: 1.) Tachy/Brady syndrome 2.) Bifascicular ventricular tachycardia 3.) Sick sinus syndrome 4.) Atrial fibrillation 5.) Hypertension Discharge Condition: good, hemodynamically stable, chest pain free Discharge Instructions: You were admitted to the hospital because of an irregular heart beat. During your hospitalization you were placed on medications that help prevent your heart from beating too fast (metoprolol), and also had a pacemaker placed to prevent a very low heart rate. Please take all medications as instructed, and continue to keep all health care appointments. Please resume your coumadin as before and follow up with Dr. [**Last Name (STitle) **] to have your INR checked. You have also been placed on a water pill (lasix) to keep fluid off. . If you experience, chest pain, worsening shortness of breath, lightheadedness, dizziness, or loss of consciousness, or your condition worsens in any way, seek immediate medical attention. Followup Instructions: The visiting nurse will check your coumadin level on [**2119-8-25**] and fax the results to Dr.[**Name (NI) 74064**] office. . Please follow-up with Dr. [**Last Name (STitle) **] on Monday [**2119-9-4**] at 2:45. Dr. [**Last Name (STitle) **] will check your INR (coumadin blood test.) . Please follow up with Dr. [**Last Name (STitle) **] on [**2119-9-14**] at 2:30PM at [**Hospital1 18**]-[**Location (un) 620**] ([**Telephone/Fax (1) 4105**]). Please check-in at patient registration at 2:15 on the ground floor of the hospital, and then proced to the [**Location (un) 453**] to Dr.[**Name (NI) 40168**] office. Your in-patient cardiologist recommended that you get a nuclear stress test. Please discuss this with Dr. [**Last Name (STitle) **]. . Please follow up in the device clinic to ensure that your pacemaker is functioning properly: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2119-9-1**] 10:30

[ "E878.8", "276.2", "413.9", "427.31", "998.12", "414.01", "401.9", "V58.61", "428.0", "425.4", "427.1", "427.81" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "99.62", "37.72", "37.26", "88.72", "37.83", "37.34" ]

icd9pcs

[ [ [] ] ]

9750, 9813

4463, 8839

283, 403

9988, 10036

2931, 4440

10812, 11769

2107, 2125

8919, 9727

9834, 9967

8865, 8896

10060, 10789

2140, 2912

223, 245

431, 1889

1911, 1977

1993, 2091

57,139

123,589

42558

Discharge summary

report

Admission Date: [**2185-11-15**] Discharge Date: [**2185-11-24**] Date of Birth: [**2126-1-11**] Sex: F Service: MEDICINE Allergies: Keflex / Ciprofloxacin / Ertapenem Attending:[**First Name3 (LF) 943**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: Status post airway intubation (performed at outside hospital, extubated here) PICC placement [**2185-11-17**] History of Present Illness: Hepatologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] . Ms. [**Known lastname 92101**] is a 59yo woman with h/o Hepatitic C Cirrhosis with portal hypertension s/p TIPS, MELD score 23, who presented to an OSH with altered mental status. . Her father found her on the morning of admission with her legs hanging over the side of the bed. She was unresponsive. The family reports that she had been feeling well at home but becoming increasingly confused. They admit that she often fights against taking lactulose, though they feel she is largely compliant with it. She may have spit out her lactulose dose last night. Otherwise, ROS significant for some nausea. She has nevertheless been eating and drinking well. No diarrhea. No fevers. . When EMS arrived, her blood sugar was 146. She was noted to be incontinent of urine. . Upon arrival to [**First Name8 (NamePattern2) **] [**Hospital3 6783**], her VS were 129/60 117 21 98% RA. She was intubated because of failure to protect her airway. Although the lowest recorded temp was 96.2 rectally, she was noted as being hypothermic and a bair hugger was placed. Labs were notable for K of 6.2 and non-gap acidosis with HCO3 of 14. Lactate was elevated at 5.6. WBC elevated at 16 with Hct and Cr at baseline. UA significant for large leukocytes and negative nitrites. CT Head without contrast revealed vague area of low attenuation in the lft frontal region, ? related to small vessel ischemia. There was no evidence of bleed, mass, or midline shift. CXR revealed vascular congestion. She was transferred to [**Hospital1 18**] for further care. . Upon arrival to [**Hospital1 18**] MICU, she was intubated. Further history was obtained via phone call through the patient's son. . ROS: unable to obtain Past Medical History: Hepatitis C, Genotype 1: Diagnosed in [**2185-1-8**] with last VL 263,000 in [**8-/2185**] Cirrhosis (Methotrexate and Hepatitis C Induced) Portal Hypertension Chronic Kidney Disease with baseline Cr 1.8-2.0 Diastolic CHF: Grade I diastolic dysfunction [**7-17**], EF 75% Ascites Diuretic-Resistant Esophageal Varices per report; however, EGD [**7-/2185**] reports normal esophagus Psoriasis with Arthropathy - s/p Methotrexate x 15 years (MTX d/c in 12.07 when patient developed ascites and now uses halobetasol cream) Anemia with baseline Hct 25-30 Thyroid nodule 2.2cm identified on ultrasound [**9-16**], needs Bx (has f/u in Thyroid nodule clinic) Admission [**Date range (1) 92102**]: for elective TIPS, also had UTI Admission [**Date range (1) 92103**]: for hyponatremia and ARF Foot drop from peroneal nerve injury during TIPS procedure (per DC summary) Hyponatremia with baseline Na 128-130 . Social History: Quit smoking in [**2184**]. No alcohol problems, no drugs. Lives with her son and her father. Uses a cane and walker. Family History: no FH of liver disease Physical Exam: vitals: 97.7 131 122/72 26 100% on AC 100% 500/16 PEEP +5. Gen: Intubated, not responsive to voice but does move upon touch and withdraw from painful stimuli (not on sedating meds) HEENT: Eyelids closed, eyes are often gazing to the right but she will move her eyes to midline to look toward examiner. Pupils equally reactive, not pinpoint. Face symmetric, mucous membranes moist. Neck: supple, small thyroid nodule in mid-left thyroid. CV: S1, S2, regular tachycardia with I/VI systolic murmur at LUSB, non-radiating. Lungs: clear b/l, no crackles appreciated. Abd: obese with ascites, BS present. umbilical veins prominent. Soft and she does not flinch with palpation. Hepatosplenomegaly. Skin: Flaking, dry skin on scalp and LE b/l. Large skin tear on right calf. Violaceous plaques on chest and raised subcutaneous areas on her right arm. Ext: Erythema of LE, L>R, but not particularly warm. 2+ edema of LE b/l. Distal pulses +1 b/l. Neuro: No asterixis when hands are extended at wrists. . Pertinent Results: [**2185-11-24**] 06:27AM BLOOD WBC-9.8 RBC-2.74* Hgb-8.4* Hct-25.3* MCV-92 MCH-30.7 MCHC-33.3 RDW-17.3* Plt Ct-164 [**2185-11-23**] 05:00AM BLOOD WBC-9.2 RBC-2.75* Hgb-8.7* Hct-25.2* MCV-92 MCH-31.7 MCHC-34.6 RDW-17.5* Plt Ct-149* [**2185-11-16**] 06:00AM BLOOD Neuts-77.3* Lymphs-15.9* Monos-5.1 Eos-1.5 Baso-0.2 [**2185-11-24**] 06:27AM BLOOD PT-19.9* PTT-46.1* INR(PT)-1.9* [**2185-11-23**] 05:00AM BLOOD PT-21.2* PTT-48.8* INR(PT)-2.0* [**2185-11-24**] 06:27AM BLOOD Glucose-146* UreaN-23* Creat-1.5* Na-129* K-3.7 Cl-103 HCO3-19* AnGap-11 [**2185-11-23**] 05:00AM BLOOD Glucose-156* UreaN-22* Creat-1.4* Na-131* K-3.8 Cl-106 HCO3-21* AnGap-8 [**2185-11-24**] 06:27AM BLOOD ALT-19 AST-29 LD(LDH)-239 AlkPhos-94 TotBili-1.7* [**2185-11-24**] 06:27AM BLOOD Albumin-2.9* Calcium-9.7 Phos-3.1 Mg-1.9 . [**2185-11-16**] CT Head without constrast: No acute intracranial process . [**2185-11-16**] MR [**Name13 (STitle) 430**] and Brain without contrast: Limited study due to motion artifact. No contrast was administered due to the patient's inability to further cooperate and the marginal renal status. There is no evidence of infarction. The MRA demonstrates a dominant and patent right vertebral artery with a tiny, but apparently patent left vertebral artery, and patent internal carotid arteries bilaterally. The remainder of the study, although limited, demonstrates no evidence of hemorrhage or other abnormalities. . [**2185-11-17**] CT abd and pelvis w/o contrast: 1. No evidence of hemoperitoneum or retroperitoneal hemorrhage. 2. Cirrhotic liver, with signs for portal hypertension with a large amount of ascites. 3. Consolidation within the lower lobes of the lungs bilaterally, most likely represents atelectasis. However, superimposed infection cannot be excluded. 4. Cholelithiasis. 5. Anasarca. . [**2185-11-22**] Liver, gallbladder u/s: 1. Patent TIPS with abnormally high velocities within the mid and distal aspects of the shunt, similar to the previous exam. Findings remain compatible with TIPS malfunction. 2. Limited evaluation of the left and anterior right portal vein although suggestion of abnormal directionality of flow within the left portal vein is compatible with shunt dysfunction. 3. Cirrhotic liver with moderate-to-severe perihepatic ascites and cholelithiasis. . [**2185-11-24**] TTE: The left atrium is moderately dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. . Compared with the findings of the prior study (images reviewed) of [**2185-10-27**], no major change is evident. . IMPRESSION: no obvious vegetations seen Brief Hospital Course: Ms. [**Known lastname 92101**] is a 59yo woman who presented w/ altered mental status in the setting of Hep C cirrhosis. # Altered Mental Status: Given her hx of hep C cirrhosis and recent TIPs procedure, her AMS was thought to be most likely due to hepatic encephalopathyy. She was reported to have a hx of poor compliance with lactulose at home. Of note, she has not had other episodes of hepatic encephalopathy prior to this. Head CT at OSH was negative. Given her leukocytosis on admission, infection, particularly SBP or pneumonia, were also considered. Overdose was also a possibility, although family denies drug use. Upon arrival in the MICU she was started on lactulose and rifaximine. She underwent a paracentesis to eval for SBP, which had a negative gram stain and culture. Given her AMS, she was considered high risk for aspiration, and she was started on empiric treatment with vanc/aztreonam/azithromycin (allergic to cipro and keflex) for nosocomial or aspiration PNA vs SBP. While there was no known hx of EtOH abuse, thiamine IV was administered. On exam the pt had some focal findings of persistent right-[**Hospital1 **] and downward deviation of her eyes, with inability to track past midline. She had a repeat head CT and an MRI/MRA which were both without evidence of significant pathology. Following extubation and decreased sedation, her mental status improved and the focal eye findings resolved. While not back at her baseline, pt was awake, alert, and oriented x3 when she was transferred to the floor. Pt seen by Neurology, but had already had significant improvement and no focal findings. On the floor, her mental status continued to improve. At time of discharge, she is back to baseline, conversational, oriented x3 but at times is tearful. She is being discharged on Rifaximin and furosemide. . # Respiratory failure: Patient was intubated for airway protection at OSH. Her CXR here suggested a possible aspiration pneumonia, which could have been [**3-12**] to her AMS. It is unclear if she received IVF at OSH. She was weaned off of the vent quickly as she required minimal pressure support and had good RSBIs. She was extubated on [**2185-11-17**] was satting well on room air at the time of transfer to the floor. On discharge, she continues to have oxygen saturations in the high 90's on room air. . # Rash: Pt arrived in the MICU with three skin findings. Bullae, blisters/breakdown, and a diffuse maculopapular rash on proximal legs and trunk. Dermatology was consulted. The blisters and bullae were thought to be [**3-12**] trauma in the setting of coagulopathy due to liver disease and thinned skin. Urine Porphobilinogens were checked to rule out porphyria in the setting of Hep C liver disease and were negative. The diffuse maculopapular rash appeared to be new, and looks more like a hypersensitivity reaction, likely to ertapenem. Pt has known allergies to Keflex ad Cipro, and had received ertapenem at the OSH. She was treated with topical clobetasol cream to the rash on abdomen and lower extremities (avoiding folds), and hydrocortisone 2.5% cream to rash in folds of abdomen and groin. Also, the bullae over time evolved into ulcerations on the pt's legs, arms and left shoulder which were treated with wound care as recommended by our wound care team and plastics. . # Cirrhosis [**3-12**] Hep C: Pt was treated as described above with lactulose and rifaximine as well as a PPI, and was followed by Hepatology. She had a RUQ ultrasound on [**11-16**] and again on [**11-23**] which showed her TIPS was patent. She should have a repeats TIPS ultrasound in 1 month. She had a 5L paracentesis on [**11-20**] which was negative for increased WBC and culture was sterile. . # VRE: Pt had blood culture [**11-16**] which grew VRE sensitive to daptomycin and linezolid in [**2-11**] bottles. Daptomycin was started on [**11-17**]. ID was consulted in house. TTE showed no vegetations on [**11-24**]. The pt should be continued on IV daptomycin to complete a 14 day course on [**2185-12-2**]. . # Sinus tachycardia: Pt was likely intravascularly dry on admission given Hct above baseline, poor urine output, and tachycardia above baseline, although some level of tachyardia appears to be chronic in her. Also may be exacerbated by acute illness. She received albumin 25g in 500cc NS x2 and her HR and urine output were followed. Her diuretics were held until the next morning. At discharge, her HR remains in the 80's to 90's. . # Chronic diastolic heart failure: Appeared hypovolemic admission, her diuretics were held as above. Her diuretics were gradually restarted on the floor. She is not accumulating ascited at the time of discharge. . # Chronic Kidney Disease: baseline Cr 1.8-2.0, Cr on discharge 1.5, urine output initially poor on admission, but improved after fluid challenge. . # Thyroid nodule: Should be followed up as outpatient. . # Hyponatremia: Pt has chronic hyponatremia seen on past admission with baseline 128-130. As diuretics were increased, her sodium gradually decreased to 129 on day of discharge. Treatment ongoing for this condition should include ongoing fluid restriction to approximately 1500cc/day. . # Hypercalcemia: Pt had transient hypercalcemia to 10.8 this admission thought to be [**3-12**] Calcium and vitamin D use at home. These were stopped and Ca is now 9.9 at time of discharge. Recommend not restarting these medications at this time. . # [**Name (NI) 1867**] Pt with thrombocytopenia this admission thought [**3-12**] chronic liver disease. Plt at discharge are 164. Medications on Admission: Metoclopramide 5mg TID Pantoprazole 40 mg daily Clobetasol 0.05 % Cream [**Hospital1 **] Ergocalciferol (Vitamin D2) 50,000 unit QWednesday Calcium-Cholecalciferol (D3) 500 (1,250)-400 mg-unit [**Hospital1 **] Nystatin 100,000 unit/mL 5ml QID Lactulose 30ml [**Hospital1 **] Furosemide 40 mg daily Spironolactone 25 mg daily . Discharge Medications: 1. 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. 2. Daptomycin 500 mg Recon Soln Sig: Four Hundred (400) mg Intravenous Q48H (every 48 hours): Please continue for 9 days. Please NOTE: patient has changing renal function. Currently GFR is less than 50, so should dose q48 hours. If GFR>50, please change to q24 hour dosing. 3. Clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for psoriasis. 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO twice a day. 7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 9. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 10. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] (2 times a day). 11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Discharge Disposition: Extended Care Discharge Diagnosis: Primary: Vancomycin Resistant Enterococcus Bacteremia Encephalopathy Traumatic Skin Rash Hyponatremia Secondary: Hepatitis C Cirrhosis Chronic Kidney Disease Discharge Condition: Afebrile, stable, ambulatory. Discharge Instructions: You were admitted after you were found passed out at home. This was likely due to encephalopathy which cleared with lactulose, and an infection that was found in your blood. You will continue on an antibiotic, Daptomycin, intravenously for a total of 14 days, finishing on [**12-2**]. Please be sure to renally dose this medication: once daily if GFR>50 or once every other day if GFR<50. . Continuing issues include hyponatremia, which should be managed initially with fluid restriction. She has had chronic hyponatremia with baseline 128-130 on previous admission here. Please monitor sodium levels while at [**Hospital1 **]. . Her course has also been complicated by easy bruising and blistering which has necessitated a dermatology consult. It was felt these were traumatically induced. They are being cared for currently with wound care. . Of note, the patient was hypercalcemic, and found to have elevated PTH level. She had been taking ergocalciferol and cholecalciferol both of which were stopped, and the calcium normalized. Please continue to hold these medications, to be restarted at the discretion of her primary care physician and [**Hospital1 **] physician. . Followup Instructions: Provider: [**Name10 (NameIs) **] THYROID NODULE CENTER Phone:[**Telephone/Fax (1) 26555**] Date/Time:[**2185-12-1**] 10:30 Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2185-12-7**] 8:40 Completed by:[**2185-11-24**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

15066, 15081

7733, 7865

318, 430

15284, 15316

4523, 7710

16539, 16819

3450, 3474

13685, 15043

15102, 15263

13333, 13662

15340, 16516

3489, 4504

257, 280

458, 2369

7880, 13307

2391, 3297

3313, 3434

6,479

105,996

27048

Discharge summary

report

Admission Date: [**2130-11-14**] Discharge Date: [**2130-11-23**] Date of Birth: [**2084-10-3**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3223**] Chief Complaint: s/p MVC Major Surgical or Invasive Procedure: [**2130-11-15**] Intramedullary nail, left tibia. Right Chest Tube History of Present Illness: 46 yo F s/p motor vehicle crash; T-boned with + airbag deployment +LOC, intubated in the field for decreased oxygen saturation. Transferred from referring hospital to [**Hospital1 18**] for continued trauma care. Past Medical History: Back surgery for lipoma removal [**4-13**] c/b seroma s/p MVC [**12-14**] Seizures Psychiatric Disorder Social History: Reportedly lives with boyfriend and one son (has 3 sons) Family History: Non-contributory Physical Exam: VS on admission: T 98.2 HR 84 BP 108/98 O2 sat 98% Gen: Intubated/vented & paralyzed HEENT: Puplis fixed 5-6 mm; left conjuctival hemorrhage; dried blood in nares Neck: collared Chest: CTA bilat Cor: RRR Back: no stepoffs Abd: soft, NT FAST exam negative Rectum: guaiac negative Pelvis: stable Extr: deformity LLE; + ecchymosis; 2+ DP/PT pulses bilat Pertinent Results: [**2130-11-14**] 09:40PM TYPE-ART PO2-197* PCO2-41 PH-7.37 TOTAL CO2-25 BASE XS--1 [**2130-11-14**] 09:40PM LACTATE-1.1 [**2130-11-14**] 09:28PM GLUCOSE-117* UREA N-10 CREAT-0.5 SODIUM-142 POTASSIUM-3.8 CHLORIDE-109* TOTAL CO2-23 ANION GAP-14 [**2130-11-14**] 09:28PM ALT(SGPT)-152* AST(SGOT)-152* ALK PHOS-89 TOT BILI-0.3 [**2130-11-14**] 09:28PM CALCIUM-9.0 PHOSPHATE-4.2 MAGNESIUM-1.6 [**2130-11-14**] 09:28PM WBC-13.0* RBC-4.71 HGB-13.5 HCT-39.7 MCV-84 MCH-28.7 MCHC-34.0 RDW-14.3 [**2130-11-14**] 09:28PM PLT COUNT-349 [**2130-11-14**] 09:28PM PT-12.8 PTT-22.7 INR(PT)-1.1 [**2130-11-14**] 02:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2130-11-14**] 02:20PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-POS amphetmn-NEG mthdone-NEG CT RECONSTRUCTION [**2130-11-14**] 3:32 PM CT L-SPINE W/O CONTRAST; CT RECONSTRUCTION Reason: 46 year old woman s/p MVA [**Hospital 93**] MEDICAL CONDITION: 46 year old woman s/p MVA REASON FOR THIS EXAMINATION: 46 year old woman s/p MVA CONTRAINDICATIONS for IV CONTRAST: None. EMERGENCY LUMBAR SPINE CT HISTORY: Motor vehicle accident. TECHNIQUE: Axial post-intravenously enhanced images of the lumbar spine were obtained. Images were only submitted at this time using a bone algorithm. FINDINGS: Within these limitations, there is no definite evidence of a fracture or abnormal alignment of the component vertebrae. The absence of soft tissue algorithm precludes optimum demonstration of the intervertebral discs and ligamentous structures. There is no definite paraspinal pathology seen, although more comprehensive analysis of the abdomen was obtained by the pre- existent torso CT scan. CONCLUSION: No definite fracture. CT RECONSTRUCTION [**2130-11-14**] 3:32 PM CT T-SPINE W/O CONTRAST; CT RECONSTRUCTION Reason: 46 year old woman s/p MVA [**Hospital 93**] MEDICAL CONDITION: 46 year old woman s/p MVA REASON FOR THIS EXAMINATION: 46 year old woman s/p MVA CONTRAINDICATIONS for IV CONTRAST: None. EMERGENCY CT SCAN OF THE THORACIC SPINE HISTORY: Motor vehicle accident. TECHNIQUE: Axial non-contrast images of the thoracic spine. These were acquired only with bone window settings with corresponding coronal and sagittal reconstructions. FINDINGS: There is no definite spine fracture seen. There is a depression of the superior endplate of L1 with small anterior bridging osteophytes. The depression, when viewed axially, appears consistent with a Schmorl's node. There is imaging of the right pneumothorax, consolidation within the superior segment of the right lower lobe and apparent collapse or consolidation of the left lower lobe. CONCLUSION: No definite spine fractures. Please note that the absence of soft tissue algorithms for reconstruction of the images precludes optimum depiction of the intervertebral discs and ligamentous structures. BILAT LOWER EXT VEINS PORT [**2130-11-16**] 8:49 AM BILAT LOWER EXT VEINS PORT Reason: please eval for DVT [**Hospital 93**] MEDICAL CONDITION: 46 year old woman with BL LE edema, immobilization REASON FOR THIS EXAMINATION: please eval for DVT INDICATION: 46-year-old female with bilateral leg edema and immobilization. FINDINGS: Grayscale and Doppler son[**Name (NI) 867**] of the bilateral lower extremity veins was performed. Bilateral common femoral, superficial femoral, and popliteal veins exhibit normal flow, waveforms, augmentation, and compressibility. No intraluminal thrombus is identified. IMPRESSION: No evidence of deep venous thrombosis in either extremity. CHEST (PORTABLE AP) [**2130-11-17**] 12:52 PM CHEST (PORTABLE AP) Reason: S/P CT PULL AP CHEST 12:55 P.M [**11-17**]. HISTORY: Chest tube pulled. Rule out effusion or pneumothorax. IMPRESSION: AP chest compared to [**11-15**] and 9: Study performed at 11:25 this morning excluding the apex of the right chest showed a right pneumothorax and right lower lobe collapse both increased substantially since [**11-15**]. Current film shows little if any change. Left lower lobe atelectasis is present as well and small left pleural effusion are stable. The heart is normal in size and midline. Poor definition of the left bronchial tree suggests significant retention of secretions. CTA CHEST W&W/O C &RECONS [**2130-11-17**] 7:30 PM CTA CHEST W&W/O C &RECONS; CT 150CC NONIONIC CONTRAST Reason: r/o PE Field of view: 36 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 46 year old woman with tachypnea, difficulty maintaining sats REASON FOR THIS EXAMINATION: r/o PE CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: History of tachypnea and difficulty maintaining sats, evaluate for pulmonary embolism. COMPARISON: Study from [**2130-11-14**]. TECHNIQUE: MDCT acquired contiguous axial images were obtained from the lung bases to the thoracic inlet. Multiplanar reconstructions were performed. CONTRAST: 100 cc of IV Optiray contrast were administered due to the rapid rate of bolus injection required for this study. CTA OF THE CHEST: No filling defects or pulmonary emboli identified within the pulmonary arteries to the level of the segmental branches. The aorta demonstrates normal caliber and contour. CT OF THE CHEST WITH IV CONTRAST: Soft tissue window images demonstrate no mediastinal fluid or pathologically enlarged mediastinal lymphadenopathy. Small bilateral pleural effusions are noted. Lung window images demonstrate prominent bibasilar atelectasis. Additionally, within the right lower lung zone, there is a focal opacity which corresponds to the area of contusion seen previously. There is now increased area of opacity adjacent to this, which may represent atelectasis. Additionally, within the left middle lung zone, there are two areas of faint opacities which may represent areas of atelectasis or aspiration. The airways are patent to the level of the segmental bronchi bilaterally. There is a right pneumothorax, which is small, but appears to have increased slightly in comparison to prior study. Additionally, there is a small amount of pneumomediastinum which is similar in comparison to the prior exam. Limited images of the superior portion of the abdomen are unremarkale. BONE WINDOWS: Again seen are fractures within the sternum, and within the first, second and third left ribs, and within the right first rib. CT RECONSTRUCTIONS: Multiplanar reconstructions were essential in delineating the anatomy and pathology. IMPRESSION: 1. No pulmonary embolism. 2. Prominent atelectasis at the lung bases bilaterally, which was not seen previously. 3. Opacity within the right mid lung zone corresponds to the area of contusion seen previously and new adjacent atelectasis. New opacities within the left mid lung zone may represent focal atelectasis or aspiration. 4. Right pneumothorax is again seen, and appears slightly increased in comparison to prior study. 5. Multiple rib fractures again seen, and a sternal fracture. Results were discussed with Dr. [**Last Name (STitle) **] [**Name (STitle) 46162**] at 10:45 p.m. on [**2130-11-17**]. Brief Hospital Course: Patient admitted to the trauma service. Orthopedic surgery was consulted, patient taken to the operating room on [**11-15**] for IM nail left tibia fracture. She is currently in a hinged [**Doctor Last Name **] brace and is on subcutaneous Lovenox. Her staples were discontinued on day of discharge. She is touch down weight bearing on her LLE and will follow up with Orthopedics in 1 week. Plastic surgery was consulted because of her nasal bone fracture; this injury was treated with splinting for 1 week. She will need to follow up in [**Hospital 3595**] clinic on [**11-28**]. Psychiatry was consulted because of her history with mental health problems; it was noted that patient was delirious during their evaluation. It was recommended that Risperidone and Klonopin to be initiated. She should have Psychiatry consult while in rehab for ongoing assessment of her issues. Social work was consulted for assessment of home situation and patient's initial reports of abusive relationship with boyfriend which she ultimately denied when social work investigated this allegation. Physical therapy consulted and evaluation revealed need for short term rehab stay. Patient has been accepted at a facility in [**Location (un) 8973**]. Medications on Admission: Percocet Paxil Valium Risperidol Zonisamide Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 2. Zonisamide 100 mg Capsule Sig: Two (2) Capsule PO QHS (once a day (at bedtime)). 3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 5. Enoxaparin 40 mg/0.4mL Syringe Sig: One (1) Subcutaneous Q 24H (Every 24 Hours): Continue for 3 weeks. 6. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. Discharge Disposition: Extended Care Facility: Southeastern [**Hospital **] Nursing and Rehab Discharge Diagnosis: s/p MVC Nasal Septum Fracture Right Pneumothorax Pneumomediastinum Left Tibia/Fibula Fracture Discharge Condition: Stable Discharge Instructions: Follow up in [**Hospital **] Clinic in 1 week. Follow up in [**Hospital 3595**] Clinic on [**11-28**]. Follow up in Trauma Clinic in [**2-10**] weeks. Take all of your medications as prescribed. Followup Instructions: Call [**Telephone/Fax (1) 1228**] for an appointment in [**Hospital **] Clinic in 1 week. Call [**Telephone/Fax (1) 4652**] for an appointment in [**Hospital 3595**] clinic for next Tuesday [**11-28**]. Call [**Telephone/Fax (1) 6439**] for an appointment in Trauma Clinic. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**] Completed by:[**2130-11-23**]

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icd9cm

[ [ [] ] ]

[ "96.71", "34.04", "21.71", "86.59", "79.36" ]

icd9pcs

[ [ [] ] ]

10584, 10657

8347, 9585

324, 392

10795, 10804

1262, 2189

11051, 11487

853, 871

9679, 10561

5708, 5770

10678, 10774

9611, 9656

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886, 889

277, 286

5799, 8324

420, 634

903, 1243

656, 762

778, 837

82,901

124,229

2855

Discharge summary

report

Admission Date: [**2174-8-16**] Discharge Date: [**2174-8-17**] Date of Birth: [**2144-12-5**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 99**] Chief Complaint: Nausea, high BP Major Surgical or Invasive Procedure: None History of Present Illness: 29 year old male with ESRD on HD, HTN, CHF, and anemia who presented to the ED after BP was 200/100 at HD today. He reports he has been feeling nauseated and has been vomiting for the past 2-3 days, but no associated abdominal pain, fevers, diarrhea/constipation. Not linked to eating, no recent exotic foods, no one else in the home is sick. Then began to feel short of breath yesterday, worse with lying down. Couldn't take BP meds this AM due to vomiting. He went to HD today and SBP was in 200/150's so he was sent to the ED. No recent fevers/chills. No diarrhea. No recent illness. He is usually followed at [**Hospital1 2177**]. Has not missed any recent HD sessions, though he has been consistently well above his dry weight. In the ED, initial vitals were 98.3 100 205/145 16 97%. He complained of HA and continued to complain of SOB. He was given Percocet, labetalol 20 mg, clonidine 0.1 mg. Also started on a nitro gtt and BP improved to 180/139. CXR showed pulmonary edema. Reported no neurologic changes. CT head negative. Labs significant for BUN/Creat 73/12.9, trop 0.09. He is being admitted to the MICU for hypertensive emergency for hemodialysis. Renal fellow plans to do HD tonight. On arrival to the MICU, he is writhing in pain and actively vomiting. He endorses a [**7-20**] throbbing headache and nausea but no abdominal pain. Past Medical History: HTN for 10 yrs ESRD for 5 years, unclear etiology ?CHF Anemia Social History: Lives in [**Location 686**] with his brother and cousin. - Tobacco: 1 PPD for 10 years - Alcohol: none - Illicits: smoked marijuana until about 3 months ago, no other drugs, denies IVDU Family History: Significant for hypertension in both parents, no one else with ESRD. No diabetes, heart disease, or cancer. Physical Exam: Admission Physical Exam: Vitals: T: 96.6 BP: 188/120 P: 104 R: 29 O2:95% General: young man lying in bed in moderate distress from anxiety and pain HEENT: Pupils approx 3mm, equal, briskly reactive. Sclera anicteric, dry mucous membranes, oropharynx clear Neck: supple, JVD present, no LAD Lungs: Coarse rhonchi bilaterally with scattered wheezes anteriorly, mild bibasilar crackles CV: tachycardic with regular rhythm, normal S1 + S2, S4 heard at aprex. No murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, decreased bowel sounds, no rebound tenderness or guarding, no organomegaly. Small reducible umbilical hernia GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: alert and oriented x3. CNs II-XII intact, strength 5/5 in all extremities. Could not elicit reflexes, confounded by patient's inability to relax. Discharge Physical Exam: Vitals: Afebrile, BP 140/90, HR 90, RR 14 98%RA General: Young man without distress Neck: supple, JVD mildly elevated, no LAD Lungs: Mild coarse rhonchi bilaterally CV: Regular rhythm, normal S1 + S2, no murmurs or S4 Abdomen: soft, non-tender, non-distended, no rebound tenderness or guarding, no organomegaly. Small reducible umbilical hernia Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2174-8-16**] 03:10PM WBC-6.1 RBC-3.19*# HGB-9.3* HCT-27.0*# MCV-85# MCH-29.2 MCHC-34.5 RDW-18.1* [**2174-8-16**] 03:10PM NEUTS-71.4* LYMPHS-23.3 MONOS-3.1 EOS-1.2 BASOS-1.0 [**2174-8-16**] 03:10PM PLT COUNT-224 [**2174-8-16**] 03:10PM CALCIUM-9.0 PHOSPHATE-7.1* MAGNESIUM-2.1 [**2174-8-16**] 03:10PM CK-MB-4 [**2174-8-16**] 03:10PM cTropnT-0.09* [**2174-8-16**] 03:10PM CK(CPK)-257 [**2174-8-16**] 03:10PM GLUCOSE-96 UREA N-73* CREAT-12.9* SODIUM-137 POTASSIUM-4.3 CHLORIDE-93* TOTAL CO2-25 ANION GAP-23* [**2174-8-16**] 04:49PM PT-12.0 PTT-24.0 INR(PT)-1.0 [**2174-8-16**] 08:07PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG Studies: [**2174-8-16**] ECG: Sinus tachycardia. Left atrial abnormality. Left ventricular hypertrophy with slight Q-T interval prolongation. The precordial voltage appears excessive even for age. There is non-specific inferior ST-T wave flattening. No previous tracing available for comparison. Clinical correlation is suggested. [**2174-8-16**] CXR: Suggestion of pulmonary edema and given cardiomegaly, cardiogenic etiology is suspected. This is atypical given patient's age. [**2174-8-16**] CT Head: 1. No intracranial hemorrhage, as questioned. 2. Single area of subcortical hypodensity in the high right frontal region, of indeterminate etiology, could be further evaluated with MRI as clinically indiciated. 3. Extraaxial spaces more prominent than expected for age, with particular prominence of the prepontine cistern, which could reflect presence of an arachnoid cyst. This may also be evaluated by non-emergent MRI. 4. Incompletely visualized diffuse paranasal sinus disease. Clinical correlation is advised. Brief Hospital Course: 29 year old male with ESRD on HD, HTN, CHF, and anemia who presented with 3 days N/V, headache, and BP 200/100 at his dialysis session. #. Hypertensive emergency: He presented with extremely high blood pressure with systolic 200-230 and diastolic 140-150. The etiology was felt to be inability to tolerate oral intake to take his BP meds and nonadherence, as well as insufficient fluid removal at dialysis. He was initially given his home medications and placed on nitroglycerin drip in the ED without much effect on his BP. He continued to have a severe headache and nausea/vomiting. CT head was negative for acute process and he had no focal neurologic deficits. He underwent HD with 4L removed the night of admission. He was transitioned from a nitro drip to a labetalol drip with excellent BP response. He was restarted on his home medications although was nonadherent prior to admission. He was weaned off the labetalol drip and was stable on his home regimen. #. Headache: He presented with a [**7-20**] throbbing headache. CT head was normal. His headache improved after improvement in his BP and discontinuation of his nitroglycerin drip and felt to be related to hypertensive emergency. #. ESRD on HD: He underwent HD with 4L removed the night of admission. His admission weight was up 14kg from his dry weight of 72kg. He was continued on his home nephrocaps, phos-lo, sensipar, and lanthanum. #. Anxiety: He was very anxious on admission, flailing around and hyperventilating. This was felt to be partially related to pulmonary edema due to volume overload and partially related to his headache. He was treated with ativan with good effect. #. Nausea, vomiting: Felt to most likely be related to his hypertensive emergency vs volume overload as it improved with HD and better BP control. #. Prophylaxis: He was given subcutaneous heparin for prophylaxis TRANSITIONAL ISSUES - Gets hemodialysis T, Th, Sat - Needs close follow-up for BP control and may need uptitration of his outpatient antihypertensives and ensurance of adherence. Medications on Admission: labetalol 100 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Sensipar 60 mg Tablet Sig: One (1) Tablet PO once a day. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. PhosLo 667 mg Capsule Sig: One (1) Capsule PO three times a day. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO three times a day simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO three times a day. minoxidil 2.5 mg Tablet Sig: Two (2) Tablet PO once a day. Discharge Medications: 1. labetalol 100 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 2. Sensipar 60 mg Tablet Sig: One (1) Tablet PO once a day. 3. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. 4. PhosLo 667 mg Capsule Sig: One (1) Capsule PO three times a day. 5. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 6. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO three times a day: Take by mouth 30 mins before each meal. 7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 8. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*0* 9. minoxidil 2.5 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Hypertensive emergency Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You are leaving the hospital against medical advice. You were admitted for blood pressure elevations that were considered lethal. We had to admit you to the intensive care unit for blood pressure control. We were able get your blood pressure down on a medication drip and were then able to switch you to oral medications. You should continue taking these oral medications every day in order to control your blood pressure. Please take the pills listed below every day. It also appears that you have sleep apnea, based on observations of your sleeping pattern. We recommend that you see your PCP about getting [**Name Initial (PRE) **] sleep study in the future to determine if you need CPAP Blood pressure medications: Labetalol 300mg twice daily Clonidine 0.2mg three times daily Minoxidil was INCREASED to 5mg daily Followup Instructions: Please make an appointment for a follow up visit with you PCP in the next 1-2 weeks.

[ "305.23", "428.1", "780.57", "285.21", "787.01", "784.0", "404.93", "300.00", "V15.81", "305.1", "585.6", "V45.11" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

8648, 8654

5209, 7276

319, 326

8721, 8721

3482, 4660

9721, 9809

2029, 2138

7893, 8625

8675, 8700

7302, 7870

8872, 9698

2178, 3022

263, 281

354, 1721

4669, 5186

8736, 8848

1743, 1806

1822, 2013

3047, 3463

82,091

171,127

33591+33592

Discharge summary

report+report

Admission Date: [**2118-7-30**] Discharge Date: [**2118-8-15**] Date of Birth: [**2047-9-30**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 30**] Chief Complaint: fall Major Surgical or Invasive Procedure: 1.) C3-T1 posterior fusion with laminectomy on [**2118-8-4**] History of Present Illness: This is a 70M h/o cdCHF, CAD, COPD, IDDM2 transferred to [**Hospital1 **] from OSH with C6 fx s/p near syncopal fall. Pt was in USOH until 2 days ago. He was boating with his family when he began to feel light-headed, similar to prior episodes of hypoglycemia (notably, his insulin regimen was recently changed with labile sugars). While getting out of the boat, the pt fell backwards, struck his head with 30sec LOC. Given candy bars after with improved LH but c/o pain in his back. No excess mobility afterwards; slept on the boat that night and went to PCP the following day (day prior to admit) who referred the pt to the [**First Name4 (NamePattern1) 392**] [**Last Name (NamePattern1) **]. He was found to have an unstable C6 fracture through the vertebral body into the disc. Notably, his head CT was negative. . Initial vitals in ED triage were T 98.1, HR 70, BP 112/52, RR 16, and SpO2 95% on RA. EKG showed sinus rhythm at 65 bpm with no STE. CBC showed anemia with Hct 32.3 above recent baseline. Chemistry panel showed elevated creatinine 1.9 (baseline 1.1) and glucose 303. His CK was elevated to 907 with CKMB 8 and Troponin 0.02, thought to be from a non-cardiac muscle source . Spine consult was called, and recommended [**Location (un) 2848**] J collar, admission to Medicine, and MRI C-spine. He was given Aspirin 325 mg PO. He was given Humalog 15 units for his elevated glucose (per his home regimen). He received Morphine 5 mg IV for pain control. . He was admitted to Medicine for further management of recent syncope and cervical fracture. Vitals prior to floor transfer were T 98.7, HR 69, BP 108/43, RR 16, and SpO2 95% on RA. On reaching the floor, he reported ongoing lower neck pain and dry mouth. Upon meeting the patient, he complained of sharp chest pain radiating down the arms similar to episodes he has previously identified as anginal. An EKG was obtained which did now show interval change. MB and troponin were due in with morning labs as they were mildly elevated when he presented to the ED. Pt had a difficult time articulating the difference between back and chest pain so SL nitro x1 was given. His chest pain resolved, and his back/arm pain persisted. This was treated with Dilaudid. He denied acute SOB, diaphoresis, N/V, incontinence, weakness, sensory loss. ROS was otherwise NC. Past Medical History: CAD s/p CABG in [**2093**], s/p cath in [**2103**] wiuth BMS to Lcx, [**2113**] revealing a severe stenosis in the SVG to the OM s/p BMS x 3, [**2115**] at [**Hospital1 112**] (patient says stent but unknown location) IDDM morbid obesity COPD sleep apnea on BiPAP CHF, diastolic, with EF 71% per OSH reports afib HTN CVA with right sided numbness history of rheumatic fever Social History: Lives with wife and four children. Worked as a carpenter. No tob/ETOH/IVDA. Family History: Adopted, unknown Physical Exam: #ADMISSION PHYSICAL EXAM: VS: T 97.9, BP 117/54, HR 69, RR 18, SpO2 94% on RA Gen: Elderly male in NAD. Oriented x3. HEENT: Sclera anicteric. PERRL, EOMI. MMM, OP benign. Neck: Cervical collar in place. Unable to asses JVP or nodes. CV: RRR with normal S1, S2. No M/R/G appreciated. Chest: CTAB on limited anterolateral exam without crackles, wheezes, or rhonchi. Abd: Hypoactive bowel sounds. Soft, NT, ND. Ext: WWP. Digital cap refill <2 sec. No C/C/E. Distal pulses intact radial 2+, DP 2+, PT 2+. Neuro: CN II-XII grossly intact. Strength 5/5 in all extremities. Normal speech. #DISCHARGE PHYSICAL EXAM: O: AF 97.9 BP 118/56 HR 69 sat 95% RA GENERAL - Alert, interactive, well-appearing in NAD. HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear HEART - RRR, nl S1-S2, no MRG LUNGS - bibasilar crackles, CTAB, no wheezes, no rales. ABDOMEN - NABS, soft/NT/ND, no masses or HSM EXTREMITIES - WWP, no clubbing or cyanosis, 2+ pitting edema b/l in lower extremities, 2+ peripheral pulses NEURO - awake, A&Ox3, CNs II-XII grossly intact, C-collar in place, cervical surgical site c/d/i s/p dressing change by ortho spine this AM. Pertinent Results: #ADMISSION LABS: [**2118-7-29**] 11:57PM BLOOD WBC-10.3 RBC-3.71* Hgb-10.6* Hct-32.3* MCV-87 MCH-28.5 MCHC-32.8 RDW-18.9* Plt Ct-199 [**2118-7-29**] 11:57PM BLOOD Neuts-77.3* Lymphs-14.5* Monos-3.8 Eos-4.0 Baso-0.3 [**2118-7-29**] 11:57PM BLOOD Plt Ct-199 [**2118-7-29**] 11:57PM BLOOD PT-11.9 PTT-26.9 INR(PT)-1.1 [**2118-7-29**] 11:57PM BLOOD Glucose-303* UreaN-48* Creat-1.9* Na-130* K-5.9* Cl-94* HCO3-27 AnGap-15 [**2118-7-29**] 11:57PM BLOOD CK(CPK)-907* [**2118-7-29**] 11:57PM BLOOD CK-MB-8 cTropnT-0.02* #[**Hospital 40963**] HOSPITAL COURSE LABS: [**2118-8-15**] 09:10AM BLOOD WBC-8.4 RBC-3.19* Hgb-9.3* Hct-28.8* MCV-90 MCH-29.0 MCHC-32.2 RDW-17.3* Plt Ct-185 [**2118-8-14**] 08:42AM BLOOD WBC-12.5* RBC-3.42* Hgb-10.0* Hct-31.0* MCV-91 MCH-29.2 MCHC-32.2 RDW-17.2* Plt Ct-246 [**2118-8-12**] 06:08AM BLOOD WBC-8.0 RBC-3.19* Hgb-9.2* Hct-28.2* MCV-88 MCH-28.8 MCHC-32.6 RDW-17.3* Plt Ct-176 [**2118-8-10**] 01:01AM BLOOD WBC-8.2 RBC-3.38* Hgb-9.6* Hct-30.1* MCV-89 MCH-28.5 MCHC-32.1 RDW-17.4* Plt Ct-186 [**2118-8-8**] 02:04AM BLOOD WBC-5.6 RBC-2.83* Hgb-8.3* Hct-25.4* MCV-90 MCH-29.2 MCHC-32.5 RDW-17.9* Plt Ct-124* [**2118-8-5**] 10:35AM BLOOD WBC-12.0*# RBC-3.89*# Hgb-11.2* Hct-34.8*# MCV-89 MCH-28.8 MCHC-32.2 RDW-17.8* Plt Ct-222 [**2118-8-4**] 06:40AM BLOOD WBC-6.4 RBC-3.71* Hgb-10.8* Hct-33.1* MCV-89 MCH-29.0.MCHC-32.6 RDW-18.1* Plt Ct-187 [**2118-8-2**] 07:10AM BLOOD WBC-8.6 RBC-3.73* Hgb-10.7* Hct-33.2* MCV-89 MCH-28.9 MCHC-32.3 RDW-18.2* Plt Ct-223# [**2118-8-1**] 06:45AM BLOOD WBC-9.4 RBC-3.97* Hgb-11.3* Hct-35.7* MCV-90 MCH-28.6 MCHC-31.7 RDW-18.4* Plt Ct-145* [**2118-7-30**] 10:10AM BLOOD WBC-8.6 RBC-3.55* Hgb-10.2* Hct-31.1* MCV-88 MCH-28.8 MCHC-32.9 RDW-18.8* Plt Ct-183 [**2118-8-11**] 08:15AM BLOOD Neuts-79.2* Lymphs-11.2* Monos-4.2 Eos-5.1* Baso-0.3 [**2118-8-7**] 01:34AM BLOOD Neuts-81.2* Lymphs-11.3* Monos-3.5 Eos-3.9 Baso-0.1 [**2118-8-6**] 02:05AM BLOOD Neuts-88.0* Lymphs-7.3* Monos-3.1 Eos-1.3 Baso-0.3 [**2118-8-5**] 10:35AM BLOOD Neuts-93.9* Lymphs-3.0* Monos-1.9* Eos-1.0 Baso-0.1 [**2118-8-9**] 02:19AM BLOOD PT-14.3* PTT-30.3 INR(PT)-1.3* [**2118-8-8**] 02:04AM BLOOD PT-14.5* PTT-44.8* INR(PT)-1.4* [**2118-8-7**] 01:34AM BLOOD PT-15.1* PTT-37.7* INR(PT)-1.4* [**2118-8-6**] 02:05AM BLOOD PT-13.9* PTT-30.0 INR(PT)-1.3* [**2118-8-1**] 06:45AM BLOOD PT-11.9 PTT-21.9* INR(PT)-1.1 [**2118-8-15**] 09:10AM BLOOD Glucose-128* UreaN-48* Creat-1.4* Na-139 K-5.0 Cl-105 HCO3-27 AnGap-12 [**2118-8-13**] 09:50AM BLOOD Glucose-121* UreaN-54* Creat-1.9* Na-139 K-4.8 Cl-101 HCO3-26 AnGap-17 [**2118-8-12**] 06:08AM BLOOD Glucose-106* UreaN-46* Creat-1.5* Na-139 K-4.1 Cl-100 HCO3-31 AnGap-12 [**2118-8-10**] 01:01AM BLOOD Glucose-121* UreaN-34* Creat-1.2 Na-142 K-3.8 Cl-102 HCO3-30 AnGap-14 [**2118-8-5**] 08:02PM BLOOD Glucose-245* UreaN-22* Creat-1.5* Na-141 K-4.6 Cl-104 HCO3-26 AnGap-16 [**2118-8-4**] 05:30PM BLOOD Glucose-120* UreaN-18 Creat-1.1 Na-140 K-4.9 Cl-105 HCO3-28 AnGap-12 [**2118-8-2**] 07:10AM BLOOD Glucose-152* UreaN-27* Creat-1.1 Na-136 K-4.7 Cl-99 HCO3-31 AnGap-11 [**2118-7-31**] 07:15AM BLOOD Glucose-193* UreaN-35* Creat-1.4* Na-138 K-5.4* Cl-102 HCO3-31 AnGap-10 [**2118-7-30**] 10:10AM BLOOD Glucose-216* UreaN-46* Creat-1.5* Na-135 K-4.9 Cl-99 HCO3-27 AnGap-14 [**2118-8-10**] 01:01AM BLOOD CK(CPK)-66 [**2118-8-7**] 01:34AM BLOOD CK(CPK)-165 [**2118-8-6**] 10:52AM BLOOD CK(CPK)-393* [**2118-8-6**] 02:05AM BLOOD CK(CPK)-614* [**2118-8-5**] 10:19AM BLOOD CK(CPK)-207 [**2118-8-4**] 05:30PM BLOOD CK(CPK)-140 [**2118-8-3**] 06:30AM BLOOD CK(CPK)-66 [**2118-7-30**] 10:10AM BLOOD CK(CPK)-565* [**2118-8-10**] 01:01AM BLOOD CK-MB-3 cTropnT-2.19* [**2118-8-9**] 02:19AM BLOOD CK-MB-4 cTropnT-1.95* [**2118-8-8**] 02:04AM BLOOD CK-MB-4 cTropnT-1.66* [**2118-8-7**] 01:34AM BLOOD CK-MB-11* MB Indx-6.7* cTropnT-1.49* [**2118-8-6**] 06:34PM BLOOD CK-MB-17* MB Indx-7.9* cTropnT-1.72* [**2118-8-6**] 10:52AM BLOOD CK-MB-35* MB Indx-8.9* cTropnT-1.78* [**2118-8-6**] 02:05AM BLOOD CK-MB-67* MB Indx-10.9* cTropnT-1.84* [**2118-8-5**] 08:02PM BLOOD cTropnT-1.11* [**2118-8-5**] 10:19AM BLOOD CK-MB-8 cTropnT-0.10* [**2118-8-3**] 06:30AM BLOOD CK-MB-3 cTropnT-<0.01 [**2118-7-31**] 07:15AM BLOOD CK-MB-2 cTropnT-<0.01 [**2118-7-30**] 10:10AM BLOOD CK-MB-5 cTropnT-<0.01 [**2118-8-15**] 09:10AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.5 [**2118-8-13**] 09:50AM BLOOD Calcium-8.5 Phos-5.2* Mg-2.3 [**2118-8-11**] 06:46PM BLOOD Calcium-8.3* Phos-3.3 Mg-2.2 [**2118-8-11**] 08:15AM BLOOD Calcium-8.7 Phos-4.0 Mg-2.3 [**2118-8-8**] 01:47PM BLOOD Calcium-8.1* Phos-3.3 Mg-2.1 [**2118-8-6**] 02:05AM BLOOD Calcium-8.7 Phos-2.6* Mg-2.4 [**2118-8-4**] 06:40AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.4 [**2118-8-1**] 06:45AM BLOOD Calcium-9.1 Phos-2.9 Mg-2.7* [**2118-7-31**] 07:15AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.6 [**2118-7-30**] 10:10AM BLOOD Calcium-8.7 Phos-4.0 Mg-2.3 [**2118-8-2**] 07:10AM BLOOD VitB12-345 [**2118-8-1**] 06:45AM BLOOD %HbA1c-7.6* eAG-171* [**2118-8-2**] 07:10AM BLOOD TSH-4.6* [**2118-8-7**] 06:45AM BLOOD Vanco-10.3 [**2118-8-9**] 02:36AM BLOOD Type-ART pO2-92 pCO2-53* pH-7.35 calTCO2-30 Base XS-1 [**2118-8-8**] 10:18PM BLOOD Type-ART pH-7.37 [**2118-8-8**] 02:22AM BLOOD Type-ART pO2-80* pCO2-48* pH-7.39 calTCO2-30 Base XS-2 [**2118-8-7**] 06:45PM BLOOD Type-ART pO2-95 pCO2-37 pH-7.46* calTCO2-27 Base XS-2 [**2118-8-6**] 02:21AM BLOOD Type-ART pO2-87 pCO2-41 pH-7.45 calTCO2-29 Base XS-3 [**2118-8-5**] 03:59PM BLOOD Type-ART Temp-38.3 pO2-122* pCO2-53* pH-7.30* calTCO2-27 Base XS-0 [**2118-8-5**] 02:13AM BLOOD Type-ART pO2-118* pCO2-49* pH-7.40 calTCO2-31* Base XS-4 [**2118-8-4**] 03:09PM BLOOD Type-ART Tidal V-500 FiO2-60 O2 Flow-6 pO2-249* pCO2-51* pH-7.36 calTCO2-30 Base XS-2 Intubat-INTUBATED Vent-CONTROLLED [**2118-8-4**] 01:43PM BLOOD Type-ART pO2-442* pCO2-50* pH-7.39 calTCO2-31* Base XS-4 [**2118-8-3**] 06:56AM BLOOD Type-ART pO2-65* pCO2-53* pH-7.33* calTCO2-29 Base XS-0 [**2118-8-9**] 02:36AM BLOOD Glucose-285* K-4.1 [**2118-8-8**] 05:11PM BLOOD Glucose-248* [**2118-8-4**] 03:09PM BLOOD Glucose-89 Lactate-1.0 Na-137 K-4.7 Cl-106 [**2118-8-9**] 02:36AM BLOOD freeCa-1.21 [**2118-8-8**] 10:18PM BLOOD freeCa-1.11* [**2118-8-5**] 05:43PM BLOOD freeCa-1.09* [**2118-8-4**] 05:58PM BLOOD freeCa-1.04* #STUDIES: []ECG Study Date of [**2118-7-31**] 9:22:44 PM Sinus rhythm. Left atrial abnormality. Low limb lead voltage. Variation in the precordial lead placement as compared to the previous tracing of [**2118-7-30**]. Non-specific inferolateral ST-T wave changes persist. No apparent No diagnostic interim change. TRACING #1 Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**] Intervals Axes Rate PR QRS QT/QTc P QRS T 78 176 110 392/423 43 0 69 #RADIOLOGY: []CT cervical spine [**2118-7-30**]: IMPRESSION: 1. Minimally displaced transverse fracture through the C6 vertebral body with associated prevertebral soft tissue prominence. Dedicated cervical spine MRI is recommended to evaluate for spinal cord edema given the nature of the injury. 2. Multilevel degenerative changes with disc space narrowing as well as large anterior and posterior osteophytes, greatest at C3-C4 with moderate central canal narrowing. This region can also be further assessed. []MR CERVICAL SPINE W/O CONTRAST Study Date of [**2118-7-30**] 2:48 PM IMPRESSION: 1. Large posterior osteophyte and spondylosis identified at C3/C4 level, impinging the thecal sac up on the left, with the questionable area of spinal cord edema demonstrated on the diffusion-weighted sequence. 2. C6 vertebral body transverse fracture, with associated bone and soft tissue edema, causing significant spinal canal stenosis up on the left with no frank evidence of diffusion abnormalities at this level. 3. Multilevel degenerative changes throughout the cervical spine as described above. []CHEST (PORTABLE AP) Study Date of [**2118-7-31**] 10:03 PM FINDINGS: In comparison with the study of [**5-7**], there are lower lung volumes which may account for the apparent increase in the transverse diameter of the heart. Ill-defined engorged vessels are consistent with elevated pulmonary venous pressure. Mild elevation of the left hemidiaphragm with opacification just above it. Although this could merely reflect atelectasis and effusion, in view of the clinical history the possibility of a supervening pneumonia in the region must be considered. [] CT HEAD W/O CONTRAST Study Date of [**2118-7-31**] 10:13 PM IMPRESSION: Old left cerebellar infarctions. No evidence of hemorrhage, fracture, or recent infarction. []TTE [**2118-8-1**] IMPRESSION: Mild symmetric LVH with mild focal left ventricular systolic dysfunction. The right ventricle is not well seen. Mild mitral regurgitation []CHEST (PORTABLE AP) Study Date of [**2118-8-3**] 5:43 AM FINDINGS: In comparison with the study of [**7-31**], there is little change. The degree of opacification at the left base is less prominent, though this could reflect slightly better inspiration. []CERVICAL SINGLE VIEW IN OR Study Date of [**2118-8-4**] 1:59 PM IMPRESSION: 1. Status post posterior C4 through T1 spinal fusion. 2. Surgical hardware appears intact. 3. Incidental note is made of an endotracheal tube terminating superior to the thoracic inlet. Radiographs performed on [**8-4**], [**2117**] at 14:00 hours, follow chest radiograph demonstrated ET tube terminating inferior to the thoracic inlet. []CHEST (PORTABLE AP) Study Date of [**2118-8-4**] 5:41 PM CONCLUSION: 1. ET tube is too high ending 9.6 cm above carina. 2. Stable pulmonary edema is mild to moderate. []TTE [**2118-8-5**] IMPRESSION: Mild regional left ventricular systolic dysfunction. Mild mitral regurgitation. Moderate pulmonary hypertension. []TTE [**2118-8-9**] IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Mild mitral regurgitation with normal valve morphology. Pulmonary artery hypertension. #MICROBIOLOGY: [][**2118-7-31**] 11:03 pm URINE Source: Catheter. **FINAL REPORT [**2118-8-2**]** URINE CULTURE (Final [**2118-8-2**]): NO GROWTH. [][**2118-7-31**] 11:36 pm BLOOD CULTURE # 1. **FINAL REPORT [**2118-8-7**]** Blood Culture, Routine (Final [**2118-8-7**]): NO GROWTH. [][**2118-8-1**] 6:45 am BLOOD CULTURE #2. **FINAL REPORT [**2118-8-7**]** Blood Culture, Routine (Final [**2118-8-7**]): NO GROWTH [][**2118-8-3**] 6:30 am BLOOD CULTURE **FINAL REPORT [**2118-8-9**]** Blood Culture, Routine (Final [**2118-8-9**]): NO GROWTH. [][**2118-8-3**] 6:01 am URINE Site: NOT SPECIFIED CHEM# [**Serial Number 77842**]S [**8-3**]. **FINAL REPORT [**2118-8-4**]** URINE CULTURE (Final [**2118-8-4**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [][**2118-8-4**] 5:30 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2118-8-7**]** MRSA SCREEN (Final [**2118-8-7**]): No MRSA isolated [][**2118-8-5**] 10:35 am BLOOD CULTURE Source: Line-aline. **FINAL REPORT [**2118-8-11**]** Blood Culture, Routine (Final [**2118-8-11**]): NO GROWTH. [][**2118-8-5**] 10:46 am BRONCHOALVEOLAR LAVAGE **FINAL REPORT [**2118-8-9**]** GRAM STAIN (Final [**2118-8-5**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2118-8-9**]): 10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora. YEAST. ~7000/ML. Isolates are considered potential pathogens in amounts >=10,000 cfu/ml. YEAST. ~5000/ML. SECOND MORPHOLOGY. Isolates are considered potential pathogens in amounts >=10,000 cfu/ml. HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. ~3000/ML. Isolates are considered potential pathogens in amounts >=10,000 cfu/ml. Beta-lactamse negative: presumptively sensitive to ampicillin. Confirmation should be requested in cases of treatment failure in life-threatening infections.. BETA LACTAMASE REQUESTED BY DR [**Last Name (STitle) **]. BARDIA (#[**2-/5016**]) [**2118-8-9**]. [][**2118-8-5**] 10:35 am URINE Site: CATHETER Source: Catheter. **FINAL REPORT [**2118-8-6**]** URINE CULTURE (Final [**2118-8-6**]): NO GROWTH. [][**2118-8-5**] 11:43 am BLOOD CULTURE AC. **FINAL REPORT [**2118-8-11**]** Blood Culture, Routine (Final [**2118-8-11**]): NO GROWTH. [] [**2118-8-5**] 4:57 pm URINE **FINAL REPORT [**2118-8-6**]** Legionella Urinary Antigen (Final [**2118-8-6**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary [][**2118-8-8**] 12:37 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2118-8-8**]** GRAM STAIN (Final [**2118-8-8**]): >25 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final [**2118-8-8**]): TEST CANCELLED, PATIENT CREDITED. [][**2118-8-8**] 1:00 am URINE Source: Catheter. **FINAL REPORT [**2118-8-9**]** URINE CULTURE (Final [**2118-8-9**]): NO GROWTH. [][**2118-8-8**] 1:00 am BLOOD CULTURE Source: Line-Rt Subclavian. **FINAL REPORT [**2118-8-14**]** Blood Culture, Routine (Final [**2118-8-14**]): NO GROWTH. [] [**2118-8-8**] 1:00 am BLOOD CULTURE Source: Venipuncture. **FINAL REPORT [**2118-8-14**]** Blood Culture, Routine (Final [**2118-8-14**]): NO GROWTH. [][**2118-8-12**] 4:00 pm SWAB Source: neck wound. GRAM STAIN (Final [**2118-8-12**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2118-8-14**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. Brief Hospital Course: []BRIEF HOSPITAL COURSE: 70M with history of CAD, diastolic CHF, COPD, and diabetes who was transferred to [**Hospital1 18**] from outside hospital with a C6 fracture after falling in a near syncopal episode, possibly from a hypoglycemic event. Patient was evaluated by ortho/spine and was taken to the OR on [**2118-8-4**], transferred to TSICU post op intubated. Patient was evaluated for NSTEMI by cardiology, treated for a presumed ventilator associated pneumonia, extubated, and aggressively diuresed prior to transfer to the floor. Once on the floor, patient continued to improve and diuresis was completeted with patient near dry weight at discharge. Patient will follow up with orthopedic surgery, cardiology, and his PCP. . []BRIEF ICU COURSE: [**8-4**] Went to OR for C3-T1 posterior fusion with laminectomy. Admitted to TSICU post-op intubated and on Neo. OGT placed. ETT advanced. 500cc bolus given. [**8-5**]: continued ST depressions on telemetry -> labetalol 10 mg IV once, febrile to 103 -> Cx drawn, bronchoscopy performed showed inflammation with purulent sputum, BAL sent for culture and gram stain. Albumin 12.5g bolus. CVL, +Vanc/Cefepime/Cipro, right subclavian placed. Trop still uptrending, cards advises just follow no hep for now. [**8-6**]: trended Troponin, esmolol drip,heparin gtt 8/19:1U PRBC (HCT24.1) followed by lasix 20 IV x1, trops trending down. Started on PO metoprolol w/ IV Metoprolol for breakthrough. [**Last Name (un) **] consulted for BS of 200's, insulin drip started. Tube feeds started and advancing to goal of 75cc/hr. Thick sputum requiring frequent suctioning. Temp 101.2-> pan-cultures sent [**8-8**]: 1 u PRBC, (+) lasix 40 iv qonce x2, d/c insulin gtt --> lantus 30 [**Hospital1 **] + RISS, increased vanc to 1 g q8h, d/c heparin gtt, (+) plavix 75 mg (fine by spine), (+) heparin tid, (+) lasix gtt [**8-9**]: d/c vanco, patient extubated on face tent. maintaing saturations. OG tube removed. Start on clear liquids. (+) bumex 1 g for diuresis,self d/ced a line [**8-10**]: d/c'ed cefepime/cipro and started unasyn for H. flu, started lasix 40 mg po and d/c'd lasix gtt, cards recs restarting Lisinopril, plan to transfer to floor. . []ACTIVE ISSUES: # NSTEMI: elevated troponins since [**2118-8-5**], c/f NSTEMI. Patient had concerning ST depressions on EKG tracings. Cardiology was consulted and continued to follow during the rest of the patient's hospitalization. Left ventricular function interval improved on echo [**8-9**]. The patient was continued on his home regimen of ASA 325mg, clopidogrel 75mg, and atorvastatin 80mg. . # Ventilator Associated Pneumonia: Patient had extended intubation s/p surgery, with bibasilar opacities L>R, c/f evolving PNA in the setting of endotracheal intubation. BAL results revealed beta-lactamase negative haemophilus influenza and patient was started on empiric treatment for VAP given recent prolonged extubation. F/u sputum culture on [**2118-8-8**] contaminated and thus not pursued. finished 7 day course of empiric therapy for VAP with cefepime/levofloxacin. . # [**Last Name (un) **]: Likely pre-renal etiology secondary to diuresis s/p surgery and subsequent ICU admission where patient was aggressively hydrated in the setting of hypotension. Differential includes ATN, AIN and obstruction. AIN less likely since no fevers or rashes. No recent contrast studies. Urine output speaks against obstruction. Between [**2118-8-8**] and [**2118-8-12**], patient had an average net negative diuresis of ~2L daily. During this time, his creatinine bumped up by roughly 0.1 per day to a plateau of 1.9 while getting 40mg PO lasix then 40mg torsemide. Diuresis was stopped on [**2118-8-13**], and by the day of discharge, the patient's creatinine was 1.4. The patient's baseline creatinine is ~1.0. The patient's home diuresis regimen is 40mg PO lasix [**Hospital1 **]. . # C6 Fracture: Minimally displaced per OSH CT and confirmed in house. Orthopedics was consulted and felt that his fracture might be amenable to nonoperative management. CT and MRI were done, which confirmed the C6 fracture and identified prevertebral edema. No neurological deficits were noted on exam, although the patient did complain of central lower neck pain radiating down both arms. Spine Surgery followed the patient. A hard collar was maintained at all times with bedrest. [**8-4**] Went to OR for C3-T1 posterior fusion with laminectomy. Admitted to TSICU post-op intubated and on Neo. OGT placed. ETT advanced. 500cc bolus given. Post op, patient's wound was c/d/i . # Hypoglycemic Episode / Diabetes: He reports that his Insulin regimen was recently changed to Lantus and fixed dose Humalog instead of 70/30 [**Hospital1 **]. He was started on approximately 70% of his home Lantus every day with a sliding scale. His home regimen will likely need to be adjusted given his apparent hypoglycemic event. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Clinic consult was called to tailor his insulin regimen given his recent event and its ostensible relation to hypoglycemia. . # Post operative pain: The patient was given oxycodone PO for post op pain, with dilaudid IV for severe breakthrough pain. On [**2118-8-12**], patient began to experience s/s of delirium thought to be likely secondary to narcotics. His dosing schedule was spaced out to Q8H PRN from Q6H PRN and over the next 24 hours, the patient's mental status returned to baseline. He required no pain medications in the 24 hours prior to discharge. . []CHRONIC ISSUES: # Angina: The patient was continued on his home dose of ranolazine. . # Hx of Paroxysmal Atrial fibrillation: The patient was monitored on telemetry during this hospitalization. He was continued on metoprolol for rate control. He had one burst of afib in the ICU that was controlled with IV metoprolol X 1 and an increased maintenence dose of metoprolol. He was transitioned from 100mg [**Hospital1 **] to 150mg [**Hospital1 **]. . # IDDM II: followed by [**Last Name (un) **], with monitoring of BS lantus [**Hospital1 **] + humalog SSI [**First Name8 (NamePattern2) **] [**Last Name (un) **] recs. . # Neurogenic pain: We continued home dose of amitiyptyline. . # Essential hypertension: Blood pressures remained stable throughout this admission. Continued home metoprolol 150 [**Hospital1 **] with hold parameters while hospitalized. Was discharged with 300mg Toprol XL daily formulation. . # OSA - CPAP at night . []TRANSITIONAL ISSUES: 1.) patient will follow up with his outpatient cardiologist. 2.) At rehab, patient will require daily weights and add a PM dose of 40mg PO lasix if fluid weight increases > 5 pounds while on 40mg PO lasix daily. 3.) The rehab facility will Check serum creatinine level every other day and report results to staff physician in charge of patient to monitor kidney function while on diuretics. 4.) The patient is very sensitive to the effects of narcotics and can quickly develop delirium. 5.) please do not give patient albuterol because the increased HR side effect makes him anxious. 6.) please set up an appointment with the patient's primary care provider within the next 1-2 weeks for medication reconciliation and f/u s/p hospitalization. 7.) patient is to wear C-collar at all times when not lying down in bed; further recs to be obtained at outpatient orthopedic surgery appointment. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Family/Caregiver. 1. Atorvastatin 80 mg PO DAILY 2. ranolazine *NF* 1,000 mg Oral [**Hospital1 **] 3. Pantoprazole 40 mg PO Q12H 4. Venlafaxine XR 75 mg PO DAILY 5. Nitroglycerin SL 0.4 mg SL PRN chest pain 6. Aspirin 325 mg PO DAILY 7. Senna 1 TAB PO BID:PRN constipation 8. Docusate Sodium 100 mg PO BID 9. Metoprolol Tartrate 150 mg PO BID 10. Lisinopril 5 mg PO DAILY 11. Furosemide 40 mg PO BID hold for sbp < 100 12. Polyethylene Glycol 17 g PO DAILY 13. Isosorbide Mononitrate (Extended Release) 180 mg PO DAILY hold for sbp < 100 14. Amitriptyline 25 mg PO DAILY 15. Glargine 70 Units Bedtime Humalog 15 Units Breakfast Humalog 15 Units Lunch Humalog 15 Units Dinner Discharge Medications: 1. Amitriptyline 25 mg PO DAILY 2. Aspirin 325 mg PO DAILY 3. Atorvastatin 80 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Isosorbide Mononitrate (Extended Release) 180 mg PO DAILY hold for sbp < 100 6. Nitroglycerin SL 0.4 mg SL PRN chest pain 7. Polyethylene Glycol 17 g PO DAILY 8. ranolazine *NF* 1000 mg ORAL [**Hospital1 **] 9. Senna 1 TAB PO BID:PRN constipation 10. Venlafaxine XR 75 mg PO DAILY 11. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q6H:PRN pain Do not exceed 4000 mg in 24 hours. 12. Lactulose 15 mL PO DAILY:PRN constipation 13. Lisinopril 5 mg PO DAILY 14. Bisacodyl 10 mg PR DAILY:PRN constipation 15. Cephalexin 500 mg PO Q6H Duration: 10 Days 16. Furosemide 40 mg PO DAILY hold for sbp < 100 or Cr > 1.5. 17. Clopidogrel 75 mg PO DAILY 18. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 19. Metoprolol Succinate XL 300 mg PO DAILY hold for SBP < 100 or HR < 60 20. Glargine 30 Units Q12H Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Extended Care Facility: [**Hospital 38**] Rehab Discharge Diagnosis: Primary: - C6 fracture dislocation - Partial surgical wound dehiscence - Ventilator associated pneumonia - Acute renal failure - Non-ST elevation myocardial infarction - Acute on chronic diastolic heart failure - Delirium - Constipation Secondary: - 3-vessel CAD s/p CABG; multiple NSTEMIs and PCIs - Upper GI bleeding - Prior stroke - Diabetes mellitus - Hypertension - COPD - Obstructive sleep apnea - Morbid obesity - Normocytic anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure caring for you while you were hospitalized at the [**Hospital1 **]. As you may recall, you were transferred to us after being diagnosed with a broken bone in your neck (a C6 fracture). We took pictures of your neck to help us assess your anatomy and determine whether any intervention would be necessary. You were taken to the operating room to stabilize your neck. There was difficulty taking out the tube used to help you breathe after the operation. During your stay in the intensive care unit, you were treated for a lung infection. There was also concern for a small heart attack. You were seen by the cardiologists and treated with medicines. Please remember to weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: As soon as you are discharged from the hospital, please call your primary care physician and arrange [**Name Initial (PRE) **] follow-up visit within 4-8 days. In addition, the following visits have already been made for you: Department: CARDIAC SERVICES When: WEDNESDAY [**2118-8-3**] at 9:00 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Admission Date: [**2118-8-19**] Discharge Date: [**2118-8-24**] Date of Birth: [**2047-9-30**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2071**] Chief Complaint: syncope Major Surgical or Invasive Procedure: NONE History of Present Illness: 70 year old male with CAD s/p CABG (SVG-OM, LIMA-LAD) in [**2093**] and multiple subsequent NSTEMIs and PCIs (most recently a BMS to SVG-OM [**2118-3-31**]), CHF (EF 40-45%), HTN, HLD, paroxysmal Afib (not on coumadin), DM, COPD, OSA, prior CVA, and recent significant GIB ([**4-/2118**]) who presents with a C6 vertebral body fracture after falling on [**2118-7-29**]. Pt known to use with recent office visits and inpatient consult in OMR. S/P cervical spine surgery after fall, complicated by severe PNA (likely [**1-20**] aspiration)/sepsis and hypotension with demand ischemia and positive TnT. Treated medically, had to be diuresed with Lasix gtt (received lots of fluids by SICU team). Transferred to [**Hospital 38**] rehab and after finishing a BM (while pulling his trousers), had a 5 sec pause and fell (was caught by nurse). Has been on Motoprolol 300/d and Ranexa. Severe CAD s/p PCI/stent to SVG [**2-/2118**] and relook few days later with patent stent. Native coronaries vessels are not amenable to PCI. Needs work up and EP consult. If this is a true (not iatrogenic or artifact) pause, then a device may need to be considered. Most recent echo [**2118-8-9**] showed recovery of his LVEF to >55% (from baseline of 40%. . ROS: 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. Denies recent fevers, chills or rigors. Denies exertional buttock or calf pain. Otherwise negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema. Past Medical History: CAD s/p CABG in [**2093**], s/p cath in [**2103**] wiuth BMS to Lcx, [**2113**] revealing a severe stenosis in the SVG to the OM s/p BMS x 3, [**2115**] at [**Hospital1 112**] (patient says stent but unknown location) IDDM morbid obesity COPD sleep apnea on BiPAP CHF, diastolic, with EF 71% per OSH reports afib HTN CVA with right sided numbness history of rheumatic fever Social History: Lives with wife and four children. Worked as a carpenter. No tob/ETOH/IVDA. Family History: Adopted, unknown Physical Exam: #ADMISSION PHYSICAL EXAM: VS: T 98.5, BP 114/71, HR 71, RR 20 , O2 98% on 3L NC. GENERAL: NAD, AxOx3. HEENT: JVP unable to assess [**1-20**] habitus and C-collar. Sclera anicteric. PERRL, EOMI. MMM CARDIAC: RRR, normal S1, S2. 2/6 SEM herad best at LUSB, No/r/g. 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. Abd aorta not enlarged by palpation. EXTREMITIES: pretibial edema 1+ No femoral bruits. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+ . #DISCHARGE PHYSICAL EXAM: VS: T 98.1, BP (104-129)/(62-67), HR 86, RR 20, O2 97% 3L. GENERAL: NAD, AxOx3. HEENT: JVP unable to assess [**1-20**] habitus and C-collar. Sclera anicteric. PERRL, EOMI. MMM CARDIAC: RRR, normal S1, S2. 2/6 SEM herad best at LUSB, No/r/g. 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. Abd aorta not enlarged by palpation. EXTREMITIES: pretibial edema 1+ No femoral bruits. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+ Pertinent Results: #ADMISSION LABS: [**2118-8-19**] 09:30PM GLUCOSE-235* UREA N-24* CREAT-1.1 SODIUM-144 POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-32 ANION GAP-12 [**2118-8-19**] 09:30PM CK(CPK)-29* [**2118-8-19**] 09:30PM CK-MB-3 cTropnT-0.49* [**2118-8-19**] 09:30PM CALCIUM-8.8 PHOSPHATE-3.7 MAGNESIUM-1.8 [**2118-8-19**] 09:30PM WBC-8.6 RBC-3.16* HGB-9.1* HCT-29.0* MCV-92 MCH-28.9 MCHC-31.5 RDW-17.7* [**2118-8-19**] 09:30PM PLT COUNT-338# [**2118-8-19**] 09:30PM PT-13.9* PTT-32.7 INR(PT)-1.3* . #PERTINENT LABS: [**2118-8-23**] 04:05AM BLOOD WBC-7.6 RBC-3.15* Hgb-9.2* Hct-28.2* MCV-90 MCH-29.1 MCHC-32.5 RDW-18.1* Plt Ct-273 [**2118-8-21**] 10:30AM BLOOD WBC-8.7 RBC-3.43* Hgb-10.0* Hct-31.3* MCV-91 MCH-29.3 MCHC-32.1 RDW-18.1* Plt Ct-342 [**2118-8-20**] 07:45AM BLOOD WBC-8.4 RBC-3.29* Hgb-9.5* Hct-30.3* MCV-92 MCH-29.0 MCHC-31.5 RDW-17.9* Plt Ct-348 [**2118-8-22**] 10:30AM BLOOD PT-13.1* PTT-33.9 INR(PT)-1.2* [**2118-8-21**] 10:30AM BLOOD PT-13.4* PTT-31.5 INR(PT)-1.2* [**2118-8-23**] 04:05AM BLOOD Glucose-131* UreaN-20 Creat-1.3* Na-141 K-3.8 Cl-98 HCO3-35* AnGap-12 [**2118-8-21**] 10:30AM BLOOD Glucose-201* UreaN-19 Creat-1.1 Na-144 K-4.1 Cl-99 HCO3-36* AnGap-13 [**2118-8-20**] 03:18PM BLOOD Glucose-144* UreaN-22* Creat-1.2 Na-144 K-5.1 Cl-102 HCO3-36* AnGap-11 [**2118-8-20**] 07:45AM BLOOD Glucose-157* UreaN-22* Creat-1.0 Na-145 K-4.3 Cl-103 HCO3-34* AnGap-12 . #MICROBIOLOGY: [][**2118-8-20**] 12:47 pm SWAB Source: posterior neck. GRAM STAIN (Final [**2118-8-20**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2118-8-23**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH. ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. . #RADIOLOGY: []CHEST (PA & LAT) Study Date of [**2118-8-20**] 11:50 AM IMPRESSION: When compared to prior study, [**8-10**], there has been interval increase in pleural effusions, mainly on the left. Brief Hospital Course: []BRIEF CLINICAL COURSE: 70 year old male with CAD s/p CABG (SVG-OM, LIMA-LAD) in [**2093**] and multiple subsequent NSTEMIs and PCIs (most recently a BMS to SVG-OM [**2118-3-31**]), CHF (EF 40-45%), HTN, HLD, paroxysmal Afib (not on coumadin), DM, COPD, OSA, prior CVA, and recent significant GIB ([**4-/2118**]), recently admitted in early [**Month (only) **] s/p fall with c6 fracture and surgical repair, c/f NSTEMI, now with 5 second pause on tele at rehab post d/c, admitted for possible pacemaker placement. . []ACTIVE ISSUES: . # Sinus Arrythmia: Patient was recently discharged from [**Hospital1 18**] to [**Hospital **] rehab. At rehab on [**2118-8-17**], the patient had a 5 second pause on telemetry that coincided with a syncopal event. He was sent to [**Hospital6 33**] for further workup. No pauses were seen on tele there. The patient was transferred to [**Hospital1 18**] for further workup and eval for placement of pacemaker. EP was consulted upon arrival of the patient; they reviewed OSH tracings and EKGs. According to EP, there was no indication for pacemaker placement if the patient's symptoms were related to taking too high a dose of metoprolol. We decreased his home dose of 200mg toprol XL to 50mg PO BID and the patient was asymptomatic throughout the remainder of this hospitalization. . # Acute on chronic CHF (EF 40-45%): Patient is clinically volume overloaded. Was aggressively diuresed during recent admission. Patient also has pleural effusions. The patient was switched from 40mg PO lasix daily to PO torsemide 80mg Qday. His net diuresis was between 500cc-1500cc per day. We trended his creatinine daily and at the time of discharge his creatinine 1.2, near his baseline. . # NSTEMI: Multiple document NSTEMI's in past, most recently on [**2118-8-5**] s/p C6-T1 laminectomy on [**2118-8-4**]. At OSH, trops elevated [**2118-8-15**] 0.66 then 0.56. Baseline Cardiac enzymes on admission trop 0.46 and CKMB 3. We decided not to continue trending troponins given that the CKMB was continuing to downtrend. We monitored the patient on telemetry and obtained serial EKGs that did not reveal any new pathology. We continued the patient on a lower dose of his metoprolol. . # Cervical spine drainage: The patient presented with posterior neck surgical site drainage, c/f ongoing dehiscence, seen by ortho spine. They cleaned the wound and put in their recommendations for nursing staff to continue. The patient has follow up in the Spine Center. . # OSA: The patient was continued on CPAP at night, with oxygen saturations >95%. . []TRANSITIONAL ISSUES: -patient will likely require home O2 for symptomatic control of dyspnea -patient will need to have his posterior cervical neck surgical site monitored for continued wound dehiscence. He has follow up scheduled with the Spine Center. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientAtrius transfer records. 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Bisacodyl 10 mg PR DAILY:PRN constipation 3. Lorazepam 0.5 mg PO Q8H:PRN anxiety 4. Nitroglycerin Ointment 2% 0.5 in TP Q6H 5. Nitroglycerin SL 0.4 mg SL PRN chest pain 6. Sorbitol 30 mL PO QHS: PRN constipation 7. Amitriptyline 25 mg PO HS 8. Aspirin 325 mg PO DAILY 9. Atorvastatin 80 mg PO HS 10. Cephalexin 500 mg PO Q6H 11. Clopidogrel 75 mg PO DAILY 12. Docusate Sodium 100 mg PO BID 13. Furosemide 40 mg PO DAILY 14. Heparin 5000 UNIT SC TID 15. Glargine 30 Units Bedtime 16. Isosorbide Mononitrate (Extended Release) 180 mg PO DAILY 17. Lisinopril 5 mg PO DAILY 18. Levofloxacin 500 mg IV Q24H 19. Metoprolol Succinate XL 200 mg PO DAILY 20. Multivitamins 1 TAB PO DAILY 21. Pantoprazole 40 mg PO Q24H 22. Polyethylene Glycol 17 g PO DAILY:PRN constipation 23. ranolazine *NF* 1,000 mg Oral [**Hospital1 **] 24. Senna 1 TAB PO HS:PRN constipation 25. Tamsulosin 0.4 mg PO HS 26. Venlafaxine XR 75 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Amitriptyline 25 mg PO HS 3. Aspirin 325 mg PO DAILY 4. Atorvastatin 80 mg PO HS 5. Bisacodyl 10 mg PR DAILY:PRN constipation 6. Clopidogrel 75 mg PO DAILY 7. Docusate Sodium 100 mg PO BID 8. Glargine 30 Units Bedtime 9. Isosorbide Mononitrate (Extended Release) 180 mg PO DAILY 10. Lisinopril 5 mg PO DAILY 11. Multivitamins 1 TAB PO DAILY 12. Nitroglycerin SL 0.4 mg SL PRN chest pain 13. Pantoprazole 40 mg PO Q24H 14. Polyethylene Glycol 17 g PO DAILY:PRN constipation 15. ranolazine *NF* 1,000 mg Oral [**Hospital1 **] 16. Senna 1 TAB PO HS:PRN constipation 17. Tamsulosin 0.4 mg PO HS 18. Venlafaxine XR 75 mg PO DAILY 19. Outpatient [**Hospital1 **] Work Please check AST, ALT, Alk Phos, Total Bili on [**2118-8-29**] and fax results to Attn: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Hospital **] Clinic Fax: [**Telephone/Fax (1) 1419**] 20. Metoprolol Tartrate 25 mg PO BID hold for SBP < 100 or HR < 60 and page H.O. if holding RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice daily [**Telephone/Fax (1) **] #*60 Tablet Refills:*0 21. Torsemide 80 mg PO DAILY Hold for SBP < 100 RX *torsemide 20 mg 4 tablet(s) by mouth daily [**Telephone/Fax (1) **] #*120 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: sinus pause acute on chronic systolic congestive heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure taking care of you. You were admitted to the [**Hospital1 69**] after you had some abnormal heart rhythms that caused you to feel faint. Because of this, we decreased the medicine that slows down your heart rate (metoprolol) and gave you some medication to take off some fluid to improve your breathing. You will go back to rehab to continue your progress. You will follow up with your outpatient cardiologist Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Department: CARDIAC SERVICES When: WEDNESDAY [**2118-8-31**] at 11:40 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: WEDNESDAY [**2118-8-31**] at 12:40 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: SPINE CENTER When: WEDNESDAY [**2118-8-31**] at 1 PM With: [**First Name4 (NamePattern1) 1141**] [**Last Name (NamePattern1) 4983**], NP [**Telephone/Fax (1) 8603**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 2073**]

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32679

Discharge summary

report

Admission Date: [**2133-7-22**] Discharge Date: [**2133-7-31**] Date of Birth: [**2111-10-1**] Sex: M Service: MEDICINE Allergies: Pollen Extracts / Cat Hair Std Extract / Banana / Mold Extracts / Grass Pollen-Bermuda, Standard / vancomycin Attending:[**First Name3 (LF) 2181**] Chief Complaint: polymicrobial sepsis Major Surgical or Invasive Procedure: TEE Central Line Placement PICC Line Removal Transesophageal Echocardiogram Turning off and on Deep Brain Stimulators History of Present Illness: 21yoM with polysubstance abuse, depression, multiple sclerosis with deep brain stimulator placed at [**Hospital1 18**] 2208 for severe dystonia presenting for fever and hypotension. Regarding his DBS, the patient had a prior left sided lead fracture is s/p revision. On [**2133-6-15**], he presented for bilateral battery replacement for low voltage and subsequently had his sutures removed by his PCP. [**Name10 (NameIs) **] returned for a wound check on [**7-3**] and was found to have a left sided wound infection, and was admitted for a removal and washout of the distal left IPG and connecting wire on [**7-5**]. The left sided electrode was left in place. He was discharged on Nafcillin and Keflex, which was completed [**7-21**] and was to transition to po antibiotics subsequently. The patient gives a limited history but per his mother, the patient was in good health until [**Month/Day (4) 766**] [**7-20**], when he was found to have an infected left PICC which was removed. He had a PIV placed in his right arm which became significantly swollen and erythematous per his mother. The IV was removed on [**7-21**] and a right PICC was placed in the same arm at that time, which was reportedly difficult to place due to the swelling in his arm. The patient's mother reports that the patient began having fevers to 106.5 and rigors later that day and she called his ID fellow, Dr. [**Last Name (STitle) 6137**]. She then brought the patient to [**Hospital 41128**] Hospital in [**State 1727**]. The patient denies other complaints including headache, vision changes, cough, nausea/vomiting, abdominal pain, diarrhea, rash, myalgias or arthralgias. The patient denies swelling or pain at his right and left DBS incision sites. At [**Hospital 41128**] Hospital, the patient was found to be hypotensive despite 3L IVF and Neosynephrine, and he was started on Levophed. Cultures were drawn and he was given Vanc, Zosyn, and Ceftriaxone. He was transferred to [**Hospital1 18**] for further evaluation. In the [**Hospital1 18**] ED, initial VS: 100.4, 86, 65/47, 19, 99% on 2L The patient was A&Ox3. Neurosurgery was consulted, and felt the wound site was unconcerning and recommended obtaining head CT with and without contrast to r/o infection. Blood and urine cultures were drawn and CXR was obtained, and femoral CVL was placed. He received a total of 8L NS and was on Levophed 0.15 mcg/kg/hr with SBP 110's. He spiked to 102.3 while in the ED and was given Tylenol. Transfer VS: 111, 23, 126/66, Levo at 0.12, 96% RA. In the MICU, the patient denied any symptoms including headache, n/v, abdominal change, or pain different from his typical chronic total body pain. Past Medical History: bilateral deep brain stimulators placed [**6-/2130**], revised in [**2130-11-15**] as a lead fracture was found s/p recent battery replacement in early [**2133-6-14**] s/p Botox injections for cervical dystonia anxiety depression s/p sepsis from [**Female First Name (un) 564**] and Bacillus Social History: Tobacco: Recent smoking [**2-15**] cigarettes/day, reports quit 2 weeks ago. - EtOH: Drinks 2 alcoholic drinks weekly. - Illicit Drugs: Marijuana several times weekly, h/o polysubstance abuse including prescription medications. Denies recent IVDU or intranasal drug use. Functional at baseline, currently lives by with his mother at home. He finished high school but is not currently working, on disability. Divorced. He has been arrested twice including a charge of hit and run with possession of prescription drugs. His licence was previously taken away for several MVAs. Family History: - 2 maternal uncles with cerebral palsy - 3 cousins that have now been diagnosed with DYT1 dystonia Physical Exam: (per admitting resident) GEN: Pleasant, comfortable, well-appearing, NAD HEENT: PERRL, sclera anicteric, MMM, op unable to be clearly visualized [**3-18**] poor patient cooperation RESP: CTAB with good air movement throughout, no wheezes/rales/rhonchi CV: RRR, S1 and S2 wnl, split S2, no m/r/g ABD: Soft, minimal left sided diffuse tenderness, non-distended, +BS, no masses or hepatosplenomegaly appreciated EXT: No c/c/e, 2+ DP pulses b/l SKIN: No rashes/no jaundice/no splinters NEURO: AAOx3. Deferred for now. Pertinent Results: Admission Labs: [**2133-7-22**] 12:55AM WBC-6.0 RBC-3.55* HGB-10.4* HCT-30.2* MCV-85 MCH-29.3 MCHC-34.5 RDW-14.1 [**2133-7-22**] 12:55AM NEUTS-84* BANDS-5 LYMPHS-6* MONOS-3 EOS-1 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [**2133-7-22**] 12:55AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2133-7-22**] 12:55AM PT-17.7* PTT-33.8 INR(PT)-1.6* [**2133-7-22**] 12:55AM PLT COUNT-110* [**2133-7-22**] 12:55AM URINE COLOR-AMBER APPEAR-Hazy SP [**Last Name (un) 155**]-1.011 [**2133-7-22**] 12:55AM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2133-7-22**] 12:55AM URINE RBC-5* WBC-43* BACTERIA-FEW YEAST-NONE EPI-0 TRANS EPI-2 [**2133-7-22**] 12:55AM CALCIUM-6.7* PHOSPHATE-2.5* MAGNESIUM-1.5* [**2133-7-22**] 12:55AM ALT(SGPT)-35 AST(SGOT)-78* [**2133-7-22**] 12:55AM UREA N-21* CREAT-2.1* [**2133-7-22**] 01:00AM GLUCOSE-129* LACTATE-3.0* NA+-135 K+-3.8 CL--107 [**2133-7-22**] 10:15AM ALBUMIN-3.0* CALCIUM-7.7* PHOSPHATE-4.3# MAGNESIUM-1.6 [**2133-7-22**] 10:15AM GGT-185* [**2133-7-22**] 10:15AM ALT(SGPT)-34 AST(SGOT)-53* LD(LDH)-262* ALK PHOS-343* TOT BILI-0.9 [**2133-7-22**] 10:15AM GLUCOSE-101* UREA N-19 CREAT-1.9* SODIUM-140 POTASSIUM-4.2 CHLORIDE-111* TOTAL CO2-19* ANION GAP-14 Microbiology: [**2133-7-22**] Blood Culture, Routine (Preliminary): [**Female First Name (un) **] ALBICANS. [**2133-7-22**] IV catheter tip: No significant growth. [**7-23**] - [**2133-7-25**] blood cultures: NTD Imaging: [**2133-7-24**]: TEE No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 40 cm from the incisors. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mass or vegetation is seen on the mitral valve. No mitral regurgitation is seen. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: No valvular vegetations or abscesses seen [**2133-7-24**]: MRI head 1. No evidence of fluid collection, abscess, or infection. 2. Unchanged appearance of DBS leads, with lacune in putamen, caudate, and anterior limb of internal capsule on the left. 3. Small amount of fluid in the left mastoid air cells and petrous apex. [**2133-7-22**]: CT chest 1. Multifocal pneumonia involving the right left upper and lower lobes with bilateral simple-appearing right greater than left pleural effusions. 2. No evidence of perforation. 3. Splenomegaly [**2133-7-22**]: RUE U/S No drainable fluid collections in the evaluated right upper extremity and in the right chest wall in the region of the PICC line Brief Hospital Course: Mr. [**Known lastname 4587**] is a 21-year-old male with PMH of depression, substance abuse, and DYT1 genetic dystonia, with a deep brain pallidal stimulator (DBS) placed at [**Hospital1 18**] [**2130**], who was admitted to the [**Hospital1 18**] ICU on [**2133-7-22**] from an OSH in [**State 1727**] with sepsis and positive OSH blood cultures from [**2133-7-21**] growing C. albicans and Clostridial species. Prior to this admission, he was admitted to the OSH from [**Date range (1) 76141**] with a pocket infection of his infraclavicular L DBS battery. The battery was removed, but the wire tracking to his brain was left in place given the high risk of removal. He was discharged on a two week course of nafcillin with a PICC line in place, which ultimately became blocked. He was readmitted to the OSH on [**7-13**], where PICC line placement was attempted once again. On discharge, he then developed asymptomatic low grade temperatures of 101 for three days, and on [**7-17**] developed a fever of 103. . On [**2133-7-21**], Mr. [**Known lastname 4587**] had finished the course of nafcillin, but developed fever to 105.5 and was taken to ED in [**State 1727**], where he was found to be febrile to 106 with rigors. Once cultures were drawn, he was given Vancomycin, Zosyn, and CTX and sent to [**Hospital1 18**] for further management. . 1. Polymicrobial Sepsis: Patient present with fever to 106, hypotension and blood cultures positive for GPR ([**2133-7-21**]) and C. albicans ([**2133-7-22**]). Source of polymicrobial infection was uncertain, but most likely etiology was felt to be the PICC line placed for treatment of MSSA battery pocket infection. Full infectious work-up, including CT/ MRI head, TTE and TEE, RUE U/S, ophthalmologic exam, urinalysis showed no nidus of infection or evidence of septic emboli. Both his right PICC line and femoral line (placed in the ED for volume resuscitation) showed cultures with no significant growth. His chest CT was notable for question of multifocal pneumonia vs volume overload in setting of aggressive fluid resuscitation. After initial volume resuscitation, patient remained hemodynamically stable, with no pressor requirements. Daily surveillance blood cultures remained negative. Infectious disease followed Mr. [**Known lastname 17365**] hospital course and guided antibiotic therapy. . Upon transfer out of the MICU, Mr. [**Known lastname 4587**] was initially started on PCN 4 Million Units IV Q4H, Linezolid 600 mg PO Q12, and Micafungin 100 mg IV Q24H on [**2133-7-22**]. When cultures speciated showing C. albicans, he began therapy with Fluconazole 400 mg Q24h on [**2133-7-26**] and will be continuing this regimen until [**2133-8-19**] for a four week total course. The GPR initially showed resistance to PCN, which was thereby discontinued. As per ID recommendations, he will continue a two week course of linezolid on the same dose until [**2133-8-5**]. Repeat chest x-ray on [**2133-7-27**] showed resolution of the bilateral pulmonary opacities seen on admission. He remained hemodynamically stable and afebrile throughout his post-MICU course until discharge. . 2. DYT1 generalized dystonia s/p bilateral DBS: History of generalized dystonia secondary to DYT1 genotype. Symptoms have been poorly managed despite maximal medical therapy and bilateral deep brain stimulator placement. Of note, patient had recently been admitted for MSSA battery pocket infection s/p naficillin. CT head and subsequent MRI showed no evidence of infection. Neurology was also consulted for management of movement disorder and recommended continued treatment with artane, ativan and oxycodone. Increased severity of symptoms and pain noted by Neurology following removal of the L DBS battery after infection. Further plans for possible L IPG revision after clearing of infection to be discussed with Neurosurgery. . 3. Acute Renal Failure: In the MICU, patient was admitted with creatinine of 2.1 up from his baseline of 1.0, likely secondary to hypoperfusion from sepsis. With volume resuscitation and treatment of sepsis, Cr improved to 0.8 and remained stable throughout the rest of his hospital course. . 4. Bradycardia: Following intial resolution of sepsis with tachycardia, the patient was notably bradycardiac, with HR dropping to 40 - 50s. He denied SOB, chest pain, or complaints of dizziness and remained asymptomatic through this episode. His DBS was shut off, and EKG showed sinus pause with no evidence of heart block. Rarely implantation of DBS has been associated with vagal nerve stimulation and bradycardia, but his is a pallidal stimulator, making that a very rare potential cause. Patient remained asymptomatic, with HR ranging from 40-50 while on the Medicine service, which did not warrant additional workup. He was regularly monitored, but did not require placement on telemetry since transfer out of the MICU. . 5. Elevated LFTs: Mildly abnormal LFTs (ALT 34, AST 53, LDH 262, AlkPhos 343, Tbili 0.9) observed on ICU admission, which was thought to be in the setting of sepsis and hypoperfusion. Resolved during his hospital course. Medications on Admission: - Lorazepam 2 mg q4h prn anxiety, discomfort - Percocet [**2-15**] tablet q4h prn pain - Trihexyphenidyl 3 mg po bid (patient reports he was not taking at home) Meds on transfer: - Levophed gtt - Vancomycin 1gm x1 - Ceftriaxone 2gm x1 - Zosyn 3.375gm x1 Discharge Medications: 1. linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 6 days: Last day of Linezolid on [**2133-8-5**]. Disp:*12 Tablet(s)* Refills:*0* 2. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO once a day for 20 days. Disp:*40 Tablet(s)* Refills:*0* 3. lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for per home regimen for dystonia. 4. trihexyphenidyl 2 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 5. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every six (6) hours as needed for pain. 6. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 20 days: 45 minutes before taking fluconazole as needed for nausea. Disp:*20 Tablet(s)* Refills:*0* 7. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) for 14 days. Disp:*qs 14 days* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1) Septick Shock 2) Fungemia due to [**Female First Name (un) 564**] Albicans 3) Bacteremia due to Bacillus species 4) Congenital Dystonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 4587**], you were admitted to the [**Hospital1 **] ICU with a severe infection ultimately found to be both a bacteria and a fungus which we think came from your prior PICC line. You were given a large amount of IV fluids initially as well as medications to support your blood pressure. You were also given antibiotics and antifungal medications and the infectious disease service saw you in consult to help with your infection management. The neurology and neurosurical services also saw you to help with the management of your dystonia and to evaluate if your deep brain stimulators were infected. An MRI of your head showed no infection of your deep brain stimulators and a CT scan of your abdomen showed no infection there. You received an ultra-sound of your heart to make sure your hear valves were not infected. You improved with the above treatments and were ultimately transitioned to oral antibiotics for your infection. When you blood counts normalized you were deemed safe to send home to complete your antibiotic pills as an outpatient. The following changes were made to your medications: 1) Start Linezolid 600mg by mouth twice each day for 6 more days (finish on the evening of [**2133-8-5**]) 2) start Fluconazole 400mg by mouth once each day for 20 more days )finish on the evening of [**2133-8-19**]) 3) Continue your other home medications You should follow-up with your PCP and Infectious Disease as noted below. Since you will be on new antibiotics, please be aware for any symptoms of a drug reaction (rash, itching, fevers, swelling of face or hands). Your PCP with check your blood count in [**3-19**] weeks (CBC with differential) to evaluate for this (increased numbers of cells called eosinophils) as well as persistance of "band" forms. If these persist you may benefit from an outpaitent visit with a hematologist. Your PCP should also perform an imaging test to evaluate your spleen in [**3-19**] months beacuse it was noted to be enlarge on the CT scans from this admission. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] F Location: [**State **] [**University/College **] FAMILY PRACTICE Address: 4 [**Location (un) **] DR, [**Location (un) **],[**Numeric Identifier 76142**] Phone: [**Telephone/Fax (1) 76143**] When: [**Last Name (LF) 766**], [**8-3**], 2:55PM Department: INFECTIOUS DISEASE When: [**First Name3 (LF) **] [**2133-8-10**] at 9:30 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: INFECTIOUS DISEASE When: [**Hospital Ward Name **] [**2133-9-14**] at 10:30 AM With: [**First Name4 (NamePattern1) 2482**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

14164, 14170

7851, 12981

391, 511

14372, 14372

4821, 4821

16577, 17522

4169, 4271

13287, 14141

14191, 14191

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3259, 3553

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13187, 13264

68,457

164,074

51427

Discharge summary

report

Admission Date: [**2129-7-27**] Discharge Date: [**2129-8-4**] Date of Birth: [**2062-6-28**] Sex: F Service: CARDIOTHORACIC Allergies: Aspirin / Compazine Attending:[**First Name3 (LF) 165**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2129-7-27**] Coronary artery bypass graft x3: Left internal mammary artery to left anterior descending artery and saphenous vein sequential grafting to obtuse marginal 1 and 2 History of Present Illness: This 66 year old black with a complicated medical history was initially evaluated by Dr. [**First Name (STitle) **] in [**2129-3-21**] at which time cardiac catheterization revealed severe two vessel disease. She was in rehabilitation at the time and very deconditioned. It was decided to optimize medical management. She susequently returned following discharge from rehab, reporting improved strength. She is walking with a walker, and experiences dyspnea on exertion, but as had no further chest pain. She saw Dr. [**Last Name (STitle) **] last week, who believes the patient is ready for surgery now. Past Medical History: Coronary Artery Disease s/p Cerebrovascular accident with L hemiparesis noninsulin dependent Diabetes mellitus Chronic renal insufficiency with microalbuminuria Hyperlipidemia Hypertension Asthma Morbid obesity s/p Bilateral carpal tunnel release Social History: Race: black Last Dental Exam: Lives with: alone Occupation: nurse Tobacco: none ETOH: none Family History: mother with DM Physical Exam: admission: Pulse: 66 Resp: 16 O2 sat: 100%RA B/P Right: 170/64 Left: Height: Weight: General: Skin: Dry [x] intact [x] no rash HEENT: PERRLA [] 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] obese Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [] trace edema bilateral LEs, no varicosities Neuro: Grossly intact x Pulses: Femoral Right: 1+ Left: 1+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: NP Left: NP Radial Right: 2+ Left: 2+ Carotid Bruit Right: Left: no bruits Pertinent Results: [**2129-7-27**] Echo: PRE-BYPASS: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are focal calcifications in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. There is no pericardial effusion. Dr. [**First Name (STitle) **] was notified in person of the results on [**Known firstname 1743**] [**Known lastname **] before surgical incision POST-BYPASS: Preserved biventricular systolic function. LVEF 55%. Intact thoracic aorta. Rest of the findings similar to prebypass. [**2129-8-3**] 04:42AM BLOOD WBC-9.8 RBC-3.16* Hgb-9.9* Hct-28.0* MCV-89 MCH-31.3 MCHC-35.3* RDW-15.5 Plt Ct-196 [**2129-7-29**] 04:26AM BLOOD WBC-10.6 RBC-3.31* Hgb-10.0* Hct-29.0* MCV-88 MCH-30.3 MCHC-34.6 RDW-16.5* Plt Ct-110* [**2129-8-4**] 04:59AM BLOOD UreaN-64* Creat-2.9* Na-141 K-3.5 Cl-101 [**2129-8-3**] 04:42AM BLOOD Glucose-155* UreaN-65* Creat-2.8* Na-139 K-4.0 Cl-100 HCO3-24 AnGap-19 [**2129-7-31**] 08:32PM BLOOD Glucose-149* UreaN-60* Creat-3.1* Na-135 K-4.2 Cl-100 HCO3-22 AnGap-17 [**2129-7-26**] 12:22PM BLOOD Glucose-113* UreaN-42* Creat-1.5* Na-142 K-4.6 Cl-102 HCO3-27 AnGap-18 Brief Hospital Course: Mrs. [**Known lastname **] was a same day admit after undergoing all pre-operative work-up as an outpatient. On [**7-27**] she was brought to the Operating Room where she underwent a coronary artery bypass graft x 3. Please see operative report for surgical details. Following surgery she was transferred to the CVICU for invasive monitoring in stable condition. She was extubated on post-op day 2. Beta-blockers and diuretics were initiated and she was diuresed towards her pre-op weight. Chest tubes and epicardial pacing wires were removed per protocol. Nephrology was consulted on post-op day four for acute on chronic renal failure (diuretics were discontinued) as the creatinine rose from 1.5 baseline to 3.1. She was followed by Dr. [**First Name (STitle) 805**] (nephrology). She remained in the CVICU until post-op day six when she was transferred to the telemetry floor for further care. She developed urinary tract infection symptoms which were treated with Cipro. Appointments were scheduled for cardiology, renal, and cardiac surgery after discharge. The creatinine on the day of discharge was stable at 2.9. It is felt that this will improve somewhat over time. She was cleared for discharge to rehab on POD #8. She will have twice weekly labs drawn to follow her renal insufficiency. Glucose has been under good control and finger sticks have required rare coverage with sliding scale Humalog insulin. If her glucose were to become frequently elevated above 140 as her intake improves, sliding scale coverage would be indicated. Wounds were clean and healing well at discharge. She remained about 4 kilograms above her preoperative weight, but diuretics have been on hold due to her renal dysfunction. She has had good urine output and weight decreases without treatment.There remains some peripheral edema that should resolve with increased activity and autodiuresis. Medications on Admission: amlodipine 10mg daily plavix 75mg daily furosemide 80mg daily gabapentin 300mg daily insulin- lantus insulin- lispro (humalog) lidoderm 5% (700mg/patch) 12h on, 12h off nebivolol 20mg daily actos 15mg daily ramipril 5mg qam, 10mg qpm ranitidine 150mg daily crestor 40mg daily januvia 50mg daily tramadol 50mg prn trazodone 25mg hs prn colace 100mg daily Discharge Medications: 1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for back pain. 6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units SC Injection TID (3 times a day). 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 9. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-22**] Spray(s) NU Nasal Q 8H (Every 8 Hours). 10. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen (17) gram/dose powder PO DAILY (Daily). 11. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO three times a day. 12. Rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime. 13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days: last dose 7/16. 14. 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. 15. Outpatient Lab Work please follow BUN/creatinine/K+; first draw Monday [**8-9**]; labs should be drawn twice a week with results to be called to 16. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever or pain. 17. Bisacodyl 5 mg Tablet Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 18. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO three times a day. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3 s/p Cerebrovascular accident with L hemiparesis noninsulin dependent Diabetes mellitus Chronic renal insufficiency with microalbuminuria Hyperlipidemia Hypertension Asthma Morbid obesity s/p Bilateral carpal tunnel release Discharge Condition: Alert and oriented x3, nonfocal Does not ambulate; goal is to baseline walking with cane Moves with 2 person assist Incisional pain managed with tramadol Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema- BLE [**1-22**]+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 170**]) on Monday, [**9-5**] @ 2:15 PM [**Hospital Ward Name **] 2A Please call to schedule appointments with: Primary Care: Dr. [**Last Name (STitle) **] [**Doctor Last Name 43476**] ([**Telephone/Fax (1) 106636**]) in [**1-22**] weeks after discharge from rehab Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) 2053**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 2052**],([**Telephone/Fax (1) 62**]) after discharge from rehab Date/Time:[**2129-8-22**] @ 2:40 Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 815**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2129-8-24**] 2:10 Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**] (renal) [**Hospital **] Clinic [**Telephone/Fax (1) 3637**] **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:[**2129-8-4**]

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icd9cm

[ [ [] ] ]

[ "96.71", "39.61", "36.12", "38.93", "36.15" ]

icd9pcs

[ [ [] ] ]

8037, 8108

3970, 5865

304, 484

8436, 8732

2245, 3947

9570, 10734

1512, 1528

6269, 8014

8129, 8415

5891, 6246

8756, 9547

1543, 2226

245, 266

512, 1118

1140, 1388

1404, 1496

13,183

149,652

20078

Discharge summary

report

Admission Date: [**2116-1-14**] Discharge Date: [**2116-2-12**] Date of Birth: [**2048-7-14**] Sex: M Service: MEDICINE Allergies: Amoxicillin / Bactrim Attending:[**First Name3 (LF) 5552**] Chief Complaint: fever, vomiting, weakness, dyspnea Major Surgical or Invasive Procedure: Endotracheal Intubation History of Present Illness: 67yo man with h/o esoph CA dx'd [**6-29**] on endoscopy after he presented with dysphagia and hematemesis, s/p chemo and XRT in [**8-5**], s/p esophagectomy [**2115-11-14**], with recovery c/b poor nutrition requiring G-tube placement, who was doing well until 4d PTA when he began to have fevers and dyspnea. He developed a productive cough with greenish sputum 3d PTA, then began vomiting 1d PTA with his wife noticing [**Name2 (NI) **] streaks in his mucus. When the streaking became worse on the AM of admit, the patient's wife brought him into the [**Name (NI) **] for evaluation. [**Name (NI) **] wife reports recent URI and feels that the patient may have caught her illness. In ED, CXR showed RML and RLL infiltrates with persistant small bilateral pleural effusions. The patient was given 2L of normal saline, as well as Azithromycin and Levaquin, and then transferred to the floor. Past Medical History: Stage IIA Esophageal AdenoCA, T3N0M0 (PET positive) Status-post MVR and CABG x 3 (LIMA to LAD, SVG to OM, SVG to PDA) on [**2114-11-23**] Status-post J-tube and portacath placement [**7-30**] Hypertension Status-post pace-maker/defibrillator implantation on [**2115-2-27**] Heartburn x 20 years Atrial Fibrillation Hypothyroidism Social History: The patient is married and lives in [**Location 5110**], MA. He has three children and is a former engineer. He has never smoked and denies ever drinking alcohol. He does not use recreational drugs. Family History: Denies any h/o cancer, CAD. Parents died when he was young, unsure of causes. Physical Exam: Vitals: 97.5 116/64 88 28 66% on RA with HOB at 10 deg, 100% on NRB with HOB at 30 deg Gen: thin, elderly asian man appearing older than stated age, in moderate to severe resp distress, with accessory muscle use, unable to speak except in one word sentences HEENT: PERRL, EOMI, anicteric sclera, MMM Skin: warm and dry Chest: diffuse rales throughout, decreased bs in R lower [**12-29**], no apparent wheezing or rhonchi CV: tachy, regular, soft s1 loud s2 click, [**2-2**] syst murmur at apex, rads to abd Abd: soft, PEJ tube in place, nt/nd, +bs Ext: no c/c/e, no peripheral edema Pertinent Results: [**2116-1-14**] Chest PA and Lat: Comparison with [**2115-12-12**]. The [**Year (4 digits) **] electrodes are unchanged. Median sternotomy wires and clips and replacement valve are unchanged. Stable cardiac and mediastinal contours. There is a stable left pleural effusion. There is probably also a small right effusion, stable. There is a new air space opacity in the right lower lobe and possibly right middle lobe. No pneumothorax. There is also probably atelectasis in the left retrocardiac region. The left subclavian central venous catheter remains unchanged. Labs on Admission: [**2116-1-14**] 10:06PM URINE HOURS-RANDOM CREAT-17 SODIUM-53 [**2116-1-14**] 10:06PM URINE OSMOLAL-319 [**2116-1-14**] 10:06PM URINE [**Month/Day/Year 3143**]-LGE NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2116-1-14**] 10:06PM URINE RBC-195* WBC-0 BACTERIA-NONE YEAST-NONE EPI-<1 [**2116-1-14**] 07:04PM GLUCOSE-118* UREA N-24* CREAT-0.7 SODIUM-120* POTASSIUM-3.4 CHLORIDE-86* TOTAL CO2-28 ANION GAP-9 [**2116-1-14**] 07:04PM CALCIUM-7.7* PHOSPHATE-4.5# MAGNESIUM-1.8 [**2116-1-14**] 07:04PM TSH-0.55 [**2116-1-14**] 07:04PM WBC-8.8 RBC-3.13* HGB-9.6* HCT-28.5* MCV-91 MCH-30.5 MCHC-33.5 RDW-16.6* [**2116-1-14**] 07:04PM PLT COUNT-171 [**2116-1-14**] 12:01PM LACTATE-1.4 [**2116-1-14**] 11:30AM GLUCOSE-111* UREA N-25* CREAT-0.6 SODIUM-118* POTASSIUM-3.7 CHLORIDE-88* TOTAL CO2-29 ANION GAP-5* [**2116-1-14**] 11:30AM CALCIUM-8.1* PHOSPHATE-2.9 MAGNESIUM-1.2* Brief Hospital Course: 1. Hypoxia/resp distress: [**1-29**] R sided PNA, flu, ?UIP and CHF. Presently not felt to be related to heart failure as echo with no change in LV function and no evidence of pulm HTN. Creatinine and BUN rising so aggressive diuresis aborted. Feel that underlying respiratory distress may be related to interstitial pneumonitis. He initially presented on the floor, but subsequent respiratory distress necessitated transfer to the [**Hospital Unit Name 153**]. His respiratory distress was thought to be multifactorial; due to CHF (he was in afib, likely volume overloaded), influenza (tested positiv from nasal aspirate), ?pneumonia, and his underlying lung disease. Although he has never had a lung biopsy, he has been radiographically diagnosed with UIP. Pulmonary followed him while in-house. They felt that the differential for his interstitial lung disease was UIP, amiodarone toxicity, and BOOP. They recommended high dose steroids to be continued for a month (prednisone 60 mg). This will then be tapered, and he will follow up in pulmonary clinic. He was diuresed in the unit, started on broad spectrum antibiotics, and given supportive care. His empiric ceftriaxone/flagyl was stopped on [**2116-1-30**]. Follow up CT scan showed improvement in the ground glass appearance, and he remained afebrile and without leukocytosis. He was also paced out of his afib/aflutter by electrophysiology. The irregular rhythm had probably been contributing to his CHF and volume overload. He remained in normal sinus rhythm after this intervention and had not more problems with volume overload. He was kept even with respect to Ins and Outs. When clinically stable, he was transferred back to the floor where he remained afebrile, was saturating stably on 2 L NC. He did not require more aggressive ventilation. He was saturating well on room air at time of discharge. He will continue 60 mg Prednisone daily until the beginning of [**Month (only) 958**] when he will follow up with Pulmonary clinic (steroids will likely be tapered at this time). He will also need to follow up with Dr. [**Last Name (STitle) **] after leaving rehabilitataion. In terms of volume status, he should still be kept even with respect to his Ins/Outs, for he gets volume overloaded very easily. 2. Esophageal Cancer (T3N0M0): He is s/p chemotherapy and radiation in [**6-29**] followed by esophagectomy in [**10-30**]. His recovery has been complicated by issues of nutrition. Postoperatively, he had a J-tube placed to aid with nutrition, and he has not been able to take PO's safely (has failed multiple speech and swallow evaluations). He failed video swallowing study repeatedly on this admission. He likley needs to regain more strength and then retry this study in a few weeks. He should be maintained solely on J-tube feeds until that time. 3. Hypernatremia-He had some hypernatremia while in the [**Hospital Unit Name 153**] which responded to free water boluses. He remained clinically euvolemic with normal sodium subsequently. 4. CV a) Ischemia: he had a small troponin leak while in the unit, likely demand related. Beta blocker, statin, and ace were started. He was discharged on a regimen of Toprol, Lisinopril, and Digoxin. He will follow up with Dr. [**Last Name (STitle) 284**]. b)Pump: EF 30%, MVR. He was aggressively diuresed in the unit (component of volume overload likely contributing to his respiratory distress and requiring [**Hospital Unit Name 153**] stay). Upon returning to the floor, he was kept even with respect to Ins/Outs and had no further problems with volume overload. c) Valve: S/p MVR: He was kept appropriately anticoagulated on heparin and coumadin as necessary while in-house and discharged on coumadin. He will need to have his [**Hospital Unit Name 263**] checked twice a week (goal [**Hospital Unit Name 263**] 2.5-3.5), and his coumadin dose may need to be adjusted accordingly based on these results. d) Rhythm: s/p [**Hospital Unit Name **] + ICD/h/o afib- on coumadin. Required cardioversion initially in hospitalization and was paced out of afib [**1-31**]. He remained in NSR throughout the remainder of his hospitalization. 5. Anemia: He had somewhat stable Hct in the range of 26-30; anemia was likely multifactorial (anemia of chronic disease). He was transfused as necessary for a HCT<26. 6. Hypothyroidism: He was continued on levoxyl throughout his hospitalization. 7. Diabetes: He was continued on 40 U lantus and covered with sliding scale insulin while in-house. His sugars remained under good control with this regimen. 8. FEN, s/p Esophagectomy: he was continued on tube feeds via his J-tube. He failed speech and swallow evaluations on multiple occasions, and had a video swallowing study on [**2116-2-7**] where he failed thin and nectar thick liquids (frank aspiration noted with inappropriate coughing/clearing reflex). 9. Disposition: He was quite physically debilitated at the conclusion of his hospitalization, and he required rehabilitation where aggressive physical therapy and occupational therapy can be continued. Medications on Admission: (Per wife's report) Coumadin 2mg qThFrSaSu, 1.5mg qMoTuWe Levothyroxine 100mcg po qd Amiodarone 200mg po bid Zocor 10mg po qd Impact w/Fiber tube feeds, at 90cc/hr until this weekend, then 70cc/hr *** No longer taking Lasix since his immediate post-op period in [**10-30**] Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levothyroxine Sodium 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Ipratropium Bromide 0.02 % Solution Sig: [**12-29**] Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 5. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation. 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for constipation. 7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): COntinue until early [**Month (only) **] when you follow up in pulmonary clinic, and then taper as directed. 9. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 10. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): Please have your [**Month (only) 263**] checked weekly. Your coumadin dosing may need to be adjusted based on your [**Month (only) 263**]'s. 11. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day: Hold for SBP<95. 12. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: [**12-29**] Tablet Sustained Release 24HR PO once a day: Hold for SBP<95, HR<55. 13. Heparin Flush (10 units/ml) 5 ml IV PRN 14. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day. 15. Lantus 100 unit/mL Cartridge Sig: Forty (40) Units Subcutaneous qam: [**Month/Day (2) **] sugars should be checked twice daily, and he should be covered with regular SSI as necessary. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary Diagnoses: 1. Respiratory Failure 2. Interstitial Lung Disease 3. Esophageal cancer 4. Influenza Secondary Diagnoses: 1. Coronary Artery Disease 2. Congestive Heart Failure 3. s/p Mitral Valve replacement Discharge Condition: Stable Discharge Instructions: 1. Please take all your medications as prescribed and described in this discharge paperwork. We made the following changes to your medication regimen: - We added Lisinopril, a medication to help your heart. Please take 2.5 mg daily - We added Toprol XL, a medication to help your heart. Please take 12.5 mg daily - We added Digoxin 0.125 mg daily - We added Prednisone 60 mg. This should be continued for 1 month (until early [**Month (only) 958**]) or until you follow up in Pulmonary clinic. They will instruct you how to taper these steroids when you follow up. - Take 2 mg Coumadin daily. You will have your [**Month (only) 263**] checked regularly while at rehabilitation, and they may need to adjust your dosage. - We decreased your Levoxyl dose to 88 mcg daily. - We discontinued your Amiodarone. Do not take this medication. - We added Lansoprazole, a medication to help with symptoms of GI reflux and upset - We added Lantus, 40 Units, to be taken in the morning to help with control of your [**Month (only) **] sugars. 2. Please follow up with Dr. [**Last Name (STitle) **], your PCP, [**Name10 (NameIs) **] clinic, Dr. [**Last Name (STitle) 284**], as described below. 3. Please call your PCP if you are experiencing chest pain, shortness of breath, fever, chills, difficulty breathing, or with any other concerns. Followup Instructions: . Please follow up in Pulmonary Clinic with Dr. [**First Name (STitle) **] on [**2116-3-6**], 9:15 am. This is on the [**Location (un) 436**] of the [**Hospital Ward Name 23**] building in Medical Specialties ([**Telephone/Fax (1) 513**]). 2. Please follow up with Dr. [**Last Name (STitle) 284**] in Cardiology on [**2116-3-16**]. First you should go to Device clinic at 9:30 am and then Dr.[**Name (NI) 3811**] office at 10:00am. These are both in the [**Hospital Ward Name 23**] building ([**Telephone/Fax (1) 5862**] or [**Telephone/Fax (1) 32625**]). 3. You should follow up with Dr. [**Last Name (STitle) **] in Oncology. Please call to schedule this appointment once you are discharged from rehabilitation ([**Telephone/Fax (1) 5562**])

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icd9cm

[ [ [] ] ]

[ "96.6", "99.04", "93.90" ]

icd9pcs

[ [ [] ] ]

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4106, 9222

317, 343

11559, 11567

2560, 3134

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22406

Discharge summary

report

Admission Date: [**2160-2-11**] Discharge Date: [**2160-2-15**] Date of Birth: [**2096-2-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1711**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac Catheterization with Balloon Angioplasty to OM2 History of Present Illness: Mr. [**Known lastname 58248**] is a 64yo M w/ PMH of GERD, anxiety, and spinal stenosis who presented to OSH this AM after waking up with 8/10 chest pain. He described it as diffuse, across his chest, radiating through to his back. Was short of breath, but did not wake his wife for 3 hours. No diaphoresis, + nausea. At 5am, woke his wife who brought him to OSH where he was found to have ST depressions in V1, V2. He was given ASA, SL ntg, lopressor IV x1, and heparin bolus + heparin gtt and then transferred to BIMDC for cath. On admission here, he had possible ST elevations in inferior leads and diffuse J point elevation in precordial leads. Cardiac enzymes on admission were negative. He was given SL ntg and ativan, started on nitro gtt, and transferred to cath lab. . ALLERGIES: NKDA Past Medical History: GERD Anxiety h/o atypical chest pain Hard of hearing Social History: Patient lives with his wife in [**Name (NI) 1474**]. Has 3 sons, 1 daughter, 3 grandkids. Used to work for [**Company 2318**] until a fall several years ago (? from spinal stenosis) at which point he retired (denies any head trauma from his falls). Was in [**Country 3992**] War, has not smoked or drank since. Prior to then, used to smoke 2ppd. Family History: + CAD in his father, [**Name (NI) 9876**], and brothers -> no sudden death Physical Exam: PE: VS - T 98.4, BP 130/71, HR 82 (78-82), RR 17 (17-21), sats 98% 3L nc PA 36/21 (mean 26) GEN - WDWN elderly male, appears older than stated age, in NAD. Lying flat post-cath. HEENT - Sclera anicteric. EOMI, PERRL. MMM. Dentures not in place. NECK - Neck supple. JVP not able to be appreciated [**1-24**] body habitus. CV - RR, normal S1, S2. No m/r/g. LUNGS - CTA anteriorly, no crackles. ABD - Distended, but soft. Tender in LUQ. + BS. No masses. EXT - Cool, well perfused. No edema. 2+ PT/DP pulses bilaterally. Sheath still in place in R groin, PA cath in. SKIN - No rashes. NEURO - CN II-XII grossly intact. Pertinent Results: Admission Labs: [**2160-2-11**] 08:10PM O2 SAT-70 [**2160-2-11**] 07:37PM POTASSIUM-4.3 [**2160-2-11**] 07:37PM CK(CPK)-23* AMYLASE-25 [**2160-2-11**] 07:37PM LIPASE-21 [**2160-2-11**] 07:37PM CK-MB-NotDone cTropnT-<0.01 [**2160-2-11**] 07:37PM MAGNESIUM-1.9 [**2160-2-11**] 07:37PM PLT COUNT-248 [**2160-2-11**] 12:00PM GLUCOSE-124* UREA N-17 CREAT-1.2 SODIUM-137 POTASSIUM-4.9 CHLORIDE-101 TOTAL CO2-27 ANION GAP-14 [**2160-2-11**] 12:00PM ALT(SGPT)-31 AST(SGOT)-21 CK(CPK)-29* ALK PHOS-87 TOT BILI-0.5 [**2160-2-11**] 12:00PM cTropnT-<0.01 [**2160-2-11**] 12:00PM CK-MB-NotDone [**2160-2-11**] 12:00PM WBC-15.7* RBC-5.03 HGB-15.6 HCT-45.3 MCV-90 MCH-31.1 MCHC-34.4 RDW-13.1 [**2160-2-11**] 12:00PM NEUTS-84.5* LYMPHS-11.1* MONOS-3.8 EOS-0.3 BASOS-0.2 [**2160-2-11**] 12:00PM PLT COUNT-285 [**2160-2-11**] 12:00PM PT-12.7 PTT-82.0* INR(PT)-1.1 Pertinent Labs/Studies: . CK: 29 -> 23 -> 23 -> 91 -> 114 -> 100 -> 55 CK-MB: not done -> 13 -> 7 -> not done Troponin: < .01 -> .12 -> .21 -> .16 -> .21 . [**2160-2-11**] Cardiac Cath: RA 25/19/18 RV 37/15/20 PW 31/30/26 -> 22/21/18 PA 45/23/36 -> 42/18/30 PA sat 67% . COMMENTS: 1. Selective coronary angiography of this left dominant system revealed two vessel coronary artery disease. The LMCA was patent. The LAD had 70-80% proximal stenosis. The LCX had 90% lower pole OM1 stenosis. The RCA was small without significant stenoses. 2. Resting hemodynamics demonstrated elevated right and left sided pressures (mean RA pressure was 18mmHg, mean PCWP was 18mmHg, and LVEDP was 31mmHg). There was evidence of moderate pulmonary hypertension (mean PAP was 30mmHg). The cardiac index was low at 1.7 L/min/m2. 3. Left ventriculography revealed 2+ mitral regurgitation without wall motion abnromalities. Calculated ejection fraction was 50%. 4. Successful POBA of OM2 (see PTCA comments). . FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Cardiogenic shock with severe diastolic and mild systolic dysfunction. 3. Mild-moderate mitral regurgitation. 4. Successful PTCA of OM2. . Imaging: [**2160-2-11**] ECHO: The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with focal hypokinesis of the basal third of the inferolateral wall and the distal third of the anterior wall. The remaining segments contract well. The aortic root is mildly dilated. The ascending aorta is mildly dilated. The aortic valve leaflets appear structurally normal with good leaflet excursion. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with regional systolic dysfunction c/w multivessel CAD. Mild aortic regurgitation. Mild mitral regurgitation. Pulmonary artery systolic hypertension. . [**2160-2-11**]: Portable Chest - The heart is upper limits of normal in size. The lung volumes are decreased bilaterally with bilateral elevation of the hemidiaphragms. There is no pneumothorax. The osseous structures appear within normal limits. IMPRESSION: No evidence of pneumonia. . [**2160-2-12**]: CTA Chest - There is a small focal opacification within the right upper lobe that may represent a focal atelectasis. Atelectasis is seen at the lung bases bilaterally. A small amount of concavity is noted in the left main stem bronchi, best seen on sagittal views. There are no pleural effusions. Both lungs are otherwise unremarkable. Soft tissue windows demonstrate no appreciable lymphadenopathy. The heart and great vessels are unremarkable. . A Swan-Ganz catheter is seen extending into the distal aspect of the right pulmonary artery. There are no filling defects. There is no evidence of pulmonary embolism. The visualized aorta shows no evidence of dilatation or dissection. BONE WINDOWS: There are no suspicious lytic or sclerotic bony lesions. IMPRESSION: No evidence of pulmonary embolism, aortic aneurysm, aortic dissection. . [**2160-2-12**]: CT A/P - There is moderate cardiomegaly. There is bibasilar atelectasis and tiny pleural effusions. The liver, gallbladder, pancreas, spleen, adrenal glands, kidneys, stomach, and bowel loops are unremarkable within the limits of this noncontrast study. There is no free air or free fluid. No mesenteric or retroperitoneal lymphadenopathy is identified. CT PELVIS: Foley catheter and air are observed in the bladder. There are multiple prosthetic calcifications. Scattered sigmoid diverticula are observed without evidence of diverticulitis. There is a stranding and a small amount of fluid in the pelvis along the iliac vessels. No large retroperitoneal hematoma is identified. Stranding in the right groin is consistent with the recent arterial puncture. BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions. IMPRESSION: Small amount of stranding and fluid along the right common iliac vessels consistent with a small amount of blood. No large retroperitoneal hematoma is identified. Discharge Labs: . [**2160-2-15**] 06:10AM BLOOD WBC-9.7 RBC-4.38* Hgb-13.6* Hct-38.6* MCV-88 MCH-31.0 MCHC-35.1* RDW-13.1 Plt Ct-294 [**2160-2-15**] 06:10AM BLOOD Glucose-101 UreaN-21* Creat-1.0 Na-135 K-3.6 Cl-102 HCO3-25 AnGap-12 [**2160-2-15**] 06:10AM BLOOD Mg-1.9 Brief Hospital Course: A/P: Patient is a 64 year old Male who presents with chest pain with inferolateral ECG deviation on admission s/p POBA to OM2, with small enzyme leak. The etiology of clinical presentation not completely clear, question UA, NSTEMI, vs. myopericarditis. . #. CAD: With regards to his symptoms of chest pain and inferolateral ST changes, the patient was brought to the cath lab for evaluation. Cardiac cath revealed a left dominant system with 70-80% proximal stenosis of the LAD and LCx remarkable for a 90% lower pole stenosis of OM1. Hemodynamics revealed elevated left and right sided pressures with depressed cardiac index of 1.7. The patient underwent POBA to OM2 and was transferred to the CCU with plan at that time for likely repeat cath in a.m. for LAD lesion. The patient's course was complicated by persistent chest pain s/p cath with increasing ST segment elevations in the inferior leads despite intervention. At this time, all cardiac enzymes were negative. This pain was refractory to a nitro gtt but was noted to be resolved with Maalox. Given these persistent pains, it was questioned whether the etiology of the patient symptoms was an alternative diagnosis such as PE, coronary vasospasm, or myopericarditis. Although the patient was having ongoing pain and ECG changes, his ECG changes were not in the distribution of the LAD, again making it less likely that the patient's unopened LAD was the source of his ongoing symptoms. The patient underwent a CTA that did not reveal any PE. The patient was additionally started empirically on a trial of a calcium channel blocker given consideration of coronary vasospasm. The patient did eventually have resolution of his pain although the exact alleviating intervention, if any, is unknown. The patient did demonstrate eventually a bump in his cardiac enzymes, although of note this was after signficant resolution of his symptoms. Ultimately, given that the etiology of the patient's symptoms were not clear and there was no evidence for a dynamic lesion as the cause of the patient's pain, the decision was made to postpone repeat cardiac catheterization until this acute event had resolved, after which the patient could have the procedure performed electively as an outpatient. . #. Pump: The patient had an echo performed post-cath that revealed an EF of 40% with focal hypokinesis of the basal third of the inferolateral wall and the distal third of the anterior wall. Given evidence of elevated left and right sided pressures on cath, the patient was gently diuresed with 10mg IV lasix on transfer to the CCU. Throughout his hospital course the patient appeared euvolemic to mildly hypervolemic given obligate fluids for post-cath hydration as well as contrast studies. The patient was given one additional bolus of 10mg IV lasix only for the remainder of his stay only. Throughout his course with movement and ambulating the patient's O2 requirement resolved and his pulmonary exam cleared. His ACE was reinitiated the day prior to discharge and tolerated well. . #. RHYTHM: Patient remained in NSR throughout his admission without significant events on telemetry. . #. Anemia - The patient was noted to have a significant Hct drop from 45.3 on admission with serial values of 36.5 to 29.4. Given this precipitous drop post cath there was concern for a possible RP bleed. Of note however, other than persistent chest pain as above, the patient remained hemodynamically stable without a significant tachycardia which would be expected in the setting of an acute bleed. CT of the abdomen and pelvis without contrast was performed and revealed no evidence for an RP bleed. Of note, the patient's next Hct level without transfusion was 39.8, demonstrating that the previous values were likely spurious. . #. HTN: On transfer to the CCU the patient's antihypertensive medications were held given depressed cardiac index. Low dose metoprolol 12.5mg po bid was first introduced for it's cardioprotective effects, then titrated to 25mg po tid. As above, given consideration of vasospasm as the etiology of the patient's symptoms amlodipine 5mg po qd was additionally added to the patient's regimen. Finally, the patient's ACE was serially added and tolerated well. Upon discharge all meds were converted to once daily formulations as detailed in med discharge list. Medications on Admission: Paxil 20mg PO QD Ranitidine 150mg PO QD Norpramin 2 tabs PO BID ASA prn Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: 1.5 Tablet Sustained Release 24HRs PO DAILY (Daily). Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Primary: NSTEMI with ? vasospasm s/p balloon angioplasty to OM2 . Secondary: GERD Anxiety Hx of atypical chest pain Hard of hearing Discharge Condition: 1. Good. Patient is chest pain free, afebrile, hemodynamically stable, with O2 sat > 94% on room air. Patient is able to walk without assitance or oxygen. Patient has appropriate follow up planned for repeat evaluation/intervention of 70% occlusion of LAD. Discharge Instructions: 1. Please take all medications as prescribed. . 2. Please keep all outpatient appointments. You will need to be followed by your PCP within the next two weeks. . 3. Please return to the hospital immediately for symptoms of chest pain, shortness of breath, nausea/vomiting, dizziness or any other concerning symptoms. . 4. You have a diagnosis of congestive heart failure. It is very important that you weigh yourself every morning. If your weight increases by more than 3 pounds from your baseline, you should call your PCP or cardiologist to evaluate the need for any changes in your medical regimen. It is additionally very important that you adhere to a low salt diet with daily intake less than 2 grams per day. . 5. You underwent cardiac catheterization during your admission to [**Hospital1 18**]. During this procedure you received balloon angioplasty to one of your blood vessels. It was also observed that another blood vessel is stenotic and will require intervention. You will be contact[**Name (NI) **] at home by the nursing staff at [**Hospital1 18**] to schedule a time for you to come and have this procedure performed electively as an outpatient. . 6. Your home medications have changed since you were admitted to [**Hospital1 18**]. In addition to Paxil, you will now need to take a number of new medications for your heart. These include ASA, Plavix, Atorvastatin, Amlodipine, Lisinopril, Toprol XL. These new medications will be reviewed with you before you go home and VNA nursing staff will additionally visit you at home to review these medications with you and make sure they are being taken properly. Followup Instructions: 1. Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] within one to two weeks. You have an appointment on Tuesday [**2-26**] at 2:00 p.m. at his office. His address is [**Street Address(2) **], [**Hospital1 1474**] [**Numeric Identifier 8728**]. Please call his office at [**Telephone/Fax (1) 3183**] with any questions or scheduling needs. . 2. You should receive follow up care with a cardiologist from now on. You may follow up with the office of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 18**]. His office number is ([**Telephone/Fax (1) 5909**]. You currently have an appointment with Dr. [**Last Name (STitle) **] [**3-14**] at 11:00 a.m., after your repeat cardiac cath will be performed. Please call his office if you would like to cancel or change this appointment. If you would prefer to be followed by a cardiologist in [**Hospital1 1474**] instead, please contact your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and request that he refer you to a cardiologist closer to your home. . 3. You underwent cardiac catheterization during your admission to [**Hospital1 18**]. During this procedure you received balloon angioplasty to one of your blood vessels in the heart, called OM2. It was also observed that another blood vessel is stenotic and will require intervention. You will be contact[**Name (NI) **] at home by the nursing staff at [**Hospital1 18**] to schedule a time for you to come and have this procedure performed electively as an outpatient within the next one to two weeks. If you or your family have any questions regarding this procedure please contact Dr. [**Last Name (STitle) **] at [**Hospital1 18**] at ([**Telephone/Fax (1) 5909**].

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icd9cm

[ [ [] ] ]

[ "88.53", "00.66", "00.40", "99.20", "37.23", "88.42", "88.56" ]

icd9pcs

[ [ [] ] ]

13357, 13412

7871, 12201

326, 383

13588, 13847

2388, 2388

15521, 17394

1662, 1738

12323, 13334

13433, 13567

12227, 12300

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13871, 15498

7594, 7848

1753, 2369

276, 288

411, 1206

2404, 4254

1228, 1282

1298, 1645

21,766

115,324

2779

Discharge summary

report

Admission Date: [**2150-2-19**] Discharge Date: [**2150-4-15**] Date of Birth: [**2089-5-20**] Sex: M Service: SURGERY Allergies: Desipramine Hcl Attending:[**First Name3 (LF) 148**] Chief Complaint: Pancreatic cancer Major Surgical or Invasive Procedure: Whipple procedure with J tube placement, Exploratory laparotomy for wound dehisence. s/p closure with rentention sutures [**2-25**], s/p Trach [**3-9**], s/p open drainage of splenic abscess [**3-26**] History of Present Illness: This 60-year-old man has COPD and coronary artery disease as well as bipolar depression and he originally presented with two weeks of nausea, diarrhea, dark colored urine and jaundice. He has been suffering from upper respiratory symptoms for the last three weeks and saw his pulmonologist who started on antibiotics for the steroid taper. He reported diarrhea at this time and he actually had C. diff colitis identified. He reports no change in appetite, recent weight loss or other particular symptoms. He underwent an ERCP/stent placement on [**1-27**] which showed a distal CBD stricture and atypical cells. CTA abdomen showed a 3.6 cm head of pancreas mass. He had a Whipple and J-tube on [**2150-2-19**] Past Medical History: COPD (Chronic Bronchitis, Emphysema), CAD, OSA (thumbs, right shoulder and neck), Melanoma, Bipolar/manic depression, sleep apnea, Hx C.diff PSH: Cardiac Stent x4 ([**2145**]), Melanoma excision (abdomen) [**2140**] Social History: Lives alone in [**Location (un) 5289**]. Quit tobacco [**2145**]. No EtOH. Works part-time in sales. Family History: Mother with breast CA Physical Exam: Gen: Looks a bit disheveled, but is awake and oriented x3 and fully conversant. HEENT: No evidence of scleral icterus at this point. Chest: clear to auscultation. CV: Cardiac exam shows a regular rate and rhythm. Abd: soft, nontender, and nondistended with positive bowel sounds and is quite protuberant and rotund. Ext: show no cyanosis, clubbing, or edema. Pertinent Results: On admission: [**2150-2-19**] 10:44PM BLOOD WBC-25.0*# RBC-4.04* Hgb-12.1* Hct-36.0* MCV-89 MCH-30.1 MCHC-33.7 RDW-15.5 Plt Ct-195 [**2150-2-19**] 10:44PM BLOOD PT-15.0* PTT-43.8* INR(PT)-1.3* [**2150-2-19**] 10:44PM BLOOD Glucose-186* UreaN-14 Creat-1.0 Na-140 K-5.0 Cl-107 HCO3-22 AnGap-16 [**2150-2-19**] 10:44PM BLOOD ALT-1015* AST-818* AlkPhos-96 Amylase-24 TotBili-2.1* [**2150-2-19**] 10:44PM BLOOD Lipase-15 [**2150-2-19**] 10:44PM BLOOD Calcium-8.8 Phos-5.6*# Mg-1.7 [**2150-2-19**] 12:18PM BLOOD Type-ART pO2-93 pCO2-49* pH-7.28* calTCO2-24 Base XS--3 Intubat-INTUBATED . CXR [**2150-2-20**] IMPRESSION: AP chest compared to [**2-19**]: Lung volumes remain quite low. Mild pulmonary edema is new, accompanied by increased caliber to mediastinal and hilar vessels. Small left pleural effusion is presumed. Tip of the Swan-Ganz catheter projects over the right descending pulmonary artery. ET tube tip ends at the thoracic inlet, partially withdrawn since the prior study. Nasogastric tube passes below the diaphragm and out of view. Small left pleural effusion is presumed. No pneumothorax. . Duplex Doppler Abd/Pelvis [**2150-2-20**] HISTORY: 60-year-old male status post Whipple's procedure. IMPRESSION: Replaced common hepatic artery posterior to the portal vein was not visualized; however, normal arterial waveforms were obtained in the right and left hepatic arteries. . CXR [**2150-2-20**] REASON FOR EXAM: Increased O2 requirement. FINDINGS: There are low lung volumes. Increased diffuse density of the left hemithorax is most likely due to layering pleural effusion. Cardiac silhouette is accentuated by the low lung volumes, appears to be mildly enlarged. There is engorgement of the mediastinal and pulmonary vasculature with no overt pulmonary edema. Right lower lobe atelectasis is new. NG tube tip is out of view, below the diaphragm. IMPRESSION: Increased left pleural effusion with increased adjacent atelectasis. [**2150-4-14**] 05:05AM BLOOD WBC-23.9* RBC-3.93* Hgb-11.1* Hct-34.6* MCV-88 MCH-28.3 MCHC-32.2 RDW-17.5* Plt Ct-988* [**2150-4-13**] 05:10AM BLOOD WBC-19.5* RBC-3.81* Hgb-10.8* Hct-33.7* MCV-88 MCH-28.3 MCHC-32.0 RDW-17.5* Plt Ct-940* [**2150-4-13**] 05:10AM BLOOD calTIBC-186* Ferritn-561* TRF-143* [**2150-4-6**] 02:49PM BLOOD calTIBC-120* Ferritn-610* TRF-92* [**2150-4-6**] 02:49PM BLOOD Triglyc-140 [**2150-3-25**] 02:21AM BLOOD Lithium-0.8 . CHEST (PA & LAT) [**2150-4-12**] 10:18 PM IMPRESSION: Persistent but slightly improved retrocardiac opacity which may be secondary to aspiration, pneumonia, or atelectasis. Left pleural effusion is unchanged. Subsegmental right lower lobe atelectasis. . VIDEO OROPHARYNGEAL SWALLOW [**2150-4-7**] 1:23 PM IMPRESSION: Penetration and intermittent aspiration with thin and nectar consistency barium. . CHEST (PORTABLE AP) [**2150-4-5**] 4:47 AM FINDINGS: The left chest tube is unchanged. There continued to be bilateral pleural effusions moderate in size that layer posteriorly, given positioning it is unclear but these are likely increased compared to prior. There is pulmonary vascular re-distribution, perihilar haze consistent with fluid overload. There is obscuration of both hemidiaphragms due to the effusions and an underlying infiltrate cannot be excluded. . ECHO Conclusions The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are 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 ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . CT ABDOMEN W/CONTRAST [**2150-3-31**] 11:16 AM IMPRESSION: 1. Overall, no significant change. Infarcted spleen and subsequent hematoma is unchanged in size, with indwelling large-bore catheter. Heterogeneity within the hepatic parenchyma, left lobe, likely due to retractor injury, no definite evidence for infection at this time. 2. Loculated left pleural effusion with near-complete collapse of the left lower lobe. Small right effusion and atelectasis. . CT PERITINEAL DRAIN EXCLUDING APPENDICEAL [**2150-3-21**] 2:39 PM IMPRESSION: Successful CT-guided percutaneous drainage of splenic collection. . CT PELVIS W/CONTRAST [**2150-3-10**] 3:33 PM IMPRESSION: 1. Splenic vein thrombosis with extensive splenic infarction. Interval development of gas within the infarcted splenic parenchyma concerning for infection. 2. Multiple poorly defined hypoenhancing areas in the left hepatic lobe that may be related to retractor injury. However, superimposed infection cannot be excluded. 3. Small left pleural effusion and near complete collapse of the left lower lobe. 4. Emphysema. 5. No definite evidence of enterocutaneous fistula. However, please note that the small bowel was not well opacified with oral contrast at the time of the examination which limits the sensitivity of this exam. . Brief Hospital Course: Patient was admitted after a Pylorus-preserving Whipple w/ J-tube placement and placement of gold fiducial seeds for CyberKnife therapy (please see full operative note for details). Because of the pt's baseline cardiopulmonary issues, he remained intubated and was transferred directly to the ICU. Neuro: He was awake and alert after extubation and was successfully transitioned to a PCA for pain control. . Cardiac: He initially had a Swan-Ganz catheter, which was removed with stable cardiac function. He was maintained on ASA. . Pulmonary: Pt was extubated on POD 2 and eventually transitioned to O2 by nasal canula. However, he was electively re-intubated on [**2-25**] after his wound dehiscence and emergent return to OR. He required ventilatory support post-op was he had a percutaneous tracheostomy placed on [**2150-3-9**]. . FEN: Pt was on a lasix drip initially for diuresis and was eventually transitioned to intermittent doses. He responded well to the treatment. Trophic J tube feeds were started on POD#4 and were slowly advanced towards goal. He tolerated them well. They were held briefly during his evisceration but was eventually restarted and advanced to goal. Nutrition was following for tube feed recommendations. He was evaluated by Speech and Swallow and he was cleared for ground solids and nectar thick liquids. . GI: Immediately post-op, he had elevated LFTs but ultrasound of the hepatic vasculature was negative for pathology. He developed a wound infection that required re-opening of his wound. With the infection and his concurrent steroids, he eviscerated through his wound after a violent cough. He was brought back to the OR emergently on [**2-25**] and his wound was irrigated/debrided and primary closed with retention sutures. He required large amounts of PEEP up to 15 to maintain his oxygenation. He continued to be hypotensive requiring vasopressors for several post-operative days. His cortisol stim test showed a marginal response (34 to 41) and steroids were not restarted. An ECHO was obtained which showed intact LV function with no thrombi. On [**3-7**] he developed an low-output colocutaneous fistula through his abdominal wound. It's output was bilious and did not appear to have any tube feeds or methylene blue when placed via the NGT. A vacuum dressing was applied after initially using wet to dry dressings. His wound continued to improved and he will need continued wound care. . ID: He spike fevers intermittently and cultures were positive for: enterococcus faecium on [**2-21**] in blood x2 bottles, sputum culture for sparse yeast [**2-21**]; Sputum cultures from [**2-26**], [**3-2**], [**3-4**] revealed enterobacter cloacae and he was treated with appropriate ABX. On [**3-4**] (POD 13 and 7) he developed a fever to 102 and leukocytosis to 34K. CT showed Infarction of the spleen with thrombosis identified within the splenic vein and colitis. He was treated non-operatively with bowel rest for the colitis and an Aspirin for the splenic vein thrombus. . Heme: Pt had consistently decreasing platelet count while on heparin. All heparin products were d/c'd and he was maintained on pneumoboots for prophylaxis throughout his ICU stay. CT abd [**3-4**] showed infarction of the spleen with thrombosis. CT abd [**2150-3-10**] showed splenic abscess, which was drained on [**2150-3-12**] via IR. Approximately 800cc blood/foul-smelling fluid was drained and a drain was left in place. . Endo: Pt was adrenally deficient on POD#1 and started on a steroid taper, which was appropriately weaned and then stopped after he eviscerated from his incision. His blood sugars continued to be elevated and [**Last Name (un) **] Diabetes was seeing him and adjusting his sliding scales. . Psych: Lamictal and lithium were restarted on POD#4 through the J tube. Psych continued to see him and he was discharged with Diazepam PRN. Medications on Admission: ASA, Plavix 75', Toprol 25', Lipitor 80', atacand 4', prilosec', lamictal 200', lithium 900', valium 5-10mg'' prn, advair 500/50'', celebrex 200', colace prn Discharge Medications: 1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 2. Calcium Carbonate 500 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 3. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6 hours) as needed. 5. Ascorbic Acid 90 mg/mL Drops [**Last Name (STitle) **]: Five Hundred Four (504) mg PO DAILY (Daily). 6. Ferrous Sulfate 300 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO DAILY (Daily). 7. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 8. Therapeutic Multivitamin Liquid [**Last Name (STitle) **]: One (1) Cap PO DAILY (Daily). 9. Papain-Urea 830,000-10 unit/g-% Ointment [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **] (2 times a day). 10. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) Injection TID (3 times a day). 11. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: Three (3) Tablet PO TID (3 times a day). 12. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: Six (6) Puff Inhalation Q6H (every 6 hours) as needed. 13. Thiamine HCl 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 14. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Hospital1 **]: [**4-12**] Puffs Inhalation Q4H (every 4 hours). 15. Fluticasone 110 mcg/Actuation Aerosol [**Month/Day (3) **]: Four (4) Puff Inhalation [**Hospital1 **] (2 times a day). 16. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule, Delayed Release(E.C.) [**Hospital1 **]: [**4-12**] Caps PO QIDWMHS (4 times a day (with meals and at bedtime)). 17. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Month/Day (3) **]: 5-10 MLs PO Q6H (every 6 hours) as needed. 18. Cholestyramine-Sucrose 4 gram Packet [**Month/Day (3) **]: One (1) Packet PO QID (4 times a day). 19. Insulin NPH Human Recomb 100 unit/mL Suspension [**Month/Day (3) **]: Twenty Five (25) Units Subcutaneous twice a day. 20. Lithium Carbonate 300 mg Capsule [**Month/Day (3) **]: Three (3) Capsule PO QHS (once a day (at bedtime)). 21. Lamotrigine 100 mg Tablet [**Month/Day (3) **]: Two (2) Tablet PO QHS (once a day (at bedtime)). 22. Miconazole Nitrate 2 % Powder [**Month/Day (3) **]: One (1) Appl Topical TID (3 times a day) as needed. 23. Clopidogrel 75 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO DAILY (Daily). 24. Zolpidem 5 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO HS (at bedtime) as needed. 25. Vancomycin 250 mg Capsule [**Month/Day (3) **]: Two (2) Capsule PO Q6H (every 6 hours) for 1 weeks. 26. Metronidazole 500 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO TID (3 times a day) for 1 weeks. 27. Diazepam 5 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO TID (3 times a day) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 1110**] Discharge Diagnosis: Whipple, J-tube [**2-19**] wound dehiscence s/p closure with rentention sutures [**2-25**], s/p Trach [**3-9**], s/p open drainage of splenic abscess [**3-26**] Adrenal Insufficiency, enterococcal bacteremia, MRSE line sepsis, wound infection, splenic vein thrombosis, splenic infarct respiratory failure, enterocutaneous fistula Discharge Condition: Good Tolerating tubefeedings Wound Healing 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 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 (>[**10-21**] lbs) for 6 weeks. * Monitor your incision for signs of infection * Keep your incision clean and dry. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] on [**5-15**] at 10:30am. Call [**Telephone/Fax (1) 1231**] with questions or concerns. Completed by:[**2150-4-15**]

[ "496", "444.89", "V46.11", "296.7", "577.1", "414.01", "327.23", "518.0", "157.0", "558.9", "288.60", "038.0", "998.59", "575.11", "511.9", "V45.82", "255.41", "V10.83", "995.91", "518.81", "V15.82", "196.2", "E879.9", "998.32", "569.81", "285.9" ]

icd9cm

[ [ [] ] ]

[ "54.19", "54.61", "96.72", "46.39", "52.7", "99.04", "86.28", "96.07", "33.21", "51.22", "96.05", "31.1" ]

icd9pcs

[ [ [] ] ]

14605, 14688

7486, 11381

292, 496

15062, 15107

2033, 2033

16647, 16818

1615, 1639

11589, 14582

14709, 15041

11407, 11566

15131, 16624

1654, 2014

235, 254

524, 1240

2048, 7463

1262, 1480

1496, 1599

25,986

148,193

46260

Discharge summary

report

Admission Date: [**2191-2-26**] Discharge Date: [**2191-3-7**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: Fall Major Surgical or Invasive Procedure: None History of Present Illness: cc: fall HPI: [**Age over 90 **] yo man recently d/c'd from [**Hospital1 18**] ICU (pna and urosepsis) who was left in BR on [**2-26**] and a few minutes later a thud was heard. Pt was found on the ground, conscious, and brought to ED where he had hypoxia, hypercarbia, delta MS. [**Name13 (STitle) **] was admitted to the floor on [**2-26**] on 100% shovel mask and was increasingly lethargic. ABG: 7.30/69/65. Transferred to MICU for hypercarbia. Past Medical History: 1. s/p ICU stay for pna [**12-15**] since then on 2L home O2 2. Restrictive lung disease last PFT's [**4-/2186**] (see below) 3. High Grade Urothelial Bladder Ca s/p transurethral resection on [**2189-2-20**] and XRT in [**5-13**] for recurrence 4. CAD s/p CABG with SVG to LAD, D1 and RPLv and [**Last Name (un) 3843**]-[**Doctor Last Name **] bioprosthetic MVR [**2184-5-5**] 5. Afib since PNA in [**11-11**], on Coumadin 6. Adm for E. coli urosepsis [**10-14**] 7. HTN 8. DM II 9. CRI with baseline Creatinine around 1.7 10. Gout 11. Reactive arthritis 12. h/o fracture of Left hip s/p ORIF or left hip 13. s/p [**2191**] c/b L humerus and C1-C2 ([**Location (un) 26524**] Fracture) both treated non-operatively (C-collar x12 weeks per neurosurg) 14. s/p b/l inguinal hernia repairs 15. s/p pna and E.Coli urosepsis [**10-14**] 16. memory loss 17. [**12-14**] MRSA in sputum Social History: Lives at home with his wife, retired businessman. Has remote smoking history Family History: Mother had breast cancer. A sister had gastric cancer. Physical Exam: PE: Tm=Tc 98.6 HR 80 (70-80s) BP 158/64 (100-180/30-60) RR 18 O2 sat 100% on 70% shovel mask I/Os over past 20 hours (at 8 pm): 1490/775 + 715 LOS + 7397 gen- elderly male, ill-appearing, opens eyes to voice and squeezes hand to commands, somnolent HEENT- dry MM (mouth open), pinpoint pupils, nl conjunctiva, anicteric Neck- supple, no LAD, + JVP sitting upright in bed CV- RRR mech s1, s2, [**1-16**] HSM at apex Chest- anteriorly- clear- no wheezes, rohonchi or rales- decreased at bases, unable to lift (with RN) to listen to posterior aspect Abd- NABS, soft, NT/ND, obese Ext- +2 edema in LE b/l, chronic venous stasis changes b/l Neuro- as above- moving all exteremities, toes downgoing b/l Pertinent Results: [**2191-2-26**] 12:40AM PT-22.6* PTT-32.9 INR(PT)-3.2 [**2191-2-26**] 12:40AM CK-MB-NotDone cTropnT-0.03* [**2191-2-26**] 12:40AM CK(CPK)-63 [**2191-2-26**] 12:40AM GLUCOSE-184* UREA N-26* CREAT-1.7* SODIUM-139 POTASSIUM-5.4* CHLORIDE-99 TOTAL CO2-34* ANION GAP-11 [**2191-2-26**] 02:30AM PLT SMR-NORMAL PLT COUNT-288 [**2191-2-26**] 02:30AM WBC-21.7*# RBC-4.69 HGB-13.5* HCT-41.0 MCV-87 MCH-28.7 MCHC-32.9 RDW-15.4 [**2191-2-26**] 02:30AM NEUTS-91.0* BANDS-0 LYMPHS-5.8* MONOS-2.5 EOS-0.5 BASOS-0.2 [**2191-2-26**] 02:30AM ALBUMIN-3.4 CALCIUM-8.6 PHOSPHATE-4.2 MAGNESIUM-1.9 [**2191-2-26**] 02:30AM GLUCOSE-205* UREA N-26* CREAT-1.7* SODIUM-142 POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-33* ANION GAP-12 [**2191-2-26**] 06:06AM LACTATE-1.3 LABS: ABG [**3-1**]: 7.41/38/68 Pertinent results: [**4-/2186**] PFT's FEV 1 0.89 L FVC 1.43L FEV1/FVC 102% . [**11-12**] TTE: LVEF >65%, bioprosthetic MV, 1+ MR, mod [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 17972**], mild symp LVH, mild dil. asc aorta RAD: CXR no effusions, no consolidation, improved c/w [**2190-12-26**] . Head CT: No acute intracranial hemorrhage or mass affect. Brief Hospital Course: [**Age over 90 **] yo man w/ CAD, COPD on home O2, DM, CRI, MVR, afib on coumadin presents s/p fall with hypercarbia and aspiration pneumonia. Admitted to MICU on [**2-26**] and called out to floor [**3-1**]. Patient died [**3-6**]. . 1) Aspiration PNA: In the MICU, aspiration pneumonia was suspected- no infiltrate on CXR, but copious purulent secretions. He was briefly on Bipap and then transitioned to shovel mask. Staph aureus found on sputum cx. Hypercarbia may have been secondary to concomitant COPD exacerbation, although no documented h/o COPD (despite smoking history). No longer hypercarbic by transfer to floor. Low probability of PE (although pt has h/o cancer) given supratherapeutic PT. No evidence of ischemic changes on EKG. Pulmonary edema with bilateral pleural effusions seen on CXRs [**2-26**] and [**2-27**]. He was started on vanc/levo/flagyl (day 1 = [**2-26**]) and prednisone/nebs/chest PT for presumed COPD exacerbation. He was kept NPO and failed swallow study on [**2-28**]. PEG placement was recommended and presented to the patient and family as an option which they decided not to pursue as it was against the patients known wishes. Tube feeds were given as temporizing measure until family took patient home. He was breathing comfortable on shovel mask and received frequent chest PT to help mobilize secretions. 2) Anasarca: However, his course was complicated by significant volume overload/anasarca. He received IVF boluses in MICU (+6 liters during stay) for low BPs and had 3rd spaced much of this fluid. He was diuresed w/ increasing doses of IV lasix which worsened his renal function. . 2) Fall/MS changes: DDx of fall is mechanical, orthostasis, ischemic. Mental status slightly better [**2-28**] but he is demented at baseline and still w/ waxing and [**Doctor Last Name 688**] mental status. There were no EKG changes to suggest myocardial ischemia and MI ruled out. Initial head CT was negative and CT neck w/ chronic mid-thoracic changes; no change from prior. It was likely his current infection that was causing delirium which is exacerbation baseline dementia. Olanzepine was started for agitation. . 3) CAD s/p CABG: no evidence of ischemic ekg changes. MI ruled out. He was continued on aspirin & statin & metoprolol held for hypotension & COPD . 4) AFib: Alternates with normal sinus rhythm. He was initially supratherapeutic on coumadin (stopped [**2-28**])- likely from levoquin- and it was held for this reason and for hematuria (h/o bladder CA). Coumadin was not restarted when his INR normalized after several days, since risk of bleed high and only on anticoagulation for AFIB. . 5) CRI: Creatinine elevated above baseline (which is upper 1s to low 2s). Not pre-renal. Sediment with muddy brown casts and [**2-12**] hyaline casts. Renal U/S was unchanged from prior- with chronic stable mod left hydronephrosis and chronic nonobstructing stones in left ureter. He was given prn boluses in MICU to improve urine output, then lasix was started [**2-28**] for which he did respond, however it was difficult to get him net negative since so many fluids going in. Antibiotics were concentrated and other IV infusions minimized. Lasix was increased which did worsen renal functioning. A mild hypernatremia was treated w/ free water boluses. His only option to remove this fluid was hemodialysis, but this aggressive measure was not pursued as his care was transitioning to comfort measures, as well as it is unclear if this would actually provided any benefit or improved quality of life. . 6) HTN: Metoprolol and hydralazine held for hypotension in the MICU. Getting IV hydralazine prn for hypertension. ACE avoided [**1-12**] renal failure. . 7) Type II DM: RISS; HgbA1C 5.5 [**2-12**] . 9) Anemia: Hct slowly dropping while in MICU, likely from hematuria- no other obvisou source of bleeding. Baseline likely mid-30s. He was given 2 unit PRBCs during admission. . 10) Code: Initally was full code, however after many discusses with wife and discussions with Dr. [**Last Name (STitle) 14069**] and patient's daughters, he was changed to DNR/DNI. Social worker closely involved. Palliative care was consulted and plan was to go home with hospice on Monday [**3-7**]. His care was predominately comfort care, however treatment continued until decision for hospice to be made on [**3-7**] (when daughter arrived in town). However, Mr. [**Known lastname **] passed away the night of [**3-6**]. The family was present and Dr. [**Last Name (STitle) 14069**] as well as covering attending was notifed. Medications on Admission: Meds on transfer to floor: asa 325 qd folic acid finasteride 5 qd simvastatin 20 qd mvi colace RISS flagyl 500mg IV Q 8 vancomycin IV 1 gm Q48 levofloxacin 250 mg IV Q 24 atrovent nebs Q6 combivent nebs Q4 prednisone 60 mg qd ([**2-28**]-) lansoprazole Tube feeds olanzepine disintegrating tabs 5 [**Hospital1 **] tylenol prn bisacodyl prn albuterol nebs prn lasix 20 Iv x1 ([**2-28**] and [**3-1**] pm) hydralazine held (20 IV q6) Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Aspiration pneumonia Anasarca Discharge Condition: Died Discharge Instructions: n/a Followup Instructions: n/a

[ "403.91", "E888.9", "V10.51", "331.0", "414.00", "491.21", "276.5", "507.0", "294.10", "V58.61", "584.9", "427.31", "V45.81", "V42.2", "274.9", "285.9", "599.7", "518.81", "293.0", "250.00", "428.0" ]

icd9cm

[ [ [] ] ]

[ "96.6", "38.93", "99.04", "93.90" ]

icd9pcs

[ [ [] ] ]

8804, 8813

3734, 8294

265, 271

8886, 8892

3362, 3651

8944, 8950

1762, 1819

8776, 8781

8834, 8865

8320, 8753

8916, 8921

1834, 2534

221, 227

299, 750

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Discharge summary

report

Admission Date: [**2190-6-7**] Discharge Date: [**2190-6-14**] Service: NEUROLOGY Allergies: Penicillins Attending:[**First Name3 (LF) 5018**] Chief Complaint: Right hand weakness and dysarthria - "code stroke" Major Surgical or Invasive Procedure: tPA administration History of Present Illness: Mr. [**Known lastname 6359**] is a 86-year-old right-handed man presenting with dysarthria and right hand weakness on a background of collagenous colitis and irregular heart rhythm, coronary artery disease and numerous other problems. Mr. [**Known lastname 6359**] was at home at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] this morning. He awoke normally and ate breakfast according to his typical routine. He then sat down to watch television. He was holding the remote control in his right hand. On trying to change channel, the remote control fell out of his hand, which he then noticed that he could not move. He thinks that his voice became slower and less clear at about the same time. There was no headache, his leg was not weak, he could understand and speak, but said that others found him difficult to understand. The [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] staff called his PCP's coverage who noted normal vitals and recommended coming to the ED. His functional status: Uses a walker, needs help with washing, dressing, has meals prepared for him. Cognitive: quite intact. Review of systems is positive for shortness of breath that has been present for two years, worse over the last few days and worse still this morning. He knows that his heart is irregular. There is no chest pain or recent episode of chest pain. No recent infections, fever, chills. All other review of systems negative except as above. Time Code Stroke called: 12:34 Time Neurology at baseline for evaluation: 12:39 Time (and date) the patient was last known well: [**2190-06-07**], 10:00 NIH Stroke Scale Score: 4 Contraindications to t-PA: None t-[**MD Number(3) 6360**]: Y Time given: 13:09 I was present during the CT scanning and reviewed the images as they were captured. NIHSS: NIH SS: 1a. Level of Consciousness: 0 1b. LOC questions: 0 1c. LOC commands: 0 2. Best gaze: 0 3. Visual: 0 4. Facial palsy: 0 5a. Motor arm, left: 0 5b. Motor arm, right: 2 6a. Motor leg, left: 0 6b. Motor leg, right: 0 7. Limb ataxia: 1 8. Sensory: 0 9. Best language: 0 10. Dysarthria: 1 11. Extinction and inattention: 0 Past Medical History: PAST MEDICAL HISTORY: 1. Abdominal abscess - The patient had an abdominal abscess that grew pseudomonas aeruginosa which was drained and treated with antibiotics in 10/[**2187**]. 2. Prostate cancer - This was diagnosed in [**2178**]. The patient was treated with radiation therapy. Prostate cancer has now reoccurred with a pelvic mass and possible bone met. Being treated with Lupron therapy by Dr. [**Last Name (STitle) 770**]. 3. Basal and squamous cell skin cancers 4. CAD status post stent x6 (last was eight years ago), Cardiologist is Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. 5. Hypertension 6. Hypothyroidism 7. Bilateral hearing loss - The patient wears hearing aids bilaterally. He reports that his hearing loss is greater in the left ear than the right. 8. Headaches 9. Diverticulitis - [**11/2187**] 10. Orthostatic hypotension and micturition syncope 11. Dysphagia, negative barium swallow in [**2164**], both liquids and solids EGD shows pulsatile extrinsic compression from aberrant subclavian artery and possible left-sided aortic arch 12. Glaucoma, at least from [**2175**], blind in left eye. 13. Osteopenia 14. Collagenous colitis, dx in [**2189**] 15. Hearing loss is marked, using bilateral hearing aids at home 16. Possible prior TIA. Patient presented to hospital in ? [**State 108**] several years ago with neurologic symptoms. He was told that he did not have a stroke. Per son. PAST SURGICAL HISTORY: 1. Status post drainage of abdominal abscess - [**10/2187**] 2. Status post removal of basal cell and squamous cell skin cancers 3. Status post appendectomy - Appendix was ruptured at the time of this surgery in [**2186**]. 4. Status post bilateral carpal tunnel repair Social History: Lives at [**Hospital3 **], [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]. Wife is 84. Son, [**Name (NI) **], is HCP and power of attorney. Smoked ~ 60 pack year. Smoked [**1-10**] ppd for ~50 years, quit [**2167**]. Rare EtOH. Family History: Father with coronary disease in 60s. Mother and brother with hypertension. His sister has hypertension and cancer of unknown origin. Physical Exam: Exam on admission: Vitals: 97.9 F 70 BPM 155/64 mmHg 18 breaths 98% 3L NC General Appearance: Comfortable, no apparent distress. HEENT: NC, OP clear, MMM. Neck: Supple. No bruits. Lungs: CTA bilaterally. Mild wheeze Cardiac: Irregular. Normal S1/S2. No M/R/G. Abdominal: Soft, NT, BS+ Extremities: Trophic changes throughout, most marked at ankles. Onychomycosis. GU: Foley in place. Neurologic: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, date and context. Language: Normal fluency, comprehension, repetition, naming. No paraphasic errors. Cranial Nerves: I: Not tested. II: Right pupil, round and reactive. Left pupil irregular and fixed at about 5 mm, distended scleral vessel at limbus of [**Doctor First Name 2281**]. Visual fields are full to confrontation on the right and, the left eye is blind. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. Mouth appeared asymmetric due to denture. VIII: Hearing diminished bilaterally. IX, X: Palatal elevation symmetric. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Posture normal and no truncal ataxia. Tone normal in arms, mildly increased in both legs. Power D B T WE WF FE FAb | IP Q H AT G/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 938**] TF R 4 4+ 4- 0 0 0 0 | 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 | 5 5 5 5 5 5 5 Reflexes: B T Br Pa Ac Right 1 1 0 0 0 Left 1 1 0 0 0 (reenforcement not attempted) Toes up on left and down on right. Sensation intact to light touch, pinprick bilaterally, but mildly diminished over right hand. Vibration, joint position mildly impaired at feet. Normal finger nose on left, normal [**Doctor First Name 6361**] on left (feet not tested). Gait: Deferred. Pertinent Results: [**2190-6-7**] 03:43PM BLOOD WBC-10.2 RBC-3.89* Hgb-11.2* Hct-34.7* MCV-89 MCH-28.8 MCHC-32.2 RDW-16.1* Plt Ct-211 [**2190-6-7**] 12:40PM BLOOD PT-13.3 PTT-24.1 INR(PT)-1.1 [**2190-6-8**] 02:40PM BLOOD Fibrino-483* [**2190-6-7**] 12:40PM BLOOD Glucose-124* UreaN-29* Creat-1.3* Na-145 K-4.2 Cl-109* HCO3-25 AnGap-15 [**2190-6-7**] 04:18PM BLOOD %HbA1c-6.2* eAG-131* [**2190-6-7**] 03:43PM BLOOD Triglyc-62 HDL-25 CHOL/HD-2.4 LDLcalc-24 EKG: Sinus rhythm with atrial premature beat and ventricular premature beat. Left bundle-branch block. Since the previous tracing of [**2190-1-24**] intra-atrial conduction delay is less prominent and further intraventricular conduction delay is present. CT head: No acute intracranial process. Specifically, there is no CT evidence of a large vascular territorial infarction, although MRI is a more sensitive test to rule out acute ischemia or infarction, particularly in the setting of extensive chronic small vessel ischemic disease. There are scattered, tiny, punctiform calcifications, superficially located in the sulci of the right cerebral hemispheres (e.g. 2:12), likely representing old healed neurocysticercosis. MRI of head: 1. Numerous bilateral, left greater than right, cortical infarcts, acute. 2. No evidence of hemorrhage. 3. Moderate atherosclerotic involvement of the vessels of the head and neck, particularly of the proximal left internal carotid artery. Echocardiogram: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with basal inferior akinesis and hypokinesis of the inferolateral and lateral walls. There is milder hypokinesis of the remaining segments (LVEF = 35%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. 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. There is mild pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. The main pulmonary artery is dilated. There is no pericardial effusion. IMPRESSION: Moderate regional left ventricular systolic dysfunction, c/w CAD (LCx distribution). Mild aortic regurgitation. Moderate mitral regurgitation. Mild pulmonary hypertension. Compared with the report of the prior study (images unavailable for review) of [**2183-3-3**], LV function has significantly deteriorated (although on the left ventriculogram from [**2-/2183**] the LV function appears to be similar to today's echocardiogram). Brief Hospital Course: Mr. [**Known lastname 6359**] is an 86 year-old right-handed man with a history of hypertension, CAD s/p stents x 6, cardiac arrhythmia, prostate cancer with pelvic recurrence and possible metastasis, collagenous colitis, and dysphagia who developed right upper extremity weakness (most prominent in the distal extremity) and dysarthria on the day of admission. He received tPA approximately 3 hours after the onset of his symptoms. Head CT did not demonstrate an acute intracranial hemorrhage, but head MR revealed numerous acute, bilateral, cortical infarcts, particularly in the area of the left precentral gyrus. The patient's history and examination were consistent with a cortical stroke, resulting in a "cortical hand" and mild dysarthria. Echocardiogram did not demonstrate thrombi, vegetations, or other masses, though there was moderate regional LV systolic dysfunction. EKG was notable for atrial and ventricular premature beats with LBBB, and telemetry revealed PVCs and runs of ventricular tachycardia. Given the frequent PVC's and non-sustained Vtach's, cardiology was consulted who recommended titrating up metoprolol as tolerated and restarting low dose lisinopril once safe from stroke perspective. He was also recommended to maintain K+ > 4.0 and Mg2+ > 2.0. Due to the bilateral nature of the infarcts and the presence of cardiac arrhythmias, the stroke was likely caused by thromboemboli of cardiac origin. There may have been contributions from hypercoagulability of inflammation (collagenous colitis) and dehydration. While hospitalized, the patient underwent swallowing evaluations, which revealed small amounts of aspiration while swallowing. As a result, he was kept NPO and received home medications and enteral nutrition through a Dobhoff tube. After a follow-up swallowing evaluation suggested advancement to PO nectar-thick liquids and soft solids, his PO diet was advanced appropriately, and his Dobhoff tube was removed. Due to worsened shortness of breath, he also received albuterol nebulizers q6h prn with improvement in his breathing as well as furosemide boluses. Per family, his dyspnea has been long-standing and does not appear to have any clinical correlates including CXR and O2 saturation. During his stay, Mr. [**Known lastname 6362**] dysarthria mostly resolved, though he continued to have distal right upper extremity weakness at the level of the wrist and fingers. Given the bilateral infarcts consistent with embolic strokes, Coumadin was discussed with family and he was started on Coumadin with aspirin bridging. Patient's aspirin should be discontinued once Coumadin therapeutic with INR > 2.0. Also, given the [**Doctor Last Name 6056**], he was started on low dose Simvastatin 10mg once daily. Patient was also found to have urinary tract infection on [**6-14**] and was started on ciprofloxacin. Given that this is a complicated UTI, he will be treated with 10 days of ABX. He will be following up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] (neurologist) as an outpatient. Medications on Admission: - Lupron injections, every four months, last on [**2190-4-26**] - Levothyroxine 25 mcg - ASA 81 mg - Lisinopril 2.5 mg - Bisacodyl 10 mg PR PRN constipation - Loperamide 2 mg QD PRN diarrhea - APAP 1000 mg Q8H PRN pain - Milk of Mag., PRN - Fleets enema PRN - Toprol XL 100 mg QD - Vitamin D3 800 U QD - Cholestyramine 4 g QD - Simvastatin 20 mg QD - Travatan 0.004 % OD QD - Ca Carbonate 500 mg chew TID - Colace 100 mg QD Discharge Medications: 1. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a day). 2. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 4. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for pain or fever. 5. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. therapeutic multivitamin Liquid Sig: One (1) Tablet PO DAILY (Daily). 7. budesonide 3 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO TID (3 times a day). 8. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days: Please stop once patient's INR > 2.0 and Coumadin therapeutic. 10. cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO DAILY (Daily). 11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath. 12. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 13. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): Goal INR 2~3 and please stop ASA once INR > 2.0. 15. metoprolol tartrate 25 mg Tablet Sig: 2.5 Tablets PO BID (2 times a day). 16. ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 9 days: started on [**6-14**] for UTI. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**] Discharge Diagnosis: Stroke - embolic strokes likely from cardiac arrhythmia 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). Neuro deficit: Patient has unreactive left eye. Mild dysarthria and complains of dyspnea but this is chronic. R hand weakness - wrist extenstion [**2-13**] and some flexion of fingers but "cortical hand." Discharge Instructions: You were admitted to the hospital as "code stroke" for acutely weakened right hand and slurring of speech. Given the acute presentation and NIHSS score of 4, he received IVtPA and was initially admitted to the ICU. His MRI showed multiple, bihemispheric strokes likely embolic etiology. He was monitored on telemetry which showed multi-focal atrial tachycardia and PVC's hence cardiology was also consulted who recommended titrating up metoprolol as tolerated. Given the embolic strokes, Coumadin was discussed with the patient and family and he was started on Coumadin with ASA bridging this admission. ASA should be discontinued once Coumadin therapeutic (INR 2~3). He was also found to have urinary tract infection during this admission and was started on ciprofloxacin 500mg once daily on [**6-14**]. Patient is returning to [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] where he resided before admission and will receive physical and occupation therapy. Followup Instructions: Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], neurologist who oversaw your care during this admission on [**2190-8-17**] 2:30 pm [**Hospital Ward Name 23**] [**Location (un) 858**], [**Hospital 878**] Clinic Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD,PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 22**] Date/Time:[**2190-7-29**] 10:00 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6353**], LPN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2190-7-29**] 10:30 [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**] Completed by:[**2190-6-14**]

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Discharge summary

report

Admission Date: [**2175-9-4**] Discharge Date: [**2175-9-21**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 425**] Chief Complaint: Ventricular Tachycardia Pericardial Effusion Major Surgical or Invasive Procedure: Pericardial window Chest Tube Placement EP Study History of Present Illness: Patient is an 83 yo man with pmhx CAD s/p multiple stents, Afib, CHF with EF 15-20% s/p prophylactic AICD [**2173**], HTN, hyperlipidemia who was transferred from [**Hospital3 **] for VTac ablation. Patient initially presented to [**Hospital3 **] [**5-6**] with slow stable VT and again [**2175-8-25**] with recurrent VT with rates 140s. At that time, he was symptomatic with diaphoresis, generalized weakness, malaise and dizziness. Denies syncope or presyncope, cp, abd pain, nausea, vomiting, palpatations. He was at that time started on amiodarone which was subsequently stopped for an acute rise in LFTs. In addition, patient noted to have pericardial effusion and underwent pericardial window at [**Hospital3 **]. During his stay at [**Hospital3 **], patient had several episodes of VT and was subsequently transferred to [**Hospital1 18**] today for VTac ablation. During the procedure, extensive mapping was done and the earliest activation was found to be -2 ms so it was deduced that the focus of VT was epicardial so ablation was not done. . On transfer to CCU, initial vs were T 97.8 BP 108/64 (baseline BP 80-90s systolic) HR 76 R 15 O2 sat 100% 5 liters. Patient reported that he felt well, denied dizziness, cp, sob, palp, n/v/abd pain. . At [**Hospital1 18**], chest tube (s/p pericardial window) was pulled and led to a right pneumothorax. Chest tube was re-inserted and pneumothorax resolved over two days. He subsequently developed episodes of nausea and diarrhea. C. diff was sent and found to be negative X 3. He also had episodes of hypoxia with O2 saturations in the low 80s. His blood pressure at times decreased to systolics in the 70-80 range. An echo taken on [**2175-9-13**] showed a larger pericardial effusion in comparison to an echo from [**2175-9-7**]. . He was subsequently taken to surgery on [**2175-9-14**] for a pericardial window for pericardial effusion and tamponade. Approximately 1250 cc of fluid was removed from the pericardium with some improvement in hemodynamics. Post-op, he was taken to the CSRU. Overnight in the CSRU, he has been on pressors to maintain hemodynamic stability. He had a couple of episodes of rapid ventricular response in the setting of his chronic afib. On [**2175-9-15**], he had drops in his Oxygen saturation to the 80s. . On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: VT CAD s/p multiple stents CHF with EF 15-20% pericardial effusion s/p pericardial window ICD [**3-/2173**] for primary prevention HTN hypercholesterolemia PVD Social History: Social history is significant for the absence of current tobacco use. Smoked [**6-4**] cig per day x 20 years and quit in [**2138**]. Occasional ETOH, few beers per month. No illicits Family History: Daughter died at 52 of arrythmia. No family history of CAD or cancer. Physical Exam: VS: T 97.8 , BP 110/64, HR 73, RR 15, O2 100 % on 5 liters Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Dry MM. Neck: Supple with JVP of 10 cm. CV: PMI displaced to left, midclavicular line. irregular, normal S1, S2. No S4, no S3. [**3-7**] HSM loudest at apex. Midline scar with drain- no erythema or drainage from incision site. Chest: anterior exam was clear to auscultation. No use of accessory muscles. Abd: +bs, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. DP and PT were dopplerable. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: [**2175-9-4**] 05:47PM TYPE-ART O2 FLOW-3 PO2-89 PCO2-46* PH-7.41 TOTAL CO2-30 BASE XS-3 [**2175-9-4**] 05:30PM GLUCOSE-123* UREA N-16 CREAT-1.0 SODIUM-135 POTASSIUM-4.8 CHLORIDE-99 TOTAL CO2-29 ANION GAP-12 [**2175-9-4**] 05:30PM estGFR-Using this [**2175-9-4**] 05:30PM WBC-7.3 RBC-3.99* HGB-12.8* HCT-38.4* MCV-97 MCH-32.2* MCHC-33.3 RDW-14.2 [**2175-9-4**] 05:30PM NEUTS-72.1* LYMPHS-15.4* MONOS-8.8 EOS-3.6 BASOS-0.1 [**2175-9-4**] 05:30PM PLT COUNT-190 [**2175-9-4**] 05:30PM PT-20.1* PTT-150* INR(PT)-1.9* Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2175-9-21**] 04:01AM 7.0 3.35* 10.8* 32.3* 97 32.4* 33.5 15.8* 219 [**9-21**] INR = 3.1 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2175-9-21**] 04:01AM 90 21* 1.1 139 3.9 94* 42*1 7 . [**2175-9-16**] The left atrium is markedly dilated. There is symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. LV systolic function appears depressed. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is severe mitral annular calcification. There is moderate thickening of the mitral valve chordae. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the findings of the prior study (images reviewed) of [**2175-9-13**], the pericardial effusion has been drained. PLEURAL FLUID: negative for malignant cells PERICARDIUM PATHOLOGY: Biopsy specimen shows chronic congestion and inflammatory changes. [**9-16**] Echo Summary: Conclusions: The left atrium is markedly dilated. There is symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. LV systolic function appears depressed. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is severe mitral annular calcification. There is moderate thickening of the mitral valve chordae. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. . [**9-17**] CXR FINDINGS: A single portable image of the chest is compared to the prior examination dated [**2175-9-15**]. Allowing for differences in technique, there is no significant interval change. The supporting lines are stable. A left chest tube is again noted at the left apex. No apparent pneumothorax is seen. Persistent bilateral pleural effusions are noted associated with bibasilar opacities. The cardiac silhouette remains enlarged. Mitral valve annular calcifications are again seen. There is perihilar fullness associated with loss of definition of the pulmonary bronchovasculature likely reflects underlying mild edema. Persistent subcutaneous emphysema is noted overlying the left chest wall. IMPRESSION: Stable examination as described above with no apparent pneumothorax. . C. Cath ([**9-13**]) COMMENTS: 1- Right heart catheterization was atttempted via the RIJ. Despite obtaining access instantly, the guidewire did not advance into the SVC, suggesting possible RIJ occlusion. 2- We then performed the RHC via R femoral vein access. Elevated filling pressures were noted with mPCWP of 22 mmHg. 3- Moderate pulmonary arterial hypertension (57/37 mmHg). 4- Preserved cardiac index (2.33 ml/min/m2). FINAL DIAGNOSIS: 1. Elevated filling pressures. 2. Preserved cardiac index. . Liver Gallbladder US ([**9-8**]) IMPRESSION: 1. Normal liver echotexture, without a focal lesion seen. However, cirrhosis cannot be entirely excluded by ultrasound. There is no evidence of portal hypertension. 2. The gallbladder contains several shadowing stones and sludge. 3. Cyst at the upper pole of the right kidney. 4. Bilateral pleural effusions. . CT Chest ([**9-6**]) IMPRESSION: 1. Moderate to large pericardial effusion, nonhemorrhagic by measurement with possible right failure. 2. Pulmonary hypertension. 3. Severe coronary artery disease. Marked left more than right atrial enlargement. 4. Bilateral right more than left pleural effusion with loculated right basal hydropneumothorax. The chest tube position is not optimal for its evacuation. 5. Left breast soft tissue mass. Further evaluation with dedicated imaging is recommended for differentiation of assymetric gynecomastia from neoplastic disease. 6. Subpleural left more than right anterior upper lobe interstitial abnormality which might represent either early stages of interstitial disease or sequela of breast treatment (if obtained). 7. Small amount of intraperitoneal fluid. 8. Tubular soft tissue mass in the anterior upper abdominal wall most likely represents sequela of remote pericardial drain. . PORTABLE ABDOMEN, 10:10 AM ON [**9-10**] HISTORY: CHF, now with nausea, vomiting, and diarrhea. IMPRESSION: AP abdomen reviewed in the absence of prior abdominal images: The colon is moderately distended and appears to be displaced superiorly, both the cecum, and a portion of the transverse colon or splenic flexure. The small bowel is not dilated. Clinical and radiologic followup is recommended to exclude possibility of developing torsion. Findings were discussed by telephone with Dr. [**Last Name (STitle) 15750**] covering for Dr. [**Last Name (STitle) **] at the time of dictation. . Brief Hospital Course: 83 year old male with CAD, CHF (ef 15-20%), prophylactic ICD [**2173**], and ventricular tachycardia presented to [**Hospital1 18**] from [**Hospital1 **] after a pericardial window procedure to treat refractory pericardial effusion. At [**Hospital1 18**], he was evaluated for VT ablation which did not find an endocardial focus---thus, concluding focus was most likely epicardial. Also found to have recurrent pericarial effusion, pleural effusions, hypoalbuminemia. He had no further episodes of ventricular tachycardia, but did remain in chronic atrial fibrillation. He had transient episodes of hemodynamic instability as well low oxygen saturation. He also had a right pneumothorax after chest tube removal ([**2175-9-4**]) which resolved after re-inserting a chest tube. In the CCU, he developed a worsening pericardial effusion with tamponade physiology. He was then taken for surgery for a new/revised pericardial window. He recovered in the Cardiac surgury recovery unit, and was transferred to the CCU for further care. During his second CCU stay, he was hemodynamically stable and had oxygen saturation in the high 90s on room air, and was subsequently transferred to the general floor. . CARDIAC #RHYTHM / VT No recent sustained ventricular tachycardia on amiodarone + mixelitine. His liver function panel was flat, thus no evidence of amio induced LFT abnormality. He remained in chronic afib with a ventricular rate near 100. Patients primary cardiologist was contact[**Name (NI) **] and updated prior to discharge. - For rate control, beta blockade was increased to (Metoprolol 50 mg PO BID). - He was started on amiodarone (goal > 10g) at a dosage of 200 mg [**Hospital1 **]. After [**10-19**], his amiodarone should be changed to 200 mg daily. - He was also started on mexelitine, 150 mg (TID), which should be discontinued by [**10-2**]. - He remained on digoxin - ICD in place for pacing and defibrillation; set for rate correction / overdrive pacing when HR > 120 bpm - He has chronic atrial fibrillation. Warfarin 1.5 mg PO HS was held at the time of discharge because of a high INR. His INR should be checked so that coumadin can be restarted once he reaches an INR < 2.0. - His electrolytes were continuously checked and repleted. Please check magnesium and potassium and replete as needed. . #ISCHEMIA / CAD He has a history of cad s/p stenting. A recent cath [**8-28**] is without evidence of new treatable stenosis. Metoprolol and statin was continued. Ace-inhibitor was held due to low blood pressures. Metoprolol was continued for rate control benefits in the setting of chronic atrial fibrillation and rapid ventricular response, and to prevent ICD firing in response to rapid afib. . #PUMP / CHF Likely ischemic cardiomyopathy, however mixed myopathy possible given EF is decreased out of proportion to CAD. At the time of discharge, respiratory status improved as he had an O2 sat in the 90s on room air. However, he had persistent lower extremity edema (to his knees) and an elevated JVP. - He was continuously diuresed with a final lasix dose of 40 mg PO BID. Please follow daily weights. . #Pericardial Effusion Unknown etiology. Extensive workup at [**Hospital3 **]. Now S/P pericardial window with 1250 cc removed at [**Hospital1 18**]. Echo of [**9-16**] shows no evidence of new pericardial effusions. Cytology and Culture of pericardial fluid was negative for bacteria, fungus, AFB. - He will be followed by CT surgery for wound care of left chest tube site. In the interim, dry sterile strips should be applied. Wound sutures will be resorbed/fall off without need for removal. - He was previously on colchicine to treat the effusions, but this was discontined as he began to develop nausea and vomiting. . #Lower Extremity Edema He has had persistent Lower extremity edema that did not resolve, but did slightly improve by day of discharge. The etiology is unclear but may be secondary to heart failure, hypoalbuminemia, or vascular/lymphatic disease. - Continue diuresis with lasix, and DVT prophylaxis . #Pneumothorax He had a pneumothorax from ([**2175-9-4**]) after right chest tube removal. A right sided chest tube was reinserted with subsequent resolution of the pneumothorax. This chest tube was removed several days later without complication. In addition, he had a left sided chest tube placed at time of repeat pericardial window. A chest x-ray from ([**9-17**]) shows no evidence of pneumothorax following left chest tube removal. . #Diarrhea/nausea He had transient episodes of diarrhea and vomiting after starting colchicine treatment. C. diff test was negative, and colchicine was discontinued. - speech and swallow test for nausea and swallowing difficulty recommened thin liquids and soft solids as tolerated. . #PVD He has a history of atherosclerosis that is secondary to hyperlipidemia. Peripheral pulses were dopperable bilateral (DP/PT). Aspirin and statin were continued. . #Skin care/decubutus - evaluated by wound care nurse [**First Name (Titles) **] [**Last Name (Titles) **]n for decubutus. Recommendations are as follows: pressure relief, turning and repositioning every 1-2 hours, heels off bed surfaces at all times, limit sit time to one hour at a time and sit on a pressure relief cushion, 4" foam. Elevate LE's while sitting, moisturize lower extremities and feet with Aloe Vesta Moisture Barrier Ointment. Foam cleanser to perianal tissue, coccyx, scrotum, medial thighs. Pat tissue dry. Apply a thin layer of citric acid clear to the intergluteal and right gluteal ulcer daily and prn. Apply antifungal citric acid clear ointment to the scrotum, medial groin and thighs daily and prn. . #ACCESS On the day of discharge, his PICC line was discontinued. He had a foley catheter removed on the day of discharge. . #FEN Hypoalbuminemia- now on cardiac diet. -Speech and swallow evaluated patient and recommended thin liquids and soft solids. -K and Mg repleted as necessary . #Ppx -continue ranitidine, restart coumadin once INR is therapeutic as it is currently being held as his INR was supratherapeutic. . Code: Full . Medications on Admission: CURRENT MEDICATIONS: toprol xl 150 mg [**Hospital1 **] digoxin 250 mcg alt with 125 mcg qd lasix 20 mg qd lisinopril 5 mg QD colchicine aldactone 25 mg qd zocor 25 mg qd coumadin Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours): discontinue this medication on [**2175-10-2**]. Disp:*60 Capsule(s)* Refills:*0* 4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*6* 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): please continue at 200 MG [**Hospital1 **] until [**10-19**], and then change to only 200 MG Daily. Disp:*60 Tablet(s)* Refills:*6* 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*6* 8. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*6* 9. Digoxin 125 mcg Tablet Sig: one half Tablet PO once a day: please take 0.0625mg daily (one half of a pill daily).* Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary Diagnosis:Pericardial effusion, Ventricular Tachycardia . Secondary Diagnosis:Congestive Heart Failure, Pleural Effusions, Lower Extermity Edema, Acute renal failure Atrial fibrillation Diarrhea Discharge Condition: Fair Discharge Instructions: Please take all medications as directed, a complete list is enclosed with this paperwork. . You were admitted to the hospital because of an abnormal heart rhythm called Ventricular tachycardia. This rhythm was evaluated in the electrophysiology lab but it could not be ablated. You were started on amiodarone and mexiletine in order to prevent this heart rhythm. Continue to take these medicines as directed. The amiodarone dose should be decreased to 200mg daily on [**2175-10-19**]. You should stop taking mexiletine on [**2175-10-2**]. You will follow up with Dr. [**First Name (STitle) 2572**] who will advise you further about treatment for this rhythm. . You are on a medicine called coumadin, your INR (blood test to measure coumadin level) should be checked frequently and the dose of this medication should be adjusted accordingly. . In addition, you had a pericardial effusion (fluid in the heart sac), this fluid was drained by opening up the sac (similar to the minor surgery that you had before you came to this hospital). In addition you had a chest tube placed on the left side at the time of the pericardial window to help drain the fluid. Please apply dry sterile dressings to left chest tube wound site. You have absorbable sutures and steri-strips on your left chest from the pericardial window, please allow the strips to fall off on their own. The sutures underneath will absorb on their own. . You were evaluated by speech and swallow while you were in the hospital. They recommend that you follow a diet that is soft solids and thin liquids. . You have a pressure sore on your buttocks. You were evaluated by the wound nurse in the hospital. They recommended pressure relief, turning and repositioning every 1-2 hours, heels off bed surfaces at all times, limit sit time to one hour at a time and sit on a pressure relief cushion, 4" foam. Elevate LE's while sitting, moisturize lower extremities and feet with Aloe Vesta Moisture Barrier Ointment. Foam cleanser to perianal tissue, coccyx, scrotum, medial thighs. Pat tissue dry. Apply a thin layer of citric acid clear to the intergluteal and right gluteal ulcer daily and prn. Apply antifungal citric acid clear ointment to the scrotum, medial groin and thighs daily and prn. . If you have any signs of chest pain, shortness of breath, high fevers, significant diarrhea/vomiting, weight gain, worsening leg swelling, blood in your urine, loss of conciousness, light-headedness please contact your physician [**Name Initial (PRE) 2227**]. Followup Instructions: EP (Dr. [**Last Name (STitle) 2232**] [**2175-10-6**] at 3:00pm. Office is in [**Hospital1 **], building [**Apartment Address(1) **]. Phone #[**Telephone/Fax (1) 5985**] . Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] (Cardio-thoracic Surgery) [**2175-10-4**] 2PM, Phone # [**Telephone/Fax (1) 170**] . Completed by:[**2175-9-21**]

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icd9cm

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[ "37.12", "34.04", "37.34", "37.21", "38.93", "37.27" ]

icd9pcs

[ [ [] ] ]

17119, 17198

9588, 15700

305, 356

17446, 17453

4299, 7589

20033, 20382

3432, 3503

15930, 17096

17219, 17219

15726, 15726

7606, 9565

17477, 20010

3518, 4280

221, 267

15747, 15907

384, 3031

17305, 17425

17237, 17285

3053, 3215

3231, 3416