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7,275	145,466	43639+58643	Discharge summary	report+addendum	Admission Date: [2131-8-12] Discharge Date: Date of Birth: [2078-11-11] Sex: M Service: Medicine HISTORY OF PRESENT ILLNESS: The patient is a 52 year old male with a history of idiopathic glomerulonephritis, status post renal transplant times two, most recent in [2128], seizure disorder (on Depakote), status post subtotal parathyroidectomy, and hypertension (on Norvasc, labetalol) who was admitted for decreased urine output. This spring, he had had several episodes of acute renal failure and his creatinine had been drifting up. He had also developed profound hypocalcemia which suggested worsened renal function. For this reason, a renal biopsy was performed electively 5 days prior to admission. The biopsy was done under ultrasound guidance and was uncomplicated. He felt well and returned to work with strict instructions on heavy lifting restrictions for two weeks. On the first of [Month (only) ], he called his nephrologist, Dr. [Last Name (STitle) ], for a dramatic decrease in urine output over the course of that day with pain over the graft. He was sent urgently to the ER for evaluation and renal transplant ultrasound. The patient called his primary care physician, [Name10 (NameIs) 1023] referred him to the Emergency Room. In the Emergency Room, the patient was given morphine sulfate for pain and had increased potassium and was given D50, insulin, Kayexalate and calcium gluconate. For decreased urine output, the patient underwent straight catheterization with no urine output. The patient also had a renal ultrasound which showed a perinephric hematoma. PAST MEDICAL HISTORY: 1. Idiopathic glomerulonephritis, status post renal transplant times two, most recent in [2128]. 2. Seizure disorder, diagnosed at age ten with both [Doctor Last Name 11332] mal and grand mal seizures. 3. Subtotal parathyroidectomy. 4. Hypertension. 5. Lactose intolerance. FAMILY HISTORY: There is no family history of renal disease. SOCIAL HISTORY: The patient does not use alcohol. He smoked three to four packs per day times years but not currently. The patient is a retired broadcaster. He is divorced with two children. ALLERGIES: Penicillin (rash), Tegretol and intravenous contrast. MEDICATIONS ON ADMISSION: Labetalol 300 mg p.o.b.i.d., Norvasc 100 mg p.o.q.h.s., Prednisone 5 mg p.o.q.d., Prograf 2 gm p.o.q.a.m. and q.p.m., Lasix 40 mg p.o.q.d., Depakote 750 mg p.o.b.i.d., Prevacid, calcium 500 mg p.o.b.i.d., Rocaltrol 0.25 mg p.o.q.d.. PHYSICAL EXAMINATION: On physical examination on admission, the patient's weight was ([2131-8-5]) was 168 pounds, blood pressure 175/79, oxygen saturation 100% in room air. General: Patient appeared somnolent but easily arousable. Head, eyes, ears, nose and throat: Pupils equal, round, and reactive to light and accommodation. Neck: Carotid bruits, right greater than left, positive jugular venous distention 6 to 7 cm. Chest: Clear to auscultation bilaterally but poor effort. Cardiovascular: Regular rate and rhythm, positive II/VI systolic ejection murmur. Abdomen: Pain on palpation, positive bowel sounds. Extremities: No cyanosis, clubbing or edema. Genitourinary: Foley catheter in, no urine output noted. Neurologic examination: Somnolent but alert and oriented times three, grossly nonfocal. LABORATORY DATA: Electrocardiogram: Normal sinus rhythm at 60 beats per minute, left axis, left ventricular hypertrophy, T wave slightly peaked in V3 through V6, slight ST depressions in V5 and V6, I and AVL which are less than 0.5, noted in the past. White blood cell count was 7.3 with 67% neutrophils, 20% lymphocytes, 13% monocytes and 0.3% eosinophils, hematocrit 29.2, platelet count 159,000, MCV 91, prothrombin time 13.1, partial thromboplastin time 31.5, INR 1.1, sodium 137, potassium 6, chloride 103, bicarbonate 18, BUN 73, creatinine 4.2, baseline 1.5 to 2.6, glucose 104, anion gap equals 16, calcium 7.5, albumin 4.1, corrected calcium 7.5, phosphorous 6.5 and magnesium 1.8. Renal ultrasound on [2131-8-7] after biopsy: No hydronephrosis, no stones, positive cysts, no fluid collections, no abnormal resistive index. Results of biopsy on [2131-8-7]: No globally sclerotic glomeruli, mild mesangial prominence and proliferation, mild glomerulitis, positive patchy interstitial fibrosis, positive tubular atrophy, positive chronic inflammation, positive intimal fibroplasia in arterioles, positive single focus of epitheliitis; impression, consistent with chronic transplant nephropathy but endothelitis s is concerning for cellular rejection. A renal ultrasound from [2131-8-12]: Impression (1) perinephric hematoma with mass effect on the transplant kidney; (2) elevated arterial velocities with reversal of diastolic flow, no venous flow identified, findings consistent with renal vein occlusion, likely secondary to tamponade caused by hematoma, rather than primary thrombosis. HOSPITAL COURSE: In summary, the patient is a 52 year old male with a history of idiopathic glomerulonephritis, status post renal transplant in [2122] and in [2128], complicated by recent acute renal insufficiency felt secondary to diuretic use and diarrhea but with continued renal function decline since [2131-5-13], status post renal biopsy [2131-8-7] consistent with chronic cellular rejection and complicated by hematoma. Increased abdominal pain was noted on [2131-8-12] and patient became anuric. The patient required admission on [2131-8-13] for further workup and treatment. After hospitalization, the patient remained anuric and required urgent hemodialysis for an increased potassium. The patient required dialysis daily during the first week of admission. Ultimately, the patient underwent partial evacuation of the hematoma on [2131-8-14], which was complicated by a change in mental status, felt secondary to narcotics. The day after surgery, the patient experienced a respiratory acidosis, requiring admission to the Surgical Intensive Care Unit. Given a decreased blood pressure of 85/40 and a white blood cell count of 28, there was also concern for a postoperative sepsis, but blood cultures have remained negative to date. In the Surgical Intensive Care Unit, the patient was treated with Narcan and BIPAP. It was felt that the patient had improved mental status and arterial blood gases. His course was complicated by a decreased calcium, requiring several ampules of calcium gluconate supplement, and by a gradually falling hematocrit. The patient was placed on Levaquin and clindamycin times two days but was these were discontinued when blood cultures remained negative. He had no urine output despite a Lasix challenge, except for 0.5 cc, which did not reveal white blood cell casts on examination. On [2131-8-19], the patient was afebrile and was hemodynamically stable. The patient was deemed stable for transfer back to the medicine team. On arrival to the floor, the patient seemed somewhat lethargic although arousable. He was oriented times three and complained of mild abdominal pain, but denied chest pain, shortness of breath or fever. Since [2131-8-19], the patient has remained hemodynamically stable but has had no change in mental status since arriving from the Surgical Intensive Care Unit. The patient had symptoms of delirium and, as reported by his son, has been seen talking to nonexistent people and experienced other hallucinations. The patient has been noted to have periods of being lucid but, otherwise, is not oriented to time or place or person. At this time, a magnetic resonance imaging scan of the head with gadolinium was attempted but the patient was combative during the examination and was sent back to the floor. It was felt that sedation at this point would be unwise, as the patient has been lethargic since admission. It was felt that the risks of putting the patient in respiratory acidosis again would outweigh the benefits of the magnetic resonance imaging scan at this time. A CT scan was done to rule out any mass lesions or effect and it was noncontributory. A lumbar puncture was deferred at this time because, since admission from the Surgical Intensive Care Unit, the patient has had decreased platelets, to a low of 70,000, and has possible uremic platelets since his BUN and creatinine have remained elevated. It was felt that, since the patient had been on antibiotics, a lumbar puncture would give low yield information. There was concern that the change in mental status was secondary to infection. Chest x-rays done on [8-17] and 9, [2131] showed opacities at the right medial lung base and left lower lobe. This could represented atelectasis and/or pneumonia. The patient was started on ceftriaxone 1 gram daily and Flagyl 500 mg three times a day for a possible aspiration pneumonia or hospital acquired pneumonia. The patient also had a urine culture which revealed Enterococcus, greater than 100,000 colonies, found sensitive to ampicillin, levofloxacin, nitrofurantoin and vancomycin. The patient was therefore started on intravenous ampicillin 1 gram, to be dosed with hemodialysis. At the time of this dictation, the patient has not had significant improvement in his mental status. It is unclear whether narcotics are still playing a role at this point as it has been a prolonged course since his Surgical Intensive Care Unit admission. Also during this hospitalization, the patient's blood pressure has been less well controlled. His average blood pressure has been from the 130s to 190s. Therefore, the patient was restarted on Norvasc 5 mg, which had been discontinued during his Surgical Intensive Care Unit admission because of hypotension. At the time of dictation, the patient's blood pressure has been still elevated. Of note, neurology was consulted during this hospitalization, and has been following this patient. An electroencephalogram was done on [2131-8-21], with the following impression: Abnormal electroencephalogram due to infrequent generalized epileptiform discharges and due to slow and disorganized background and bursts of generalized slowing; the first abnormality includes the potential for generalized seizures, but secondary generalization from a focus cannot be excluded; the slow and disorganized background and bursts of generalized slowing indicate the wide spread encephalopathy condition affecting bot cortical and subcortical structures; medications, metabolic disturbances and infection are among the most common causes; there were no focal abnormalities evident. The neurology consult at this time felt that the patient was most likely experiencing a toxic metabolic encephalopathy. Seizures were less likely. Also during the hospitalization, it was noted that the patient was becoming thrombocytopenic. The differential diagnosis at this time included thrombotic thrombocytopenic purpura, DIC, liver dysfunction, drugs, infection, dilutional effects, vitamin B12/folate deficiencies or possible component of transplant rejection. Thrombotic thrombocytopenic purpura was ruled out by examining the blood smear, which showed no schistocytes. There was also felt to be other causes for the patient's renal failure, change in mental status, fevers. It was felt that the patient was not in DIC because all coagulation panels have been within normal limits thus far. Liver dysfunction was also not a strong possibility because liver function tests and coagulation studies were within normal limits to date. It was thought that perhaps heparin might be contributing to the thrombocytopenia as the patient was still receiving heparin flushes through his central venous line. This was discontinued on [2131-8-22]. There was also a question of whether the patient had [Doctor Last Name 3271]-[Doctor Last Name ] virus or cytomegalovirus causing a viral suppression of bone marrow production. It was also noted that both CellCept and Viramune could cause thrombocytopenia, as well as Depakote. As of this dictation, the platelet count has remained stable at 82,000. An addendum will be dictated at a later date, which include the patient's discharge medications and subsequent hospital course. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 15463], M.D. [MD Number(1) 15464] Dictated By:[Last Name (NamePattern1) 218] MEDQUIST36 D: [2131-8-25] 12:20 T: [2131-8-26] 11:48 JOB#: [Job Number 93827] Name: [Known lastname 14821], [Known firstname 1080] W Unit No: [Numeric Identifier 14822] Admission Date: [2131-8-12] Discharge Date: [2131-9-6] Date of Birth: [2078-11-11] Sex: M Service: ADDENDUM: Mr. [Known lastname ] remained stable throughout the remainder of his hospital course. Please see the previously dictated discharge summary by Dr. [First Name8 (NamePattern2) 14823] [Last Name (NamePattern1) ] for details of the bulk of the hospital course. Renal: The patient continued to have Monday, Wednesday, Friday dialysis without complications. He is to have follow-up with Dr. [Last Name (STitle) ], his nephrologist, as an outpatient. He has to continue dialysis at the [Hospital1 ] Center. ID: The patient was treated in the hospital for an Ampicillin sensitive urinary tract infection with IV Ampicillin. He will be discharged on Ampicillin 500 mg po times three days. Blood, urine and central venous catheter tip cultures drawn subsequent to the urinary tract infection showed no growth. Neuro: Mr. [Known lastname ]' mental status gradually improved such that he was at baseline at discharge, speaking coherently, fully interactive and with good eye contact. Nutrition: The patient gradually tolerated increasing oral intake. By the day before discharge his appetite had improved significantly. He is encouraged to discharge to continue po intake. Physical therapy/ Occupational therapy: The patient is to continue PT/OT therapy on discharge to increase his strength and recovery capacity. DISCHARGE MEDICATIONS: Ampicillin 500 mg po bid times three days, Rapamune 3 mg po q d, Prednisone 5 mg po q d, Depakote 750 mg po bid, RenaGel two tablets po bid, TUMS 1,000 mg po tid, Rocaltrol 0.5 mcg po q d, Labetalol 300 mg po bid (hold for heart rate less than 60, systolic pressure less than 105). Colace 100 mg po bid prn, Senokot two tablets po q h.s. prn, Mycostatin powder applied to groin [Hospital1 ], Epogen 3,000 units IV q hemodialysis, Protonix 40 mg po q d, Tylenol 650 mg po q 4-6 hours prn fever and pain. DISCHARGE DIAGNOSIS: 1. Renal failure. DISCHARGE STATUS: Stable. DISCHARGE INSTRUCTIONS: Please continue good po intake and continue with Boost nutritional supplements. Continue physical therapy and occupational therapy. Continue hemodialysis. Follow-up with Dr. [Last Name (STitle) ]. The patient is to be discharged today to the [Hospital1 ] Center Rehabilitation facility. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 14824], M.D. [MD Number(1) 14825] Dictated By:[Last Name (NamePattern1) 30] MEDQUIST36 D: [2131-11-19] 19:37 T: [2131-11-22] 10:55 JOB#: [Job Number 14826]	[ "287.4", "276.2", "293.0", "599.0", "998.12", "996.81", "584.5", "780.39", "486" ]	icd9cm	[ [ [] ] ]	[ "59.09", "39.95" ]	icd9pcs	[ [ [] ] ]							1959, 2005		14200, 14709		14730, 14778		2295, 2529	4990, 14176		14803, 15383																								2552, 3263																								149, 1629														3288, 4972		1652, 1942	2022, 2268
57,001	147,970	14302	Discharge summary	report	Admission Date: [2133-2-25] Discharge Date: [2133-3-25] Date of Birth: [2062-5-29] Sex: M Service: NEUROSURGERY Allergies: Biaxin Attending:[First Name3 (LF) 1271] Chief Complaint: Ataxia, confusion, emesis Major Surgical or Invasive Procedure: [2133-2-25]: VP shunt revision with new [Hospital1 5832] programmabel valve at 100 [2133-3-5]: Removal of entrie Right VP shunt and placement of new EVD [2133-3-18]: Placement of new Left VP shunt History of Present Illness: This is a physician who is known to service for previous placement of R VPS for treatment of hydrocephalus following a ruptured AVM. It was initially placed in [2126] but more recently revised on [2133-1-5] and [2133-1-13] by Dr. [Last Name (STitle) 739]. He presented to the ED with increased lethargy, ataxia, confusion and one episode of emesis. He is scheduled for a R VPS revision. Past Medical History: Right Frontal spongioform AVM s/p bleed in [2126] and s/p VP shunt(treated at BW). Static frontal lobe syndrome following AVM bleed. Has had problems with short term memory since the bleed. (followed in cognitive neurology clinic at [Hospital1 18] and as a cognitive therapist at [Doctor First Name 1191].)[2133-1-13] Revision of distal part of ventriculoperitoneal shunt and replacement of peritoneal catheter by Dr [Last Name (STitle) 739], Laparoscopic guidance of distal ventriculoperitoneal catheter by [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern1) ] [2133-1-13],Interrogation and revision of programmable ventriculoperitoneal shunt; removal and revision of proximal catheter; removal and revision of valve of ventriculoperitoneal shunt and replacement with programmable [Company 1543] valve, Strata/24/11 History of alcohol abuse Hyperlipidemia IVC filter placement [2126] Social History: Retired physician, [Name10 (NameIs) ] with wife, known short term memory loss, was receiving continuous cognitive therapy Family History: Congential AVMs Physical Exam: On Discharge: Awake, upgaze palsy, PERRL, MAE to command. Verbal intermittently, more with family and at times, responds more readily to Spanish. Sutures clean dry and intact. Pertinent Results: [2133-2-25] 07:25AM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.009 [2133-2-25] 07:25AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-NEG [2133-2-25] 06:48AM GLUCOSE-140* LACTATE-1.2 NA+-140 K+-4.0 CL--101 TCO2-26 [2133-2-25] 06:43AM UREA N-13 CREAT-1.0 [2133-2-25] 06:43AM CALCIUM-8.7 PHOSPHATE-2.6* MAGNESIUM-2.1 [2133-2-25] 06:43AM WBC-8.2 RBC-4.62 HGB-14.0 HCT-40.4 MCV-87 MCH-30.4 MCHC-34.8 RDW-12.7 [2133-2-25] 06:43AM NEUTS-72.5* LYMPHS-17.0* MONOS-6.3 EOS-4.0 BASOS-0.3 [2133-2-25] 06:43AM PLT COUNT-289 [2133-2-25] 06:43AM PT-12.9 PTT-22.3 INR(PT)-1.1 EKG [2133-2-25]: Sinus tachycardia. Borderline low precordial voltage in the precordial leads. Since the previous tracing of [2133-1-12] the rate is faster. Clinical correlation is suggested. Intervals Axes Rate PR QRS QT/QTc P QRS T 107 162 96 308/390 50 11 32 CT Head pre-op [2133-2-25]: 1. Right transfrontal ventricular catheter in place, with interval enlargement of the ventricles, most pronounced increase in the size of the third ventricle. 2. Stable appearance of known cavernomas involving the midbrain, as described on the recent MRI. CT Head [2133-2-25] post-op: 1. Following revision of the intraventricular shunt, there has been a decrease in the ventricular size as measured both across the frontal horns at the level of the caudate heads and at the level of the third ventricle. 2. Unchanged appearance of transependymal migration of CSF. 3. No evidence of intracranial hemorrhage. CT HEAD W/O CONTRAST [2133-3-5] Significantly increased ventriculomegaly since the prior scan three days ago. CT HEAD W/O CONTRAST [2133-3-5] Decrease in the size of the ventricles - post-placement of a new EVD. However, correlate clinically and follow up as clinically indicated for any complications. MRI Brain [3-6] - Increased hydrocephalus since the previous study 18 hours previously. There are no new infarctions. Otherwise, unchanged appearance of numerous susceptibility artifacts throughout the cerebrum, cerebellum and brainstem consistent with micro-hemorrhages or cavernomas CT Head [3-9] - Small focus of intraventricular blood in the right lateral ventricle unchanged since [3-6]. Ventricles are normal in size, no change to explain the patient's somnolence. Ct Head [3-10] - Normal ventricular size. Interval resolution of bilateral occipital [Doctor Last Name 534] intraventricular hemorrhages. Small amount of right frontal pneumocephalus, decreased CT HEAD W/ & W/O CONTRAST [2133-3-15] Small hyperdense focus within the left temporal [Doctor Last Name 534] most likely represents intraventricular hemorrhage which is new since [3-10], [2132]. LENIs [3-15] neg UE Nonvasive [3-15] - Upper extremity venous thrombosis involving the PICC containing right basilic and right axillary vein. CT head [3-18] - Ventricular size and resolution of intraventricular hemorrhage since prior study three days ago. Ct head [3-18] - s/p L VPS placement. New left frontal [Last Name (un) ] tract ICH. BILAT LOWER EXT VEINS [2133-3-20]-No DVT in either lower extremity BILAT UP EXT VEINS US [2133-3-20]- 1. Interval resolution of previously noted right axillary DVT. 2. The right basilic clot is intervally diminished in size. 3. No new DVT. [2133-3-20]: CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. [2133-3-22]:CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2133-3-23]): Feces negative for C.difficile toxin A & B by EIA. DC date labs: [2133-2-25] 10:21AM CEREBROSPINAL FLUID (CSF) PROTEIN-<6* GLUCOSE-91 [2133-2-25] 10:21AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* POLYS-0 LYMPHS-36 MONOS-8 EOS-3 OTHER-53 [2133-2-25] 07:25AM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.009 [2133-2-25] 07:25AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-NEG [2133-2-25] 06:48AM GLUCOSE-140* LACTATE-1.2 NA+-140 K+-4.0 CL--101 TCO2-26 [2133-2-25] 06:43AM UREA N-13 CREAT-1.0 [2133-2-25] 06:43AM CALCIUM-8.7 PHOSPHATE-2.6* MAGNESIUM-2.1 [2133-2-25] 06:43AM WBC-8.2 RBC-4.62 HGB-14.0 HCT-40.4 MCV-87 MCH-30.4 MCHC-34.8 RDW-12.7 [2133-2-25] 06:43AM NEUTS-72.5* LYMPHS-17.0* MONOS-6.3 EOS-4.0 BASOS-0.3 [2133-2-25] 06:43AM PLT COUNT-289 [2133-2-25] 06:43AM PT-12.9 PTT-22.3 INR(PT)-1.1 Brief Hospital Course: This is a 70 year old physician who came to the ER the morning of a previously scheduled VP shunt revision. He was lethargic and nauseas with worsening ataxia and he underwent a revision of the distal portion of the VP shunt. Post-operatively, he remained intubated and was then extubated in the PACU. His mental status continued to improve. He had a clear dinner without issue on [2-25] and on [2-26] he had bowel sounds and flatus. His diet was advanced. He later developed some increasing abdominal distention but his he had flatus and his belly was soft. Abdominal xray showed ileus and he was made NPO. His mental status continued to improve. However, he had an episode of emesis that evening and then again overnight requiring NG tube placement by general surgery. On [2-28], he had a loose BM in am and was advanced to sips- vomited x2, was switched back to NPO, and had an unremarkable UA for symptoms of urinary urgency. On [3-1] he had a repeat KUB which continued to show dilated small bowel and was transferred to the general surgery service for management of his ileus. On [3-2] Mr. [Known lastname ] had episodes of respiratory distress with an increased oxygen requirement. CXR appeared wet and he was given Lasix per the medicine team request. His NGT output was replaced on a 1:1 basis. Repeat head CT was stable from prior episode, without hydrocephalus. CT abdomen showed dilated small bowel with decompression in terminal ileum. He was taken to the OR on [3-3] by Dr. [Last Name (STitle) ] for abdominal exploration for obstruction vs. infection. On [3-5] he was found to be obtunded and was taken to radiology for a CT scan and was escorted by anesthesia. CT showed significant increase in ventricular size. He shunt was accessed at the bedside in the ICU and opening pressure was found to be 19 but the shunt was functioning well. An external drainage device was set attached to the shunt to drain CSF. His mental status improved but 1-2 hrs later he was again lethargic. Only 5 cc could safely be withdrawn from the shunt and he only minimally improved. He was taken to the OR emergently for removal of VP shunt and placement of a new antibiotic impregnated external ventricular drain. CSF was sampled from the valve in the OR and set for a CSF panel per ID. The entire VP shunt system was sent to microbiology per Dr. [Last Name (STitle) 739]. He was taken to the SICU intubated. His EVD was open at 5cm h20 Shortly afterwards, he was extubated in the SICU and was following commands. His post-op CT showed significant decrease in ventricular size and his drain was raised to 10cm H2O. Overnight, patient developed a limited R lateral gaze and was seen to be staring. EEG was ordered and to rule out seizure activity. On [3-6], patient was examined and he continued to have limited R lateral and upward gaze, he was also aphasic and not following commands as well as he has been in the past. He was seen to have a R UE tremor. His drain was dropped back to 0cm H20 to drain for 20cc and then EVD was raised to 5cm H2O. An MRI w/o contrast was ordered to rule out stroke and stroke neurology was consulted. EEG showed complex partial seizures and epilepsy team was consulted for appropriate management. He was to drain 400cc/day or 100cc/6hr, if goal is not met,the orders were to drop the drain to 0cc H2O and drain until goal is achieved, then raise back to 5cc H2O. His neuro checks were changed to Q2H. On [3-8], patient's exam remained stable, he was placed on Dilantin for his complex partial seizures and his level was 11.1. On [3-9], his EVD output was lower than the desired goal, his drain was dropped to 0 to drain 20cc then raised back to 5. A repeat head CT showed improvement of hydrocephalus and CSF was sent for vancomycin trough. Patient had lateral and upward gaze limitation, but was following complex commands. On [3-10], patient's exam much improved, alert and oriented to self and place with prompting, full strength, slight L drift. He passed a speech and swallow and could have a regular diet. His drain is periodically dropped to -5 to drain CSF to obtain goal of 400cc/day. CSF cultures remain negative to date. He improved neurologically. On [3-11] his daily goal of CSF drainage was dropped to 320cc/day. He continued to remain stable and his diet was advanced. He tolerated die without nausea or vomiting. On [3-12], he was transferred back to Neurosurgery service, Dr. [Last Name (STitle) 739] for planned internalization of VP shunt. ID consult recommended a repeat CSF culture to completely ensure that he has no evidence of meningitis. CSF as of [3-14] showed no evidence of growth. Additionally, his diet was advanced and he was on a regular diet without issues. On [3-15] he was lethargic throughout the day. He had a fever of 101.6F in the afternoon and a fever work up was initiated. CSF was sent from EVD. On [3-16], CT head showed slightly larger ventricles and small amount of IVH in L lateral [Doctor Last Name 534]. His daily goal from EVD drainage was increased to 360cc/day. EEG was also re-ordered to re-evaluate for seizure activity. LENS and cultures were sent to workup fever. LENS showed RUE blood clots in axillary and basilic veins. No heparin was started. PICC line for TPN administration located near clots and was removed. On [3-18]. patient was difficult to arouse during morning rounds. Although, 1 hours later he was much better given his neurological change in exam a head CT was obtained which demonstrated resolved IVH and small ventricles. On [3-18], patient under a left VPS. He tolerated the procedure well and was intubated without incident. Please review dictated operative report for details. He was transferred back to SICU for further management. Post-op CT showed placement of VPS. New Left frontal catheter tract ICH without significant mass effect. He was extubated without incident, pt remained stable. Subsequently, R EVD was removed in routine fashion on [3-19] and post pull CT showed stable ICH and decrease in ventricle size. On [3-20], his exam was more lethargic in AM, EO to voice and commands with BUE and wiggles toes. He was experiencing narrow complex tachycardia, cardiology was consulted and beta blocker was started. Patient also spiked fever to 102.5. He was pan cultured and LENS ordered. He was seen to have LUE rhythmic tremors, he was restarted on dilantin. Over the weekend, patient was found to have positive c.diff culture and fevers were thought to be from a combination of IV vancomycin and c.diff. He was started on Flagyl and vancomycin changed to oral medication. Cardiology recommendations were to start him on metoprolol 12.5 PO BID for tachycardia. On [3-23], patient was more alert, EO spontaneously, alert to self and following commands in all 4 extremities. He was transferred to step down unit. LENS were negative for new DVT and showed some resolution of the axillary and basilic clots in the RUE. On [3-24] he was stable and transferred to the floor. Flagyl was made po per ID. IT was decided that he should have a full two week course of these antibiotics. Tucks ointment was ordered for hemorrhoids. His Dobbhoff was found coiled din his mouth overnight and it was removed. On [3-25], he was following commands and moving his four extremities spontaneously. Calorie counts were continued and his calcium was repleted. He was tolerating a regular diet. He was medically cleared for rehab. Medications on Admission: Lipitor 40mg daily, Lexapro 10mgdaily, Wellbutrin 100mg qam, 150qpm Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: max 4 g/24 hrs. 2. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 3. pramoxine-mineral oil-zinc 1-12.5 % Ointment Sig: One (1) Appl Rectal TID (3 times a day) as needed for hemorrhoids. 4. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 7. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day): hold for SBP<110,HR<55 . 8. bupropion HCl 150 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO QAM (once a day (in the morning)). 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 10. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 2 weeks: Duration: 2 Weeks started [3-21] . 11. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO BID (2 times a day) as needed for agitation. 12. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 13. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 2 weeks: Duration: 2 Weeks started [3-21] . 14. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Hydrocephalus Ileus Urinary Retention Failed VP shunt Post-op Fever Aspiration pneumonia Right UE DVT basillic and cephalic veins Lethargy Left Frontal intracerebral hemorrhage C diff Discharge Condition: Mental Status: Confused - always. 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 have been removed. !!SUTURES SHOULD BE REMOVED ON [3-28]!! ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? You have been 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 rehab, but please have the results faxed to [Telephone/Fax (1) 87]. ?????? 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. !!If you need any antibiotic treatment in the next 12 months FOR ANY REASON, you should take oral Vancomycin and Flagyl during this treatment and one week after to prevent C diff!!! Followup Instructions: Please follow-up with Dr. [Last Name (STitle) 739] in one month with a Head CT. Please call Paresa at [Telephone/Fax (1) 1669] for this appointment [Name6 (MD) 742] [Name8 (MD) ] MD [MD Number(2) 1273] Completed by:[2133-3-25]	[ "789.59", "310.0", "568.0", "788.20", "560.1", "787.20", "780.62", "345.50", "348.30", "272.4", "331.4", "008.45", "996.2", "E879.8", "507.0", "431", "996.74" ]	icd9cm	[ [ [] ] ]	[ "02.2", "99.15", "02.43", "54.95", "54.51", "38.97", "02.34" ]	icd9pcs	[ [ [] ] ]	16067, 16137	6891, 14453	297, 512	16365, 16365	2319, 6868	18480, 18762	2089, 2107		14572, 16044		16158, 16344		14479, 14549			16547, 18457											2122, 2122																	2136, 2300							232, 259													540, 944										16380, 16523						966, 1929	1945, 2073
2,949	123,187	20849	Discharge summary	report	Admission Date: [2198-6-5] Discharge Date: [2198-6-6] Service: [Last Name (un) ] ADMISSION DIAGNOSIS: Pancreatitis. DISCHARGE DIAGNOSIS: Pancreatitis. HISTORY OF PRESENT ILLNESS: Mrs. [Known lastname 4587] is an 84 year old female who was admitted with vague abdominal pain on [2198-6-4], to an outside hospital - this hospital is the [Hospital ] Hospital in [Location (un) 620]. At this time, ultrasound revealed gallstones and pancreatitis. At this time it was decided to transfer the patient to [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ], the [Hospital 1426] Medical Cemter for Intensive Care Unit monitoring and possible further invasive management if necessary. PAST MEDICAL HISTORY: History of chronic urinary tract infection. Polymyalgia rheumatica. Osteoarthritis. Congestive heart failure. Lower gastrointestinal bleeding. Depression. MEDICATIONS: 1. Prednisone 15 milliunits po qd 2. Regular insulin 3. Synthroid 4. Protonix PHYSICAL EXAMINATION: The patient was hemodynamically stable and was afebrile. HEENT: Anicteric. No asymmetry. CVS: Regular rate and rhythm. No murmurs. Rubs and bruits. RESPIRATORY: Clear to auscultation bilaterally. ABDOMEN: Soft and nontender, nondistended. Hypoactive bowel sounds. EXTREMITIES: Trace edema bilaterally without calf tenderness. LABORATORY DATA: On admission lipase approximately 750. Significantly, creatinine of 1.3 initially. BRIEF HOSPITAL COURSE: The patient was admitted to the Intensive Care Unit for close observation and fluid resuscitation. A Foley catheter was used to monitor the patient's urine output. She was stable in Intensive Care Unit and received approximately 1500 cc of fluid boluses in addition to intravenous fluid at 150 cc an hour. She remained stable for the next 48 hours. Her laboratory values were significant for white blood cell count of 9.9, hematocrit of 35, platelet count of 270. Her potassium was low and this was repleted. Her lipase was 179 and her amylase 110. Her ALT and AST were 16 and 12 respectively with an alkaline phosphatase of 62. Her total bilirubin was 0.8. Her urinalysis revealed nitrites and urine culture revealed greater than 100,000 colonies of E. Coli. She was continued on all her regular medications and in addition was started on levofloxacin for her urinary tract infection. On her second hospital day, she had a Magnetic Resonance Cholangiopancreatography which revealed mild pancreatitis without necrosis or fluid collection. This also revealed multiple stones in the gallbladder. There was no common bile duct stone or bile duct dilatation. Chest x-ray was interpreted as being within normal limits. She was deemed stable and making good progress. She was tolerating clears in the afternoon of hospital 'Intensive Care Unit' day 2. At this point it was decided that the patient would be appropriate for the floor and her family was in agreement that it would be appropriate for her to be transferred back to the [Hospital 4068] Hospital for management on the [Hospital1 ]. This situation was discussed with the general surgical team taking care of the patient and it was decided to transfer the patient to the [Hospital 4068] Hospital at that time. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: Transferred to [Hospital 4068] Hospital floor. DISCHARGE DIAGNOSIS: Hypovolemia. Pancreatitis secondary to gallstones Hypokalemia. Urinary tract infection. History of congestive heart failure. History of lower gastrointestinal bleed. Depression. DISCHARGE MEDICATIONS: 1. Regular insulin sliding scale. 2. Synthroid. 3. Subcutaneous heparin. 4. Protonix. 5. Lopressor 5 mg intravenous q 6 hours. 6. Timolol eye drops. 7. Azopt eye drops. 8. Prednisone 15 mg intravenous qd 9. Levofloxacin 250 mg po qd for urinary tract infection. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 18475] Dictated By:[Last Name (NamePattern1) 55518] MEDQUIST36 D: [2198-6-7] 00:10:30 T: [2198-6-7] 02:08:34 Job#: [Job Number ]	[ "V58.65", "577.0", "276.8", "574.20", "276.5", "428.0", "599.0", "311", "725" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]		1558, 3345		3367, 3447					3673, 4211		3469, 3650																													1099, 1534	127, 142																							208, 799																822, 1076
46,205	161,204	41838	Discharge summary	report	Admission Date: [2185-9-16] Discharge Date: [2185-11-17] Date of Birth: [2123-11-12] Sex: M Service: SURGERY Allergies: morphine / Iodine Attending:[First Name3 (LF) 473] Chief Complaint: Pancreatitis Major Surgical or Invasive Procedure: [2185-9-17] Right PICC placement [2185-9-20] Right hemodialysis line placement [2185-9-30] Endotracheal intubation [2185-9-30] endoscopic retrograde cholangiopancreatography [2185-9-30] percutaneous biliary drain [2185-10-18] 1. Open pancreatic debridement. 2. Roux-en-Y pancreatic cyst jejunostomy. 3. Small bowel resection. 4. Open cholecystectomy. 5. Umbilical hernia repair. [2185-10-21] Thoracentesis [2185-10-25] Pleural pigtail catheter placement [2185-10-27] Tracheostomy [2185-11-9] Pleural pigtail catheter replacement [2185-11-15] Tunneled hemodialysis catheter placement History of Present Illness: 61 year old male with h/o DM and HTN who was admitted to OSH with pancreatitis, now being transferred to [Hospital1 18] with acute kidney injury on HD and concern for necrotizing pancreatitis. . He was admitted to [Hospital3 ] Hospital on [9-7] with abdominal pain and vomiting and diagnosed with pancreatitis. Admission lipase was 3000 and RUQ u/s showed cholelithiasis. AST/ALT were elevated (191/160) as well so felt it was related to gallstone pancreatitis, although no CBD dilation on ultrasound. He eventually required intubation felt to be due to ARDS and developed hypotension requiring pressors. His abdomen became progressively distended and he had multisystem organ failure. He was started on HD [9-9] for ATN (did not have CVVH machine at CCH). He had a PICC line placed and TPN was initiated. He was treated with meropenem (d7 today of Abx, was initially on zosyn). Had right subclavian CVL placed, as well as left groin HD line. Given 1 unit PRBCs [9-12] for Hgb 9. Levophed gtt was stopped on [9-13]. Was placed on an insulin gtt for hyperglycemia. Had 63-80cc urine output in last 24 hours which is an improvement from previous. Over the last few days, he has had fevers and a bandemia. His mental status has been poor and was on on ativan and fentanyl drip until recently when he was switched to just fentanyl. He has not followed commands. He had a CT abd/pelvis repeated on [9-15] that showed development of pseudocyst and concern for necrotizing pancreatitis. He was then transferred to [Hospital1 18]. . Upon admission he is intubated and sedated. Past Medical History: Diabetes Hypertension Hyperlipidemia Nephrolithiasis Vertebral disc disease Social History: Lives in [Location ], PA, but was vacationing in [Hospital3 ]. Smokes 1 cigar/day, drinks 2 drinks/night (had more recently while on vacation and a lot the night before presentation). Family History: non-contributory Physical Exam: Admission Physical Exam: Vitals: 97.8 111 145/69 16 100% 550x16 PEEP 5 FiO2 100% General: Intubated and sedated HEENT: Sclera anicteric, pupils minimally reactive with L slightly larger than right, OG tube in place Neck: Supple, no LAD Lungs: Mild coarse ventilated breath sounds CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: distended but relatively soft, bowel sounds present, no tenderness noted, organomegaly not palpable GU: Foley in place Skin: Erythematous slightly scaly rash over groin and bilateral flanks, right PICC, right subclavian and left groin HD line in place without significant surrounding erythema Ext: warm, well perfused with 1+ nonpitting edema Pertinent Results: Admission Labs: [2185-9-16] pH 7.37 pCO2 35 pO2 237 Lactate:1.0 O2Sat: 99 133 96 53 ------------- < 247 4.8 21 5.4 Ca: 7.8 Mg: 2.1 P: 7.4 ALT: 30 AP: 119 Tbili: 0.6 Alb: 2.3 AST: 64 LDH: 510 Dbili: TProt: [Doctor First Name ]: 46 Lip: 19 CBC: 21.3 > 11.0 /32.0< 475 N:92.8 L:3.1 M:3.8 E:0.1 Bas:0.1 PT: 13.9 PTT: 31.3 INR: 1.2 Discharge Labs: 133 97 29 --------------<138 AGap=9 4.0 31 2.1 ∆ Comments: Glucose: If Fasting, 70-100 Normal, >125 Provisional Diabetes Ca: 8.1 Mg: 1.8 P: 2.8 ∆ ALT: 29 AP: 227 Tbili: 0.2 Alb: 2.4 AST: 34 LDH: 200 Dbili: TProt: [Doctor First Name ]: Lip: 7.7> 9.2< 314 28.6 PT: 11.4 PTT: 36.3 INR: 1.1 SELECTED MICRO: [10-7]: Bile: coag neg staph, [Female First Name (un) ] [2099-10-10]: Blood cultures negative [10-12]: Sputum negative [10-11]: C dif negative [10-12]: C dif negative [10-12]: Urine Culture negative [10-18]: panc cyst fluid: rare [Female First Name (un) ] albicans [10-19]: sputum - gram stain negative. Yeast [10-19]: blood cx - pending [10-21]: left pleural fluid - no growth [10-22]: BAL - no growth [10-24]: right pleural fluid: NG [10-25]: sputum - gram stain NG, Cx- NG [10-25]: blood - negative (including picc line tip) [10-25]: urine legionella - negative [10-26]: C.diff- negative [10-30]: BAL: yeast [11-9]: pleural fluid gram stain/culture: no growth [11-14]: blood cx: pending, no growth to date SELECTED IMAGING: CT ABDOMEN W/O CONTRAST ([2185-9-21]) 1. Similar appearance of large fluid collection anterior to the pancreas, which does not yet have the characteristics of a mature pseudocyst. 2. Incidental note is made of sludge and gallstones within an otherwise normal-appearing gallbladder. 3. Solid exophytic nodule in the mid pole of the left kidney is not completely characterized, and could be better evaluated with ultrasound on a non-emergent basis. 4. Stable bilateral pleural effusions with adjacent atelectasis. 5. Lytic lesions in the left iliac, recommend comparison with priors if available, and attention on follow up. . RUQ Ultrasound ([2185-9-25]) 1. Limited view of the gallbladder demonstrates no signs of acute cholecystitis. 2. Midline ovoid fluid collection consistent with patient's known peripancreatic fluid collection. 3. No intrahepatic biliary ductal dilatation. Common bile duct not visualized due to limited acoustic windows. 4. Mild intraperitoneal ascites . LIVER OR GALLBLADDER US ([2185-9-29]) 1. Limited evaluation of the liver, though no intrahepatic biliary ductal dilatation or definite lesion. Increased echogenicity, which is unchanged from prior. 2. Normal gallbladder fundus without evidence of stones; the gallbladder neck and common bile duct were not visualized. 3. Mild intra-abdominal ascites. 4. Hemorrhage within a midline pseudocyst as previously described on prior CT. CT Abdomen ([2185-10-9]) 1. Large peripancreatic fluid collection, increased in size from prior study. While it contains no gas locules and there is no surrounding fat-stranding, superinfection cannot be entirely excluded. This fluid collection demonstrates marked mass effect on the stomach and to a lesser extent the splenic flexure and transverse colon, but the nasointestinal tube sits in a post-pyloric position and is functional. 2. Moderate to large bilateral simple pleural effusions with associated atelectasis. 3. No evidence of hydronephrosis or hydroureter; gas locules in the bladder likely represents prior catheterization although if clinical concern for gas-producing infection exists, correlate with results of UA. Brief Hospital Course: 61 year old male with history of diabetes and hypertension was admitted to outside hospital with pancreatitis complicated by acute kidney injury requiring hemodialysis, and transferred to [Hospital1 18]. He was found to have severe necrotizing pancreatitis, most likely secondary to gallstones, with hemorrhagic tranformation. He developed cholangitis for which PTBD was placed after unsuccessful ERCP. He developed a large pancreatic pseudocyst requiring operative internal drainage and was transferred to the surgical service for post-operative care. He remained in the SICU post-operatively, requiring prolonged intubate and tracheostomy placement. Neuro: At admission, the patient was initially sedated, however he continued to be obtunded after sedation was discontinued. Benzodiazepines were avoided. Oxycodone was given as liquid form in low doses to control his pain. His mental status gradually cleared and started to open eyes, have short conversations, answering appropriately with moving his hands and feet. Extensive physical therapy will be needed to bring back his strength. Pt transferred to [Hospital Unit Name 153] on [2185-10-10] for resp. distress, altered mental status, and septic shock. EEG and MRI done in unit were unremarkable. At time of transfer to surgical service he was intubated and sedated, and mental status was difficult to evaluate. Postoperatively, he remained off sedation with only PRN pain control. His mental status gradually improved and he became interactive and responsive. Although he remained intubated he was responding appropriately, engaging with staff and family members, and participating with physical therapy. On [2185-11-1] he was agitated and became less responsive. He was weaned off sedation but remained minimally responsive and agitated. He gradually improved and by the time of discharge was speaking and interacting appropriately with family and staff members. His pain was controlled with tylenol and oxycodone. Cardiovascular: Pt was consistently tachycardic at this admission. He is hypertensive at baseline and takes lisinopril and HCTZ at home, these were held during his acute illness. He was started on metoprolol for tachycardia and this was titrated up over the course of his stay to a goal of HR <100. On [2185-11-11] he became intermittently hypotensive and was started on standing midodrine 2.5mg TID and his metoprolol was held. He continues to be on standing midodrine at the time of transfer to rehabilitation, additionally, he continues on metoprolol which was restarted on [2185-11-14]. Pulmonary: As per outside hospital report, his initial respiratory failure was thought to be due to ARDS secondary to his pancreatitis. He was transfered to [Hospital1 18] while intubated. He was extubated on [2185-9-21] without incident. He continued to have an oxygen requirement following extubation but did not have difficulty protecting his airway. He was electively re-intubated on [9-30] for ERCP and successfully extubated on [10-2]. He was diuresed at this time with intravenous lasix to decrease oxygen requirements. However, on [2185-10-10] he had an episode of emesis around the dobhoff tube and developed respiratory distress and altered mental status. He was transferred to the [Hospital Unit Name 153] and reintubated. It was thought at this point that his symptoms were likely due to aspiration pneumonia versus ventilator-associated pneumonia; he was started on vanc/cefepime/flagyl/fluc and continued on these antibiotics until he was taken for surgery on [2185-10-18]. He was also noted at this point to have large pleural effusions. After operative drainage of his pseudocyst he remained intubated post-operatively. On [10-21] the left sided pleural effusion was succesfully tapped for 1L of fluid, however he continued to require ventilatory support. He underwent bronchoscopy to remove a large right upper lobe mucus plug on [10-22]. Thoracentesis was repeated and a pigtail catheter was left in place to drain the left lung on [2185-10-25]. As his respiratory status was not improving, he had a tracheostomy placed [2185-10-27] for continued ventilator requirements. He remained on the ventilator until [2185-11-2], at which time he was able to be weaned off and spontaneously breath with oxygen via a tracheostomy collar. On [2185-11-3] his pigtail catheter was DC'ed. He did well from a pulmonary perspective until [2185-11-9] at which point a CXR demonstrated worsening pleural effusion, hence thoracentesis and placement of a pigtail catheter was performed on [2185-11-9]. The pigtail was left in place until [2185-11-14] at which point it was pulled. At the time of discharge he has been breathing spontaneously. FEN/GI: #. Severe pancreatitis: The patient was admitted with profound pancreatitis with quick development of respiratory distress and acute renal failure. He had evidence of necrosis on CT with development of pseudocysts. Initial pancreatitis likely due to gallstones given elevated LFTs on admission and gallstones on the ultrasound. He was evaluated by GI, and it was decided that as he had no fever antibiotics were unwarranted. He was provided with nutrition through dobhoff located at the jujenum. Later on, his Hct started to gradually decrease and repeat CT showed hemorrhagic transformation at the tail. He received blood transfusion and afterwards his Hct stabilized. A new NG tube was placed by IR on [10-4] after oral access was lost while having ERCP for cholangitis. Pt transferred to [Hospital Unit Name 153] on [2185-10-10] for resp. distress, altered mental status, and septic shock. A repeat CT demonstrated an enlarging pancreatic pseudocyst compressing the stomach and transverse colon. He was taken to the operating room on [10-18] for open roux-en-Y cyst-jejunostomy and pancreatic debridement. During the operation it was necessary to resect a section of small bowel as well as perform a cholecystectomy. # Cholangitis: It was noticed on [9-29] that his bilirubin doubled and started to have low grade fever after several days of being afebrile. He was started on Zosyn ([10-1]). RUQ US was limited (please see results) and ERCP was pursued. Unfortunately it was not successful, however severe narrowing of the CBD and CHD was seen likely secondary to pancreatic inflammation +/- possible pseudocyst compression. There was proximal dilation of the biliary system to 15 mm. He underwent PTC for biliary drainage. His biliary drain culture grew [Female First Name (un) ] for which micafungin was given x14 days (day 1 [10-3]). His Zosyn was later switched to Cipro and Flagyl given slight worsening in his kidney function with moderate eosinophilia concerning for possible AIN (later found to be ATN, please see below for details about acute renal failure). He had rising LFTs and lack of bile output in his drain so IR replaced his biliary drain on [10-5] with improved biliary flow and improvement on his LFTs. His PTBD drain was capped after surgery. His antibiotics were DC/ed on [2185-10-31]. He subsequently became febrile on [2185-11-5] and on [2185-11-6] was restarted on empiric vanco/meropenem/flagyl. On [2185-11-8] a tube cholangiogram was performed which demonstrated some common duct stenosis hence his biliary drain was upsized. It HIs antibiotics were discontinued on [2185-11-10]. His external biliary output slowed and the drain was capped on [2185-11-12]. #Nutrition: At time of transfer he was maintained NPO/IVF; he was started on tube feeds via post-pyloric dobhoff for nutrition. However, on [2185-10-10] he had an episode of possible emesis around the tube and developed acute respiratory distress warranting transfer to [Hospital Unit Name 153]. Tube feeds were discontinued with concern that the pseudocyst was compressing the stomach and transverse colon. He was started on TPN and continued on this until after his operation. At that point he was restarted on tube feeds; TPN was slowly weaned off as tube feeds were increased to goal. [Last Name (un) ] was consulted and assisted in managing blood sugars throughout his hospital course. At the time of transfer he has been tolerating tube feeds (Nepro) at 40cc/hour. He was unable to pass a speech and swallow evaluation on the day prior to discharge to rehabilitation, and will need ongoing evaluation for his ability to take PO. GU: The patient had been receiving hemodialysis at the OSH prior to transfer. His HD line was re-sited upon transfer to [Hospital1 18] and he continued to receive HD. His ARF was considered ATN due to severe pancreatitis. His urine output began to recover with improvement in BUN/Cr and the HD line was eventually removed. Urine eosinophils and FeUrea were suggestive of AIN. He had urine spinning which showed muddy brown/granular casts suggestive of ATN. Urine eosinophilia was attributed to Zosyn that was started for cholangitis as mentioned above. Zosyn was discontinued and Cr remained stable and gradually improved. His renal function had normalized upon transfer to surgery with good urine output. It remained stable at his baseline (0.9) until [2185-10-26] when it began to trend upwards. It was thought that he may have been over-diuresed; he was restarted on IVF and given boluses as needed to maintain urine output. He was also on vancomycin at this point, and vanc levels came back elevated. Vanc was held and levels followed, and held for several days due to high trough levels. He was started on CVVH from [2185-11-1] until [2185-11-4]. On [2185-11-7] he was started on hemodialysis. He continued to be intermittently dialyzed for the remainder of his hospital course. Notably on [2185-11-15] a tunneled HD line was placed in anticipation of ongoing dialysis requirements. Also of note, during his hospital course a left sided renal mass which was exophytic and intrapolar was appreciated for which he will need follow up as an outpatient. ID: At time of transfer to the [Hospital Unit Name 153] on [2185-10-10], he was treated for septic shock with fluid resusciatation and transient pressor requirement. He was maintained on vanc/cefepime/flagyl/fluc for possible aspiration PNA vs. VAP. These antibiotics were continued until after his surgery for open drainage of pancreatic pseudocyst on [2185-10-18]. Infectious disease was consulted throughout his hospital stay. After surgery, the antibiotics were discontinued; as his culture data at that point was positive only for sparse yeast, he was maintained solely on fluconazole therapy. However, he continued to have fevers, and per recommendations from ID he was restarted on vanc/cefepime/cipro in addition to fluconazole. His antibiotics were discontinued on [2185-10-31]. On [2185-11-5] he became febrile, and was restarted on empiric vancomycin/meropenem and flagyl on [2185-11-6]. These were discontinued on [2185-11-10]. On [2185-11-14] he was febrile to 101.7 and was pan cultured. Blood cultures from that date have not shown growth to date. Of note, he also recieved 2 units of PRBCs on that date immediately prior to his fever. On [2185-11-16] he had a low grade temperature of 101.2, however this had resolved spontaneously at the time of transfer. Medications on Admission: Home Medications: Metformin 500mg po daily HCTZ/Lisinopril 12.5mg/10mg po daily Discharge Medications: 1. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 2. senna 8.8 mg/5 mL Syrup Sig: 1-2 Tablets PO BID (2 times a day) as needed for Constipation. 3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 5. midodrine 2.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. ferrous gluconate 325 mg (37.5 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 8. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea. 9. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [12-19] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 10. collagenase clostridium hist. 250 unit/g Ointment Sig: One (1) Appl Topical DAILY (Daily). 11. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 12. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 14. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. insulin glargine 100 unit/mL Cartridge Sig: Twenty Five (25) units Subcutaneous at bedtime. 16. insulin regular human 100 unit/mL Solution Sig: One (1) units Injection four times a day. 17. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 18. heparin (porcine) 1,000 unit/mL Solution Sig: One (1) Injection PRN (as needed) as needed for line flush. 19. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 20. heparin (porcine) 1,000 unit/mL Solution Sig: One (1) Injection PRN (as needed) as needed for line flush. Discharge Disposition: Extended Care Facility: [Hospital6 85585] Discharge Diagnosis: Primary: Severe pancreatitis Secondary: ARF/ATN, respiratory failure, cholangitis, hypotension Discharge Condition: Mental Status: Intermittent disorientation. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: The patient will be discharged to an extended care facility for ongoing rehabilitation from his illness. He will have ongoing tube feeds. He was not able to pass a speech and swallow evaluation on the day prior to discharge and will need ongoing evaluation as his ability to tolerate oral intake returns. He continues to have a dialysis requirement. He is able to cap his tracheostomy to speak and is breathing spontaneously. He continues to require intensive chest physical therapy to clear secretions and has significant weakness after his prolonged hospitalization for which he will require physical therapy. Please see discharge summary for further explanation of this [Hospital 228] hospital course. Followup Instructions: Please follow up with Dr. [Last Name (STitle) 468] in [1-20] weeks or as needed. If you are no longer in the area, please follow up with a pancreatic surgeon in [State 5887] as soon as you return to that area. Please call your primary care provider to make an appointment to be seen as soon as possible. Additionally, you will need to have follow up for the left sided renal mass that was found on imaging. As you will need ongoing management of your blood sugars as well as your kidney function, you should continue to see the nephrologist and the endocrinologist. Please arrange with your primary care physician to be followed for those conditions. Completed by:[2185-11-17]	[ "511.9", "349.82", "401.9", "272.4", "357.82", "112.89", "577.0", "276.0", "038.9", "995.92", "934.9", "552.1", "276.7", "574.20", "576.2", "507.0", "576.1", "518.81", "250.02", "599.0", "276.2", "785.52", "577.2", "997.31", "584.5" ]	icd9cm	[ [ [] ] ]	[ "38.95", "51.10", "96.72", "31.1", "34.91", "39.95", "52.96", "45.62", "33.24", "53.49", "87.51", "97.05", "38.93", "96.6", "99.15", "51.87", "52.22", "51.22", "34.04", "00.14" ]	icd9pcs	[ [ [] ] ]	20815, 20863	7331, 18762	291, 921	21003, 21003	3634, 3634	21927, 22624	2877, 2895		18893, 20792		20884, 20982		18788, 18788			21188, 21904				3996, 7308							2935, 3615			18806, 18870																					239, 253													949, 2552						3650, 3980				21018, 21164						2574, 2652	2668, 2861
23,890	146,097	18244+56927	Discharge summary	report+addendum	Admission Date: [2146-1-4] Discharge Date: [2146-1-16] Date of Birth: [2089-5-28] Sex: F Service: PRIMARY DIAGNOSIS: Coronary artery disease, aortic stenosis PRIMARY PROCEDURE: Aortic valve replacement with [Street Address(2) 6158]. [First Name5 (NamePattern1) 923] [Last Name (NamePattern1) 50358] mechanical valve. BRIEF HISTORY: Ms [Known lastname 50359] is a 56 year old female with a chief complaint of increased shortness of breath and lightheadedness over the past three months. History of present illness is significant for a heart murmur diagnosed approximately 30 years ago, followed by echocardiogram. She had increasing shortness of breath over the past few months. Cardiac catheterization on [2145-11-11] revealed [First Name8 (NamePattern2) ] [Location (un) 109] of 1.0 cm squared with an ejection fraction of 52%. An echocardiogram in [2145-10-4] and revealed [First Name8 (NamePattern2) ] [Location (un) 109] of .6 with a peak of 90, mean 60. PAST MEDICAL HISTORY: His past medical history is significant for hypertension, aortic stenosis and mild obesity. PAST SURGICAL HISTORY: Significant for a left open reduction and internal fixation of an ankle. MEDICATIONS ON ADMISSION: Effexor 37.5 mg q.o.d., Verapamil 180 mg p.o. q.d., Zestoretic 20/12.5 p.o. q.d., Calcium p.o. q.d., Miacalcin p.o. q.d., Vitamin C q.d., garlic q.d., Fish oil q.d. and Multivitamin q.d. ALLERGIES: She had no known drug allergies. FAMILY HISTORY: Significant for mother deceased at 79, father deceased at 80. SOCIAL HISTORY: She is an office manager. She smoked 1.5 packs per day times 40 years and quit nine months ago. She lives with her husband. She drinks 2 glasses of wine per day. She does not use cocaine. PHYSICAL EXAMINATION: Physical examination is significant for being alert and oriented times three. Her lungs are clear to auscultation. Her heart has a IV/VI holosystolic murmur with radiation to the neck. Her abdomen is soft, nontender, nondistended. She has no costovertebral angle tenderness. The extremities had no cyanosis, clubbing or edema. Her cranial nerves are intact II through XII, nonfocal examination. Excellent strength in all four extremities. HO[Last Name (STitle) ] COURSE: Mrs. [Known lastname 50359] was taken to the Operating Room on [2146-1-4] with a diagnosis of aortic stenosis and underwent an aortic valve replacement with a [Street Address(2) 6158]. [First Name5 (NamePattern1) 923] [Last Name (NamePattern1) 50358] mechanical valve. This was done by Dr. [Last Name (Prefixes) 411] and assisted by Dr. [Last Name (STitle) 7625], MD, and Tepperow and [Initials (NamePattern4) ] [Last Name (NamePattern4) ]. She came out into the Recovery Room on Propofol 30 and EO 1. Th[Last Name (STitle) 1050] was admitted to the Cardiac Surgery Recovery Unit and had an uneventful day on postoperative day #1. He was transferred to R2 on [2146-1-5]. Of note, on [2146-1-5], the patient did have a cardiac arrest. However, this was shortlived and the patient was found immediately in her room to have a heart rate in the 30s with a blood pressure of approximately 90 pace was actually at that time but she had poor capture. Dr. [Last Name (STitle) 70] was at the patient's bedside at the time. A Dopa drip was started with some improvement in the patient's blood pressure. However, she continues to have asystole and then went back into a rhythm. The patient was taken emergently to the Electrophysiology Laboratory where a temporary transvenous wire was placed with ventricular capture. The patient was then returned to the Cardiac Surgery Recovery Unit and was being depaced, 100%, blood pressure of 130 in stable condition. The director of the Cardiac Surgery Recovery Unit, Dr. [Last Name (Prefixes) ] was notified and was aware of all events surrounding the patient's care. On postoperative day #2, [1-6], the patient was stable and was deemed ventricularly paced at a rate of 96 with a blood pressure of 117/52 on no drips at that time. On [2146-1-6], the patient was taken to the Electrophysiology Laboratory for transvenous screw and temporary pacer. At that time, a VVI [Company 1543] Sigma SGR 303 pacemaker was placed with a bipolar connector (IS-1VI). During the HV measurement, the patient was noted to have complete heartblock with a block below the bundle of HIS. The placement of a permanent pacemaker was delayed until her fever had come down. The patient was transferred from the Cardiac Surgery Recovery Unit to Far 2 on [2146-1-6]. Her pacer was interrogated on [2146-1-7]. At this time she was on intravenous heparin for her valve and this was continued. She was on Vancomycin and Levofloxacin at this time for this pacemaker. She was transfused on postoperative day #[4-6] for a hematocrit of 18 which came up to 24. This was done without complications. She was taken back on [2146-1-10] to the Electrophysiology Laboratory for the placement of a dual chamber rate-responsive pacemaker, Model #SDR303B. The bipolar connector was Model #4092 and the second bipolar connector was IS-1 VI, Model 5076. The mode was set at a mode of DDI with the lower rate of 55 PPM and paced AV at 420 milliseconds, Serial # [Serial Number 50360], manufactured by [Company 1543]. On postoperative day #7, the patient received another 2 units of blood for anemia. Her heparin was continued and based on INR, it is not yet therapeutic. Her antibiotics were continued and her Lopressor was also continued. The plan was for discharge upon stabilization of her INR. The following days of her hospitalization were significant for a physical therapy evaluation, deeming her steady in gait and stable for discharge. On postoperative day #10 her temperature maximum was 100.1 and she continued to have edema in her lower extremities. She was continued on her diuretics, and her Lopressor dose was increased. On [2146-1-16], she was deemed stable for discharge. Her INR was 2.6. She was discharged with a dose of 2.5 mg of Coumadin for [2146-1-16] with [Hospital6 407] for blood draw the following day. She had instructions and her primary care physician was aware to accept a phone call from her on Monday to dose her Coumadin appropriately, based on her mechanical aortic valve. DISCHARGE DIAGNOSIS: 1. Improved critical aortic stenosis 2. Hypertension 3. Placement of a permanent pacemaker, aortic valve replacement 4. Infection of unknown origin 5. Obesity 6. Depression DISCHARGE MEDICATIONS: 1. Lasix 20 mg p.o. b.i.d. times two weeks 2. Potassium 20 mg b.i.d. times two weeks 3. Aspirin 81 mg, enteric coated one tablet p.o. q.d. 4. Coumadin 2.5 mg p.o. times one on [1-16] with rigorous follow up starting tomorrow [2146-1-17] with blood draw with [Hospital6 407] and a phone call to her physician who will be expecting this phone call tomorrow afternoon with the result of her INR with meticulous follow up after that point for her valve. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Dictator Info ] MEDQUIST36 D: [2146-1-20] 16:57 T: [2146-1-20] 21:40 JOB#: [Job Number 50361] Name: [Known lastname 9318], [Known firstname 779] Unit No: [Numeric Identifier 9319] Admission Date: [2146-1-4] Discharge Date: [2146-1-16] Date of Birth: [2089-5-28] Sex: F Service: DISCHARGE MEDICATIONS: As mentioned Coumadin 2.5 mg per day with strict follow up starting tomorrow with [First Name (Titles) 2050] [Last Name (Titles) 9167] draw. Venlafaxine 37.5 mg p.o. q.o.d. 3. Percocet 5/325 one to two tablets p.o. q. 4-6 hours prn for pain. Colace 100 mg p.o. b.i.d. Outpatient laboratory levels, [Hospital6 1346] to draw INR on Monday, Wednesday, and Friday and forward results to Dr.[Doctor Last Name 9320] office. Lopressor 75 mg p.o. b.i.d. CONDITION ON DISCHARGE: Stable. DI[Last Name (STitle) 1390]E FOLLOW UP: She will follow up with Dr. [Last Name (STitle) ] in one week. She will follow up with Dr. [Last Name (Prefixes) ] in approximately one month. DIET: As tolerated. PHYSICAL THERAPY: She will be weightbearing as tolerated with above restrictions including weight and activity as dictated in her paperwork upon dictation. [Doctor Last Name ] [Last Name (Prefixes) ], M.D. [MD Number(1) 681] Dictated By:[Dictator Info ] MEDQUIST36 D: [2146-1-20] 16:39 T: [2146-1-20] 20:09 JOB#: [Job Number 9321]	[ "414.01", "427.5", "401.9", "426.0", "E849.7", "997.1", "424.1", "278.00", "E878.1" ]	icd9cm	[ [ [] ] ]	[ "35.22", "37.78", "37.83", "37.72", "39.61", "39.64" ]	icd9pcs	[ [ [] ] ]							1532, 1595		7656, 8123		6463, 6642		1281, 1515												1180, 1254			8396, 8775								8202, 8377				1829, 6442																															150, 1040									1063, 1156	1613, 1806	8148, 8190
18,708	147,705	14293	Discharge summary	report	Admission Date: [2169-12-18] Discharge Date: [2169-12-22] Date of Birth: [2089-5-31] Sex: F Service: ORTHOPAEDICS Allergies: Penicillins / Tetracycline / Macrobid Attending:[First Name3 (LF) 11415] Chief Complaint: s/p fall with R hip fracture Major Surgical or Invasive Procedure: Endotracheal intubation Right hip hemiarthroplasty Transesophageal echocardiogram Central venous line Arterial line History of Present Illness: Pt s/p CVA wheelchair bound. Yesterday, while repositioning self in wheelchair, she slipped out of chair and landed on buttock. Pt does not appear to have lost consciousness. The following day in the nursing home she was c/o R hip pain, guarding her R hip with shortened R leg and externally rotated. XRay of hip done at nursing home. Pt transferred to [Hospital1 ] for further evaluation of R hip fracture and found to be in RAF upon arrival to ED. In ED received 3L NS for BP 86/71, levaquin 500mg IV X1 and flagyl 500mg IV X1. . Pt unable to answer questions, unable to assess for ROS. . XRay at NH results showed: Pelvis--no acute fracture or dislocation. No bony erosions or destructive changes. R Hip-- fracture deformity of the R hip, however cannot elucidate whether acute or chronic. Suggest further evaluation of fracture/deformity of R hip. Past Medical History: -AF -CVA, L-MCA [2-/2168] -Severe Werwicke type Expressive Aphasia -HTN -MV prolapse -Hypercholesterolemia -Vascular Dementia -Anxiety -Anemia -Depression -Dysphagia -G Tube placement [2169-4-6] -R lateral malleolus fracture [2168-4-29] -Neuropathy -Hypothyroid Social History: Pt was living independently prior to stroke in [2167]. She moved into [Doctor First Name 391] [Hospital ] nursing home [4-/2169], in [Hospital1 392]. She never married and has no children. She quit smoking 50+ years ago. She used to drink 1 glass of brandy per day prior to her stroke. Family History: F: died of MI, CVA M: died of MI Brother w/Parkinson's. Other brother died of leukemia at 77yo. Other brother with skin CA Physical Exam: VS: 101.8 BP 86/71 HR 100-116 RR 28 100%RA GEN: elderly woman in NAD HEENT: PERRL, dry MM, no cervical LAD, no thyromegaly RESP: CTA b/l anteriorly, no wheezes CV: Irreg, nml s1,s2, no M/R/G appreciated ABD: soft, ND/NT, +BS, G-tube in place EXT: R leg shortened & externally rotated, LE w/non pitting edema, cold feet 2+ DP pulses b/l. R hand with contractures. NEURO: pt alert, does not follow commands, eyes follow to voice, does not speak. did move toes on L foot not on R foot Pertinent Results: At Nursing home: INR 2.3 . LABS: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2169-12-19] 12:25PM 12.2* 3.41* 10.1* 29.3* 86 29.5 34.3 17.0* 184 [2169-12-19] 02:00AM 12.9* 3.58* 10.1* 29.9* 84 28.1 33.7 16.3* 184 [2169-12-18] 03:40PM 12.1* 3.78* 10.9* 31.7* 84 28.8 34.3 16.7* 212 Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos [2169-12-18] 03:40PM 82* 1 8* 6 1 1 0 0 1* . Glucose UreaN Creat Na K Cl HCO3 AnGap [2169-12-19] 12:25PM 135* 63* 2.2* 140 4.0 104 191 21 [2169-12-19] 02:00AM 119* 66* 2.4* 134 5.6* 103 171 20 [2169-12-19] 12:00AM 135 65* 2.4* 134 5.5* 101 171 22 [2169-12-18] 03:40PM 181* 61* 2.2* 132* 5.3* 97 181 22 . CE: CK-MB cTropnT [2169-12-19] 02:00AM NotDone1 0.14* [2169-12-19] 12:00AM 3 0.14* [2169-12-18] 03:40PM 2 0.14* . STUDIES: . HIP 1 VIEW: RIGHT HIP, SINGLE AP VIEW. There is a very unusual appearance to the right proximal femur, with disruption of [Last Name (un) 42445] line (cortex along medial femoral head and neck). This finding is highly suggestive of a subcapital fracture, particularly in light of the abnormality on the true lateral view obtained earlier today. . Bilateral Hips(AP & Lat). IMPRESSION: Osteopenia. Probable right femoral neck fracture, not optimally demonstrated here due to rotation on AP view. . CHEST, SINGLE AP VIEW. There is mild-to-moderate cardiomegaly. The aorta is calcified and slightly tortuous. There is upper zone redistribution, without overt CHF. No focal infiltrate or effusion is identified. Osteopenia, degenerative changes, and mild scoliosis of the thoracic spine are noted. Multiple rounded densities overlie the spleen -- ? splenic granulomas. Bilateral carotid artery calcifications noted. There is persistent prominence of the right paratracheal soft tissues, most likely representing vascular ectasia in a patient of this age. . Portable CXR: IMPRESSION: Upper zone redistribution, without overt CHF. No pneumonia. Attention to the right paratracheal soft tissues on a true AP view is recommended when the patient is stable. I suspect this represents age-related variation in this individual. . Head CT w/o contrast: IMPRESSION: 1. Remote left middle cerebral artery territorial infarction. 2. No intracranial hemorrhage or mass effect. . Brief Hospital Course: 80 yo F w/MMP s/p Fall now w/R hip fracture. Pt admitted to medical team on [2169-12-18] for management of multiple medical problems & pre-operative evaluation prior to having R hip fracture fixed by orthopedics. Her elevated INR on coumadin was corrected with vitamin K. Pt was deemed to be DNR/DNI, but in discussion with her health-care proxy, it was decided to reverse this for surgical fixation of hip. Pt was deemed medically optimized for surgery on [2169-12-20] & underwent R hip hemiarthroplasty. Intraoperatively pt became hypoxic & hypotensive requiring pressors - transferred to SICU care. Concern for fat emboli given sudden deterioration immediately post-procedure. Transesophageal echo performed demonstrating dilated & hypokinetic RV, dilated atria. Pt was on heparin for empiric anticoagulation, but was not candidate for thrombolytics. CT angio demonstrating only small thrombus. Continued to provide supportive care with ventilatory support & pressors while discussing poor prognosis with family who stated that pt would not want to live in a severely debilitated condition. The decision to pursue comfort measures only was made by [Hospital ] health care proxy on [2169-12-22] in discussion with the orthopedic & sicu attendings; the patient was declared dead later that afternoon. Medications on Admission: -Prevacid 30mg daily -Atenolol 25mg daily -Aricept 10mg daily -ASA 81mg daily -MVI w/mineral -Levoxyl 75mcg daily -FeSO4 325mg daily -Coumadin 4MG DAILY -Depakote 125mg TID -Remeron 30mg QHS -Zyprexa 5mg QHS -Mylanta 30cc [Hospital1 ] -Colace 100mg [Hospital1 ] -APAP 650mg daily Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Right hip fracture Hypoxia Hypotension Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2235] MD, [MD Number(3) 11417]	[ "401.9", "997.79", "444.9", "276.51", "438.11", "518.5", "V44.1", "427.31", "E884.3", "584.5", "424.0", "415.11", "820.20", "599.0", "244.9" ]	icd9cm	[ [ [] ] ]	[ "88.72", "81.52", "00.17", "99.04", "99.07" ]	icd9pcs	[ [ [] ] ]	6750, 6759	5059, 6383	334, 452	6842, 6852	2616, 5036	6904, 7040	1975, 2099		6721, 6727		6780, 6821		6409, 6698			6876, 6881											2114, 2597																								266, 296													480, 1339																1361, 1636	1652, 1959
41,121	103,403	11515	Discharge summary	report	Admission Date: [2152-2-28] Discharge Date: [2152-3-5] Service: MEDICINE Allergies: Anesthesia IV Set-Clamp / Flagyl Attending:[First Name3 (LF) 34537] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: None History of Present Illness: [Age over 90 ] F with a history of hypertension, atrial fibrillation on Coumadin, polycythemia [Doctor First Name ], prior LGIB managed conservatively, who presents with one day of BRBPR. She recently had a fever last week and was treated with a 5-day course of Bactrim beginning Friday for presumed UTI (culture from [2152-2-24] gre pan-sensitive E. coli). She held Coumadin on Friday and Saturday but resumed yesterday, with plan to re-check INR today. She awoke this morning at 5:00 AM with an episode of BRBPR. She had no associated pain, nausea, or vomiting. She had a second episode at 9:00 AM, and a third at noon; she then came into the ED. . Upon arrival to the ED vitals were: T 99.2, HR 67, BP 129/40, RR 18, O2 sat 99% on RA. She was noted to be guaiac-positive on exam with BRB on the glove during exam. She had another episode of bleeding in the ED of 400 cc of blood mixed with stool. Her Hct was noted to be 28 from recent baseline of 34 and her INR was elevated at 4.7. She was seen by the GI consult team in the ED and received 40 mg IV Protonix, 5 mg of PO vitamin K, and 1 unit of FFP. Vitals prior to transfer to the MICU were: BP 134/39, HR 69, RR 19, O2 sat 97% on RA. . On arrival to the MICU, patient is comfortable. She is awake and alert, denies any pain. Daughter [Name (NI) ] is with her. Past Medical History: HTN Paroxysmal afib Osteoarthritis Hearing loss s/p Appy 3 C sections Diverticulitis Mitral regurgitation- ECHO '[42] w/ EF 65%, 3+ MR, 2+TR, LVH Depression Osteoporosis s/p right knee replacement Social History: Social history is significant for the absence of current or past tobacco use. There is no history of alcohol abuse. Pt lives in duplex with her dtr living upstairs and her son next door. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: ADMISSION: GEN: Awake, alert, mildly hard of hearing HEENT: Pink conjunctiva, PERRL, clear OP, moist MM NECK: Supple, no JVD PULM: CTA bilaterally CARD: RRR, + 2/6 systolic murmur at apex ABD: Soft, NT/ND, + slightly hyperactive bowel sounds, no rebound/guarding EXT: palpable DP pulses, bony protrusion (non-tender) over dorsum of right foot, trace pedal edema PSYCH: Appropriate, cooperative Pertinent Results: Labs on Admission: [2152-3-1] 04:02AM BLOOD WBC-7.5 RBC-3.13# Hgb-10.4 Hct-29.9* MCV-96 MCH-33.4* MCHC-34.9 RDW-19.0* Plt Ct-236 [2152-2-29] 07:59PM BLOOD Hct-34.1* [2152-2-29] 01:49PM BLOOD Hct-28.8* [2152-2-29] 12:34PM BLOOD Hct-29.7* [2152-2-29] 04:44AM BLOOD WBC-6.9 RBC-2.47* Hgb-8.7* Hct-24.7* MCV-100* MCH-35.4* MCHC-35.4* RDW-18.3* Plt Ct-242 [2152-2-28] 11:36PM BLOOD Hct-22.1* [2152-2-28] 04:00PM BLOOD WBC-7.5 RBC-2.67* Hgb-9.6* Hct-28.2* MCV-106* MCH-36.2* MCHC-34.2 RDW-14.6 Plt Ct-271 [2152-3-1] 04:02AM BLOOD PT-17.0* PTT-30.0 INR(PT)-1.5* [2152-2-29] 04:44AM BLOOD PT-26.8* PTT-35.3* INR(PT)-2.6* [2152-2-28] 04:00PM BLOOD PT-44.0* PTT-42.5* INR(PT)-4.7* [2152-3-1] 04:02AM BLOOD Glucose-80 UreaN-33* Creat-1.5* Na-141 K-4.9 Cl-108 HCO3-25 AnGap-13 . Labs on Discharge: [2152-3-5] 07:10AM BLOOD WBC-11.3* RBC-2.84* Hgb-9.4* Hct-28.9* MCV-102* MCH-33.2* MCHC-32.6 RDW-18.0* Plt Ct-301 [2152-3-5] 07:10AM BLOOD Glucose-94 UreaN-40* Creat-1.4* Na-141 K-4.4 Cl-112* HCO3-21* AnGap-12 . CXR: FINDINGS: No focal consolidation is seen. No pneumothorax is seen. Prominent hila and elevation of the left hilum are unchanged compared to prior. Heart size is within normal limits and unchanged. Calcification of the mitral annulus is again seen. Left atrial enlargement is noted on lateral view. The aorta is calcified. There is no evidence for pulmonary edema. Blunting of the left costophrenic angle is unchanged and likely represents scarring. IMPRESSION: No radiographic evidence for acute pulmonary abnormality. Brief Hospital Course: [Age over 90 ] F with history of prior diverticulitis 12 years ago and GI bleed two years ago managed conservatively (no scope) who presented with BRBPR and falling Hct in the setting of suprtherapeutic INR to 4.7. . 1. GI BLEED: Given painless GIB, likely LGIB in setting of supratherapeutic INR from interaction of TMP/SMX with coumadin. Patient was treated conservatively with reversal of supratherapeutic INR with FFP and vitamin K, and transfusion with PRBC. Total transfusion requirement was 3 units PRBC and 3 units FFP. Patient was evaluated by Gastroenterology during admission, with further diagnostic/therapeutic procedures including colonoscopy deferred. HCT remained stable following transfusion. She continued to have small volume guaiac positive stools, but believed to represent old blood in right colon. Coumadin held at discharge. . 2. ATRIAL FIBRILLATION: Patient with known PAF on coumadin, with supratherapeutic INR on admission that was reversed as above. Coumadin was held during hospital course and at discharge. Decision will be made as outpatient visit regarding the initiation of aspirin therapy. . 3. ACUTE-ON-CHRONIC RENAL FAILURE: Believed to be pre-renal etiology in the setting of bleeding and poor appetite. . 4. POLYCYTHEMIA [Doctor First Name ]: Dr. [Last Name (STitle) ] made aware, and hydroxyurea held during presentation given bleed and anemia. Will be re-started as outpatient. 6. HYPERTENSION: Antihypertensives held on initial presentation, and discharged home off these medications as she remained orthostatic. . Transitions of Care: --Coumadin, hydroxyurea, and anti-hypertensives held at discharge. Medications on Admission: - PERI-COLACE 8.6 mg-50 mg Tab by mouth twice a day - sulfamethoxazole-trimethoprim 800 mg-160 mg Tab PO BID - Acetaminophen Extra Strength 500 mg Tab as needed - hydroxyurea 500 mg Cap by mouth once a day except on Sundays and Thursdays - Lisinopril 40 mg PO twice a day - Amiodarone 100 mg PO daily - Warfarin 2.5 mg PO daily (held Friday and Saturday) - Amlodipine 5 mg by mouth twice a day - Multiple Vitamins 1 tab by mouth daily - Ranitidine 75 mg PO daily - Calcium citrate + vitamin D - Vitamin C 1000 mg PO daily - Acidophilus PO daily (recently stopped) Discharge Medications: 1. PERI-COLACE 8.6-50 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 2. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 3. hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO daily except on Sunday and Thursday. 4. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. calcium citrate-vitamin D3 Oral 7. Vitamin C 1,000 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary Diagnosis: Lower Gastrointestinal Bleeding Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [Known lastname 36698], It was a pleasure taking care of you at [Hospital1 827]. You were admitted to the hospital with rectal bleeding. This bleeding was likely due to a condition of the bowel called diverticulosis. You were given several blood transfusions in order to maintain your blood counts. These blood counts remained stable prior to your discharge from the hospital. . Please STOP the following medications: COUMADIN LISINOPRIL AMLODIPINE . Please discuss re-starting your blood pressure medications with Dr. [Last Name (STitle) 713] when you see her in follow-up. You should also discuss the use of Aspirin (in place of coumadin) at your follow-up appointment. . If you experience any further epsisodes of bleeding, abdominal pain, dizziness or weakness, please call your primary care doctor or return to the emergency room. . Followup Instructions: We would like you to call Dr.[Name (NI) 1602] office in order to schedule an appointment for the next 2-3 days. We were unable to set this up over the weekend. . Department: GERONTOLOGY When: THURSDAY [2152-3-23] at 11:30 AM With: [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [Telephone/Fax (1) 719] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage . Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [2152-4-25] at 2:30 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3014], RN [Telephone/Fax (1) 22] Building: [Hospital6 29] [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "403.90", "286.9", "238.4", "V43.65", "427.31", "V58.61", "790.01", "585.9", "424.0", "562.12", "733.00", "311", "599.0", "584.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	6987, 7045	4175, 5745	246, 252	7140, 7140	2573, 2578	8208, 8958	2061, 2143		6449, 6964		7066, 7066		5860, 6426			7325, 8185											2158, 2554																								201, 208				3405, 4152									280, 1616							7085, 7119	2592, 3386		7155, 7301		5766, 5834				1638, 1840	1856, 2045
5,739	122,118	9235+56013	Discharge summary	report+addendum	Admission Date: [2165-3-13] Discharge Date: [2165-3-18] Date of Birth: [2131-3-8] Sex: M Service: ACOVE ADMITTING DIAGNOSIS: Acute pancreatitis. HISTORY OF PRESENT ILLNESS: The patient is a 34-year-old Russian speaking man who recently lost his job. His wife reports that he has been depressed recently and has increased his alcohol use. Normally, the patient drinks three to five drinks of Vodka per day. Approximately two days prior to admission, she had significantly more alcohol. He does not remember how much he drank. Patient complains of a one day history of epigastric pain, nausea and vomiting. He is unable to take po intake. He complains of thirst. He also has sweats and chills. He also has shortness of breath. He has had no chest pain, bright red blood per rectum, melena, urinary symptoms. His last alcoholic drink was the night prior to admission. Patient states that his symptoms are similar to previous episodes of pancreatitis. PAST MEDICAL HISTORY: 1. Multiple episodes of pancreatitis in the past; felt to be secondary to alcohol abuse. 2. Hypertension. 3. History of seizures after a motor vehicle accident. 4. Status post left knee surgery. MEDICATIONS ON ADMISSION: 1. Advil prn. 2. Tylenol prn. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives with his wife and son. [Name (NI) ] is from [Country 532]. He is an ex-smoker and quit in [2151]. He drinks approximately one bottle of Vodka per week, consuming [1-23] glasses per day. He also drinks 6-8 beers per week. His wife states that since he lost his job, he has been depressed. His wife is considering separation or divorce. PHYSICAL EXAM ON ADMISSION: Temperature 98.1. Blood pressure 160/100. Heart rate 92. Respiratory rate 20, saturating 97% on room air. Patient appears acutely ill-appearing. He is diaphoretic. He is vomiting. He is tremulous. Pupils equal, round and reactive to light bilaterally. There is no lymphadenopathy in the head or neck. The oropharynx is normal. The mucous membranes are dry. The heart is regular. There is no murmurs, rubs or gallops. The chest is clear to auscultation bilaterally. Bowel sounds are present. The abdomen is nondistended. The abdomen is diffusely tender. There is a [Doctor Last Name ]-[Doctor Last Name ] sign. There is costovertebral angle tenderness. There is no peripheral edema. There are no focal deficits on neurological exam. LABORATORIES: White blood cell count 10.7, hematocrit 39.7, platelet count 147,000. Sodium 138, potassium 3.1, chloride 95, bicarbonate 18, BUN 8, creatinine 0.7, glucose 134, anion gap 25, calcium 9.6, magnesium 1.5, phosphate 3.7. ALT 71, AST 128, amylase 35, alkaline phosphatase 61, total bilirubin 1.6, albumin 4.9. Chest x-ray shows no effusion and no congestive heart failure. An ultrasound of the abdomen shows acute pancreatitis. COURSE IN THE HOSPITAL: The patient was admitted to the [Hospital ] Medical Service. His course in the hospital will be discussed by problem: 1. Pancreatitis: This felt to be secondary to the patient's alcohol abuse. The patient was made NPO. He was given aggressive intravenous fluid rehydration, receiving a bolus of two liters, as well as 250 cc of normal saline an hour initially. His pain was controlled with Dilaudid, initially intravenously. He was given Zofran for nausea. Patient's electrolytes were monitored b.i.d. and were repleted as needed. The patient had persistent fevers and two days after admission had a CT of the abdomen which was suspicious for necrotic pancreatitis. The patient was then started on Unasyn and defervesced. After approximately three to four days in the hospital, the patient's symptoms had resolved somewhat. He was started on sips of liquids and advanced to clears. At the time of dictation, the patient is tolerating clear liquids. 2. Alcohol withdrawal: Patient was felt to be in alcohol withdrawal upon admission. His CIWA scale was checked q. 2 hours. He was given 10 mg of Valium for a CIWA greater than 10. After approximately three days, the patient's need for benzodiazepines decreased. However, at the time of dictation, he is still requiring Ativan prn. 3. Alcohol abuse: The patient was advised that if he continued to drink, he would likely die. A Social Work Consult was obtained. The patient will be given a contact for detoxification prior to discharge. 4. Depression: The patient's wife states that he is depressed. A Social Work Consult was obtained. The patient denied any suicidality. The patient was given contacts for help in the community for his alcohol abuse. 5. Diet: The patient was initially kept NPO for approximately three days. His diet was then advanced to clear liquids. Currently he is tolerating both well. 6. Hypertension: The patient was transiently hypertensive requiring one dose of hydralazine while in house. His blood pressure at its highest was 174 systolic. His blood pressure was more controlled once his fever and other symptoms were under better control. The remainder of the course in the hospital, discharge diagnoses and discharge medications will be dictated by the next intern. [Name6 (MD) 251] [Name8 (MD) ], M.D. [MD Number(1) 1197] Dictated By:[Last Name (NamePattern1) 222] MEDQUIST36 D: [2165-3-17] 02:08 T: [2165-3-17] 14:19 JOB#: [Job Number 31713] Name: [Known lastname 5505], [Known firstname ] Unit No: [Numeric Identifier 5506] Admission Date: [2165-3-13] Discharge Date: [2165-3-22] Date of Birth: [2131-3-8] Sex: M Service: ADDENDUM: The [Hospital 1325] hospital course was complicated by alcohol withdrawal versus benzodiazepines withdrawal. On [3-17], he became agitated and anxious with increasing delirium. He eventually started pulling his intravenous lines and wandering into other patient rooms. He was treated with Valium and Haldol, and eventually, a code purple was called. Given his severe withdrawal symptoms as well as sedation from medications, he was transferred to the Medical Intensive Care Unit for two days. On return to the floor, he was fully lucid on an Ativan taper. At this time, his pancreatitis was symptomatically resolved. He was tolerating a solid diet with no nausea and vomiting and had regular bowel movements. He was seen by the Addiction Service who spoke with him at length about the importance of alcohol detoxification programs and follow-up counseling. The patient was to follow up with a Russian-speaking psychiatrist as an outpatient. He was discharged home on an Ativan taper. Again, the severity of his situation was discussed at length with the attending, the psychiatrist, and the house staff. The patient demonstrated somewhat improved insight into his addiction. DISCHARGE STATUS: Discharge status was to home. DISCHARGE DIAGNOSES: 1. Necrotizing pancreatitis. 2. Alcohol abuse. 3. Alcohol withdrawal. 4. Depression. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was to follow up with Psychiatry (Dr. [First Name4 (NamePattern1) 5507] [Last Name (NamePattern1) 5508]) [Location (un) 5509], [Apartment Address(1) 5510], (telephone number [Telephone/Fax (1) 5511]). Appointment for Tuesday, [3-26] at 3 p.m. 2. The patient was also instructed to see his primary care physician in one to two weeks for followup. MEDICATIONS ON DISCHARGE: 1. Famotidine 20 mg p.o. twice per day 2. Celexa 20 mg p.o. once per day. 3. Multivitamin one tablet p.o. every day. 4. Ativan taper two tablets p.o. four times per day times one day; then one tablet p.o. four times per day times one day; then one tablet p.o. three times per day for one day; then off. [Name6 (MD) 116] [Name8 (MD) 117], M.D. [MD Number(1) 392] Dictated By:[Name8 (MD) 5512] MEDQUIST36 D: [2165-3-22] 13:21 T: [2165-3-28] 08:10 JOB#: [Job Number 5513]	[ "311", "401.9", "291.3", "305.00", "577.0", "571.1" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]								7030, 7120				7568, 8107	1244, 1315						7153, 7542																																													209, 996								1736, 7009			159, 180					1018, 1218	1332, 1721
402	177,951	8204	Discharge summary	report	Admission Date: [2155-5-23] Discharge Date: [2155-5-29] Date of Birth: [2105-9-26] Sex: F Service: MEDICINE Allergies: Penicillins / Tetracyclines / Plaquenil / Chloroquine / Sulfonamides / Floxin / Heparin Agents Attending:[First Name3 (LF) 134] Chief Complaint: Fever, hypotension. Major Surgical or Invasive Procedure: Removal of left subclavian line. Placement of right internal jugular line. History of Present Illness: 49 year old female with h/o Pulm HTN DM lupus on flolan via hickman presenting for possible line infection. A new Hickman line was placed 3 weeks ago after [Last Name (un) ] line became infected and she is s/p 14d vanco course for Micococcus. Micrococcus was grown out of Cultures on [2155-4-23] and [2155-4-25]. Subsequent cultures on [4-19] were all negative. Hickman line insertion (for Flolan) was on [2155-4-29] and PICC line (for Vanco) insertion was on [2155-4-28]. . She comes in with 2 days sweats, chills, as well as tenderness, warmth and drainage from line. Blood sugars 220, usually 100-200. It also has been draining a clear green fluid. She was apparently scheduled for a dental procedure tomorrow for ? infected tooth. No other ROS positive. Mult drug allergies. Exam: crusting and purulence at site. . In the ED: Her initial vitals were 98.1 103 145/82 12 94RA, she was started on Vancomycin but developed itching and rash, benadryl given, -> continued vanco at slower rate -> got worse -> stopped. This is strange since she finished off a 14 day course of Vancomycin dating from her recent visit. . On arrival to the floor she was noted be hypotensive 70s, 1L NS in ED, and received 500cc NS, and 2nd iv was placed. Past Medical History: -Diabetes mellitus type 2 -pulmonary arterial hypertension on Flolan -atrial septal defect of the secundum type (versus a stretched PFO) -obstructive sleep apnea on home oxygen -anticardiolipin antibody -type 1 heparin induced thrombocytopenia -systemic lupus erythematosus with history of pleuritis, glomerulonephritis ([2144]) -obesity -restrictive pulmonary disease -migraines -history of sinusitis -fibromyalgia. Social History: significant for the absence of current tobacco use. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: On Admisison to Floor: VS: T 95.5 BP 82/38 HR 104 RR27 O2 5LNC Gen: WDWN middle aged male in mild distress HEENT: NCAT. Sclera anicteric. PERRL, EOMI. OP clear, dry mm Neck: Supple, CV: S1 S2 no mrg Chest: Ant CTA b/l no w/r/r, Hickman 2cm erythema around site, no discharge Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, Pertinent Results: Labwork on admission: [2155-5-22] 11:10PM WBC-4.0 RBC-4.60 HGB-14.3 HCT-40.9 MCV-89 MCH-31.0 MCHC-34.9 RDW-16.1* [2155-5-22] 11:10PM PLT COUNT-198# [2155-5-22] 11:10PM NEUTS-64.6 LYMPHS-28.6 MONOS-5.3 EOS-0.4 BASOS-1.1 [2155-5-22] 11:10PM GLUCOSE-150* UREA N-16 CREAT-0.7 SODIUM-141 POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-24 ANION GAP-19 [2155-5-22] 11:27PM PT-20.5* PTT-28.2 INR(PT)-2.0* [2155-5-22] 11:36PM LACTATE-2.6* [2155-5-23] 12:25AM URINE RBC-0 WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-[3-24] [2155-5-23] 12:25AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [2155-5-23] 09:16AM CORTISOL-39.3* [2155-5-23] 09:16AM ALT(SGPT)-25 AST(SGOT)-51* LD(LDH)-262* ALK PHOS-40 TOT BILI-0.2 . CHEST (PA & LAT) [2155-5-22] IMPRESSION: No evidence of pneumonia. . ECHO Study Date of [2155-5-23] Conclusions: The left atrium is mildly dilated. The estimated right atrial pressure is >20 mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is markedly dilated. Right ventricular systolic function appears depressed. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic root is moderately dilated athe sinus level. 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. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is at least moderate to severe pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. No vegetations seen (cannot definitively exclude). Compared with the prior study (images reviewed) of [2155-4-9], the IVC is now more dilated. Brief Hospital Course: 49 F PMH pulmonary HTN on flolan, SLE, APA syndrome, underwent recent Hickman change due to line infection who returned with likely line sepsis. . #) Sepsis: Most likely due to Hickman line infection. She was in the ICU for sepsis for a few days where she received several liters of fluids, pressors which were quickly weaned, high dose antibiotics and stress dose steroids. She was subsequently transferred to the floor when off pressors x 48 hours. UA/culture remained negative. CXR negative for infection. Of note, her Hickman was removed [5-24] and a RIJ placed. She was treated with Gentamycin/Linezolid since [5-24] until [5-26] when Daptomycin replaced Linezolod (see "Headache" section below) and then on [5-27] we switched Gentamycin to Levofloxacin to prevent Gentamycin induced toxicity. All of the antibiotic regimens were per ID recs. No blood or catheter tip cultures grew out any organisms during this admission. On the floor she remained hemodynamically stable and afebrile with no further signs of sepsis. She had a midline placed [5-28] for 8 more days of home antibiotics (per ID) to end [6-6] and she had her Hickman replaced by surgery without event on [5-29]. . #) Pulmonary HTN: She had a right heart cath on [5-27] which revealed pulmonary hypertension with mean PA pressure of 47mmHG with PA systolic of 70. The PVR was 513. There was elevation of RA pressure with mean RA of 15mmHG. The PCWP was near normal at 13mmHG. The cardiac index was preserved. Based on this, and concersations with Dr. [Last Name (STitle) ] (pulmonology) we will continue Flolan at home for now via her Hickman. She has follow up scheduled with Dr. [Last Name (STitle) ] to discuss further management of her Pulmonary HTN. . #) Tooth pain: Pt with right questionable tooth infection prior to admission. She had considerable pain and headaches off Amitriptyline. based on this we got Panorex films of her jaw and a Dental consult. Per Dental recs, there was no obvious source of infection/abscess and she was recommended for outpatient dental workup. . #) SLE: Stable throughout admission. We continued steroid taper for a few days after stress dose steroids. As she has had recurrent infections in the past few months, we consulted Dr. [Last Name (STitle) ] (Rheum) re: tapering her home Prednisone which may be contributing to her susceptibility to infections. Per Dr. [Name (NI) 29165] recs, we will discharge Ms. [Known lastname ] on 9mg daily Prednisone and she will follow in the outpatient setting and consider a further taper. . #) Migraine HA: Patient was off amytriptilline for migraine prophylaxis while on Linezolid (due to increased risk of Seratonin syndrome). Her headaches were significantly worse off her home meds. We temporized with Toradol, and Dilaudid PRN and eventually switched from Linezolid to Daptomycin per ID so we could resume Amytriptilline which we did a few days prior to discharge. Her headaches subsequently improved significantly. . #) APA syndrome/history of HIT: Stable. Coumadin was held for procedures/line placements and she remained off Heparin products without event. We resumed Coumadin on day of discharge which she is on for line patentcy. She will follow INRs in the outpatient setting. . #) DM: Stable. FS QID, SSI while in house. We resumed oral agents prior to discharge. . #) OSA: Stable. On home oxygen during admission with stable O2 sats. . Medications on Admission: 1. Allopurinol 100 mg daily 2. Amitriptyline 50 mg qhs 3. Estrogens Conjugated 0.625 mg PO DAILY 4. Fexofenadine 60 mg [Hospital1 ] 5. Fluticasone 50 mcg spray daily 6. Furosemide 20 mg daily 7. Gabapentin 300 mg PO DAILY 8. Gabapentin 600 mg PO HS 9. Metformin 850 mg [Hospital1 ] 10. Prednisone 10 mg daily 11. Warfarin 1 mg daily 12. Zolpidem Tartrate 10 mg PO HS Discharge Medications: 1. Daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours) for 8 days: Last dose 5/18. Disp:8 Recon Soln(s) Refills:0 2. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. PredniSONE 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Disp:120 Tablet(s) Refills:2 4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day: Take with four 1mg tablets for a total of 9mg a day. Disp:30 Tablet(s) Refills:2 5. Epoprostenol 0.5 mg Recon Soln Sig: One (1) Recon Soln Intravenous INFUSION (continuous infusion). 6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day. 7. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1) Nasal once a day. 8. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 10. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 12. Conjugated Estrogens 0.625 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Amitriptyline 50 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime). 14. Metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day. 15. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 8 days: Last dose 5/18. Disp:8 Tablet(s) Refills:0 16. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Four (4) Capsule, Sustained Release PO once a day. Disp:120 Capsule, Sustained Release(s) Refills:2 17. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 18. Flush Please flush Midline catheter with saline flushes before and after antibiotics daily 19. Saline Flush 0.9 % Syringe Sig: One (1) Injection twice a day for 8 days: Before and after antibiotics. Disp:8 Days Refills:0 Discharge Disposition: Home With Service Facility: VNA Assoc. of [Hospital3 ] Discharge Diagnosis: Sepsis -Diabetes mellitus type 2 -pulmonary arterial hypertension -obstructive sleep apnea -systemic lupus erythematosus -migraines Discharge Condition: Fair Discharge Instructions: You were admitted for sepsis secondary to a presumed Hickman line infection. The line was pulled and you were placed on antibiotics and did quite well. You had the Hickman replaced and are now ready for discharge on antibiotics through [2155-6-6]. . Seek medical attention immediately if you experience new symptoms including shortness of breath, chest pain, fainting, arm/jaw pain or numbness, coughing, blood in sputum, worsening diarrhea or other concerning symptoms. . Follow up as per below. Have your potassium checked by your doctor this week as well as your INR (to assess Coumadin level). . Take all medications as prescribed. Followup Instructions: [Doctor Last Name ]-[Last Name (LF) ],[First Name3 (LF) 29166] L. [Telephone/Fax (1) 27854] Call today for an appointment within 1 week. Have your INR and potassium checked this week Provider: [Name10 (NameIs) ] [Name8 (MD) ], M.D. Phone:[Telephone/Fax (1) 612] Date/Time:[2155-7-15] 10:00	[ "278.00", "996.62", "745.5", "729.1", "787.91", "327.23", "710.0", "995.91", "E849.0", "346.80", "458.9", "E879.8", "493.90", "038.9", "250.00", "682.2", "416.9", "285.9", "V58.67" ]	icd9cm	[ [ [] ] ]	[ "38.93", "89.63" ]	icd9pcs	[ [ [] ] ]	10616, 10677	4913, 8386	374, 450	10853, 10859	2871, 2879	11550, 11877	2304, 2386		8812, 10593		10698, 10832		8412, 8789			10883, 11527											2401, 2852																								315, 336													478, 1737								2893, 4890								1759, 2181	2197, 2288
52,347	173,792	54748	Discharge summary	report	Admission Date: [2154-6-17] Discharge Date: [2154-6-22] Date of Birth: [2072-3-6] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2777] Chief Complaint: abdominal aortic aneurysm Major Surgical or Invasive Procedure: 1. Endovascular aortic aneurysm repair of juxtarenal aneurysm with fenestrated stent graft. 2. Bilateral catheter in aorta. 3. Bilateral femoral artery exposure. 4. Left renal artery embolization. 5. Right renal artery stent graft [5-18] iCAST. 6. Superior mesenteric artery bare metal stent [10-10] Genesis. History of Present Illness: Mr. [Known lastname 111939] is an 82-year-old gentleman referred by Dr. [Last Name (STitle) ] for evaluation of an aortic pseudoaneurysm. He is status post repair of an infrarenal abdominal aortic aneurysm with an aortobifemoral graft at [Hospital6 2561] in the late [2121]. I believe this was done by Dr. [Last Name (STitle) 111940]. He had a CT scan approximately one year ago that demonstrated aneurysm above to the existing graft, and this was recently repeated, demonstrated approximately 6-cm aneurysm. He denies any abdominal or back pain. He has an extensive past medical history of coronary artery disease status post MI, TIAs on coumadin, CABG x 3 ([2135]). He is a former smoker who quit in [2116]. He has pacemaker. He has had coronary artery bypass grafting in [2135]. He has CHF. He has got several skin cancers removed. He has had hernia repair. He has prostate hypertrophy, psoriasis, and cholecystectomy. Past Medical History: PMH: TIAs on coumadin, CAD (s/p MI), CHF (EF 40-45%), BPH, psoriasis, prostate ca (s/p radiation), TIA( on coumadin) PSH: CABG ([2135]), pacemaker, hernia repair, cholecystectomy, multiple skin ca (bcc) removals Social History: Lives at home with his wife. Family History: tobacco - quit [2116] etoh - Drinks one glass of wine with lunch and a [Doctor Last Name 6654] before dinner and a shot of scotch after dinner every day. Physical Exam: General: well appearing, no apparent distress Vitals: 98.7 98.3 84 138/68 20 98%RA Cardio: rrr, normal s1 s2 Pulm: faint rhonchi, mild tachypnea Abd: soft, nontender, nondistended, Ext: groins w/dsg bilaterally, clean dry intact; pulse exam: L- palpable throughout, R-palpable femoral and popliteal with doplerable DP and PT Pertinent Results: [2154-6-21] 05:16AM BLOOD WBC-10.6 RBC-3.02* Hgb-10.0* Hct-28.8* MCV-95 MCH-32.9* MCHC-34.6 RDW-17.1* Plt Ct-100* [2154-6-22] 05:08AM BLOOD WBC-8.7 RBC-2.96* Hgb-9.6* Hct-28.0* MCV-95 MCH-32.5* MCHC-34.4 RDW-16.4* Plt Ct-145* [2154-6-21] 05:16AM BLOOD PT-16.0* PTT-31.7 INR(PT)-1.5* [2154-6-22] 05:08AM BLOOD PT-17.7* PTT-31.4 INR(PT)-1.7* [2154-6-21] 05:16AM BLOOD Glucose-104* UreaN-44* Creat-2.8* Na-134 K-4.8 Cl-100 HCO3-29 AnGap-10 [2154-6-22] 05:08AM BLOOD Glucose-107* UreaN-47* Creat-2.6* Na-135 K-4.6 Cl-100 HCO3-26 AnGap-14 [2154-6-20] 09:29AM BLOOD CK(CPK)-144 [2154-6-20] 04:53PM BLOOD CK(CPK)-141 [2154-6-18] 09:45AM BLOOD CK-MB-2 cTropnT-0.02* [2154-6-20] 09:29AM BLOOD CK-MB-2 cTropnT-0.01 [2154-6-21] 05:16AM BLOOD Calcium-8.2* Phos-2.6* Mg-2.5 [2154-6-22] 05:08AM BLOOD Calcium-8.2* Phos-2.3* Mg-2.4 Brief Hospital Course: The patient was admitted to the Vascular Surgery Service for scheudled endovascular surgical treatment of and abdominal aortic aneurysm. On [2154-6-17] the patient underwent endovascular aortic aneurysm repair with fenestrated graft, which went well without complications (see operative note for further details). Of note, pt's After a breif uneventful stay in the PACU, the patient arrived to the floor NPO on IV fluids and on antibiotics, with a foley catheter, and with minimal pain. The patient was hemodynamically stable. Neuro: The patient received minimal doses of Dilaudid IV for pain. Dilaudid was eventually D/C'ed because the patient was not complaining of pain. CV: The patient has a pacemaker; had one episode of SVT with HR ~150's for approx 40sec during which he was completly asymptomatic. Cardiology saw the patient, adjusted the pacemaker to include a monitoring range from 140-160, and made no further changes or recs. No additional medications were given during the episode and the episode did not recur. Pt had a central venous line installed for access but that was removed prior to discharge. Pt remained stable after that episode and was stable on discharge. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Early ambulation and incentive spirometry were encouraged throughout hospitalization. No acute issues. GU: Pt with poor urine output after surgery secondary to L renal artery embolization related to graft placement. Cr was elevated as well as high as 2.9. Foley catheter was placed and daily weights were recorded to evaluate fluid status. Renal ultrasound performed indicated that the remaining R-kidney had adequate blood flow. Per Renal Service recommendation, we DC'ed the pt's home dose of Ramipril for concern of glomerular hypoperfusion. Urine output was routinly monitored and adequate on discharge and Cr declined to 2.6. GI/GU/FEN: Post-operatively, 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. Now on a regular Diabetic Diet. ID: Pt found to have UTI on UA and treated with 3 days of Ciprofloxacin in house. Otherwise, the patient's white blood count and fever curves were closely watched for signs of infection. Wound care: bilateral EVAR incision sites were monitored and well maintained. No signs of infection. Endocrine: The patient's blood sugar was monitored throughout his stay and found to be somewhat elevated ranging from 110's-230's so placed on a sliding scale of insulin. However pt never diagnosed with diabetes, so consider discontinuing the regimen on discharge from the Rehab. Prophylaxis: The patient received subcutaneous heparin during this stay; would continue HSQ until patient is theraputic on his Coumadin then DC at that time. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding through a condom catheter (for urine output monitoring), and complaining of no pain. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: coumadin 4', carvedilol 6.25'', vytorin 10/40', ramipril 2.5', Ca carbonate (dose unk), Vit D3, VitB12 Discharge Medications: 1. Acetaminophen IV 1000 mg IV Q6H:PRN pain 2. Aspirin 81 mg PO DAILY 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 4. Carvedilol 6.25 mg PO BID 5. Vytorin 10-40 NF (ezetimibe-simvastatin) 10-40 mg Oral daily hypercholesterolemia 6. Warfarin 4 mg PO DAILY16 7. Cyanocobalamin 50 mcg PO DAILY 8. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Extended Care Facility: [Hospital1 11057] Place Nursing Center Discharge Diagnosis: Abdominal aortic aneurysm 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: What to expect when you go home: 1. It is normal to feel weak and tired, this will last for [5-24] weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? You may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have incisional and leg swelling: ?????? Wear loose fitting pants/clothing (this will be less irritating to incision) ?????? Elevate your legs above the level of your heart (use [1-18] pillows or a recliner) every 2-3 hours throughout the day and at night if you find your legs swellilng. ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? You should get up every day, get dressed and walk, gradually increasing your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (let the soapy water run over incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, UNLESS OTHERWISE DIRECTED ?????? Take one baby aspirin daily (81mg), unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal if applicable. What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 101.5F for 24 hours ?????? Bleeding from incision ?????? New or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Follow up with Dr. [Last Name (STitle) ] in 2 weeks. Call his office on MONDAY at ([Telephone/Fax (1) 9393] to schedule an appointment. *You will need to have a follow up noncontrast CT SCAN of your abdomen and pelvis. At this appointment you will also need to have a Duplex of your aorta. Please call Dr.[Name (NI) 7446] office to schedule this appointment. Completed by:[2154-6-22**]	[ "362.50", "401.9", "E878.2", "790.29", "412", "V15.3", "272.4", "V45.81", "V45.02", "584.5", "427.1", "V10.83", "V12.54", "441.4", "V70.7", "696.1", "599.0", "V15.82", "V10.46", "V58.61", "414.8", "997.5", "428.0", "369.4", "V45.79", "997.1" ]	icd9cm	[ [ [] ] ]	[ "38.93", "88.47", "39.78" ]	icd9pcs	[ [ [] ] ]	7324, 7393	3369, 5834	328, 655	7463, 7463	2480, 3346	10275, 10683	1950, 2114		6907, 7301		7414, 7442		6779, 6884			7646, 9822	9848, 10252										2129, 2461																								263, 290										5846, 6753			683, 1647										7478, 7622						1669, 1888	1904, 1934
49,068	194,877	51264	Discharge summary	report	Admission Date: [2192-11-6] Discharge Date: [2192-11-18] Date of Birth: [2120-11-29] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2972] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 71M with coronary artery disease s/p CABG, CHF, CKD (baseline Cr [3-30]), hypertension, hyperlipidemia, DM2 on insulin, complains of worsening dyspnea in the past few days. Pt was recently admitted on [2191-10-27] for CHF exacerbation, and [Date range (1) 17344] for NSTEMI and possible pneumonia. He was treated with levofloxacin at home. After discharge, pt was ambulating in the house, and will become dyspneic on exertion. Over the weekend, he became increasingly dyspneic and lightheaded. He also has an intermittent achy flank / RLQ pain, which has been attributed to muscle spasm for which he takes hydromorphine. Pt otherwise denies fever, chill, cough, chest pain, N/V/D. There is no recent sickness or sick contacts. [Name (NI) ] was noted to have slightly increased appetite compared to the last a couple of weeks, and probably decreased urine output despite lasix use over the weekend. His edema in legs has been stable. . Pt went to the clinic today, and was instructed by Dr. [Last Name (STitle) 106365] to go to the ED if his symptoms worsens, which was the case. . In the [Name (NI) ], pt's BPs 90s/50s, trigger to 80s after morphine dosing. BP resolved after 1L fluid. His lab showed WBC 31, stable Hct, potassium of 5.8, worsening Cr to 5.9, Troponin of 1.01 and BNP of [Numeric Identifier 106366]. Chest X-ray showed worsening right side opaciy, concerning for mass vs effusion. CT head showed no evidence of hemorrhage. Bedside ultrasound showed no pericardial effusion. He was given aspirin, started on heparin given the concern for NSTEMI. He aslo received zosyn, levaquin, and vanco. . On arrival to the MICU, Pt's VS are T: 95.6 BP: 106/61 P: 60 R: 18 O2: 100% on 2L nc. There was no pulsus on the exam. Past Medical History: - Hypertension - Hyperlipidemia - Systolic heart failure, history of low EF with improvement on TTE [12/2188] (LVEF>55%) - Hx of inducible VT, s/p upgrade to a BiV ICD [2186] - CAD s/p CABG [2163]; s/p DES to LAD in [2186]; history of MI - Atrial fibrillation/flutter - Diabetes mellitus, diagnosed 7 years ago, HgA1c 8.5% in [August 2190] - OSA on CPAP with 3 liters O2 - Question of reactive airway disease - Chronic renal insufficiency, stage 3 disease, baseline Cr ~2.8 - history of Strep bovis bacteremia c/b acute renal failure [2188] - Hypothyroidism - Bronchitis - s/p resection of benign colon polyps - s/p cholecystectomy - Gout - GERD Social History: The patient is retired, previously worked as a manager in a paint factory where he had some asbestos exposure. He has a remote 40 pack-year tobacco history. He reports no alcohol use, no illicit drug use. He lives with his wife at home. Family History: He has a brother also with CABG at age 60 doing well. His mother died during childbirth, father died of cirrhosis that the patient thinks was alcohol related. Physical Exam: Physical Exam on admission: Vitals: T: 95.6 BP: 106/61 P: 60 R: 18 O2: 100% on 2L nc General: Alert, oriented X3, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP ~10 cm, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: CTA on the left, crackles over right base, egophony on right. Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or 2+ edema to mid-shin Physical Exam on discharge: 96.8 (97) 93/58 74 (60's to 70's) 20 97% on 2L bs: 79, 71, 115, 113 General: Alert, oriented X3, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI Neck: supple, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Coarse breath sounds bilaterally, decreased breath sounds over the right base, dullness to percussion with decreased tactile fremitus over R base, bibasilar crackles. Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley present Ext: cold feet but well perfused with 2+ DP pulses and ~2 sec cap refill, 2+edema to mid-shin, multiple excoriations of skin Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, finger to nose intact Pertinent Results: Labs on admission: [2192-11-7] 08:34AM BLOOD WBC-22.4* RBC-2.93* Hgb-8.0* Hct-25.7* MCV-88 MCH-27.2 MCHC-31.0 RDW-17.7* Plt Ct-217 [2192-11-6] 03:10PM BLOOD WBC-31.0* RBC-3.36* Hgb-9.1* Hct-29.7* MCV-89 MCH-26.9* MCHC-30.4* RDW-17.5* Plt Ct-301 [2192-11-6] 03:10PM BLOOD Neuts-94.5* Lymphs-1.5* Monos-1.4* Eos-2.4 Baso-0.1 [2192-11-7] 08:34AM BLOOD Plt Ct-217 [2192-11-7] 02:20AM BLOOD PT-14.9* PTT-45.7* INR(PT)-1.3* [2192-11-7] 01:12PM BLOOD Glucose-163* UreaN-107* Creat-5.0* Na-135 K-5.2* Cl-104 HCO3-18* AnGap-18 [2192-11-7] 02:20AM BLOOD CK(CPK)-15* [2192-11-7] 02:20AM BLOOD CK-MB-2 cTropnT-0.89* [2192-11-6] 03:10PM BLOOD cTropnT-1.01* [2192-11-6] 03:10PM BLOOD CK-MB-3 proBNP-[Numeric Identifier 82429]* [2192-11-7] 01:12PM BLOOD Calcium-7.6* Phos-4.7* Mg-2.4 [2192-11-6] 03:10PM BLOOD Calcium-8.8 Phos-5.0* Mg-2.6 [2192-11-6] 03:10PM BLOOD D-Dimer-761* Lower extremity US: No lower extremity DVT with subcutaneous edema in the calves. ECHO [11-7]: IMPRESSION: No echocardiographic evidence of endocarditis. Mild regional left ventricular systolic dysfunction. Mild mitral regurgitation. If clinically indicated, a transesophageal echocardiogram may better assess for valvular vegetations. Compared with the prior study (images reviewed) of [2190-11-15], the findings are similar. CT Head W/O contrast: Final Report: INDICATION: 71-year-old male with non-STEMI and lung mass concerning for malignancy. Question intracranial hemorrhage prior to heparin therapy. COMPARISON: [2188-6-16]. TECHNIQUE: Contiguous non-contrast axial images were acquired through the brain, with multiplanar reformations. FINDINGS: There is no intracranial hemorrhage, mass effect, edema, or shift of normally midline structures. The [Doctor Last Name 352]-white matter differentiation is preserved. Ventricles and sulci are prominent, consistent with age-related involution. There is no major vascular territorial infarct. Suprasellar and basilar cisterns are patent. Paranasal sinuses and mastoid air cells are well aerated. There are vascular calcifications in the cavernous carotid and vertebral arteries. Globes and soft tissues are unremarkable. Incidental note is made of leftward deviation of the nasal septum. IMPRESSION: No acute intracranial process. Chest X-ray [11-8]: FINDINGS: Single frontal view of the chest was obtained. The heart is of top normal size with a stable cardiomediastinal silhouette. Pulmonary vascular congestion is unchanged with mild bilateral pulmonary edema with associated right pleural effusion. Known pleural and pulmonary nodules are better evaluated on CT. No pneumothorax. Atrial biventricular AICD pacer leads follow their expected course. Sternotomy wires are aligned. IMPRESSION: Unchanged pulmonary vascular congestion with pulmonary edema and small right pleural effusion. #Pleural Fluid: Negative for malignant cells #CT-guided Pleural Biopsy: Peliminary Report: Positive for malignancy Labs on discharge: [2192-11-16] 06:00AM BLOOD Glucose-15* UreaN-112* Creat-5.5* Na-137 K-5.7* Cl-100 HCO3-22 AnGap-21* [2192-11-16] 06:00AM BLOOD Calcium-8.7 Phos-6.3* Mg-2.3 Brief Hospital Course: Pt is a 71 year old male with pmh of coronary artery disease s/p CABG, CHF, CKD (baseline Cr [3-30]), hypertension, a fib w/ PPM on amiodarone, hyperlipidemia, DM2 on insulin with recent admissions for CHF exacerbation, NSTEMI/pneumonia who represents with worsening dyspnea on exertion. # Dyspnea - Pt's etiology of dyspnea is most likely multifactorial including lung malignancy w/ worsening pleural effusion, CHF exacerbation (based on increased crackles and bilateral 2+ pitting lower extremity edema) and ESRD. We attempted to diurese pt with IV lasix [Hospital1 ] and metolazone with minimal success as pt was unable to maintain a negative fluid balance because of his ESRD. Pt initially had a thoracentesis that was negative for malignant cells. Pt then had a CT-giuded IR biopsy on Tuesday [11-13] which did confirm the presumed diagnosis of malignancy. Pt will be sent home on PO lasix 80 mg [Hospital1 ] and metolazone 2.5 mg [Hospital1 ] for symptomatic relief of dyspnea and orthopnea. He will also continue albuterol nebulizer treatments every 6h for dyspnea relief. # Acute on Chronic renal failure - pt p/w Cr 5.9, worse than his baseline. His creatinine intially trended downward to a nadir of 4.7 before steadily rising to 5.5 on discharge. Discussion of hemodialysis had been brought up on last admission with renal and was briefly discussed after malignancy diagnosis, but pt was not amenable to this plan. Pt will be continued on sevelamir 800 mg tid with meals and calcitriol 125 mcg daily. # Hypotension - Pt was hypotensive on non-invasives on admission, but had SBP's in 120's when an A-line was placed. Non-invasive SBP's were persistently in the 90's and 100's throughout the admission, likely representing the pt's baseline BP because of CHF. Chest x-ray's did not show any sign of pneumonia and pt was afebrile (pt with baseline leukocytosis). He also denies any cough or sputum production consitent with PNA. Echo did not show any acute worsening of pump function. Pt dis not have any s/s of sepsis (blood cultures were negative). Imdur and metoprolol were held during admission becuase of low blood pressures. # Hyperkalemia - Pt had a persistently elevated potassium despite recieving IV lasix [Hospital1 ]. It is possible that kidneys are not able to excrete potassium because of a severely depressed GFR. Pt recieved multiple doses of kayexalate to reduce potassium levels with minimal affectiveness. He will be discharged with daily kayexalate to reduce potassium levels and for contibued constipation. He will also be discharged with zofran 4 mg q8h for nausea [2-29] the kayexalate. # Pleural effusion and multiple pulmonary nodules- Initial pleural biopsy results were consistent with malignancy. # Leukocytosis - Has had chronic WBC of 20-30 since [Month (only) 216] most likely [2-29] lung malignancy. # Anemia - H&H has remained stable during admission around 8-9/25-27. Does have history of severe bleed into renal cyst and was recently on heparin, however no evidence of active bleed throughout the admission # Abdominal pain: Thought to be [2-29] fluid distention of abdomen or MSK in nature as CT scan from [9-/2192] showed no evidence for an acute process. Pain was controlled during the admission with oxycodone 5 mg q3h prn. #Diabetes: Pt on insulin at home. We adjusted his sliding scale for persistent hypoglycemia in the am, as wel as decreasing his lantus to 7 units at bedtime. He was also kept on a diabetic diet. #Hyperlipidemia: Pt was d/c'd from rosuvastatin 20 mg daily on discharge #Atrial fibrillation: Pt on amiodarone with AV pacing. He will be continued on amiodarone 200 mg daily for rhythm control. # Hypothyroid: Pt will be continued on levothyroxine 125 mcg /day for symptomatic relief. # Gout: not active but will continue with allopurinol to prevent gout flare. #Constipation: Pt had issues with constipation during admission and will be discharged with docusate, senna, mirlalax and kayexalate. #CAD: Pt will continue on aspirin 81 mg daily and SL nitro for relief of chest pain. Transitional Issues: -Pt will be discharged to home hospice -Pt had code status changed to DNR/DNI on discharge -Pt opted to have his BiVICD remain on at this time Medications on Admission: 1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO BID (2 times a day). 6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a day. 11. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO once a day. 12. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: 1.5 Tablet Extended Release 24 hrs PO once a day. 13. furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day in the morning. 14. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day in the evening. 15. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 4 days: Please only take as needed for pain control. Please do not drive or operate heavy machinery after taking this medication as it can cause drowsiness. Disp:24 Tablet(s) Refills:0 17. Lantus 100 unit/mL Solution Sig: Forty Two (42) units Subcutaneous at bedtime. 18. Humalog 100 unit/mL Solution Sig: Ten (10) units Subcutaneous three times a day: Please take with meals and administer according to sliding scale. 19. epoetin alfa 10,000 unit/mL Solution Sig: One (1) injection Injection once a week. 20. aspirin 162 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 21. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 4 days. Disp:2 Tablet(s) Refills:0 Discharge Medications: 1. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day as needed for shortness of breath. Disp:60 Tablet(s) Refills:2 2. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for shortness of breath or wheezing: please take thirty minutes before lasix dose. Disp:60 Tablet(s) Refills:2 3. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:60 Tablet(s) Refills:2 4. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. sodium polystyrene sulfonate 15 g/60 mL Suspension Sig: One (1) PO once a day for 4 weeks. Disp:qs Refills:0 6. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. Disp:90 Tablet, Rapid Dissolve(s) Refills:0 7. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 8. Lantus 100 unit/mL Solution Sig: One (1) Subcutaneous at bedtime: Please take 7 units of lantus at bedtime. 9. sliding scale insulin Please take humalog sliding scale based on attached sheet 10. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) treatment Inhalation Q6H (every 6 hours) as needed for shortness of breath for 4 weeks. Disp:qs Refills:0 13. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:30 Tablet(s) Refills:0 16. Miralax 17 gram/dose Powder Sig: One (1) PO once a day as needed for constipation. Disp:30 Refills:0 17. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 18. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. Disp:30 Tablet, Sublingual(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 3005] Hospice Discharge Diagnosis: Primary: Lung Malignancy Secondary: Congestive Heart Failure End-Stage Renal Disease Diabetes Mellitus Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [Known lastname 106362], It was a pleasure taking care of you during your hositalization at [Hospital1 69]. You were admitted with shortness of breath. We found that you did not have an infection, but had a worsening of your heart failure. We attempted to get some fluid off, but it was difficult because of your renal failure. We also performed a biopsy of the tissue surrounding your lung because of a very concerning Chest CT a few weeks ago. The biospy was in fact positive for cancer. After discussions with you, your family and your doctors, you decided to enter home hospice. You will have a hospital bed delievered to your home and will recieve extensive home services from hospice. MEDICATION CHANGES: STOPPED OMEPRAZOLE 20 MG DAILY STOPPED ISOSORBIDE MONONITRATE 60 MG DAILY STOPPED FOLIC ACID 1 MG DAILY STOPPED FERROUS SULFATE 300 MG THREE TIMES A DAY STOPPED METOPROLOL 100 MG DAILY STOPPED ROSUVOSTATIN 20 MG DAILY CHANGED LASIX TO 80 MG TWICE A DAY AS NEEDED FOR SHORTNESS OF BREATH CHANGED HYDROMORPHONE TO OXYCODONE 5 MG EVERY THREE HOURS AS NEEDED FOR PAIN CHANGED LANTUS TO 7 UNITS AT BEDTIME CHANGED HUMALOG SLIDING SCALE (PLEASE SEE NEW ATTACHED SCALE) CHANGED ASPIRIN 162 MG TO 81 MG DAILY STARTED METOLAZONE 2.5 MG DAILY, PLEASE TAKE 30 MINUTES BEFORE LASIX DOSE STARTED KAYEXALATE ONCE A DAY FOR CONSTIPATION AND HIGH POTASSIUM STARTED SENNA AND MIRALAX FOR CONSTIPATION STARTED 0.3 MG OF SUBLINGUAL NITRO AS NEEDED FOR CHEST PAIN STARTED ONDANSETRON 4 MG THREE TIMES A DAY AS NEEDED FOR NAUSEA STARTED ALBUTEROL NEBULIZER AS NEEDED FOR SHORTNESS OF BREATH Followup Instructions: Department: ADULT MEDICINE When: WEDNESDAY [2193-2-6] at 8:30 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8471], MD [Telephone/Fax (1) 1144] Building: [Location (un) 2355] ([Location (un) ], MA) [Location (un) 551] Campus: OFF CAMPUS Best Parking: Free Parking on Site	[ "V58.67", "585.6", "285.9", "162.5", "584.9", "274.9", "V45.81", "428.0", "511.9", "403.91", "428.23", "458.9", "427.31", "288.60", "789.09", "410.72", "414.00", "272.4", "276.7", "250.00", "197.2", "V15.82", "V45.01", "V49.86", "327.23", "564.00", "244.9", "V45.82" ]	icd9cm	[ [ [] ] ]	[ "34.04", "38.91", "34.24" ]	icd9pcs	[ [ [] ] ]	16480, 16538	7798, 11928	326, 332	16686, 16686	4580, 4585	18512, 18839	3084, 3245		14297, 16457		16559, 16665		12122, 14274			16873, 17597											3260, 3274															3817, 4561			11950, 12096					17617, 18489	267, 288				7610, 7775									360, 2119								4599, 7590		16701, 16849						2141, 2813	2829, 3068
46,504	148,470	5147	Discharge summary	report	Admission Date: [2194-4-13] Discharge Date: [2194-4-20] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1674] Chief Complaint: hypotension Major Surgical or Invasive Procedure: none History of Present Illness: 86 yo male with history of atrial fibrillation, s/p pacemaker placement on [2194-3-20], and known AAA was admitted from the ED with cellulitis and hypotension. . Patient reports that on the morning of admission he woke up to urinate but was unable to stand up. He was then brought in by ambulance to the [Hospital1 ] ED. ROS was notable for the following: increased left lower extremity swelling, erythema, and tenderness x 3 weeks for which he has been taking increased doses of lasix. Reivew of systems was otherwise unremarkable. Denies feeling lightheaded, dizzy, SOB, chest pain, loss of consciousness, diarrhea, dysuria, nausea, or vomiting. . Patient initially presented to [Hospital1 ] with temp 100, BP 78/50. HR and pulse ox not documented. He was started on peripheral dopamine, received broad spectrum antibiotics with ceftriaxone 1 g IV x 1 andvancomycin 1g IV x 1, and received approximately 3.5-4L NS. He was then transferred to [Hospital1 18] ED, where upon arrival temp 98.3, HR 60s, BP 114/64, RR 18, and 100% on 4L NC. He had a central line placed and was started on levophed Past Medical History: 1. Atrial Fibrillation 2. Rheumatoid Arthritis 3. Hypertension 4. Tremor 5. Glaucoma 6. Abdominal Aortic Aneurysm 7. Anemia 8. Edema 9. Prostate Cancer 10. Chronic Renal Insufficiency 11. Radiation Proctitis 12. Osteoarthritis Social History: Home: lives with wife and daughter at home in [Name (NI) 620] Occupation: retired FBI [Doctor Last Name 360] and executive at Hertz Corporation EtOH: Denies Drugs: Denies Tobacco: quit smoking approximately 50 years ago with a 15-20 PPY history Family History: Father - died of MI at 62. Mother - died at 91 of bowel ischemia. Physical Exam: On admission: HEENT: Clear OP, MMM NECK: Supple, No LAD, No JVD CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops LUNGS: CTA, BS BL, No W/R/C ABD: Soft, NT, ND. NL BS. No HSM EXT: No edema. 2+ DP pulses BL SKIN: No lesions NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [1-22]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [Location (un) 620] Blood and urine cultures: pan sensitive Kebsiella Lab results on day of discharge: wbc 5.6 hct 27.1 (baseline) plt 70 creatinine 1.7 (baseline) C diff negative Brief Hospital Course: 86 yo male with history of recent pacemaker placement on [2194-3-20] for complete heart block, atrial fibrillation, and hypertension was admitted with urosepsis and cellulitis, acute renal failure. Hospital Course by Problem: 1. Urosepsis: Patient was transferred to the [Hospital1 18] ED from [Location (un) 620] having recieved about 4L fluids. He remained hypotensive and was started on phenylephrine to maintain MAP >60. He was eventually weaned off >48 hours. Patient had evidence of severe sepsis given bandemia, hypotension, and acute on chronic renal failure. The patient blood and urine cultures (from [Location (un) 620]) grew pan sensitive Klebsiella, including sensitive to cefzolin. Susbsequent cultures negative. He was intially started on cefepine and vanco, once sensitivies to klebsiella came back, he was switched over to cefzolin. He will complete a 14 day course cefzolin on [2194-4-27]. 2. Acute on Chronic Renal Insufficiency: Patient with creatinine elevated to 2.7 on admission from baseline of 1.6. Urine sediment showed muddy brown casts, but he appears most likely secondary to pre-renal in the setting of hypotension. Renal u/s showed evidence of medical renal disease, no hydrophrosis. After volume resuscitation, creatinine returned to baseline. 3. Cellulitis: On admission LLE with erythema, 4+ edema, improved on IV vancomycin and given that he was low risk for MRSA, he was transitioned to Cefzolin on [4-17]. He continued to have improvement of cellulitis. Continue cefzolin until [2194-4-27], be sure to continue diuresis for complete healing. 4. Rheumatoid Arthritis Stable. Should eventually restart Enbrel per outpatient, held in acute setting, likely restart as outpt. 5. Hypertension: Pt was not hypertensive during hospital stay. 6. Glaucoma Stable, continued eye drops. 7. Prostate cancer: Pt reports that he received radiation and that as far as he understands, there was no metastasis. Given the multiple fractures seen on the pelvis, he should follow up with his oncologist. 8. Anemia: Continued B12 orally. 9. Osteoporosis Stable, continue fosamax, calcium, and Vitamin D. 10. Tremor: Continue Primidone 250mg PO qAM / 125mg PO qPM 11. B/l pelvic fractures: Both are old. Left was known to pt, right unknown to pt. CT obtained and showed that both of these are old. Films discussed with orthopedic surgeon and there are no weight bearing limitations. No surgery necessary. 12. Atrial fibrillation: Pt is intermittently paced, received a dual chamber pacer in [2194-3-20], cardiologist is Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3321]. Continue Toprol. Not anti-coagulated due to low platelets from MDS. Continue aspirin. 13. MDS: Persistent MDS, all cell lines at baseline low. Pt has a follow up appointment scheduled with Dr. [Last Name (STitle) ] at [Hospital3 328]. Medications on Admission: 1. Lasix 100mg qAM / 8qPM 2. Multivitamin daily 3. Terazosin 4mg PO qPM 4. Primidone 250mg PO qAM / 125mg PO qPM 5. Calcium Carbonate 1000mg PO daily 6. Timolol ou gtt .25% 1 drop each eye 7. Testim 1% daily 8. Vitamin B12 1000mg PO daily 9. Vitamin D 50,000mg twice weekly 10. Tylenol prn 11. Claritin prn 12. Fosamax 70mg PO q weekly 13. Mysoline 250mg PO qAM / 125mg PO qPM 14. Aspirin 81mg PO daily 15. Enbrel 50mg PO q weekly . DISCONTINUED MEDICATIONS: 1. Metolazone 5mg 30 minutes prior to lasix 2. Lisinopril 5mg PO qAM Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 3. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 4. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every Monday). 5. Primidone 250 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 6. Primidone 50 mg Tablet Sig: 2.5 Tablets PO QPM (once a day (in the evening)). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) u Injection TID (3 times a day). 9. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 10. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day as needed for allergy symptoms. 12. Tylenol 325 mg Tablet Sig: One (1) Tablet PO every [6-29] hours. 13. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. 14. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 15. Caltrate 600 600 (1,500) mg Tablet Sig: One (1) Tablet PO twice a day. 16. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 17. Cefazolin in Dextrose (Iso-os) 1 gram/50 mL Piggyback Sig: One (1) gram Intravenous Q12H (every 12 hours) for 7 days: last day is [2194-4-27]. 18. 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. Discharge Disposition: Extended Care Facility: [Hospital3 5277] - [Location (un) 745] Discharge Diagnosis: cellulitis klebsiella bacteremia klebsiella UTI Renal Failure pelvic fracture (old) Discharge Condition: stable, requires full assist to get oob and to ambulate Discharge Instructions: Complete the course of antibiotics (14 days total) and keep legs elevated as much as possible. If you have any fevers, leg pain, or other concerning symptoms, please alert the physician at the rehab. Followup Instructions: 1)Please follow up with your oncologist regarding the pelvic fracture to be sure it is not related to your prostate cancer. 2)Please follow up with your primary care doctor within the next month to discuss whether you should increase or decrease your lasix dose. 3)Please schedule an appointment with the orthopedic surgeon for further evaluation of your pelvic fracture. The orthopedic surgeon is Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1005], [Hospital1 ] [Telephone/Fax (1) 1228]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(2) 1677] Completed by:[2194-4-20]	[ "365.9", "682.6", "585.9", "787.91", "714.0", "995.92", "733.00", "285.21", "427.31", "276.6", "038.49", "599.0", "785.52", "403.90", "427.89", "584.9", "286.9", "238.75", "V15.3", "V10.46" ]	icd9cm	[ [ [] ] ]	[ "38.93", "99.61" ]	icd9pcs	[ [ [] ] ]	7973, 8046	2750, 2954	274, 280	8174, 8232	2541, 2727	8481, 9155	1957, 2024		6241, 7950		8067, 8153		5689, 6218			8256, 8458											2039, 2039																								223, 236							2983, 5663						308, 1420								2053, 2522								1442, 1671	1687, 1941
55,953	132,357	35728	Discharge summary	report	Admission Date: [2195-3-5] Discharge Date: [2195-4-8] Date of Birth: [2125-9-13] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 552] Chief Complaint: Atrial fibrillation Major Surgical or Invasive Procedure: PVI ablation Central line placement Intubation, extubation History of Present Illness: This is a 69 year-old male with a mechanical aortic valve, CAD and persistent A fib, who is admitted for heparin administration before a planned PVI ablation tomorrow by Dr. [Last Name (STitle) 13177]. He has been cardioverted twice, the last on [2194-12-10]. Antiarrythmics have not been started due to significant bradycardia in the past. He is currently symptomatic with dyspnea on exertion and generalized fatigue. He can walk the length of one hallway before needing to rest. Denies orthopnea, chest pain or pressure, diaphoresis or edema. On review of systems, he endorses stable hearing loss, intermittent pain in left leg, foot drop in left foot, anxiety. 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: St. [Male First Name (un) 923] mechanical aortic valve. Placed [2179] for calcified bicuspid valve A fib, began about 3 years ago, s/p 3 ablation procedures, last about 1 month ago. s/p angioplasty, stent in left circumflex non-ischemic cardiomyopathy, ? related to EtOH class III CHF, EF 35% on echo [7-/2194] 3 surgical procedures on left calf for removal of benign tumor Social History: Social history is significant for the absence of current tobacco use. Pt quit smoking age 20. Per patient he consumes [3-4] drinks per day, per wife it is 10 drinks per day. Patient has experienced "shakes" before during hospitalization, but never seizures or hallucinations. Family History: Family history is notable for father who died of MI at age 50. Physical Exam: ADMISSION VS - T 98.1, BP 126/87, HR 88, RR 18, O2 Sat 97% on RA Gen: WDWN male in NAD. Oriented x3. Mood, affect appropriate. Tremulous. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 10 cm. CV: PMI located in 5th intercostal space, midclavicular line. irregular rate, mechanical S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM 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+ Femoral 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Pertinent Results: [2195-3-5] 03:15PM GLUCOSE-84 UREA N-19 CREAT-0.9 SODIUM-139 POTASSIUM-4.0 CHLORIDE-99 TOTAL CO2-26 ANION GAP-18 [2195-3-5] 03:15PM MAGNESIUM-1.8 [2195-3-5] 03:15PM WBC-6.7 RBC-4.86 HGB-15.2 HCT-43.7 MCV-90 MCH-31.3 MCHC-34.8 RDW-14.2 [2195-3-5] 03:15PM PLT COUNT-207 [2195-3-5] 03:15PM PT-29.9* PTT-150* INR(PT)-3.1* [2195-3-6] 03:35AM BLOOD PT-22.2* PTT-36.3* INR(PT)-2.1* EKG: A fib, rate 84. axis slightly right. qRs 172, LBBB. No prior in system, but per cardiologist note, prior shows wide left bundle branch block with qRs duration of 190 ms. ECHO: [7-/2194] EF 30-35%, severe hypokinesis of septal,inferoseptal and inferobasal walls. Mild apical hypokinesis. RV size and function normal. 2+ MR. 2+ TR, RA and [Name Prefix (Prefixes) ] [Last Name (Prefixes) 6878]. Normally functioning bioprosthetic aortic valve. Dilated aortic root. CT HEAD W/O CONTRAST Study Date of [2195-3-9] 3:07 PM No acute intracranial process. CT PELVIS W/O CONTRAST Study Date of [2195-3-9] 3:08 PM No significant interval change in the large hematoma in the left thigh adductor muscle compartment since the prior CT scan dated [2195-3-8]. CT CHEST W/O CONTRAST Study Date of [2195-3-9] 3:08 PM 1. Bilateral small-to-moderate pleural effusions with almost complete collapse of the left lower lobe and right basilar opacities, could be due to atelectasis or aspiration, much less likely pneumonia. 2. 6-mm and less lung nodules, warrant further followup in one year if the patient has no risk factor, and in 6 to 12 months if the patient has risk factors for malignancy. 3. Aortic valve replacement. Cardiomegaly. Coronary artery and mitral annulus calcifications. 4. Mediastinal lymph nodes, likely reactive. 5. Ascending aorta enlargement, up to 4.7 cm, above the sinotubular junction. Pulmonary artery enlargement, could be pulmonary hypertension. 6. Signs of volume overload. Mild upper lobe predominant centrilobular emphysema. MR CERVICAL SPINE W/O CONTRAST Study Date of [2195-3-14] 9:22 PM Limited study. No definite sign of restricted diffusion to suggest acute spinal cord ischemia. MR HEAD W/O CONTRAST Study Date of [2195-3-14] 9:21 PM No signs of diffusion-weighted abnormalities CT ABDOMEN W/O CONTRAST Study Date of [2195-3-16] 12:15 PM 1. Interval increase in size of large hematoma in the left thigh adductor muscle compartments since prior CT of [2195-3-9], with internal hematocrit effect. This could represent a liquefying hematoma or, if the thigh circumference has increased, could be due to acute bleeding. 2. No retroperitoneal hematoma. 3. Malpositioned NG tube, with side ports at the level of the GE junction, advancement recommended. Brief Hospital Course: Patient is a 69 year old man with mechanical heart valve and a fib, admitted for anticoagulation before PVI ablation by EP the day after admission. Initially his INR was 3.1, so heparin drip was discontinued. Continued on home dose of atenolol and aspirin. Continue home rosuvastatin 10 mg po daily. Repeat INR the morning of [2195-3-6] was 2.1, so patient was taken to cath lab for procedure. After his procedure, he became tremulous and agitated in the PACU with significant groin bleeding. This was attributed to alcohol withdrawl and the patient confirmed his last drink was 36 hours prior and that he drinks 10 beers per day. Per patient, he has become tremulous during admissions in the past. No history of seizures or hallucination. Given difficulty with holding pressure and significant groin bleeding, patient was intubated in the PACU and sent to the ICU on [3-6]. He was then treated with IV diazepam for withdrawl per CIWA protocol. On [3-7] patient was restarted on Warfarin 10mg but had a significant Hct drop and was treated with Vitamin K, platelets and FFP on [3-8]. On [3-8] extubation was attempted but the patient failed due to altered mental status so was reintubated. Sputum grew GPCs. # Respiratory status- For his respiratory status, patient was initially intubated for delirium, inability to control bleeding. He was then extubated and reintubated on [3-8] with continued altered mental status in the setting of Valium. On [3-8] he was also started on Vanc/Levofloxacin for concern for CAP and GPC in sputum & CXR concerning for left lung process. [3-11] Vanco was discontinued as sputum grew MSSA. Mini-BAL on [3-15] revealed no microrganisms and no PMNs, which ultimately grew oral flora. TEE was obtained to look for vegetations, but none were found. Also on [3-15], he spiked a new fever and was pancultured and antibiotics were broadened to Cipro/Vanc/Zosyn for VAP. Given his failure to improve for several days following, IP was contact[Name (NI) ] for possible trach placement but could not do so given his C-collar. Ultimately, his RSBI did improve to < 105 and on [3-19] he was extubated. His cough was not overly strong initially and he did require frequent suctioning but was able to protect his airway. On [3-20] his sputum culture revealed ENTEROBACTER AEROGENES and his antibiotics were narrowed to cefepime. The patient finished a full 8 day course of cefepime and had no furthe symptoms. Pt was also found to have small lung nodules on CT scan of your chest. It is unclear if these are significant. The radiologists recommend follow up in 6 months. # Groin Hematoma- For his traumatic sheath pull, EP and Vascular continued to monitor his groin wound and provide recommedations. Given his AVR, EP encouraged heparin gtt as much as possible to minimize the risk of emobolic CVA. Ultimately, patient was restarted successfully on a heparin gtt without a Hct drop until [3-15]. Left thigh was also thought to be expanding at that time. Vascular evaluated the patient and thought a wound exploration was warranted. Thus, on [3-16] he went to the OR were evaluation revealed no active extravasation but old, liquified hematoma. A JP was placed and monitored for several days until ultimately pulled on [3-21]. On [4-8] pt was reevaluated by vascualar surgery, looked well, and his staples were taken out. # AMS - For his altered mental status, this was initially attributed to Valium use in the setting of poor hepatic function and failure to clear. As time continued, more extensive work-up was pursued for infectious etiology (pneumonia was found, but no other source was identified) versus a neurologic process. There was also concern that the patient was moving his left side more sluggishly. Per his wife, he always had a left foot drop. Evoke potentials were obtained and were unremarkable. Repeat CT / MRI imaging was unrevealing. EEG without evidence of seizure. The patient was noted to have cervical spondylosis with mild-to-moderate spinal stenosis at C3-4 and C4-5 with mild extrinsic indentation on the spinal cord, but no evidence of cord impingement. Neurosurgery was consulted and recommended wearing a c-collar until could be clinically cleared. Thyroid studies checked and normal. Patient was treated with thiamine, folate and a multivitamin given his alcohol history. For concern for hepatic encephalopathy he was started on Lactulose. This was continued as his primary bowel regimen, though there was no definitive evidence of hepatic encephalopathy. His lactulose was discontinued as hepatic encephalopathy was unlikely. Pt was thought to have delirium vs. Korsakoff syndrome [2-2] etoh. Pt intially had significant sundowning and agitiation that would require haldol 2-3mg overnight. His mental status slowly improved at time of discharge he is now A&Ox3, conversing with memory intact. He may require a small dose of haldol for the next few days, but we do not expect this to be an ongoing issue with is resolving delirium. Thaimine and folate were added to his outgoing medications. # Cervical Spondylosis: (As above) Per neurosurgery, pt to remain in C collar until neurosurg f/u in [4-6] wks w/ Dr. [Last Name (STitle) ]. He can come out of C collar for showers and shoort periods but should careful to avoid hyperextension. # Atrial fibrillation- For his atrial fibrillation, patient underwent PVI placement. Anticoagulation was above, being held when evidence of active bleeding, and continued when more stable. Given his tenuous status, warfarin was not restarted after the initial trial on [3-7] while the patient was in the MICU. Plan to restart Warfarin on the floor. He was continued on Amiodarone taper per EP service. While in ICU, patient remained in sinus rhythm. Pt is going to be continued on Amiodirone. His TSH was mildy elevated but FT4 was normal, and LFTs were mildly elevated. Pt should have PFTs as outpatient as a baseline, and be followed every 6 months. His TSH and LFTs should also be continued to be followed. Concerning anticoagulation pt was placed on heparin while his INR became subtherapeutic, but was d/c once pt reached his goal of 2.5-3.5 (due to the mechanical valve). Pt's warfarin was increased to 9mg four times per week, and 7.5mg three times per week. # [Name (NI) 11646] Pt was on vanco for Coag neg staph from [3-22] in [4-4] bottles coag neg staph. The source was unclear as had no central lines at that time. TTE was neg [3-23] but not optimal for evaluation of valve but pt not stable enough for TEE. PICC in place and plan to cont vanco for 6 wk course. The cultures were reviewed by Infectious disease who believed that the bactermia was contiminant and vancomycin was discontinued. Pt did also have VRE in one bottle on [4-1] from PICc which was removed and pt remined afebrile, w nl wbc, continued clinical improvement, also future blood cultures remained negative, and again this was not treated. # Dilated ascending aorta - incidentally noted on one of the cT scans done in ICU. CT surgery here thought that this would be okay to be followed up as outpt with CT surgery. [Name (NI) 1094] wife was informed about this and about the lung nodules and phone numbers for cT surgery provided for outpt fu # hyperlipidemia, the patient was continued on Rosuvastatin Medications on Admission: furosemide 40 mg po daily lisinopril 20 mg po daily atenelol 25 mg po daily rosuvastatin 10 mg po daily warfarin, usually 4 days 7.5 mg, 3 day 5 mg. Last dose 2 nights ago. aspirin 81 mg po daily amitriptylene 50 mg po daily for sleep hydroxycloroquine 200 mg prn joint pain/swelling (last used c. 1 month ago) roxicet (oxycodone/aceitaminophen)prn pain (uses 30 in about 3 months) Discharge Medications: 1. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO HS: prn as needed for agitation. 2. Warfarin 3 mg Tablet Sig: Three (3) Tablet PO DAYS ([Doctor First Name ],TU,TH,SA). 3. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO DAYS (MO,WE,FR). 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 10. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO qHS, prn: as needed for insomnia. 11. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [6-8] hours as needed for pain. 12. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital 671] [Hospital 4094] Hospital Discharge Diagnosis: Primary: Atrial Fibrillation, Ventillator associated Pneumonia Secondary: mechanical aortic valve, hypertension, dyslipidemia, alcohol withdrawal, spinal stenosis Discharge Condition: Hemodynamically stable and afebrile. Discharge Instructions: You had a procedure done (pulmonary vein isolation) to correct the rhythm of your heart. Your procedure was complicated by alcohol withdrawal, bleeding from your groin, confusion requiring intubation for lung safety and extubation. Imaging also revealed that you have narrowing in your spinal canal so you were placed in a hard cervical collar. Once improved, you were sent from the ICU to the regular hospital floor. We treated you for pneumonia with Zosyn, and were thought to have endocarditis but the bacteria in the blood was found to be a contaminated and the antibiotic was discontinued. His mental status is likely delirium that is slowly resolving. You will have a monitor at home to use if you notice yourself going back into the atrial fibrillation rhythm. Medication changes: - We have added a new medication called amiodarone to help you stay in a regular rhythm. Follow the directions on your prescription. Your atenolol was changed to metoprol while inpatient and you have been stable on this metoprol dose. - Your lisinopril dose was decreased - Folic acid and Thiamine are vitamins that are important to take every day. You were found to have small lung nodules on CT scan of your chest. It is unclear if these are significant. The radiologists recommend follow up in 6 months. Followup Instructions: Follow-up scheduled with Dr. [Last Name (STitle) 13177] on [2195-3-26] at 9:30 AM. Phone for Dr.[Name (NI) 66351] office is [0-0-]. . Please wear your C collar until you follow up with Dr. [First Name (STitle) ](neurosurgery) in 4-6wks. The office number is [Telephone/Fax (1) 58980]. Vascular [Doctor First Name ] to remove staples in groin [2195-4-7]. Please follow up with Dr. [First Name (STitle) ] in cardiac surgery. Phone number:([Telephone/Fax (1) 81265] Completed by:[2195-4-8]	[ "V45.82", "V43.3", "998.12", "303.90", "291.0", "453.2", "427.31", "721.0", "425.4", "428.0", "997.31", "348.31", "428.22", "285.1", "518.81", "414.01" ]	icd9cm	[ [ [] ] ]	[ "37.26", "96.6", "96.71", "33.24", "37.34", "96.04", "94.62", "38.93", "37.27", "86.04" ]	icd9pcs	[ [ [] ] ]	14629, 14703	5820, 13246	332, 392	14911, 14950	3059, 5797	16302, 16837	2144, 2209		13678, 14606		14724, 14890		13272, 13655			14974, 15747											2224, 3040																							15767, 16279	273, 294													420, 1421																1443, 1831	1847, 2128
25,708	125,381	52316	Discharge summary	report	Admission Date: [2179-3-23] Discharge Date: [2179-3-30] Date of Birth: [2120-6-4] Sex: M Service: Medicine HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old white gentleman with multiple medical illnesses who was admitted to the Medical Intensive Care Unit on the date of admission with respiratory failure. He complained of progressive shortness of breath over one week with cough, fever, night sweats, and nausea. He had lethargy as well. It was a concern in the Emergency Room of the right lower lobe pneumonia. He has had several recent medical admissions including course of rehabilitation at [Hospital ] Hospital for hypoxic respiratory failure. His past medical history is extensive and includes HIV infection, methadone maintenance, history of DVT/PE, chronic pancreatitis, end-stage renal disease on hemodialysis, chronic lung disease, hepatitis B and hepatitis C positive. History of pneumonia with methicillin-resistant Staphylococcus aureus and intubation, and obstructive-sleep apnea. His medications on admission included amiodarone 200 mg/day, Epivir 25 mg/day, Protonix 40 mg/day, Megace 400 mg po q day, MVI one po q day, Zoloft 50 mg po q day, Zerit 20 mg po q day, Warfarin 2.5 mg po q day, methadone 50 mg po q day. He used Bactrim double strength one tablet 3x a week and Roxicet, albuterol, zinc sulfate. He had allergies to Thorazine and intolerant to H2 blockers for thrombocytopenia. Also did not tolerate due to rash Haldol, clindamycin, Stelazine, and codeine. SOCIAL HISTORY: He is a chronically ill gentleman who lives at home with his wife. [Name (NI) ] is unemployed and disabled. Former heavy IVDU and tobacco user. Family history includes pneumonia. REVIEW OF SYSTEMS: He complained of diffuse body pain, shortness of breath, no chest pain, some cough. No lower extremity edema. No travel or sick contacts. His admission laboratory data included the following: White blood cell count 7.4, hematocrit 46.0, platelet count 209,000. There was no left shift. INR was 2.3, PTT 38.2. Sodium 137, potassium 9.3, bicarbonate 21, chloride 104, creatinine 8.1, BUN 65, glucose 121. TSH was 4.0 in [Month (only) 956]. His electrocardiogram showed a right axis deviation, sinus rhythm with a rate of 100 with no ischemic type changes. His x-ray showed upper lobe interstitial pattern and a right lower lobe opacity. His admission physical examination showed a blood pressure of 153/80, temperature of 99.6, heart rate 104, respiratory rate 26. His oxygen saturation was 100% on 100% nonrebreather. He was pleasant and interactive and appeared reasonably comfortable. His jugular venous pressure was elevated to the jaw. His oropharynx was clear. His neck was supple without lymphadenopathy, thyromegaly, or mass. The lungs with diffuse crackles, scant wheezes at the bases. The heart had a [1-27] murmur that was nonradiating, otherwise regular, rate, and rhythm. Abdomen is soft and nontender, normoactive bowel sounds. He had a palpable spleen. No ascites. Extremities: There was no cyanosis or clubbing, there was trace ankle edema, bilateral excoriations, and chronic venous stasis changes. He has a right subclavian hemodialysis catheter that looked clean. HOSPITAL COURSE: Mr. [Known lastname 108131] was admitted to the Medical Intensive Care Unit for treatment of what was thought to be hypercapnic respiratory failure. There was also concern about a right lower lobe pneumonia. He was treated with BiPAP and remained hemodynamically stable. He had a series of arterial blood gases which showed marked acidosis with an initial pH of 7.06. A subsequent arterial blood gas showed pH of 7.14, pO2 of 49, pCO2 of 69 on 40% oxygen. He was treated with bicarbonate and Renagel, and continued to be monitored in the Intensive Care Unit. He was followed by the Renal Service and had dialysis. The cause of his decompensation was unclear, initially thought to be related to an aspiration event and then thought to likely be primary metabolic process due to his muscle weakness and inability to adequately ventilate. He was transferred to the Medical Service on [2179-3-24], where he continued to do well. The Pulmonary Service completed a consultation and recommended therapy with more aggressive dialysis, bicarbonate repletion. They felt his underlying respiratory weakness was likely related to either myopathy or simply debility on top of his underlying lung disease. Nutrition service was also consulted. He remained clinically stable. His antibiotics were discontinued as there was no definite evidence of pneumonia. The sputum culture was thought to be colonized only. There was an attempt to arrange for placement, but this was ultimately not successful as he thought not to be a good rehabilitation candidate. He was ultimately discharged to home with followup arranged with his primary care physician and with Dr. [Last Name (STitle) 217] in the Pulmonary Unit. DISCHARGE DIAGNOSES: 1. Metabolic acidosis. 2. Hypercarbic respiratory failure. 3. Acquired immunodeficiency disorder syndrome. 4. End-stage renal disease. 5. Cirrhosis. 6. Chronic lung disease. 7. Cardiomyopathy. DISCHARGE MEDICATIONS: Stavudine 20 mg po q day, sevelimer 1500 mg po q day, calcium carbonate 500 mg po tid, sodium bicarbonate 300 mg po bid, Bactrim DS one po tid, Megace 400 mg po q day, pantoprazole 40 mg po q day, lamivudine 25 mg po q day, Ascorbic acid 500 mg po bid, amiodarone 200 mg po q day, warfarin 200 mg po q hs, sertraline 50 mg po q day, multivitamin 1 capsule po q day, lactulose 30 mL po tid prn, methadone 50 mg po q day, Atrovent and albuterol inhalers prn, zinc sulfate 220 mg po q day. [First Name11 (Name Pattern1) 4283] [Last Name (NamePattern4) 4284], M.D. [MD Number(1) 7551] Dictated By:[Last Name (NamePattern4) ] MEDQUIST36 D: [2179-8-5] 08:56 T: [2179-8-11] 13:25 JOB#: [Job Number 31402]	[ "518.81", "070.54", "585", "070.32", "496", "276.2", "425.4", "042", "263.9" ]	icd9cm	[ [ [] ] ]	[ "39.95" ]	icd9pcs	[ [ [] ] ]								5033, 5227	5251, 6017					3291, 5012																																		1762, 3273																165, 1539																	1556, 1742
32,247	180,961	15731	Discharge summary	report	Admission Date: [2122-9-11] Discharge Date: [2122-9-17] Date of Birth: [2059-1-8] Sex: F Service: SURGERY Allergies: Percocet / Motrin / Nsaids / Aspirin / Dilantin Attending:[First Name3 (LF) 668] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [2122-9-13]: negative exploratory laparotomy History of Present Illness: 62yo F w/ a PMH of ESRD on HD s/p failed kidney transplant, DVT (associated w/ HD cath), and HTN who presents to the ED today with right lower quadrant abdominal pain and hypotension. She was nauseated last night and had vomiting x 1. Nonbloody, nonbilious. Last bowel movement was 2 days ago. Not constipated. No diarrhea. No fever chillls or night sweats. She has had the abdominal pain for weeks. Food makes the pain better. She has not eaten today so the pain has gotten worse over the last couple of days. Past Medical History: 1. Diabetes mellitus.- unclear hx, not on medication, nl [Name (NI) ] 2. End-stage renal disease secondary to diabetes mellitus s/p failed dual kidney transplant 3. Hemodialysis. 4. Hypertension. 5. Hyperlipidemia. 6. Thrombosis of bilateral IVJ (catheter placement)-- DVT associated with HD catheter RUE on anticoagulation 7. SVC syndrome [1-13], s/p thrombectomy, on anticoagulation, hospitalization complicated by obturator hematoma and required intubation, PEG and Trach with VAP, and questionable seizure 8. Currently, in hemodialysis. 9. Osteoarthritis. 10. Arthritis of the left knee at age nine, treated with ACTH resulting in secondary [Location (un) ]. 11. rheumatic fever as child 12. Afib with RVR Past Surgical History: 1. Kidney transplant in [2119]. 2. Left arm AV fistula for dialysis. 3. Removal of remnant of AV fistula, left arm. 4. Catheter placement for hemodialysis. 5. Low back surgery (unspecified) Social History: -lives with her nephew [Name (NI) ], but does not know his number -Brother is HCP -[Name (NI) 1139]: 10pkyr [Name2 (NI) 1818], recently quit but states that she has restarted and smoking 5 cigs per day -denies etoh/illicits Family History: Mother and sister with diabetes mellitus. Kidney failure in mother, sister Physical Exam: Vital signs: T 96.0 HR 110 BP 96/46 RR 16 O2sat 95% on RA General: No acute distress Cardiovascular: regular rate and rhythm, systolic murmur Pulmonary: clear to ausculation bilaterally Abdomen: Soft, nondisteded, tender to palpation in the suprapubic area and in the right lower quadrant, no guarding Rectal exam: guiac negative, no gross blood, no hemorrhoids on exam Pertinent Results: On Admission: [2122-9-10] WBC-9.2 RBC-4.33 Hgb-14.1 Hct-42.7 MCV-99* MCH-32.5* MCHC-33.0 RDW-15.4 Plt Ct-451* PT-22.3* INR(PT)-2.1* Glucose-199* UreaN-47* Creat-9.7# Na-139 K-4.0 Cl-92 HCO3-26 AnGap-25* ALT-9 AST-12 AlkPhos-45 TotBili-0.3 Calcium-9.7 Phos-7.0* Mg-2.3 On Discharge [2122-9-17] WBC-6.2 RBC-2.94* Hgb-9.5* Hct-29.9* MCV-102* MCH-32.4* MCHC-31.9 RDW-14.5 Plt Ct-317 PT-31.2* PTT-40.3* INR(PT)-3.2* K-3.6 Brief Hospital Course: 63 y/o female s/p failed kidney transplant in past and recent admission for She now returns with abdominal pain. A CT scan of the abdomen demonstrated portal venous air and pneumatosis involving the right colon. She was taken to the OR with Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. In summary, upon inspection of the peritoneal cavity there was no free fluid. No fibrinous exudate and no foul smell. There was virtually no adhesions in the abdominal cavity. The terminal ileum was identified. This was run retrograde to the ligament Treitz without evidence of small bowel pathology. There was no significant pathology involving the right colon. No evidence of the pneumatosis or gangrenous changes were identified. The colon was run from the right colon to the distal sigmoid. Multiple diverticula are noted throughout the left-sided colon as well as 1 or 2 small diverticula in the small bowel, but again no evidence of perforation, no gangrenous changes, no pneumatosis was identified. There was no fibrinous exudate. In the PACU following the case she became increasingly somnolent, BP hypertensive, she was reintubated and transferred to the ICU. She was started on IV Levaquin. She was extubated on POD 1 and remained stable thereafter. HD via tunneled line with last HD on [9-16] with 2 Liters removed. She was kept on telemetry and had an episode of tachycardia which resolved without additional beta blockade. Every day she became more alert and more able to participate with PT, so she was able to be discharged home with full services for OT/PT, nursing and social work Coumadin restarting [9-19] with PT/INR to be drawn and results faxed to [First Name8 (NamePattern2) 5969] [Last Name (NamePattern1) 5970] by the VNA. She will then resume monitoring with Dr[Name (NI) 4849] at [Location (un) ] as she was pre-hospitalization. Next HD Saturday [9-20]. Stable per renal. Medications on Admission: ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once a day B COMPLEX-VITAMIN C-FOLIC ACID [RENAL CAPS] - (Prescribed by Other Provider) - 1 mg Capsule - 1 Capsule(s) by mouth once a day CINACALCET [SENSIPAR] - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 90 mg Tablet - 1 Tablet(s) by mouth once a day DARBEPOETIN ALFA IN POLYSORBAT [ARANESP (POLYSORBATE)] - (Prescribed by Other Provider) - 40 mcg/mL Solution - once per week weekly LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth daily METOPROLOL TARTRATE - (Prescribed by Other Provider) - 100 mg Tablet - 1 Tablet by mouth daily SERTRALINE [ZOLOFT] - (Prescribed by Other Provider) - 100 mg Tablet - 1 Tablet(s) by mouth hs WARFARIN - (Prescribed by Other Provider) - 2 mg Tablet - 4 Tablet(s) by mouth once a day Discharge Medications: 1. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr [Month/Year (2) ]: One (1) Tablet Sustained Release 24 hr PO once a day. 2. Atorvastatin 20 mg Tablet [Month/Year (2) ]: One (1) Tablet PO once a day. 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule [Month/Year (2) ]: One (1) Cap PO DAILY (Daily). 4. Cinacalcet 90 mg Tablet [Month/Year (2) ]: One (1) Tablet PO once a day. 5. Sertraline 100 mg Tablet [Month/Year (2) ]: One (1) Tablet PO once a day. 6. Lisinopril 5 mg Tablet [Month/Year (2) ]: One (1) Tablet PO DAILY (Daily). 7. Acetaminophen-Codeine 300-30 mg Tablet [Month/Year (2) ]: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:20 Tablet(s) Refills:0 8. Warfarin 1 mg Tablet [Month/Year (2) ]: Two (2) Tablet PO once a day: Please restart [2122-9-18]. Do NOT dose on [9-17]. 9. Levetiracetam 250 mg Tablet [Month/Year (2) ]: One (1) Tablet PO twice a day: Started with previous admission, scripts given at last discharge. Disp:90 Tablet(s) Refills:2 10. Levetiracetam 250 mg Tablet [Month/Year (2) ]: One (1) Tablet PO following HD. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Abdominal pain s/p ex-lap for potential small bowel obstruction, which was negative Discharge Condition: Good Discharge Instructions: Please call the transplant clinic at [Telephone/Fax (1) 673] for fever > 101, chills, nausea, vomiting, diarrhea, increased abdominal pain, inability to take or keep down medications. Monitor incision for redness, drainage or bleeding. Incison may be left open to air. Continue hemodialysis via left tunneled dialysis line. Next HD [9-19] at [Location (un) ] Continue food, fluid and medications per renal recommendations No showering with dialysis catheter Dr[Name (NI) ] at [Location (un) ] dialysis will continue to follow PT/INR, dialysis unit aware Followup Instructions: [Last Name (LF) ],[First Name3 (LF) ] TRANSPLANT SOCIAL WORK Date/Time:[2122-9-25] 1:00 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD Phone:[Telephone/Fax (1) 673] Date/Time: [2122-9-25] 2 PM [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2122-10-16] 2:00 [Month/Day/Year 1220]. [Name5 (PTitle) 540] & [Doctor Last Name ] Phone:[Telephone/Fax (1) 44] Date/Time:[2122-11-10] 4:30 Completed by:[2122-9-17]	[ "585.6", "276.2", "427.31", "250.40", "518.5", "403.91", "458.9", "569.89", "V45.1" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.04", "54.11", "39.95", "38.95" ]	icd9pcs	[ [ [] ] ]	7102, 7160	3087, 5028	320, 371	7288, 7295	2636, 2636	7917, 8475	2150, 2227		5950, 7079		7181, 7267		5054, 5927			7319, 7894									1685, 1880		2242, 2617																								266, 282													399, 917								2650, 3064								939, 1662	1896, 2134
13,599	190,685	26420+57499	Discharge summary	report+addendum	Admission Date: Discharge Date: Date of Birth: [2111-6-19] Sex: M Service: ORT PREOPERATIVE DIAGNOSES: Need for enteral nutrition and prolonged dysphagia. POSTOPERATIVE DIAGNOSES: Need for enteral nutrition and prolonged dysphagia. PROCEDURE: Upper endoscopy and percutaneous endoscopic gastrostomy tube. ASSISTANT: [First Name4 (NamePattern1) 401] [Last Name (NamePattern1) 65332], MD. ANESTHESIA: General endotracheal anesthesia. INDICATIONS FOR PROCEDURE: The patient is a 70 year-old gentleman with multiple issues status post a cervical fusion with multiple failures of swallowing studies. He now presents for PEG after risks and benefits were explained. DESCRIPTION OF PROCEDURE: The patient was taken to the operating room. General anesthesia was administered by our anesthesia department without difficulty. The C spine collar was left in place. An endoscope was introduced into the esophagus under direct visualization. The stomach was inspected. There was no evidence of any gastritis and the entire stomach appeared normal. The scope was not retroflexed. We then proceeded to palpate underneath the left subcostal area and were actually able to visualize this endoscopically. We then proceeded to transilluminate and were able to see it completely. Therefore, we were ensured that this was indeed in the stomach. We then proceeded to place our needle through the stomach under direct vision, past the snare down the endoscope, past the blue wire, through the catheter and then snared the blue wire, brought this up through the mouth, wrapped the 20 French PEG around this and then proceeded to pull it from the stomach wall down. This came up through the anterior abdominal wall without difficulty. The skin was opened to approximately 1 cm to accommodate the PEG. The PEG itself was located at 3 cm. I then performed a repeat endoscopy to confirm position. There was no undue bleeding. We then secured the PEG at 3 cm without undue tension. It was then covered in a dry sterile dressing. The plan is for drainage today and then slow feeds starting tomorrow if tolerated. He was extubated without difficulty and he tolerated the procedure without any problems. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 6633], M.D. [MD Number(2) 12418] Dictated By:[Last Name (NamePattern1) 65333] MEDQUIST36 D: [2182-3-1] 16:40:15 T: [2182-3-1] 17:02:36 Job#: [Job Number 65334] Name: [Known lastname 11493],[Known firstname 133] Unit No: [Numeric Identifier 11494] Admission Date: [2182-2-8] Discharge Date: [2182-4-25] Date of Birth: [2111-6-19] Sex: M Service: MEDICINE Allergies: Vancomycin / Rifampin Attending:[First Name3 (LF) 406] Addendum: Discharge Summary Chief Complaint: neck pain, fever, altered mental status Major Surgical or Invasive Procedure: [2-9] Wound exploration, hardware removal, CSF leak repair and dural alloallograft [2-12] Incision and drainage C7, with exchange of hardware [2-22] Dura graft replacement and debridement [3-15] left subclavian central line [3-21] right subclavian temporary hemodialysis line History of Present Illness: 70 year old male who was recently admitted to the orthopedic spine service at the [Hospital ] [Hospital ] [First Name (Titles) ] [Last Name (Titles) ]. He had sustained a fall with a fracture dislocation at C6-C7 with herniated C6-C7 disc. The patient underwent an open reduction internal fixation of the C6-C7 fracture dislocation with partial laminotomy from a posterior fusion 6-C7 and iliac bone graft. The surgery was performed on [1-23]. The patient returned yesterday overnight to the [Hospital ] [Hospital ] [First Name (Titles) ] [Last Name (Titles) ] with excruciating neck pain, high grade fever up to 104 and a white count of 15,000. He had a left shift of 90%. The patient was worked up with an MRI scan that revealed a large fluid collection in the cervical wound area. The patient was take urgently to the operating room for wound exploration. Past Medical History: 1. Coronary artery disease s/p 3 V cabg in [2145] per pt 2. HTN 3. Anxiety 4. DM 5. Hypercholesterolemia 6. BPH 7. C6-7 fracture as above Social History: No smoking, etoh or IVDA. Lives with wife but was at [Name (NI) 11495] since C spine fusion. Family History: NC Physical Exam: Vitals: Temp: 100.0 BP: 120/78 P: 99 RR: 28 O2sat: 96% on 2L NC FSBS [Telephone/Fax (3) 11496]-201 General: Pleasant CM in Ccollar. NAD. Breathing comfortably on 2L NC. AOX3 with appropriate responses. Cooperative. HEENT: PERRL, EOMI. No scleral icterus. MM dry. OP clear w/ poor dentition. Lungs: CTAB anteriorly, would not sit up to listen posteriorly. Overall poor effort CV: RRR S1 and S2 audible. Tachycardic. Abd: Soft, NT, ND. PEG tube in place. No drainage or erythema. Decreased bowel sounds. No masses felt. No HSM. Peripheral ext: Legs bent at knee, with no edema, erythema or palpable cords. Able to raise legs off bed, wiggle toes bilaterally. Ext warm and well perfused. Pertinent Results: [2182-2-8] 08:40PM URINE RBC-[11-4]* WBC-[2-17] BACTERIA-OCC YEAST-NONE EPI-<1 [2182-2-8] 08:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2182-2-8] 08:40PM WBC-15.1# RBC-3.88 HGB-11.1* HCT-33.1* MCV-85 MCH-28.5 MCHC-33.4 RDW-16.2* [2182-2-8] 08:40PM ALT(SGPT)-13 AST(SGOT)-16 ALK PHOS-93 AMYLASE-45 TOT BILI-0.6 [2182-2-8] 08:40PM GLUCOSE-282* UREA N-22* CREAT-0.9 SODIUM-140 POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-23 ANION GAP-22* . * CULTURE DATA 5//[5-21] c diff negative. [2182-4-20]: c diff negative [2182-4-19] C diff negative [2182-4-19]: Catheter tip negative 5//[3-21]: Blood cx negative [2182-4-16]: Blood cx final negative [2182-4-15]: blood cx positive for [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 11497] [2182-3-24]: Cdiff negative [2182-3-22]: sputum with MRSA [2182-3-22]: blood cultures negative to date [2182-3-19]: CSF negative [2182-3-17]: urine negative [2182-3-7]: Cdiff negative [2182-3-5]: blood cx X 4 pending [2182-3-4]: urine cx no growth [2182-2-20]: C5 fluid collection: 4+ PMN, no micro, coag pos MRSA [Last Name (un) ] to rifampin and vanco [2182-2-19]: CSF fluid 1+ PMN, no micro, neg fluid cx [2182-2-18]: MRSA screen positive [2182-2-18]: VRE screen positive [2182-2-17]: throat viral cx pending [2182-2-17]: blood cx X 4 pending [2182-2-17]: urine cx no growth [2182-2-16]: stool Cdiff negative [2182-2-15]: HSV/VZV unable to perform test [2182-2-14]: >25PMN, 3+ GPC pairs clusters, sputum cx MRSA, neg AFB [2182-2-13]: blood cx no growth [2182-2-12]: wound cx posterior cervical MRSA [2182-2-12]: wound cx swab MRSA [2182-2-12]: sputum MRSA [2182-2-10]: sputum MRSA [2182-2-9]: CSF 4+ PMN, no micro, MRSA [2182-2-9]: blood cx X 4 no growth [2182-2-9]: wound cx swab superficial cervical X 2 MRSA [2182-2-8]: blood cx X 4 no growth [2182-2-8]: urine cx: mixed c/w contamination . Mycolytic bottles cx [2182-3-13] [2182-3-14] [2182-3-16] [2182-4-6] [2182-4-15] [2182-4-18] All negataive to date PATHOLOGY [2-22]: no evid on osteonecrosis or osteomyelitis . Recent Imaging: [2182-3-26]: CXR - A dual-lumen right subclavian dialysis catheter and left subclavian central line remain with tips projecting over the junction of the brachiocephalics with the SVC. Following extubation, there remains small-to- moderate bilateral pleural effusions with associated bibasilar atelectasis. The upper lungs are clear. The heart is normal size and mediastinal contours are unchanged. No pneumothorax. [2182-3-23]: MRI head - Slow diffusion in the left occipital lobe with subtle enhancement, these findings would indicate subacute infarct. Diffuse increased signal in the sulci and fluid-fluid levels in the occipital horns of both lateral ventricles are indicative of proteinaceous material within the CSF spaces and correlation with lumbar puncture is recommended to exclude infection. Diffuse soft tissue changes are seen in both mastoid air cells. [2182-3-23]: MRI C-spine - Since the previous MRI examination, the fluid at the laminectomy site has decreased. There is slight deformity of the spinal cord seen, which could be secondary to focal adhesions, which is more pronounced since the previous study. Subtle increased signal suspected within the spinal cord at C7 level could be due to myelomalacia, but could not be confirmed on the axial images. The previously seen leptomeningeal enhancement has decreased. No evidence of discitis or osteomyelitis is seen. Followup is recommended. TTE [3-18]: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is moderate to severe global left ventricular hypokinesis. Right ventricular chamber size is normal with mild global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No 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: Moderate to severe global left ventricular hypokinesis c/w diffuse process (toxin, metabolic, etc.) Mild mitral regurgitation. [3-18]: RUQ US - 1. No intrahepatic biliary dilatation. 7-mm CBD with no intraductal filling defect demonstrated. 2. Moderately distended gallbladder containing sludge. This appearance can commonly be seen in the ICU setting. The ossibility of acute cholecystitis cannot be excluded with this appearance. If there is strong clinical concern for this, then further correlation with HIDA scan should be considered. [2182-3-18]: MR L spine: 1. Disc herniation noted at the level of L4-5 and L5-S1 as described above. 2. Findings suspicious for discitis at L5-S1 and possibly at L4-5. 3. No definite drainable epidural abscess noted. [2182-3-8]: CTA - 1. Non-occlusive filling defect in the distal end of the right upper lobe pulmonary artery and small area in one of its subsegmental branches, consistent with pulmonary embolus. [2182-3-8]: CT abd/pel - 1. No intra-abdominal or pelvic cause for sepsis demonstrated. 2. At present the inflated balloon of the urinary catheter lies at the level of the prostate gland rather than within the bladder and needs to be deflated and advanced. 3. An 8 to 9 mm hypodensity in the posterior aspect of the proximal pancreatic body is indeterminate but may represent a small cystic area. This could be followed up with interval imaging. A 1-cm hypodensity in segment VII of the liver unchanged. Several subcentimeter renal cortical hypodensities are too small to characterize but likely small cysts. [2182-3-6]: CXR portable IMPRESSION: Improving right lower lobe pneumonia. [2182-3-4]: CT Cspine There is left lateral fusion at C6-C7 via pedicle screws and a spinal rod. There has also been laminectomy from C6 and C7. There are surgical skin staples seen posteriorly. Paravertebral soft tissues are within normal limits. There are no signs for acute fractures. [2182-2-19]: PROCEDURE: Under fluoroscopic guidance and aseptic technique, a 16 gauge needle was introduced at the C5 level via a posterior mid-line approach. Approximately 25 ml of lightly blood stained, straw-colored fluid was aspiration. A sample of the fluid was sent for various microbiological and biochemical analysis, as requested. No immediate complications were encountered. [2182-2-17]: MRI C spine: COMPARISON STUDY: [2182-2-9] cervical spine MR imaging. Comparison with the prior study reveals persistent extensive posterior fluid within both the interspinous and paraspinous soft tissues. There is persistent, moderately longitudinally extensive epidural enhancement spanning the area of the laminectomy, with a mild degree of associated compression of the spinal cord along its dorsal surface. While the finding could represent postoperative changes, a superimposed epidural infection cannot be excluded. Similarly, it is not possible to tell whether the extensive paraspinous and interspinous fluid is either sterile or infected, either. There may be a slight quantity of prevertebral soft tissue swelling at this time. There is no sign of abnormal T2 signal either within the vertebral bodies or intervertebral disc spaces to suggest osteomyelitis or discitis, respectively. [2182-2-17]: MRI brain with contrast: CONCLUSION: Unusual tiny areas of high signal on diffusion-weighted imaging within the occipital horns of the lateral ventricles, more evident on the left side. The findings could represent the effects of known meningeal infection and/or subarachnoid hemorrhage. Other findings as noted above. [2182-2-17]: Portable CXR: FINDINGS: The extreme left CP angle is off the film but the majority of the lungs are clear with improved aeration in the left lower lobe. Patient is status post median sternotomy with mediastinal clips. Surgical staples are seen projecting over the cervical spine with the plate overlying the lateral masses of the lower cervical spine. NG tube tip is in the stomach. The endotracheal tube has been removed. [2182-2-8] 08:40PM URINE RBC-[11-4*] WBC-[2-17] BACTERIA-OCC YEAST-NONE EPI-<1 . CT CHEST W/O CONTRAST [2182-4-15] 5:51 PM CT CHEST W/O CONTRAST Reason: Please evaluate for interval worsening pulmonary process. INDICATION: Recent MRSA meningitis, PE, nosocomial pneumonia with spiking fevers. Evaluate for worsening pulmonary process. CT OF THE CHEST WITHOUT IV CONTRAST: Compared to the prior study, the previously seen left lower lobe consolidation appears smaller. There is still evidence of consolidation with air bronchograms, consistent with pneumonia in the left lower lobe . Patchy airspace opacity is also again seen in the dependent portion of right lower lung, slightly decreased from prior study, again possibly representing a small infectious source or atelectasis. Again seen are multiple mediastinal and axillary lymph nodes that do not appear to meet CT criteria for pathological enlargement, unchanged from prior study. Coronary artery calcification appears unchanged. There has been mild decrease in the previously seen pleural effusions. Limited views of the upper abdomen are not significantly changed from prior study. Again seen is a gastrostomy tube. Calcification is again noted within the pancreas. Small amount of fluid again seen surrounding the spleen. Hypodensity in the right lobe of the liver appears unchanged. BONE WINDOWS: No suspicious lytic or blastic lesions are identified. IMPRESSION: Interval decrease in size of left lower lobe consolidation. Air bronchograms and consolidations are still seen, consistent with pneumonia. Small parenchymal airspace opacity again seen in the right lower lobe, possibly representing atelectasis or small focus of infection. Otherwise, no significant change from prior study. . US ABD LIMIT, SINGLE ORGAN [2182-4-16] 12:40 PM CLINICAL DETAILS: Elevated alkaline phosphatase, fever. Evaluate gallbladder. Comparison is made to previous imaging. FINDINGS: The liver is normal in size and echogenicity, no focal lesions. No intra or extrahepatic biliary dilatation. The CBD measures less than 4 mm in diameter. Sludge within the dependent portion of the moderately gallbladder(less distended than previous scan of [2182-3-16]). No gallstones, gallbladder wall measures up to 3mm. Right kidney appears normal, no hydronephrosis. No free upper abdominal fluid. CONCLUSION: 1) Moderately distended sludge-filled gallbladder. Appearance is similar to the recent ultrasound of [2182-3-18]. No biliary dilatation. Further evaluation with HIDA scan could be considered if cholecystitis remains a concern. . CT ABDOMEN W/O CONTRAST [2182-4-18] 4:01 PM INDICATION: 70-year-old with multiple medical problems; pneumonia complicated by MRSA, meningitis, PE, and fungemia. Please evaluate for liver or spleen pathology. COMPARISONS: CT chest of [2182-4-6] and CT abdomen of [2182-3-8]. TECHNIQUE: Axial MDCT images through the chest, abdomen, and pelvis without IV contrast. CT CHEST WITHOUT IV CONTRAST: Persisting left lower lobe consolidation with small bilateral pleural effusions, greater on the left. The patient is status post CABG with coronary artery calcifications. The airway is patent to the segmental level. CT ABDOMEN WITHOUT IV CONTRAST: Moderately distended gallbladder with layering sludge/stones. The abdominal and pelvic viscera are not well evaluated without IV contrast. Small hypodense lesions in the kidneys, most likely simple cyst, but not characterized on this study. Small nonobstructing left renal calculus. G-tube appears well positioned. Multiple subcentimeter retroperitoneal nodes, none pathologically enlarged by strict CT criteria. Pancreatic parenchymal calcifications likely the sequela of chronic pancreatitis. CT PELVIS WITHOUT IV CONTRAST: There are large acute to subacute hematomas within the iliac muscles bilaterally and left psoas muscle. Rectum, sigmoid are unremarkable. Foley catheter in a nondistended bladder. Incidental note made of penile implant with intrapelvic reservoir. BONE WINDOWS: Lytic lesions involving the iliac bones bilaterally, likely site of prior bone graft harvest. Diffuse degenerative changes without other suspicious lytic or blastic lesions. IMPRESSION: 1) Large acute to subacute bilateral iliacus and left psoas muscle hematomas. Superimposed infection not excluded. 2) Liver and spleen suboptimally evaluated with out IV contrast. 3) Left lower lobe consolidation with small bilateral pleural effusions. 4) Moderately distended sludge filled gallbladder. 5) Subcentimeter retroperitoneal lymphadenopathy. 6) Nonobstructing 7 mm left renal calculus. 7) Pancreatic parenchymal calcifications likely the sequela of chronic pancreatitis. 8) Lytic lesions in the iliac bones, likely the site of prior bone graft harvest. . [2182-4-19] Echocardiogram Conclusions: 1. The left ventricular cavity size is normal. Overall left ventricular systolic function cannot be reliably assessed. 2. The aortic valve leaflets are mildly thickened. 3. The mitral valve leaflets are mildly thickened. 4. No clear evidence of endocarditis seen. . CT ABDOMEN W/O CONTRAST [2182-4-23] 12:54 PM INDICATION: 70-year-old with multiple medical problems, MRSA pneumonia, fungemia, followup iliacus and psoas hematomas. COMPARISONS: CT torso of [2182-4-18] and CT torso of [2182-3-8]. TECHNIQUE: Axial MDCT images through the abdomen and pelvis with oral but without IV contrast. CT ABDOMEN WITHOUT IV CONTRAST: Persisting left lower lobe consolidation with small stable bilateral pleural effusions. Within the left lower lobe consolidation, there is a linear hyperdensity, which was present on multiple prior CTs but appears more prominent on the current study. This may represent a calcified granuloma with adjacent streak artifact though, it is difficult to further characterize. Coronary artery calcification. Moderately-distended gallbladder with dependent sludge. G-tube appears well positioned. Ill- defined hypodense lesions in the right lobe of the liver and kidneys are not well characterized on this non-contrast study. Diffuse pancreatic parenchymal calcifications likely the sequela of chronic pancreatitis. CT PELVIS WITHOUT IV CONTRAST: Stable size and appearance of hematomas involving the iliacus muscles bilaterally and the left psoas muscle. These are unchanged from [2182-4-18]. Foley catheter in the non-distended bladder. Incidental note made of penile prosthetic with indwelling reservoir. Lytic lesions involving the iliac bones bilaterally represent sites of prior bone graft harvest. IMPRESSION: 1) Stable bilateral iliacus and left psoas hematomas. 2) Persisting left lower lobe consolidation with small bilateral pleural effusions. 3) Curvilinear hyperdensity in the left lower lobe, possibly representing a calcified granuloma with adjacent artifact, though difficult to characterize further. This was present on prior CTs, however, appears more prominent on the current study. 4) Moderately distended sludge-filled gallbladder. 5) Limited evaluation of the abdominal and pelvic viscera without IV contrast. . CT HEAD W/O CONTRAST [2182-4-23] 12:53 PM [Hospital 5] MEDICAL CONDITION: 70 year old man with CAD, DM s/p fall complicated by c7 fx, complicated course including MRSA meningitis, CSF leak, MRSA PNA, PE on heparine, Acute renal failure, who is still encephalopathic. he had positive fungal Blood Cx about 6 days ago. Labs slowly improving but persistently confused. NON-CONTRAST HEAD CT. Exam is compared to prior study of [2182-4-3]. FINDINGS: The exam is somewhat motion limited. Especially in the middle portion of the study, there is no definite evidence of mass effect or hemorrhage. Ventricles and sulci remain moderate mildly prominent consistent with mild brain atrophy. The paranasal sinuses are incompletely visualized but there is some soft tissue thickening in the maxillary and ethmoid sinuses. This was true to on the previous examination. IMPRESSION: Somewhat motion limited study. No evidence of acute mass or hemorrhage. . Brief Hospital Course: HOSPITAL COURSE: Pt is a 70yM with h/o CAD status post fall on [2182-1-2] with R C7 fx s/p ORIF and laminectomy with fusion on [2182-1-23] admitted to the SICU on [2-8] with sepsis. His present illness began on [1-2] when he fell down the stairs fracturing C7 vertebrae, he was admitted, underwent extensive workup, and was finally discharged [2182-1-5] with a brace. The pt was then followed up in [Hospital 9348] clinic on [1-21] and found to have left arm weakness, with likely C6-C7 instability. The pt was admitted that day to NSGY service, and underwent ORIF C6-7 fracture, laminectomy C6-7 posterior fusion and iliac crest bone graft with wire placement. His post op course was c/b ARF (which resolved w/ IVF and holding ACEI), UTI tx with cipro. He was discharged on [1-30] and did well until [2-8] when he developed [9-24] posterior neck pain with N/V. He was brought to [Hospital1 8] ED where he was found to have C spine MRI which revealed a posterior fluid collection from C2 to T1 without evidence of epidural abscess, intraspinal fluid collection or cord compression. He was treated with IV Vanco and CTX. He spiked to 103.6. He then underwent cervical wound exploration repair of CSF leak, removal of C5 spinous process, removal of wires and dural autograft. . LP done [2-10] consistent with bacterial meningitis complicating the wound infection and CSF leak. Pt was started on Vanco/Ceftazidime with cervical swab [2-9] and [2-13] growing MRSA. He was taken to OR on [2-12] for washout with hardware exchange. Flagyl 500mg po q8h was added to his regimen of Ceftaz/Vanco on [2182-2-13]. Ceftaz was continued b/c the pt had ongoing temps and ID wanted the pt to be covered broadly until finalization of all cxs. The pt also had a CXR [2-13] showing LLL PNA, sputum growing out MRSA. The pt was extubated [2-15], and Ceftaz and Flagyl were d/c'd [2-15], with Acyclovir IV 5mg/kg q8h being started for perioral HSV. The pt developed confusion on [2182-2-16]. Neurology was consulted and recommended MRI/MRA brain, repeat LP w/ HSV PCR, echo, and eventually pt was dx with encephalopathy [1-17] infection/metabolic. MRI/A of the brain showed new signal in occipital horns, infection vs. SAH, and MRI Cspine showed persistent, extensive fluid collection in the intra/paraspinous soft tissues, persistent epidural enhancement, mild sc compression along the posterior surface. LP was attempted [2-18] --unsuccessful, so LP under fluoro was performed [2182-2-19] as well as drainage of C spine fluid collection. At this pt, the pt was on Vancomycin IV and Acyclovir IV (finished a 7 day course), ended [2-23]). CSF demonstrated resolving meningitis. PNA was improving. On [2-22] the pt went to OR for repair of CSF leak and I&D of cervical wound. Vancomycin was continued, rifampin added at 300mg po /ng q8h on [2-23], and acyclovir was d/c'd (completed course). [Last Name (un) 616] was consulted during this time to assist w/ DM mgmt. Pt failed S&S study, and had PEG placement [3-1]. He was transferred to surgical floor on [2-26], w/ vanco and rifampin continued. PICC line placed [2-28]. ID agreed to treat for six weeks from most recent attempt at repair of CSF leak (ie through [4-6]) with vanco/rifampin and ID signed off [2-28]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] is the ID fellow following the pt. The pt started tube feeds with [Last Name (un) 616] following for strict glucose control. Neurology signed off [3-4], along with general surgery (PEG). his mental status was noted to be much improved with decreased sedation. . Then, on [3-5], he started spiked temp 103.6, with all cx (blood, Ua, urine negative, cxr--resolving PNA). Incision healing well without pus/drainage. C. diff checked and negative. The pt continued to spike low grade temps. Pt pulled out PICC and it repeat PICC was deffered in setting of low grade temps. Patient was also noted to have suicidal ideation [3-7] PM, psych consulted, and and briefly had 1:1 sitter. Pt also in the evening of [3-7], noted to be tachypneic, anxious, tachycardic to 130s. He was noted to have a pulm embolism and was started on heparin gtt and transferred to medicine floor team for further management. . AM of [3-15] patient had tachypnea, fevers, tachycardia and altered mental status and was transferred to the MICU. The hospital course there after is divided by systems as below. . ** Respiratory # Respiratory Failure: Upon transfer to MICU, pt found tachypneic to 40's w/ ?altered mental status on shovel mask. Initial ABG 7.43/39/85 and pt CXR not revealing for new infiltrate. Brief trial of BiPAP halted when follow-up gas revealed profound acidosis with large component of hyercarbia. Intubated for management of hyercarbia thought related to meds (narcotics prior to BiPAP and ?resp fatigue). Although initially improved with intubation, pt became increasingly difficult to ventilate and developed profound metaboic lactic acidosis. Etiology of lactate acidosis not entirely clear but felt seconary to underlying sepsis. Although initially did not tolerate AC/PSV, pt has shown mild improvements in ventilation w/ increased sedation. On heavy sedation and AC ventilation, PH remained in 7.15-7.2 range. Given high minute ventilation, attempts to correct metabolic acidosis included sodium bicarbonate. In addition to metabolic acidosis, pt had possible evidence of LLL PNA and was growing Staph in sputum. He was treated with Vanco/Zosyn/Flagyl for an 8 day course. He also has history of RUL PE and u/s on [3-17] did demonstrate evidence of a thrombus on right superficial vein. He had a transient episode of hypoxia/tachycarida/hypotension on [3-21] which may have been caused by recurrent PEs. He had been off of heparin gtt for a procedure. It was thought that this did not constitute a failure of anticoagulation and IVC filter was not pursued at the time. He was started on CVVH and then HD when his BP stabilized for fluid removal. He was extubated on [3-24] and is satting well on 2LNC and transferred to the floor. He was noted to have fevers and increased LLL consolidation and meropenam was added [4-6] Patient completed 14 days of meropenem. Lates Ct Scan chest showed sligly decrease of left lower lobe consolidation. Patient has been satting 94-95% on Shavel mask since arrival to the floor. . # PE - Maintained on heparin gtt. Can be transition to warfarin over the next few days. # Oropharynx bleeding - Patient had poor mouth care in setting of oral care he was noted to have bleeding from the oropharynx during . ENT was called to evaluate the patient and just prior to ENT eval patient had an episode of desaturation. He was transferred to MICU. ENT pulled out a bloody crust from the oropharynx and recommended saline nasal sprays, vaseline to nares and humidified O2. . Cardiovascular # Hypotension/Hypertension: Although initially normotensive in the micu following intubation patient developed hypotension requiring max doses of Levophed as well as vasopressin. The etiolgy of hypotension not entirely clear but thought most likely secondary to sepsis vs drug hypersensitivity. He had an echo which showed EF of 30%. He was weaned off pressors and after transfer to the floor was hypertensive and started on Metoprolol, Amlodipine. HCTZ added on [4-9]. Started hydral [4-12] and d/c [2182-4-18]. Ace started on [2182-4-14] and titrated up as tolerated. . # Atrial fibrillation: Noted to have transient episode of afib on [3-15] and [3-16]. Rate controlled on lopressor. Anticoagulated with heparin gtt which may be transitioned to coumadin. . # NSTEMI: Has h/o CAD, s/p 3V CABG in [2145]. Last PMIBI [1-21] showing normal Initially Trop 0.12 with CK-MB 6. TTE did not show evidence of focal WMA. New global HK thought to be secondary to cardiac depression from sepsis. Suspect component of demand ischemia w/ decreased clearance of enzymes in setting of renal insufficiency. Maintained on ASA, BB (once off pressors). LDL was low and statin was deffered. ACE inhibitor started on [2182-4-14] once renal function had improved. . # CHF: EF 30% though to be secondary to sepsis. Titrating BB. Ace inhibitors started on [2182-4-14]. . # Arrythmias: Pt had an episode of a bradycardic junctional rhythm [3-18] as he was having TTE performed. This was transient and thought to be secondary to increased vagal tone from the ultrasound probe. ID # Fever: Patient was febrile in the ICU and had a leukocytosis to 25K w/ profound bandemia and eosinophilia and has mixed venous sats in 80's. BC/UC/Stool cultures have been unrevealing. Aggressive search for a source of infection was unrevealing which included RUQ US, repeat LP, MRI/CT of C-spine, MRI head, and multiple blood, urine and stool cultures. Sputum cultures have grown MRSA, but given no definite infiltrate and scant sputum, it was thought more likely to be a colonizer. His abx regimen was broadened to Vanc/Zosyn/Flagyl per ID recs. Rifampin was discontined given concerns about generalized erythrodermic rash, peripheral eosinohilia and urine eosinophilia concerning for a drug hypersensitivity reaction. There was a concern that he may have a drug hypersenstivity to Zosyn or vancomycin. Zosyn was d/c'd on [3-23] and Vanco was switched to linezolid on [3-26]. After transfer to the floor he was continued on linezolid and remained afebrile for several days and then spiked again on [4-3]. After culturing over the next two days and repeat LP without meningitis meropenam was added on [4-6] for nosocomial PNA. Fevers resolved.Patient compleated 59 days of linezolid and was switch to doxicicline on [2182-4-23]. Also on [4-12] patient again spiking fevers. Blood cx on [2182-4-15] showed [Female First Name (un) ], patient was started on Caspo and then switch to voriconazol given elevated Alk phoph and LDH. Ofthalmology was consulted and there was no evidence of eye involvement. CT abdomen no liver or spleen abnormalities. TTE no evidence of endocarditis. Patient to complete 14 days of caspo- to finnished on [2182-5-1]. He should continue on doxacicline indefinite for suppresion therapy. . Neuro # Altered mental status: Pt noted with waxing/[Doctor Last Name 2364] ms on floor that was presumed secondary to increased fevers, metabolic stress. Repeat LP did not show evidence of continued meningitis. He was weaned off all sedatives and remained minimally responsive for several days. Head CT did not show evidence of acute hemorrhage. MRI head showed evidence of a small subacute left occipital infarct. Neurology was consulted and did not think that it was the cause of his mental status changes. His mental status waxed and waned thought secondary to infection. His mental status has wax and wainin thought to be multifactorial. MRI was attempted 4 times and it was unable to be performed due to cooperation. Last Ct did not reveal any gross abnormality but was limited [1-17] motion adn lac of contrast. Patient has been afebrile and last CSF sample was clean. He will continue on MRSA therapy indefinite. . # Weakness: Pt having weakness that is more proximal than distal, R>L. Neurology and orthospine following patient. DDx included ICU myopathy or steroid myopathy. Patient underwent repeat MRI head and C spine. Images were reviewed by ortho/spine attending. His impression was that the C7 lesion near the hardware was not worse then before and this would not explain his neuro exam. Neurology was reconsulted regarding the weakness. unclear etiology. Continue to be persistent. Unable to get new MRI [1-17] cooperation. When patient is off sedation and clinical "stable" his deficts are slightly improved which is hopeful that aggressive PT/OT and resolution of his myriad of medical problems will confirm a better neurologic prognosis. . # L occiptial infarct: On repeat MRI of head, L occiptial lesion had persistent T2 hyperintensity and there was concern for abscess. Neurosurgery was consulted and they recommended continuing antibiotics and a repeat MRI in 4 weeks. We have been unable to get a new MRI due to lack of cooperation by time of discharged. . MRSA Meningitis with cervical stablizing hardware: Cont Linezolid (start [3-26] to be continued until ID appt [4-30], switched to PO [4-6]) Day 58- switched to suprresion therapy on [2182-4-23] with doxicicline. * Renal # Renal Failure: Creatinine baseline 1.6 (presumably secondary to DM/HTN). Pt has had progression of renal dysfunction during MICU and became anuric. Etiology thought to represent sequalae of septic shock and interstitial nephritis given urine eos. Urine sparse for exam but did reveal urine eos and FENA less than 1%. Urine lytes did initially show pre-renal physiology. Renal u/s negative for obstructive physiology. Pt does have severe metabolic acidosis but o/w not significant hyperkalemia. He had a right subclavian temporary HD line placed [3-21] and was started on CVVH and then transitioned to HD on [3-25]. Also started on Calcium Carbonate/Renagel for phos binders. His renal function improved and patient started making urine and was HD was discontinued. Creatinine slowly resolved and even went below what was thought to be his baseline 1.6. On day of d/c creatinine 1.3, good urine output. . Hyperkalemia: Receieved Kayexalate on [2182-4-22] with K+ 5.5-->5.1-->5.0 No EKG changes. No AG on Chem 7, and renal funcion has resolved. K slightly elevated in last morning labs, 5.5, no EKG changes, kayexalate was given. Recheck prior to discharge 5.1. Ace inhibitor dose decreased. will consider swithch to renal (low K) tube feeding formula if K persist trending up. . GI Has a history of Hep C, and now on anti fungal therapy. elevated alk phoph--Patient with elevated alk phosph but currently trendings down. alt and AST normal. U/S done did not show [Last Name (un) 11498] duct dilatation, but repeat CT does reveal biliary sludge. TB is flat. Caspo switched to voraconazol [1-17] hepatic dysfunction. Will need to continue to closely monitor LFT's . Derm # Rash: Pt noted to have blanching macular morbilliform rash on initial transfer to MICU. Dermatolgy has evaluated and thought to represent delayed hypersensitivity drug eruption with unknown precipitant given many drug regimen changes around this time. His rash on BUE progressed to blistering lesions which were thought to be due to edema from fuid overload. He was started on Bactroban ointment for these lesions. After medication changes rash improved slowly. . Endocrine # Diabetes: In the ICU required insulin gtt and was taken off insulin gtt on [3-26]. Requirements were thought to be from high dose steroids. [Last Name (un) 616] followed patient and glargine dose adjusted based on fasting sugars. Please follow attached insulin sliding scale and adjust as necessary. . Heme # Anemia: Hct baseline in high 20s. Iron studies with likely anemia of chronic disease. He required PRBC tranfusion on [3-19]. He was also started on Epotein and dose titrated up. . #Iliacus Hematoma/psoas:[2182-4-19] Ct abdomen reveal along the iliacus muscle. More likely secondary to his heparin therapy. HCT remained stable. [2182-4-23] CT abdomen revealed stable hematomas. will monitor for now. . # Access: Picc line place by IR [2182-4-23] . # contacts: Daughter: [Name (NI) ] [Telephone/Fax (1) 11499], Ortho Attending Dr. [Last Name (STitle) 11500] # code: Family meeting [2182-4-23] # CODE: Full FAMILY MEETING: Discussed with wife [Name (NI) 5121] and 2 daughters after long family meeting along with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 11501] in Neurology. Explained to family that exact etiology of his waxing & [Doctor Last Name 2364] mental status, R US and bilateral LE weakness has not been fully elicited. Our work up has been limited [1-17] to cooperation; too agitated to perform MRI, and unable to follow commands for clinical exam. Family feels that when patient is off all sedation/narcotics, afebrile and hemodynamically stable, Mr. [Known lastname ] is able to communicate with them at a near-baseline functional level. Although PT/OT and RN has not seen dramatic mechanical improvement with his physical rehab, family is hopeful that if medical conditions (PE,MRSA,Candidemia,RP bleed, HTN, Cerebritis, Diabetes, Hepatitis, resolving renal failure) remain stable, that he will start to make neurologic recovery. We still do not know the full etiology of his neurogic compromise (SC infectious involvement, stroke, or ICU myopathy) his mental status is hard to determine to what functional level he will return to given the multitude of metabolic encephalopathic insults (MRSA/[Female First Name (un) 1441] infections, Cerebritis, Sepsis, Renal failure, ? of hepatic encephalopathy [1-17] his Hep C). Medically, Mr. [Known lastname ] is stable will finish out the remaining 14 days of antifungal therapy and will continue on MRSA suppressive therapy. He will also continue on Heparin for his PE as his HCT is stable and his repeat CT of his RP bleed is stable. We now have a window for him to pursue aggressive PT/[Hospital ] rehab in hopes that we will see the potential of his neurologic recovery. The family wishes to continue aggressive care and that he remains a full code. We did discuss that if he were to become reinfected, or succumb to yet another complication, it would make his chance of any recovery very guarded and that future goals of care would be broached at that time. Medications on Admission: 1. Buspirone 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day): hold for SBP < 90, HR < 60. 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 7. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Rosiglitazone 4 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. GlipiZIDE 10 mg Tab, Sust Release Osmotic Push Sig: One (1) Tab, Sust Release Osmotic Push PO DAILY (Daily). 12. Keflex 500 mg PO qid x 1 day post discharge. Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 4. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 5. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q2H (every 2 hours) as needed. 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 8. Sodium Chloride 0.65 % Aerosol, Spray Sig: [12-17] Sprays Nasal TID (3 times a day). 9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 12. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 15. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 16. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 17. Voriconazole 200 mg Solution Sig: One (1) Solution Intravenous Q12H (every 12 hours) for 6 days. 18. insulin Please follow attach insulin sliding scale. 19. heparin Please follow heparin slinding scale attached with discharge paperwork Discharge Disposition: Extended Care Facility: [Hospital3 14] & Rehab Center - [Hospital1 15] Discharge Diagnosis: Principal: Traumatic Comminuted C7 Verterbral Fracture [2182-1-2] ORIF/Laminectomy/Instrumentation/Posterior Fusion [2182-1-23] CSF Leak - Wound infection s/p drainage and dural repair [2182-2-9] Incision and drainage and hardware exchange [2181-2-12] MRSA Meningitis MRSA Pneumonia Left Heart Failure Non-ST Elevation Myocardial Infarction Left Occipital Stroke vs MRSA Cerebritis RLE Deep Venous Thrombosis Pulmonary Embolism Non-Sustained Ventricular Tachycardia Hypersensitivity Desquamative Dermatitis (Rifampin vs Vancomycin)Eosinophilia Hypoxic Respiratory Failure Septic vs. Anaphylactic Shock Delirium Cholestasis RUE Paresis Bilateral Lower Extremity Myopathy Dysphagia GI Bleed Nosocomial LLL Pneumonia Anemia - multifactorial: Illness, blood loss, CKD. Sacral and Heel Ulcers MRSA/VRE Colonization Candidemia Secondary: Diabetes Mellitus Type II Uncontrolled w/ Complications Coronary Artery Disease s/p CABG x 3 Hypertension Anxiety Hypercholesterolemia L3-L4 Surgery BPH Discharge Condition: stable Discharge Instructions: Please take your medications as prescribed. Please complete voraconzole until [2182-5-1] You should be on suppresive therapy with doxycicline indefinitely. Ambulate as tolerated. Cont with OT/PT. Followup Instructions: Please call your PCP after you leave rehab to schedule a follow up appointment within one week. Call Dr [Last Name (STitle) 11500] after you leave rehab and schedule an appointment. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 408] MD [MD Number(2) 409] Completed by:[2182-4-25**]	[ "453.40", "415.19", "785.52", "320.3", "584.9", "038.9", "427.1", "518.5", "427.31", "482.41", "V09.0", "410.71", "998.59", "707.03", "285.9", "250.02", "995.92", "997.09" ]	icd9cm	[ [ [] ] ]	[ "38.91", "96.6", "03.59", "03.4", "81.62", "43.11", "03.31", "38.93", "03.09", "00.14", "78.09", "78.69", "81.32" ]	icd9pcs	[ [ [] ] ]	42295, 42376	21722, 21722	2985, 3283	43422, 43431	5238, 20788	43680, 44024	4504, 4508		40673, 42272		42397, 43401		39674, 40650	21740, 32170		43455, 43657											4523, 5219																								2906, 2947								20824, 21699					3311, 4208										32185, 39648						4230, 4373	4389, 4488
67,423	165,107	32178	Discharge summary	report	Admission Date: [2125-5-15] Discharge Date: [2125-5-28] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2108] Chief Complaint: hypotension Major Surgical or Invasive Procedure: Intubation and central venous catheter placement History of Present Illness: Ms. [Known lastname 75257] is a [Age over 90 ] year old woman with a medical history notable for dementia on hospice care She presented from home with a 1 week history of poor oral intake and shortness of breath since midnight (per report from her daughter). EMS reportedly had difficulty obtaining a heart rate and blood pressure on arrival to her home. She was brought to the [Hospital1 18] ED without intervention. On arrival to the [Hospital1 18] ED, her initial vital signs were: Rectal temp 101.8, HR 101, BP 62/38, and no O2 sat was able to be obtained despite being on a non-rebreather. She was noted to be mottled on arrival. EKG showed deep TWI anteriorly and laterally in the setting of tachycardia and hypotension, concerning for ischemia. An intraosseus line was placed in her right tibia for access. Vancomycin and Zosyn were started and she was switched from phenylephrine to levophed for BP support. She was then intubated for respiratory support (complicated by initial right mainstem bronchus). A NG tube was placed and drained 10cc of dark brown fluid. A Foley catheter was placed, and UA was grossly positive draining very cloudy urine. Lactate was elevated to 4.2, Trop was elevated to 0.28 with flat CK and MB. She was also noted to be hypernatremic to 170. Patient recieved total of 5L NS in the ED. Cardiology was notified of elevated troponin and EKG changes and felt that no heparin gtt was indicated in setting of likely demand ischemia. She was given an aspirin. CT-A Torso showed RLL opacity, concernin for an aspiration event but there was no pulmonary embolus. She was then transferred to the ICU. In the ICU she was treated for sepsis (presumed sources were urine and possible pneumonia) with IV fluids, presors, and Vancomycin and Zosyn (this was later switched to Unasyn on [2125-5-17]). Other active issues included acute renal failure, a 2-unit GI bleed of unclear origin, and severe constipation. She was successfully extubated on [5-17] and pressors were turned off on [5-18]. Of note, due to her dementia she was minimally verbal but was able to ambulate until [9-/2124] when she broke her hip. She was then in Rehab for 2 months. Since [1-/2125], she has been bedbound, sometimes transfered to wheelchair by family members. Since this time, her geriatrician convinced the family to place her on Hospice for increased services at home, though the patient continued to be Full Code as part of the Hospice agreement. She is usually taken to [Hospital1 2177] for all hospitalizations, but she was too unstable this time. Per daughter, she is able to answer simple yes/no questions at baseline and was able to speak in short 5-word sentences up to two weeks ago. She lives with her son, though the daughter/HCP lives nearby and sees her often. Daughter reports that patient had some poor po intake a few weeks ago, decreased appetite for a couple of days, then diarrhea for a week. She was admitted to [Hospital1 2177] for a couple of days for right hand and left leg edema noted by visiting nurse; during this hospitalization, ultrasounds ruled out blood clots. Past Medical History: dementia arthritis recurrent syncope Hip Repair [9-/2124] Social History: Lives with son, Daughter [Name (NI) 54855] nearby is HCP and sees her often. Daughter is social worker. [Name (NI) ] has been bedbound since [1-/2125], after difficult recovery from Left Hip repair in 9/[2124]. Family History: Not relevant to the current admission Physical Exam: General: responsive to noxious stimuli, comfortable, no acute distress, cachectic HEENT: pupils 1-2 mm and equal, dry mucus membranes, oropharynx clear difficult to examine Neck: supple, no JVD Lungs: Clear to auscultation bilaterally CV: Regular rate and rhythm, normal S1 + S2 Abdomen: soft, mildly distended, bowel sounds present GU: foley in place, draining urine with thick sediment Ext: warm, left foot edema with trace palpable pulse, right foot edema with 1+ pulse; onychomycosis SKIN: unstageable ulcers on feet and stage II ulcer on sacrum Pertinent Results: - [2125-5-15] 03:17AM URINE COLOR-Red APPEAR-Cloudy SP [Last Name (un) 155]-1.012 BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-4* PH-5.5 LEUK-LG RBC-73* WBC->182* BACTERIA-MANY YEAST-NONE EPI-5 - [2125-5-15] 03:30AM PT-15.4* PTT-41.0* INR(PT)-1.3* [2125-5-15] 03:32AM LACTATE-4.2* GLUCOSE-145* UREA N-104* CREAT-2.2* SODIUM-170* POTASSIUM-4.3 CHLORIDE-134* TOTAL CO2-22 ANION GAP-18 [2125-5-26] 06:30AM BLOOD Glucose-68* UreaN-56* Creat-1.0 Na-142 K-4.1 Cl-117* HCO3-18* AnGap-11 [2125-5-15] 03:30AM BLOOD WBC-8.7 RBC-3.29* Hgb-11.3* Hct-33.7* MCV-103* MCH-34.3* MCHC-33.4 RDW-16.1* Plt Ct-134* [2125-5-16] 02:44PM BLOOD WBC-9.0 RBC-2.26* Hgb-7.6* Hct-24.8* MCV-110* MCH-33.8* MCHC-30.8* RDW-15.9* Plt Ct-93* [2125-5-16] 08:51PM BLOOD WBC-10.1 RBC-3.39# Hgb-10.9# Hct-32.0# MCV-94# MCH-32.0 MCHC-34.0# RDW-20.0 Plt Ct-78* [2125-5-21] 06:00AM BLOOD WBC-8.2 RBC-2.75* Hgb-8.6* Hct-26.1* MCV-95 MCH-31.2 MCHC-32.9 RDW-21.6* Plt Ct-85* [2125-5-26] 06:30AM BLOOD WBC-10.9 RBC-2.31* Hgb-7.3* Hct-22.8* MCV-99* MCH-31.7 MCHC-32.1 RDW-25.4* Plt Ct-91* [2125-5-27] 02:52PM BLOOD Hct-23.8* [2125-5-28] 07:30AM BLOOD Hct-23.3* CT HEAD W/O CONTRAST Study Date of [2125-5-15] 2:40 AM IMPRESSION: No evidence of acute intracranial abnormalities or interval change. [2125-5-15] ECG: Sinus rhythm with atrial premature beat. Left axis deviation may be due to left anterior fascicular block. Diffuse T wave abnormalities - cannot exclude ischemia. Clinical correlation is suggested. Since the previous tracing of [2124-9-21] diffuse T wave abnormalities are now present. [2125-5-15] CXR: Satisfactory NG tube position. Probable right mainstem intubation. Recommend repeat radiograph with all tubing removed from the front of the chest to better evaluate. Left basilar atelectasis but otherwise no acute findings. [2125-5-15] CHEST CT WITHOUT CONTRAST: 1. Right mainstem intubation with extensive atelectasis or aspiration in the left lower lobe. Multifocal opacities in the right lower lobe concerning for aspiration pneumonia. 2. No pulmonary embolism, but this study is not suited for evaluation for pulmonary embolism as no contrast was given. 3. Severe fecal impaction in the rectum without bowel obstruction. 4. 6-mm nonobstructive calculi in the lower pole of the left kidney. Moderate right renal pelvic dilation due to UPJ obstruction as the distal ureter is not dilated. 5. Severe coronary artery disease and atherosclerotic disease. 4.6 cm ascending thoracic aortic aneurysm. CXR [2125-5-23]: Left central venous line tip is most likely in the azygos vein. There is new bilateral pleural effusion, moderate to large with bibasilar, left more than right consolidations. Findings might be consistent with massive aspiration or infection. No evidence of edema is noted. No pneumothorax is seen. [2125-5-23] 12:12 pm BLOOD CULTURE Source: Line-tlc. FINAL REPORT [2125-5-26] Blood Culture, Routine (Final [2125-5-26]): KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES. Piperacillin/Tazobactam sensitivity testing confirmed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. SENSITIVITIES: MIC expressed in MCG/ML ________________________________________________________ KLEBSIELLA PNEUMONIAE \| AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 2 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- =>128 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Anaerobic Bottle Gram Stain (Final [2125-5-24]): GRAM NEGATIVE ROD(S). Reported to and read back by DR. [Last Name (STitle) ] @ 9:15AM [2125-5-24]. Aerobic Bottle Gram Stain (Final [2125-5-24]): GRAM NEGATIVE ROD(S). BLOOD CULTURES 5/19 X 1, [5-26] X 2 PENDING AT THE TIME OF DISCHARGE (NO GROWTH TO DATE) [2125-5-15] RPR NON REACTIVE Brief Hospital Course: [Age over 90 ] yo F with severe dementia who presented with septic shock from a UTI and pneumonia with further complications of acute renal failure, hypernatremia, GI bleed requiring transfusion and recurrent aspiration pneumonia with bacteremia. The patient initially presented with septicemia from a probable pneumonia and UTI. She was intubated and briefly required pressors for blood pressure support. With IV fluids and antibiotics, the patient was succesfully weaned from both the ventilator and pressors. Towards the end of the patient's 10 day antibiotic course with Unasyn for her presenting septicemia from pneumonia and UTI, the patient developed recurrent leukocytosis without fevers. Repeat infectious work-up revealed probable recurrent aspiration pneumonia. She also had 2 out of 2 positive blood cultures with gram negative rods (this eventually grew klebsiella sensitive to quinolones) The remainder of the infectious work-up including UA and C Diff testing were negative. She was transitioned to levofloxacin. She had a speech and swallow eval that recommended pureed solids and nectar thickened liquids. Discussion was had with the patient's daughter regarding a high risk of ongoing aspiration. The risks and benefits of allowing her to eat for comfort versus considering strict NPO status with a long-term feeding tube was discussed and the patient's daughter felt that the goals of care are most consistent with allowing the patient to continue eating for comfort. The patient will complete a 14 day antibiotic course with IV levofloxacin for the pneumonia and bacteremia. (day 14/14 will be [2125-6-7]) While in the ICU, the patient had several issues that resolved, including: - Acute renal failure that resolved with fluid rescucitation. - BRBPR with hematocrit drop consistent with a GI bleed. She received 2 units of PRBC's with appropriate improvement in Hct. She had a negative NG lavage and this lower GI bleed was thought related to her known fecal impaction seen on abdominal CT. She was manually disimpacted and started on stool softeners with good effect. After discussion with the family and in light of stabilization of her Hct without signs of further bleeding, the decision was made to not pursue colonoscopy for definitive diagnosis. - Troponin elevation and EKG changes consistent with demand ischemia. This resolved with hemodynamic improvement after treatment for sepsis. Throughout her hospitalization, the patient had intermittent hypernatremia that improved with free water repletion. The patient has terminal dementia. She is DNR/DNI after discussion with the family and she continues on home hospice. They understand her limited prognosis but were not yet prespared to make her CMO. There are concerns expressed by social work and others regarding her safety at home and elder protective services have previously and were once again contact[Name (NI) ]. For now the patient is going to rehab to complete her antibiotic course. The patient has a history of hypothyroidism and continues on levothyroxine. The patient has a sacral pressure ulcer for which she requires ongoing daily wound care. The patient has an ascending aortic aneurysm and is not a candidate for surgical intervention. The patient has massive diffuse edema likely due to chronic protein malnutrition (albumin was <2). Medications on Admission: levothyroxine 12.5mg po daily - has not been getting this reliably at home Tiny Tabs Multivitamins x4 Vitamin D3 400u x2 Mg citrate 100mg x [1-7] -2 Zn gluconate 50mg daily x [1-7] Glucosamine 375mg-Chondroitin 300mg-MSM 375mg x2.5 KAL 100%vegetarian glucosamine -1000mg daily x1.5 Discharge Medications: 1. levofloxacin in D5W 750 mg/150 mL Piggyback [Month/Day (2) ]: One (1) dose Intravenous Q48H (every 48 hours): day #14/14 is [2125-6-7]. 2. levothyroxine 25 mcg Tablet [Month/Day/Year ]: 0.5 Tablet PO DAILY (Daily). 3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Month/Day/Year ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 4. senna 8.6 mg Tablet [Month/Day/Year ]: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 5. docusate sodium 50 mg/5 mL Liquid [Month/Day/Year ]: Ten (10) mL PO BID (2 times a day) as needed for constipation. 6. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] once a day. Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: Septic shock Urinary tract infection Bacterial pneumonia Acute renal failure Hypernatremia GI bleed Anemia Thrombocytopenia Edema Dementia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted with low blood pressure from a urinary tract infection and pneumonia. This improved with antibiotics but you had a recurrent pneumonia and bacteremia. Continue to take the prescribed antibiotics. The remainder of your numerous medical problems during this hospitalization have stabilized. Followup Instructions: You will continue to receive care with hospice services at home and from your primary care doctor. Department: Primary Care Name: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] When: You will be contact[Name (NI) ] by Dr. [Last Name (STitle) 10237] office to schedule a home visit. If you have not heard from the office in 2 business days please call the number listed below. Location: [Hospital6 ] Address: [Location (un) ], [Location (un) ],[Numeric Identifier 5138] Phone: [Telephone/Fax (1) 10238]	[ "V70.7", "995.92", "584.9", "507.0", "263.9", "276.0", "482.9", "284.1", "038.9", "707.25", "294.8", "785.52", "569.3", "599.0", "441.4", "244.9", "518.81", "V49.86", "707.03", "564.00" ]	icd9cm	[ [ [] ] ]	[ "38.93", "96.04", "38.91", "38.97", "96.71" ]	icd9pcs	[ [ [] ] ]	13193, 13263	8703, 12058	263, 314	13446, 13446	4464, 8680	13914, 14471	3836, 3875		12399, 13170		13284, 13425		12084, 12376			13582, 13891											3890, 4444																								212, 225													342, 3488										13461, 13558						3510, 3573	3589, 3820
30,659	123,675	13337	Discharge summary	report	Admission Date: [2146-3-2] Discharge Date: [2146-3-26] Date of Birth: [2087-12-9] Sex: F Service: MEDICINE Allergies: Zanaflex Attending:[Last Name (NamePattern4) 290] Chief Complaint: SBP, Septic Shock Major Surgical or Invasive Procedure: Endotracheal Intubation Temporary HD catheter placement CVL placement Multiple paracenteses History of Present Illness: The pt. is a 58F y/o F with a PMH of HCV cirrhosis s/p TIPS for refractory ascites with recent revision [2146-1-28], on liver transplant list; CKD, DM, pancytopenia; now transfer from OSH with ecephalopathy due to SBP and evolving renal failure with ?HRS. Pt now transferred to MICU for worsening AMS. . She was admitted to the OSH on [2146-2-24] with encephalopathy. An 11 liter paracentesis was performed on [2-25]; she was given 25 grams of albumin. Cultures subsequently grew Klebsiella. She was treated with Ceftriaxone 2g q24 for SBP. Her renal funciton deteriorated from a Cr of 1.3 on admission to 2.2 on [2-27] and then 2.7 on [2-28]. Urine sodium was 5; this was though to be hepatorenal syndrome. She was given and IVF challenge (NS at 150 cc/hr as well as albumin 50 gram daily), however, her urine output declined (55 cc's in 8 hours on [3-2]) and the IVF accumulated in her abd. . She was transferred to [Hospital1 18] Liver Service for further care. . Of note, she was last admitted to [Hospital1 18] [1-26] - [1-29] with massive ascites and underwent paracentesis as well as tevision of her transjugular intrahepatic portosystemic shunt (TIPS). . The evening of admission, the pt. triggered for marked nursing concern related to altered mental status. Labs returned at K 6.3 and HCO3 9 with AG 22. WBC 15. She was given Insulin/D50, kayexelate PR, and antibiotics broadened to Vanc/Zosyn. ABG 7.22/23/103 Lactate 4.5 Tbili 14.5. Stat abd US was ordered. . On arrival to the MICU, the patient is awake but somnolent, moves ext and groans to verbal and painful stimuli. Past Medical History: # ESLD secondary to HCV cirrhosis - Hep C dxed [2126], unknown exposure: no hx transfusion, IVDU, tatoo placed after hep C diagnosis - genotype IA, treated with multiple courses of interferon unsuccessfully - bx [2140] stage 3-4 fibrosis - hx encephalopathy, - grade 3 varices banded [3-6]. No history of variceal bleeding. + history of hemorrhoidal bleeding. - hx refractory ascites, s/p TIPS [2145-3-19], a revision in [2145-12-22] - on transplant list # Renal insufficiency, baseline creatinine 1.5 per OSH records but previously has bumped to >2 # Diastolic CHF # Asthma # Depression # Anxiety # GERD # IDDM # Seizure disorder # Hypertension # OSA # Refractory nausea - controlled with reglan - ? gastroparesis # s/p CCY # h/o Asthma - stable # Pancytopenia - related to ESLD Social History: From [Male First Name (un) ] and visited recently. ? past h/o IVDU. Denies tobacco, EtOH, or current recreational drug use. Family History: Family History: no family history of liver disease Physical Exam: General: moaning, can't answer questions, moves ext x4. HEENT: PERRL, EOMI without nystagmus, MMM. Neck: supple, no JVD. Pulm: CTA bilaterally, some upper airway rhonchi Cardiac: RR, nl S1, S2, 2/6 SEM, no R/G. Abdomen: soft, massively distended with fluid wave, +bowel sounds, + easily reducible ventral hernia. EXT: 3+ pitting edema b/l, 2+ radial, DP/PT pulses b/l. Skin: no rashes or lesions noted. mult tatoos. . Pertinent Results: ADMISSION LABS: CBC: [2146-3-2] 09:49PM WBC-15.1# RBC-3.00 HGB-10.2* HCT-30.2# MCV-101 MCH-34.1* MCHC-33.8 RDW-16.2* [2146-3-2] 09:49PM NEUTS-88.7* LYMPHS-5.0* MONOS-5.7 EOS-0.3 BASOS-0.2 [2146-3-2] 09:49PM PLT COUNT-80* COAGS: [2146-3-2] 09:49PM PT-25.4* PTT-40.1* INR(PT)-2.5* CHEMISTRIES: [2146-3-2] 09:49PM GLUCOSE-158* UREA N-72* CREAT-3.0# SODIUM-134 POTASSIUM-6.3 CHLORIDE-109* TOTAL CO2-9* ANION GAP-22* LFTs: [2146-3-2] 09:49PM BLOOD ALT-17 AST-35 LD(LDH)-214 AlkPhos-290* TotBili-14.3* ASCITES ANALYSIS WBC RBC HCT,fl Polys Lymphs Monos Plasma Mesothe Macroph [2146-3-13] 09:19PM 1* 1* 01 100* 0 PERITONEAL FLUID [2146-3-10] 03:57PM 3.02 PERITONEAL FLUID [2146-3-8] 12:40PM 150 [Numeric Identifier 40580]* 32* 22* 46* [2146-3-6] 02:05PM 255* 6710* 55* 14* 0 1* 2* 28* [2146-3-3] 03:27PM 975* 5575* 86* 4* 9* 1* ------ ------ IMAGING STUDIES: [2146-3-3] U/S - RUQ - IMPRESSION: 1. No intrahepatic biliary dilatation. 2. Large volume ascites. . [2146-3-4] - TTE Conclusions The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild right ventricular cavity enlargement with preserved free wall motion. Moderate pulmonary artery systolic hypertension. Dynamic left ventricular systolic function. Compared with the prior study (images reviewed) of [2145-7-6], the right ventricular cavity now appears dilated with increased pulmonary artery systolic pressure c/w primary pulmonary process. The other findings are similar. . [2146-3-4] - CT abd/pelvis - IMPRESSION: 1. Large-volume ascites, nonhemorrhagic by density. 2. Cirrhosis. 3. Anasarca. 4. Bibasilar lung consolidation. 5. Small locule of gas adjacent to the anterior abdominal wall to the left of midline is likely extraluminal and may relate to recent paracentesis. 6. Splenomegaly. . Brief Hospital Course: Patien was a 58 F with history of HCV cirrhosis s/p TIPS, CKD, c/b temporary respiratory failure, with ascities and abdominal compartment syndrome s/p paracentesis with SBP who was on vanco, [Last Name (un) 2830], caspofungin until made CMO [3-25]. Patient expired [3-26] at 0605 hours. Patient was initially admitted from OSH with encephalopathy and hepatorenal syndrome requiring dialysis, s/p respiratory failure (extubated [3-11]) and s/p paracentesis complicated by intraabdominal bleed, awaiting liver/kidney transplant, desated to day in the setting of unresponsiveness and was transferred to MICU. # Hemodynamics/hypotension ?????? Patient was chronically hypotensive in setting of liver disease and had high cardiac output. Blood pressures were monitored through arterial line since patient was on levophed pressors until was made CMO on [3-25]. Blood pressures were also maintained with albumin (with additional doses after paracentesis) and small boluses. Lactates were trended as an indicator of end organ perfusion. Prior to change in code status to CMO, lactates were climbing despite pressors. # Leukocytosis ?????? Until made CMO on [3-25], patient has worseneing leukocytosis despite broad coverage with vanco, [Last Name (un) 2830], caspofungin (since [3-19]). Yeast was previously identified in urine, sputum and skin/ascites prior to transfer to the ICU. SBP was a documented source of infection, however gram stain was negative. Another possible soruce was the Left abdominal eschar that was felt to be infected and was examined by derm and gen [Doctor First Name ]. Patient had diagnostic and therapeutic tap on [3-24] where 4L removed. SBP diagnosis was made, after correcting for RBCs, however gram stain negative. ID was consulted in the treatment of the leukocytosis. The progressive severity of the infection was influential in hepatology removing her as a transplant candidate. # AMS/unresponsiveness: Multifactorial, patient became progressively less responsive. Contributors includes hepatic failure with TIPS (despite lactulose), anuric renal failure/uremia, hypoperfusion despite pressors, and sepsis. Patient was observed with Q4H neuro checks. # Hepatorenal syndrome/Abdominal Compartment Syndrome - Ascities was worsened by 11 L Para on [2-24] with only 25gm albumin. Previously, patient was listed for a kidney transplant. Patient had progressive decline in urine output until aneuric. Renal was involved in management and patient had been getting intermittent HD. Renal function worsened in the setting of Abdominal Compartment Syndrome. On [3-24], had tap to reduce pressures which did not lead to an improvement in renal function. Renal was to do CVVH until patient was made CMO on [3-25]. # Hoarse Voice: Pt reported that voice became hoarse following self-extubation. Possible that she endured vocal [Last Name (un) 40581] trauma. # HCV cirrhosis - decompensated w/ varices, massive ascites s/p tips, encephalopathy. Prior to becoming CMO, hepatology felt that she was no longer a transplant candidate. # DM2 ?????? Patient was on Lantus 32u daily for hyperglycemia, but was switched to insulin drip in setting of renal failure. # Seizure disorder - Patient was home dose of tegretol. # Depression/Anxiety. - Psych meds were held to better evaluate mental status # PPx: pneumoboots, PPI # FEN: TF at goal 40 cc/hr # Access RIJ replaced [3-24], HD line; 2 [Last Name (LF) 40582], [First Name3 (LF) ] line # Code: family meeting Dr. [First Name (STitle) ] [3-25], DNR/DNI. Dr. [Last Name (STitle) 40583] spoke to granddaughter, HCP, at 830pm on [3-25] and patient was made CMO since she was no longer a transplant candidate and was failing antibiotic therapy. Patient's medications were discontinued and patient was placed on morphine drip and expired on [3-26] at 0605 hours from cardiopulmonary arrest. Medications on Admission: MEDICATIONS AT HOME (per [2146-1-29] discharge summary): 1. Lactulose 10 gram/15 mL Syrup (30) ML PO QID 2. Rifaximin 400 mg Tablet TID 3. Pantoprazole 40 mg Tablet PO Q24H (every 24 hours). 4. Mirtazapine 15 mg Tablet PO HS 5. Carbamazepine 200 mg QAM and 400 mg QPM 6. Folic Acid 1 mg DAILY 7. Insulin Glargine (38) units Subcutaneous at bedtime. 8. Ensure three times a day. 9. Calcium . MEDICATIONS UPON TRANSFER to [Hospital1 18]: CTX 2g q24h tegretol 200 q am and 400 qpm synthroid 0.25 daily protonix 40 rifaximin 400 TID MVI lactulose enema q shift Discharge Medications: none, patient expired Discharge Disposition: Expired Discharge Diagnosis: Expired - HCV chirrosis, hepatorenal syndrome, abdominal compartment syndrome, anuric renal failure, spontaneous bacterial peritonitis, sepsis, cardiopulmonary arrest Discharge Condition: expired Discharge Instructions: none, expired Followup Instructions: none, expired [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] Completed by:[2146-3-26]	[ "276.8", "276.7", "428.32", "785.52", "403.90", "995.92", "038.49", "996.73", "284.1", "250.00", "276.2", "456.21", "V66.7", "E879.1", "276.0", "493.90", "286.6", "E879.4", "518.81", "V70.7", "478.31", "789.59", "998.11", "428.0", "288.60", "345.90", "560.1", "567.23", "584.5", "585.9", "571.5", "486", "070.44", "427.5", "275.42", "572.4", "300.4", "327.23", "286.9" ]	icd9cm	[ [ [] ] ]	[ "38.95", "99.07", "99.05", "96.72", "39.95", "96.6", "54.91", "96.04", "29.11", "38.91", "38.93", "99.04" ]	icd9pcs	[ [ [] ] ]	10844, 10853	6229, 10182	293, 387	11063, 11072	3532, 3532	11134, 11314	3042, 3078		10798, 10821		10874, 11042		10208, 10775			11096, 11111											3093, 3513																								236, 255													415, 2041						3549, 4469										2063, 2864	2880, 3010				4487, 6206
58,821	179,166	35318	Discharge summary	report	Admission Date: [2176-2-6] Discharge Date: [2176-2-15] Date of Birth: [2095-1-2] Sex: F Service: SURGERY Allergies: Norvasc / Clonidine / Pollen Extracts Attending:[First Name3 (LF) 1234] Chief Complaint: Cold left lower extremity Major Surgical or Invasive Procedure: [2176-2-7] s/p LLE thrombectomy [2176-2-7] hematoma evacuation History of Present Illness: 81F with CAD, CHF and Afib s/p AVR with bioprosthetic valve and hisotry of CEA in the past presented to [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] with pain loss of pulses in left lower extremity. Pt had a remote history of GI bleed on Coumadin in the past and is off coumadin now. Was heme neg at [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] and was bolused 4000U and run at 1000U an hour pt currently on Plavix. On seeing her in the [Name (NI) ] pt was in pain on left lower extremity with dusky appearance and weak motor but sensation in tact. Pt walks with a walker at home at baseline and has no symptoms of rest pain at baseline. Prior to the onset of symptoms the leg was normal in color, painless and warm. Past Medical History: CAD CABG AS prothetic valve a fib CHF h/o of CVA with residual right sided weakness NIDDM Social History: N/C Family History: N/C Physical Exam: VSS: 98.1, 87, 110/56, 20, 97%RA General: NAD Cardiac: irregular Lungs: CTA Abd: soft,non tender Resolving LT groin hematoma, large bruising/echymsosis resolving B/L DP/PT dop Pertinent Results: [2176-2-13] 06:42AM BLOOD WBC-12.4* RBC-3.56* Hgb-11.3* Hct-32.2* MCV-91 MCH-31.9 MCHC-35.2* RDW-16.1* Plt Ct-240 [2176-2-12] 04:41PM BLOOD Hct-31.9* [2176-2-13] 06:42AM BLOOD Plt Ct-240 [2176-2-13] 06:42AM BLOOD Glucose-130* UreaN-18 Creat-1.2* Na-137 K-4.1 Cl-103 HCO3-26 AnGap-12 [2176-2-13] 06:42AM BLOOD Calcium-9.0 Phos-2.6* Mg-2.2 [2176-2-12] 04:41PM BLOOD Hct-31.9* [2176-2-12] 03:00AM BLOOD WBC-12.3* RBC-3.53# Hgb-11.0# Hct-31.5* MCV-89 MCH-31.2 MCHC-34.9 RDW-15.7* Plt Ct-191 [2176-2-11] 01:22PM BLOOD Hct-33.9# [2176-2-11] 04:00AM BLOOD WBC-13.0 RBC-2.81* Hgb-8.6* Hct-25.3* MCV-90 MCH-30.6 MCHC-34.0 RDW-15.5 Plt Ct-187 [2176-2-10] 04:41AM BLOOD WBC-12.8* RBC-3.33* Hgb-10.2* Hct-29.1* MCV-88 MCH-30.7 MCHC-35.1* RDW-15.6* Plt Ct-171 [2176-2-9] 05:47AM BLOOD Hct-31.2* [2176-2-9] 12:44AM BLOOD Hct-25.3* [2176-2-8] 12:18PM BLOOD Hct-25.1* [2176-2-8] 03:25AM BLOOD WBC-14.8* RBC-3.19* Hgb-9.7# Hct-28.5 MCV-90 MCH-30.4 MCHC-34.0 RDW-15.3 Plt Ct-155 [2176-2-7] 11:04PM BLOOD Hct-29.7* [2176-2-7] 07:13PM BLOOD Hct-32.1* [2176-2-7] 03:13PM BLOOD Hct-30.1* [2176-2-7] 10:16AM BLOOD Hct-33.1* [2176-2-7] 05:45AM BLOOD WBC-16.2* RBC-4.17* Hgb-13.0 Hct-36.9 MCV-88 MCH-31.3 MCHC-35.3* RDW-14.6 Plt Ct-232 Brief Hospital Course: [2176-2-6]- ED consult for this 81F with CAD, CHF and Afib s/p AVR with bioprosthetic valve and history of CEA in the past presented to [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] with pain loss of pulses in left lower extremity at 2pm today. Pt had a remote history of GI bleed on Coumadin in the past and is off coumadin now. Was heme neg at [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] and was bolused 4000U and run at 1000U an hour pt currently on Plavix. On seeing her in the [Name (NI) ] pt was in pain on left lower extremity with dusky appearance and weak motor but sensation in tact. Pt walks with a walker at home at baseline and has no symptoms of rest pain at baseline. Before 2pm this leg was normal in color, painless and warm. Sent to [Hospital1 18] for evaluation, admission and treatment [2176-2-6] Underwent Left femoral popliteal/tibial embolectomy [2176-2-7]. Overnight, she was monitored in ICU and was noticed to have a slowly developing hematoma in the left groin. Heparin was stopped, but her hematocrit fell and her hematoma continued to enlarge; so the decision was made to bring to the operating room and underwent Left groin hematoma evacuation. [2-8]- Remained in CVICU. VSS. Left groin ecchymosis. JP in place draining. HCT 25, patient transfused 1unit PRBCs. [2-9]- Transferred to [Wardname ]. Tolerating diet. OOB with nursing staff and PT consulted. Lopressor IV given HR 130's. Also had 22 run VTACH. ECG-baseline afib. Electrolytes drawn, potassium repleted. [2-10]-No overnight events, VSS. Home medications resumed. [Date range (1) 35350]-Transfused 2u PRBCs for HCT 25.3. Coumadin resumed and then discontinued as pt developed bleeding from LE, lower portion of groin wound. Heparin and coumadin discontinued. ASA continued. [Date range (1) 80542] VSS. No events. HCT stable. Tolerating po. Ambulating with assist. LT groin hematoma softer. Voiding clear yellow urine. Physical therapy recommending rehab. PCP's office update on pt status and inability to continue Coumadin. Mile LLE pain, relived with tylenol. [2-15]- No overnight events. VSS. Plan discharge to rehab. Post op visit with Dr. [Last Name (STitle) ] scheduled. Medications on Admission: Lopressor 50", Nifedical 60', detrol 2', amiodarone 200', plavix 75', hydralazine 20"", Lasix 20', acidophilus 1", colace 100" Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Hydralazine 10 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q 24 (). 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Regular Insulin Sliding Scale Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Regular Glucose Insulin Dose 0-60 mg/dL [11-24] amp D50 61-159 mg/dL 0 Units 160-199 mg/dL 2 Units 200-239 mg/dL 4 Units 240-279 mg/dL 6 Units 280-319 mg/dL 8 Units 320-359 mg/dL 10 Units > 360 mg/dL 12 Units Discharge Disposition: Extended Care Facility: [Location (un) ] Discharge Diagnosis: acute onset of cool left foot PMH: CAD AS a fib NIDDM Discharge Condition: Stable Discharge Instructions: Division of Vascular and Endovascular Surgery Lower Extremity Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use [12-26] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1244], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2176-2-27] 1:45 Completed by:[2176-2-15]	[ "272.0", "728.87", "736.79", "E878.8", "444.22", "V45.81", "427.31", "V42.2", "250.00", "403.90", "428.0", "585.9", "438.89", "998.12" ]	icd9cm	[ [ [] ] ]	[ "54.0", "38.08" ]	icd9pcs	[ [ [] ] ]	6548, 6595	2870, 5132	321, 394	6693, 6702	1553, 2847	9540, 9723	1337, 1342		5310, 6525		6616, 6672		5158, 5287			6726, 9107	9133, 9517										1357, 1534																								256, 283													422, 1187																1209, 1300	1316, 1321
8,086	178,776	27647	Discharge summary	report	Admission Date: [2145-6-22] Discharge Date: [2145-7-5] Date of Birth: [2072-12-23] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 922] Chief Complaint: Chest pressure Major Surgical or Invasive Procedure: [2145-6-23] Endovascular Stent Repair of Thoracic Aortic Aneurysm [2145-6-25] Bronchoscopy History of Present Illness: The patient is a 72-year-old gentleman who presented to [Hospital3 12748] with chest and back pain. He ruled out for MI. Dobutamine stress testing was negative for ischemia. SPECT showed LVEF of 64%. Chest CT scan was suggestive of probable contained rupture of mid-thoracic aorta saccular aneurysm. He was urgently transferred to the [Hospital1 18] for further evaluation and surgical intervention. Of note, patient was recently treated with Bactrim DS for a recent pneumonia. Past Medical History: Thoracic Aortic Aneurysm, Chronic Obstructive Pulmonary Disease, Emphysema, History of Asbestosis versus Mesotheilioma - s/p RUL lung resection, Hypertension, Renal Cell Carcinoma - s/p Nephrectomy, Depression, Cholelithiasis Social History: Lives in nursing home. Admits to 100-120 pack year history of tobacco. Admits to [2-1] ETOH drink daily. Family History: Denies premature CAD. Physical Exam: Vitals: T 96.3, BP 150/60, HR 70-80, 97% on 2L General: elderly male in no acute distress, nasal cannula in place HEENT: oropharynx benign, PERRL Neck: supple, no JVD, Heart: regular rate, normal s1s2, no murmur or rub Lungs: clear bilaterally, decreased at bases, absent RUL Abdomen: obese, soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: decreased distally, bilateral femoral bruits Neuro: alert and oriented, nonfocal Pertinent Results: Chest CT [6-22]: Penetrating ulcer of the descending thoracic aorta at the level of inferior pulmonary vein, surrounded by somewhat hyperdense soft tissue mass measuring 4.3 x 2.9 cm and 50 [Doctor Last Name ] on noncontrast scan, worrisome for mediastinal hematoma in the setting of underlying penetrating ulcer. Urgent clinical attention is needed. (Other possibility of the metiastinal soft tissue mass includes metastatic disease in this patient with history of renal cell carcinoma, or esophageal in origin. However, the soft tissue is most closely related to the aorta, and is asymmetrically located on the side of penetrating ulcer.). Coronary artery calcifications. Asbestos-related pleural disease. Bilateral pleural effusion with right lower lobe consolidation, representing pneumonia versus atelectasis. Clinical correlation is recommended. Extensive emphysema. 3.2 cm infrarenal abdominal aortic aneurysm with mural thrombus. Atherosclerotic disease of thoracoabdominal aorta. Status post left nephrectomy. Right renal cyst. Calcified sludge in the gallbladder. Somewhat prominent loops of small bowel in the lower pelvis measuring up to 2.2 cm filled with fluid. Clinical correlation is recommended. Dilated fluid-filled upper esophagus, with thickend lower esophagus. Please evaluate for the possibility of esophageal disease. Echo [6-23]: Pre stent: Overall left ventricular systolic function is normal (LVEF>55%). There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. Approximately 6 cm below the left subclavian, an outpouching is seen consistent with a contained rupture of the thoracic aorta. The outpouching is at least 2.5 cm in diameter; there is no flow in this area. A wire is seen in the lumen of the thoracic aorta during the procedure. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There is no aortic valve stenosis. No aortic regurgitation is seen. Evidence of a Thoracic endostent is seen in the descending thoracic aorta in the area previously described as a probable contained rupture. The graft appears well seated. There is no evidence for endoleak. Chest CT [6-30]: Patient is status post endoluminal stent graft placement for penetrating aortic ulcer without evidence of endoleak, and decreased size of surrounding hematoma. Large subcutaneous anterior abdominal wall hematoma at site of surgical incision and partially involving the left rectus abdominis muscle. Post- surgical focal dilatation of left common iliac bifurcation consistent with Dacron graft insertion and hematoma. Stable 3.2-cm infrarenal aortic aneurysm with calcifications and mural thrombus. Stable bilateral pleural effusions. Bilateral centrilobular emphysema with scarring at the right lung base in this patient status post right thoracotomy. Retained mucous retention cyst in the distal trachea and right main stem bronchus, with fluid layering in a superiorly dilated esophagus. Clinical correlation is recommended. Status post left nephrectomy. Right renal artery stenosis with evidence of infarction. Multiple right renal cysts requiring ultrasound or MRI for further evaluation. Asbestos-related pleural disease. Gallstones. Right adrenal adenoma. CXR [7-1]: Compared with [2145-6-29], the infiltrates in the right mid and lower lung fields appear slightly more confluent. There appears to be increased volume loss on the right, as evidenced by slightly more shift of the heart and mediastinum, although this has not changed dramatically. The left lung appears grossly clear with interval re-expansion of the left lower lobe atelectasis. [2145-6-22] 06:50PM BLOOD WBC-14.3* RBC-3.97* Hgb-11.7* Hct-34.4* MCV-87 MCH-29.5 MCHC-34.0 RDW-15.7* Plt Ct-321 [2145-6-22] 06:50PM BLOOD PT-12.4 PTT-21.0* INR(PT)-1.1 [2145-6-22] 06:50PM BLOOD Glucose-110* UreaN-9 Creat-1.0 Na-135 K-4.7 Cl-96 HCO3-30 AnGap-14 [2145-6-22] 06:50PM BLOOD ALT-14 AST-14 CK(CPK)-10* AlkPhos-84 Amylase-59 TotBili-0.4 [2145-6-22] 06:50PM BLOOD CK-MB-NotDone cTropnT-<0.01 [2145-6-22] 06:50PM BLOOD Calcium-9.0 Phos-4.3 [2145-7-2] 04:30AM BLOOD WBC-10.6 RBC-3.39* Hgb-10.0* Hct-29.0* MCV-86 MCH-29.4 MCHC-34.4 RDW-16.0* Plt Ct-247 [2145-6-30] 01:31AM BLOOD PT-12.7 PTT-31.7 INR(PT)-1.1 [2145-7-1] 06:32AM BLOOD Glucose-82 UreaN-20 Creat-1.0 Na-134 K-4.1 Cl-102 HCO3-22 AnGap-14 [2145-7-2] 04:30AM BLOOD UreaN-19 Creat-1.0 K-3.9 [2145-7-1] 06:32AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.3 [2145-6-30] 03:14PM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.012 [2145-6-30] 03:14PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-9.0* Leuks-NEG Brief Hospital Course: Mr. [Known lastname 67535] was admitted and underwent CTA which demonstrated a penetrating ulcer of his descending thoracic aorta at the level of inferior pulmonary vein, surrounded by somewhat hyperdense soft tissue mass measuring 4.3 x 2.9 cm and 50 [Doctor Last Name ] on noncontrast scan, worrisome for mediastinal hematoma. The CTA was also notable for coronary artery calcifications, asbestos-related pleural disease, bilateral pleural effusions with right lower lobe consolidation, extensive emphysema, and a 3.2 cm infrarenal abdominal aortic aneurysm with mural thrombus. Based on these results, the patient was referred through Dr. [Last Name (STitle) 1391] for stent graft repair. The patient was felt to be a good candidate for stent graft repair because the penetrating ulcer was fairly localized to the junction between the proximal and middle third of the descending thoracic aorta with good landing zones for a stent graft proximally and distally. The patient and the patient's family understood the risks and benefits of the procedure, and wished to proceed. On [6-23], Drs. [Last Name (STitle) 914] and [Name5 (PTitle) ] performed an endovascular stent repair of his thoracic aortic aneurysm. For surgical details, please see seperate dictated operative note. Following the operation, he was brought to the CSRU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated. Due to some mild respiratory distress and thick secretions with hypoxia, therapeutic bronchoscopy was performed on postoperative day two. He was aggressively diuresed and required pulmonary toilet, frequent intranasal suctioning and nebulizer treatments. Due to his tenous respiratory status and fear of aspiration, a Dobboff feeding tube was placed for nutritional support. He was initially kept NPO and remained on broad spectrum antibiotics. Sputum cultures were sent off, eventually growing out Pseudomonas aeruginosa. Antibiotics were titrated accordingly, and a course of Meropenum was initiated. Over several days, his pulmonary status gradually improved. A bedside swallow evaluation on [6-29] demonstrated no signs or symptoms of aspiration or oropharyngeal dysphagia. He made slow clinical improvements and eventually transferred to the SDU on postoperative day seven. A PICC line was placed in his right upper extremity on [7-2] for long term IV antibiotics. A course of Meropenum will continue for 2 weeks with the last dose on [7-11]. He needs follow up of his psuedomonas pneumonia with a CXR on [7-11] or prior if clinically indicated. Medical therapy was optimized as he continued to work with physical therapy to regain strength and mobility. He ws ready for discharge on [2145-7-3]. Medications on Admission: Protonix 40 qd, Enalapril 5 qd, Lasix 20 qd, KCL , Prednisone 10 qd, Remeron 15 qhs, Mucinex, Ativan qhs, Iron, Zithromax, Diltiazem 180 qd, Aspirin 162 qd 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:2 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:30 Capsule, Sust. Release 24HR(s) Refills:1 5. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 6. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). Disp:1 1 Refills:2 8. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). Disp:1 1 Refills:2 9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 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. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). Capsule, Sustained Release(s) 15. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 6 days: last dose on [7-11]. 16. Meropenem 500 mg Recon Soln Sig: One (1) Intravenous every six (6) hours for 6 days: last dose on [7-11]. 17. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed: each lumen Daily and PRN. Inspect site every shift. Discharge Disposition: Extended Care Facility: [Hospital1 2670] - [Location (un) ] - [Location (un) 7661] Discharge Diagnosis: Thoracic Aortic Aneurysm - s/p Endovascular Stent, Postop Pneumonia(Pseudomonas), Chronic Obstructive Pulmonary Disease, Emphysema, History of Asbestosis versus Mesotheilioma - s/p RUL lung resection, Hypertension, Renal Cell Carcinoma - s/p Nephrectomy, Depression Discharge Condition: Stable Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving when taking pain medications. No heavy lifting. Monitor wounds for signs of infection. Please call with any concerns or questions. Followup Instructions: Dr. [Last Name (STitle) 914] in 4 weeks - call for appt Chest Xray on [7-11] CT Scan with MMS 3 months Dr. [Last Name (STitle) 26770] in 4 weeks - call for appt Dr. [Last Name (STitle) ] in 2 weeks - call for appt Completed by:[2145-7-5]	[ "501", "451.82", "440.0", "401.9", "482.1", "447.1", "519.1", "496", "440.8", "V45.73", "511.9", "997.3", "441.1", "458.29", "999.2", "518.82", "707.8", "998.12", "V58.65", "V10.52", "428.20" ]	icd9cm	[ [ [] ] ]	[ "39.50", "96.05", "38.93", "88.72", "00.40", "39.73", "88.42", "39.26", "96.6", "03.90" ]	icd9pcs	[ [ [] ] ]	11620, 11717	6666, 9435	335, 435	12027, 12035	1860, 6643	12301, 12560	1342, 1365		9641, 11597		11738, 12006		9461, 9618			12059, 12278											1380, 1841																								281, 297													463, 950																972, 1200	1216, 1326
17,828	143,867	18619	Discharge summary	report	Admission Date: [2134-9-11] Discharge Date: [2134-9-26] Date of Birth: [2059-11-11] Sex: M Service: CARDIOTHORACIC SURGERY HISTORY OF THE PRESENT ILLNESS: This 74-year-old gentleman presented with a known history of hypertension to the [Hospital ] Hospital after developing epigastric pain, nausea, vomiting, diuresis, and lightheadedness in the middle of the night. EMS found him in a junctional rhythm at approximately heart rate of 30. He was treated according to protocol and then developed atrial fibrillation. He was transferred to the Emergency Room. He had ST elevations and was transferred for cardiac catheterization which showed severe three vessel disease with the proximal LAD as the likely culprit. However, he was now reperfused and the patient was symptom-free when he was seen by the Cardiology Service at admission. PAST MEDICAL HISTORY: 1. Hypertension. 2. Question of hyperlipidemia. ADMISSION MEDICATIONS: Unknown, although apparently the patient had been on some form of hydrochlorothiazide. ALLERGIES: Penicillin and Lipitor which produced a rash. The patient was seen by the Cardiology Service and referred to CT Surgery. The patient was started on Integrelin and Amiodarone for his arrhythmias and for his severe three vessel disease by the Cardiology Service and was seen by CT Surgery on [2134-9-11]. Catheterization showed 30% left main, 80% LAD, 90% diagonal, 90% circumflex, 80% OM1, 90% RCA. His cardiac index was 1.8. An intra-aortic balloon pump was placed by Cardiology. PHYSICAL EXAMINATION ON ADMISSION: HEENT: Benign with no carotid bruits. Lungs: Clear bilaterally. Heart: Irregular in rhythm with S1 and S2. Abdomen: Soft, nontender, nondistended. LABORATORY/RADIOLOGIC DATA: The preoperative laboratories showed a PT of 14.3, INR 1.4, PTT 149. Sodium 132, K 4.0, chloride 103, C02 23, BUN 27, creatinine 1.4 with a blood sugar of 111, AST 13, ALT 27, amylase 64. HOSPITAL COURSE: He was seen by Dr. [Last Name (STitle) ] [Last Name (NamePattern4) 14968] of Cardiac Surgery who noted that his EKG was improved. He was currently without any pain with the balloon. His Integrelin was stopped. An echocardiogram was ordered and the plan was to do his bypass surgery either tomorrow or Monday, allowing time for the Integrelin to wear off. Th[Last Name (STitle) 1050] had been admitted to the CCU to be followed. The patient's creatinine remained stable at 1.4 after being 1.9 at the outside hospital. On [2134-9-12], the next day, the patient underwent a coronary artery bypass grafting times four by Dr. [Last Name (Prefixes) ] with a LIMA to the LAD, vein graft to the PDA vein graft, OM1 and vein graft to diagonal. The patient's intra-aortic balloon pump remained in place. The patient was transferred to the Cardiothoracic ICU. On postoperative day number one, the patient was on a Neo-Synephrine drip at 2.25 micrograms per kilogram per minute, an insulin drip, propofol, and milrinone at 0.5 micrograms per kilogram per minute. The patient remained intubated and sedated with a white count of 12.3, hematocrit 32.1 which was decreased from his preoperative white count of 13.5 and hematocrit of 24.8, showing an improvement in his hematocrit. On examination, his heart was regular rate and rhythm. His incisions were clean, dry, and intact. Neurologically, he appeared to be stable even though he was sedated at that time. At 5:03 that day, while turning the patient by nursing, the patient had an episode of V tach. External defibrillator paddles were applied at 200 joules times one shock. The patient immediately converted to sinus rhythm. He was started on an Amiodarone drip and given magnesium repletion as well as 1 unit of bicarbonate. He was seen by the Heart Failure attending, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], who just recommended gentle diuresis and continuing to wean his Neo-Synephrine if possible. He was seen by the Electrophysiology fellow, [Doctor First Name 28239] [Doctor Last Name 13177], who checked his pacing thresholds. The patient had no additional ectopy that afternoon and continued on an Amiodarone drip. On postoperative day number two, he was on Amiodarone, Fentanyl, heparin which was then held. The patient was on a Levophed drip at 0.15 as well as midazolam and a Natrecor drip at 0.5. He remained intubated and sedated. His examination was relatively unchanged. He remained A paced with a blood pressure of 84/54. Cardiac index of 2.4 with a balloon on 1:1 mixed venous 59%. A Swan-Ganz was floated under fluoroscopy with no complications by the EP fellow for better management of volume status. Under fluoroscopy, the CS lead position appeared to be adequate. On [2134-9-13], when the patient did go down to the Catheterization Laboratory, the patient had a bit of RV failure so dobutamine was started at 2.5 micrograms per kilogram per minute but aborted for increasing ventricular ectopy. Cardiology was consulted. Amiodarone was discontinued. Epinephrine was started. The patient had slight improvement in hemodynamics and increased SP02 but there was a mixed acidosis which was treated with bicarbonate, increased respiratory rate and volume on the balloon remained 1:1. Urine turned dark amber brown with some sediment. The patient had some cool feet but warm and strongly [Year (4 digits) ] pulses in both DPs and PTs. The patient was transported to the Catheterization Laboratory at that point for a pacing wire and a Swan change to continue his cardiac output while they were there under fluoroscopy. The patient was seen by the SICU Consult Service, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 26687] of Anesthesia, and now continued to be followed by Dr. [Last Name (STitle) 1911] of Electrophysiology, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], the Heart Failure attending. On [2134-9-13], the patient had a triple lumen catheter placed in his left groin by the CT Surgery Team for access. On postoperative day number three, the patient remained on milrinone, Amiodarone, epinephrine at 0.07, Fentanyl, Levophed at 0.08, Versed, and Pitressin for blood pressure support at 0.06. His hematocrit was stable at 32.7, K 4.1, BUN 27, creatinine 2.0 which continued to rise as the patient was suffering from acute renal failure. It was noted by the Electrophysiology and Cardiology staff that the patient had suffered an extensive RV infarct. He was requiring AV pacing and continued to suffer a bit from RV failure. He was seen by the Clinical Nutrition Team for management of his TPN issues. The patient also had been started on levofloxacin and vancomycin and was being A paced on postoperative day number four with a blood pressure of 98/57 and remaining on Amiodarone, epinephrine, Levophed, milrinone, Pitressin as well as his insulin drip. The patient had been started on Plavix for anticoagulation as the heparin had been stopped. The patient remained critically ill in the ICU. Over the course of the next couple of days, he went back into atrial fibrillation and out again. He received some boluses of Amiodarone which helped convert him back to sinus rhythm but remained on triple pressor support as well as inotropic support. His hematocrit remained stable. He remained on double antibiotic coverage. His platelet count dropped to 20,000 over the course of several days. HIT antibody screen was proposed to evaluate the cause of his thrombocytopenia. On [2134-9-13], when the patient was back in the Catheterization Laboratory, stents were deployed into the right groin area artery to help with the severe RV dysfunction after his myocardial infarction and the plan was to do PCI on his RCA and/or acute marginal while the patient was there. Thrombectomy was completed and the RCA was stented when the patient was in the Catheterization Laboratory on [2134-9-13]. EP continued to monitor his pacing thresholds. The patient continued to have worsening acidosis on [2134-9-17]. The patient's transaminases rose into the 3,000 showing liver insult. Subsequent hepatic Doppler showed an absence of hepatic arterial flow and angiography revealed a thrombus and clot in the SMA and celiac blood vessels. The SMA celiac vessels were stented and opened. A little bit of residual thrombus remained. Please refer to the General Surgery consult note. They were called for evaluation of possible mesenteric ischemia. The patient's lactate rose to 9.7 despite adequate oxygen delivery. The patient's creatinine rose to 2.7. The white count was stable at 13.9. Exploratory laparotomy was scheduled. The patient was seen with the results as previously noted. Please refer to the operative note by the General Surgery Service. The patient was seen by the Renal Service on [2134-9-18] for his management of acute renal failure and volume overload. The patient was also followed by General Surgery after the occlusion of celiac, SMA, and [Female First Name (un) 899] and the stenting of the SMA and celiac arteries with presumed restoration of flow. The patient remained critically ill with a shock liver in acute renal failure. The patient also was developing coagulopathy with a rising PT to 21.9, INR 3.2. On [2134-9-18], the ALT rose to 3,168 and AST of 8,150 with alkaline phosphatase at 134 and a total bilirubin at 3.5. The patient was taken by General Surgery, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], to the Operating Room on [2134-9-18] for mesenteric ischemia. Please refer to the operative note. Gangrenous cholecystitis was found. Hematology was also consulted about the thrombocytopenia and management of the patient's thrombotic state on [2134-9-18]. Heparin associated antibodies were negative times two. On that day, a chest x-ray showed basilar atelectasis. A peripheral smear was performed. The patient continued to be acutely acidotic with a creatinine of 2.7 and a lactate that rose to 11.2 on [2134-9-18]. On [2134-9-19], the patient remained on the epinephrine drip at 0.05, milrinone at 0.25, Pitressin at 0.04, in atrial fibrillation. The patient remained critically ill. He also remained on triple antibiotic therapy with the addition of Flagyl for his exploratory laparotomy results. The patient's abdomen was left open. The patient was started on CVDH by the Renal Service. The patient's platelet count stabilized at approximately 97,000 which ruled out DIC and TTP but his liver function continued to worsen. He was re-explored at the bedside on [2134-9-20] by Dr. [First Name (STitle) ], at the time of CVDH for a second look at his abdomen. His femoral line was changed over a wire also. Vancomycin was dosed by levels per Renal consult. The patient was seen daily by Nutrition, Renal, General Surgery, and the Cardiac Surgery Team. The patient had an episode of atrial fibrillation on the night of [2134-9-20] during CVDH. His coagulation studies continued to be abnormal. He received an Amiodarone bolus for the episode of atrial fibrillation. On [2134-9-21], he had a Cordis and Swan insertion replaced by the Cardiac Surgery Team and was seen by Vascular Surgery after he lost the pulses in his right foot with ischemic toes most likely related to his pressors. They recommended discontinuing the arterial line in his right groin. The arterial line site developed some bleeding. Pressure was held. The foot continued to look ischemic, but still warm with no palpable pulses but [Year (4 digits) ] signals were obtained. The patient continued atrial fibrillation. He was seen by Dr. [Last Name (STitle) 1476] of Vascular Surgery who suspected bilateral ischemic legs were related to femoral arterial occlusions in the presence of his long-term pressor support and noted his ischemic injury to his viscera. He did not recommend any exploration of the femoral arteries at that point given the patient's gravely ill situation and noted that if the patient survived he would most likely need bilateral amputations with the patient still requiring epinephrine and Levophed drips as well as Vasopressin. The patient was taken to the Angiography Suite. Please refer to the report from [2134-9-22] which noted anterior tibial disease in the right lower extremity with occlusion of the PT and superficial femoral artery had a 70% lesion as well as complete occlusion of the anterior tibial and the posterior tibial arteries. The patient was seen again by Vascular Surgery the following day who again noted that the patient would require bilateral amputations but would not be able to tolerate the procedure at this point. On [2134-9-23], the patient was cardioverted again for rapid atrial fibrillation which converted to normal sinus rhythm at approximately 6:00 p.m. The patient continued on triple antibiotic therapy, Plavix for anticoagulation, epinephrine at 0.012, Levophed at 0.105, and Pitressin at 0.04. The abdomen had remained partially opened at the recommendation of General Surgery. The patient remained intubated and sedated. Renal recommended CVVHD which had clotted at 4:00 in the morning on the night of [2134-9-23]. It was restarted at 6:00 in the afternoon. On [2134-9-24], the patient was severely acidotic requiring 4 amps of bicarbonate. His feet remained cool and cyanotic with no changes, barely [Year (4 digits) ] pulses in both lower extremities. Attempts were made to try to wean his Levophed. On [2134-9-24], he was noted to have dark dry gangrene in bilateral toes and he went to the Operating Room for abdominal closure and a biopsy of his liver. No frank cirrhosis was found. The right colon had several small areas that were nonviable but not perforated. The liver had significant collapse consistent with massive hepatic necrosis. Th[Last Name (STitle) 1050] spiked a temperature on [2134-9-24] in the setting of worsening acidosis. He had another round of CVHD. He was seen by Infectious Disease at the request of Dr. [Last Name (Prefixes) 411] to help with antibiotic management. They recommended continuing levofloxacin to double cover his gram-negative rods and add meropenem for his abdominal infection. Fluconazole dosing was also to be lowered given his liver dysfunction and discontinue the Flagyl as the meropenem would cover the anaerobes. The patient also continued to have a coagulopathic picture with a PT of 21.3 and INR of 3 from his liver insult and now continuing thrombocytopenia with a worsening platelet count, on the morning of [2134-9-24] was 26,000. On [2134-9-25], the patient remained on Amiodarone drip at 0.5, epinephrine drip at 0.18, Fentanyl for sedation, Levophed at 0.11, Pitressin at 0.04. He remained in atrial fibrillation with a blood pressure of 127/62, fully sedated and intubated on the ventilator with continuing ischemic bowel, liver injury. The patient was critically ill. He continued with CVHD to help with his acid base balance. His lactate was 9.2 on [2134-9-25]. On [2134-9-25], the patient went back to the Operating Room again for exploratory laparotomy to relocate his ischemic bowel on triple pressor support and triple antibiotic therapy. General Surgery Team found colonic ischemia in the cecal region and continuing hepatic necrosis, partial ischemia of the small bowel, and a patent SMA and celiac vessels. The patient returned to the CRSU critically ill after his right hemicolectomy had been performed by General Surgery with a mucous fistula and an ileostomy. The patient lost pulses in his feet after the trip to the Operating Room with no DP of PT [Name (NI) ] but popliteals were [Name (NI) ] bilaterally. He was seen again by Vascular Surgery on the morning of [2134-9-26] as well as General Surgery and Infectious Disease. He had another round of paroxysmal atrial fibrillation. Overnight on the night of [2134-9-25], the patient had a recurrent fast ventricular fibrillation and paroxysmal VT requiring numerous shocks. He remained intubated and sedated on epinephrine, milrinone, Levophed, and Pitressin. CVH was initiated again. The patient continued to deteriorate at 2:00 in the afternoon on [2134-9-26]. The patient had several more episodes of ventricular tachycardia which responded to Amiodarone and cardioversion but he continued to have progressive acidosis with a rising lactate requiring more than 10 amps of bicarbonate. His prognosis was very poor at that point. Th[Last Name (STitle) 51117]ly came in and expressed that they wanted to stop everything that was being done and have Mr. [Known lastname ] pass away. Dr. [Last Name (STitle) ] [Last Name (NamePattern4) 14968] from Cardiac Surgery spoke to Dr. [Last Name (Prefixes) ], the attending, who expressed that this was a reasonable decision. All inotropes and pressors were stopped. A Fentanyl drip was continued as a comfort measure only. Approximately ten minutes after the inotrope and pressor support was stopped, the patient expired at 1:40 p.m. The family declined autopsy and Dr. [Last Name (Prefixes) ] and Dr. [Last Name (STitle) ] were notified. The patient expired in the CSRU at 1:40 p.m. on [2134-9-26]. DISCHARGE DIAGNOSIS: 1. Status post coronary artery bypass grafting times four. 2. Status post acute myocardial infarction. 3. Hypertension. 4. Liver failure. 5. Bowel ischemia. 6. Status post right hemicolectomy. 7. Status post acute renal failure. 8. Status post right ventricular failure. DISPOSITION: The patient expired in the CRSU on [2134-9-26]. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 51118] MEDQUIST36 D: [2134-11-11] 09:50 T: [2134-11-13] 16:07 JOB#: [Job Number 51119]	[ "570", "444.21", "444.0", "427.1", "997.1", "998.11", "557.0", "444.22", "410.11" ]	icd9cm	[ [ [] ] ]	[ "36.06", "39.50", "88.56", "99.63", "36.05", "36.13", "39.90", "37.61", "37.23", "39.64", "37.22", "36.15", "39.61", "99.62" ]	icd9pcs	[ [ [] ] ]											17445, 18058			1986, 17424				969, 1580																																																						1595, 1968								894, 945
66,339	145,868	54291	Discharge summary	report	Admission Date: [2187-4-8] Discharge Date: [2187-4-11] Date of Birth: [2129-5-19] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 106] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: cardiac catheterization, with drug-eluting stent to diagonal branch. History of Present Illness: Mr. [Known lastname 111228] is a 57y/o gentleman with no significant PMH besides cigarette smoking but strong family history of early CAD who was transferred from [Hospital1 ] due to chest pain that started yesterday morning, and is admitted to the CCU due to continued chest pain. . He was in his otherwise good state of health until yesterday at 7AM when he was walking around a neighborhood before a meeting and felt the sudden onset of chest pain. It is described as substernal heartburn. It did not radiate, and was not associated with shortness of breath, nausea, or diaphoresis. He sat in his car and the pain resolved in 10 minutes. Then at 10PM last night the pain recurred while he was walking down the stairs to the basement but this time it did not resolve with rest. It was between [2185-4-16] in severity and was constant; this time he felt very clammy. He could not sleep due to the pain. He thought he might be having a heart attack but did not want to go to the hospital (he was terrified because his father died of an MI at age 39). In the morning, he told his children about the continued chest pain and they insisted that he go to [Hospital1 ]. There, EKG showed Q waves anteriorly, and troponin 11.4. He received Aspirin, SL NTG, and Morphine, as well as being started on Heparin and Integrillin drips prior to transfer to [Hospital1 18]. . In the [Hospital1 18] ED, initial VS were: pain [4-19], T 98.7, H 57, BP 142/78, RR 16, POx 100% 3L NC. EKG revealed Q waves in V1, V2. Labs notable for Trop-T 1.91, CK 1644, MB 229. Also, WBC 12.9. He was continued on the Heparin and Integrillin drips. Received 600mg Plavix load. For continued chest pain, he was given Morphine 5mg IV and was started on a Nitroglycerin drip which was uptitrated to 2.4 with resolution of his chest pain. However, he complained of some left shoulder pain so was admitted to the CCU for closer observation. . Upon arrival to the CCU, he feels fine. Says that he still has fleeting discomfort (various places including in the middle of his chest, left side of his chest, left shoulder, and back though not radiating/tearing). . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: -hepatitis A in the [2154]'s, resolved -tonsillectomy age 12 Social History: - Home: Lives with his wife and 2 of his 5 kids (age 26 and 14). - Occupation: Photographer and also manages properties in [Location (un) 111229]. - Exercise: Does not go to the gym but walks 5 miles a day to and from work. Sometimes walks up to 8 miles a day. - Tobacco history: Smokes [12-11] ppd since age 22. - EtOH: Very minimal (mostly only on holidays); no h/o heavy use. - Illicit drugs: Smoked marijuana in the [2144]'s and tried cocaine twice, but none since the [2144]'s. Family History: -Father reportedly had an MI at age 29, then died at age 39 of an MI -All of father's family died of cardiac disease -Mother died of MI at age 70. Physical Exam: On admission: VS: T: 98.4??????F HR: 74 BP: 122/66 RR: 16 SpO2: 96% 2L NC GENERAL: well-developed gentleman in NAD. Oriented x3. Mood, affect appropriate. HEENT: dry MM; sclera anicteric; EOMI NECK: no JVD CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. NEURO: AAOx3, CNII-XII intact, 5/5 strength biceps, triceps, wrist, knee/hip flexors/extensors. PULSES: Right: Carotid 2+ DP 2+ Left: Carotid 2+ DP 2+ On Discharge: Tm/Tc:98.8/98.5 HR:66-68 BP:104-117/67-79 RR:18-20 02 sat:97% RA GENERAL: 57 yo M in no acute distress HEENT: mucous membs moist, no lymphadenopathy, JVP non elevated CHEST: CTABL no wheezes, no rales, no rhonchi CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or gallops ABD: soft, non-tender, non-distended, BS normoactive. EXT: wwp, no edema. DPs, PTs 2+. NEURO: 5/5 strength in U/L extremities. gait WNL. SKIN: no rash PSYCH: alert and cooperative Pertinent Results: Admission: [2187-4-8] 03:05PM BLOOD WBC-12.9* RBC-4.93 Hgb-15.5 Hct-47.7 MCV-97 MCH-31.5 MCHC-32.5 RDW-12.8 Plt Ct-251 [2187-4-8] 03:05PM BLOOD Neuts-81.5* Lymphs-11.4* Monos-5.8 Eos-0.9 Baso-0.5 [2187-4-8] 03:05PM BLOOD PT-11.2 PTT-150* INR(PT)-1.0 [2187-4-8] 03:05PM BLOOD Glucose-111* UreaN-20 Creat-0.9 Na-139 K-4.3 Cl-105 HCO3-23 AnGap-15 [2187-4-9] 04:01AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.9 [2187-4-8] 03:05PM BLOOD CK(CPK)-1644* [2187-4-8] 03:05PM BLOOD CK-MB-229* MB Indx-13.9* [2187-4-8] 03:05PM BLOOD cTropnT-1.91* CE Trend: [2187-4-8] 03:05PM BLOOD CK-MB-229* MB Indx-13.9* [2187-4-8] 03:05PM BLOOD cTropnT-1.91* [2187-4-8] 08:30PM BLOOD CK-MB-158* MB Indx-10.6* cTropnT-2.26* [2187-4-9] 04:01AM BLOOD CK-MB-74* MB Indx-7.9* cTropnT-2.09* [2187-4-9] 03:11PM BLOOD CK-MB-23* [2187-4-8] 03:05PM BLOOD CK(CPK)-1644* [2187-4-8] 08:30PM BLOOD CK(CPK)-1487* [2187-4-9] 04:01AM BLOOD CK(CPK)-935* Other Labs: [2187-4-10] 04:30AM BLOOD ALT-38 AST-60* LD(LDH)-370* AlkPhos-69 TotBili-0.3 Discharge Labs: [2187-4-11] 06:45AM BLOOD WBC-7.1 RBC-3.93* Hgb-12.5* Hct-37.8* MCV-96 MCH-31.7 MCHC-32.9 RDW-12.6 Plt Ct-228 [2187-4-11] 06:45AM BLOOD Neuts-67.3 Lymphs-20.9 Monos-9.2 Eos-2.2 Baso-0.4 [2187-4-11] 06:45AM BLOOD Glucose-103* UreaN-25* Creat-0.9 Na-134 K-4.2 Cl-104 HCO3-24 AnGap-10 CXR [2187-4-8]: As compared to the previous radiograph, there is no relevant change. Normal size of the cardiac silhouette. Normal hilar and mediastinal structures. Normal transparency of the lung parenchyma. Currently, there is no evidence of pneumonia, pleural effusions, pulmonary edema or other acute lung changes. C.Cath [2187-4-9] Coronary angiography: right dominant LMCA: No angiographically-apparent CAD. LAD: No angiographically-apparent CAD in the LAD. Ulcerated proximal large diagonal with slow flow and 95% stenosis. LCX: No angiographically-apparent CAD. RCA: No angiographically-apparent CAD. 3.0 x 12 mm Resolute (DES) stent ASA indefinitely at 81 mg PO QD Plavix (clopidogrel) 75 mg daily X 12 months uninterrupted. TTE [2187-4-10] The left atrium is normal in size. Color Doppler study showed a trace shunt across the interatrial septum consistent with a stretched patent foramen ovale (or very small atrial septal defect). Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with mid to apical anterior and apical lateral hypokinesis/akinesis. LVEF 50-55%. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Brief Hospital Course: Mr. [Known lastname 111228] is a 57y/o gentleman with CAD risk factors of cigarette use and early family history of CAD who presented after a day of with chest pain with abnormal EKG and elevated cardiac enzymes consistent with myocardial infarction. He received DES to diag, was started on cardiac meds and was discharged home. #. Chest pain, abnormal EKG, elevated cardiac enzymes: MI. Patient presented with an MI that was likely >24 hours old. Could have been an NSTEMI. EKG without ST elevations but anterior Q waves which could in fact represent a missed STEMI. Cardiac enzymes consistent with a large territorial infarction. His chest pain was controlled on Heparin gtt, Integrillin gtt, NTG gtt, ASA, and Plavix overnight. On the morning after admission, he was taken to the cath lab and was found to have 90% occlusion of large diag branch, and as this was likely the culprit lesion it was stented with a DES resulting in good coronary flow. He remained hemodynamically stable with no complications. TTE showed mild regional left ventricular systolic dysfunction (LV EF 50-55%) with mid to apical anterior and apical lateral hypokinesis/akinesis. He was discharged on ASA, Plavix, Metoprolol, and a statin and will follow up in Cardiology clinic. #. Rigors: resolved. Rigors and fever to 102.9 developed post cardiac catherization. Patient received Solumederol, Famotidine and Benadryl with resolution of symptoms. Rigors may have resulted from protamine infusion. Questionable whether this was contrast-related reaction though Interventional Cardiology Attending indicated that patient showed no signs of reaction with any contrast load during procedure. Rigors and fevers did not develop until Protamine was infused during closing of femoral artery. Rigors resolved and infectious workup (CXR, urine studies) were negative. Blood culture final result pending at the time of discharge. #. Mild leukocytosis: resolved, likely related to MI. No localizing signs/symptoms, and WBC differential not concerning for acute infection. CXR and UA also reassuring. Patient was not treated with antibiotics. WBC was 7 at time of discharge. TRANSITIONAL ISSUES: - Patient must continue aspirin indefinitely, and plavix for at least a year - Final result of [2187-4-9] blood cultures pending at the time of discharge - Patient has no PCP but was scheduled to see a provider at [Name9 (PRE) 191] to establish care. -- Compliance: It will be important to ensure compliance (especially ASA/Plavix) as the patient expressed that he does not like to take any medications. At the time of d/c he expressed understanding of why he needed to be on these meds and said he planned to take them without any skipped doses. - Tobacco use: He was urged to f/u with his PCP regarding quitting smoking completely. Medications on Admission: None, occasionally MVI Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:11 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:30 Tablet Extended Release 24 hr(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: myocardial infarction coronary artery disease Tobacco abuse Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Last Name (Titles) 4281], It was a pleasure taking care of you at [Hospital1 ] Medial Center. You were admitted because you had a heart attack. You underwent a cardiac catheterization procedure and were found to have a blockage in one of the heart's arteries, which was stented open. It is VERY important that you continue to take Aspirin and Plavix daily to prevent the stent from closing up. Do not stop taking aspirin and plavix or miss [First Name (Titles) 691] [Last Name (Titles) 11014]s unless Dr. [Last Name (STitle) 410] or Dr. [Last Name (STitle) 696] tells you it is OK. Please see the cardiology appt below for the end of the month. In addition, please establish care with a Primary Care doctor (appointment listed below) to ensure that you are up to date with regards to general healthcare maintenance. It is especially crucial that you seek help to quit smoking completely, as this is a well-known risk factor for heart attacks. We made the following changes to your medications: -START Aspirin 81mg daily (over the counter "baby-dose aspirin") -START Plavix (for at least 1 year, please discuss this plan with your Cardiologist) -START Atorvastatin for cholesterol -START Metoprolol (to protect the heart from having another heart attack) - START nitroglycerin as needed when you have chest pain. Take one tablet under the tongue, wait 5 minutes, then take another tablet if the chest pain is still there. Call 911 for chest pain that does not go away after 2 tablets, call Dr. [Last Name (STitle) 410] if you use any nitroglycerin at all. Followup Instructions: PRIMARY CARE Your previous physician at [Name9 (PRE) 2312] Medical is no longer there, and that clinic is not accepting new patients. Also, because of your new Masshealth insurance, you will need a referreal from a Primary Care doctor before your Cardiology appointment. So, we have made the following appointment with a provider at [Hospital1 1388] primary care clinic who can see you before your scheduled Cardiology appointment in order to establish care and also arrange a referral: Department: [Hospital3 249] When: TUESDAY [2187-4-17] at 2:45 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 2010] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage CARDIOLOGY Department: CARDIAC SERVICES When: THURSDAY [2187-5-10] at 8:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. and Dr. [First Name (STitle) ] [Name (STitle) 410] [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "410.71", "780.62", "288.60", "V17.3", "414.01", "305.1" ]	icd9cm	[ [ [] ] ]	[ "88.56", "36.07", "37.22", "00.45", "00.66", "99.20", "00.40" ]	icd9pcs	[ [ [] ] ]	11663, 11669	8245, 8618	313, 384	11773, 11773	5154, 6121	13547, 14760	3719, 3867		11140, 11640		11690, 11752		11093, 11117			11924, 12929				6231, 8222							3882, 3882																	4666, 5135	10422, 11067		12958, 13524		8635, 10401		263, 275													412, 3095								3896, 4652		11788, 11900						3117, 3183	3199, 3703			6133, 6215
32,746	124,485	44039	Discharge summary	report	Admission Date: [2188-7-20] Discharge Date: [2188-7-30] Service: MEDICINE Allergies: Sulfasalazine / Percocet Attending:[First Name3 (LF) 6994] Chief Complaint: Difficulty Breathing Major Surgical or Invasive Procedure: Intubation History of Present Illness: This is a 83 year old man with CAD and DM presented from nursing home with fevers and desaturations. Per his wife, he has been fighting a URI for the past 6 weeks, which he caught from another nursing home resident. It seems like he was on a 3 day course of levofloxacin and a 10 day course of Augmentin without improvement. He was also being treated for a left ear infection with antibiotic ear drops, which was diagnosed in the VA last week. His cough was not improving and he developed a fever last night with desaturations and was subsequently transferred to [Hospital1 18] for evaluation. . In the ED, his vitals were: 101.0, 126, 62/39, 32, 84% on 6LNC. He was given 3L NS and his BP improved to 120/60. He was put on a NRB and his ABG was 7.19, 63, 79. He was then put on BIPAP and maintained his O2 sats in the 90%'s. His CXR showed bilateral LL opacities with small bilateral pleural effusions. UA was positive for a UA. Lactate was 1.5. He was given vanco/levo/flagyl. EKG showed new afib with RVR to 130's. Metoprolol 2.5mg IV x 1 was given and he eventually spontaneously converted to sinus. He was transferred to the MICU for further care. Past Medical History: 1. DM 2 2. UC s/p ileostomy and colectomy 3. HTN 4. CAD s/p stent (90's) 5. s/p CVAX3 (94, 95, 96) 6. Prostate ca s/p XRT on Hormone therapy 7. Paget's disease 8. GERD 9. Esophageal ulcer and stricture 10. Venous stasis 11. Anxiety 12. Bladder Cancer secondary to prostate ca therapy 13. Macular Degeneration 14. Pulmonary Embolism [2170] 15. Anemia 16. Hyperlipidemia 17. Hearing Loss 18. Melanoma Social History: Patient lives at [Hospital ] [Hospital ] Nursing Home. No smoking, EtoH or IVDU. Family History: NC Physical Exam: VITALS: 96.9 ax, 114/45, 56, 100% on BIPAP 12/5, 100% GEN: A+Ox2, somewhat fatigued and somnelent but arousable and interactive HEENT: Right ptosis, poor vision, BIPAP mask NECK: Obese neck, JPV estimated to be 12mm CV: distant heart sounds, s1+s2, no m/g/r, no precordial impulses PULM: upper airway noses, poor air movement, especially on left, right base crackles, scattered rhonchi, no wheezes ABD: soft, NT, ND, +BS, ostomy, midline scar EXT: trace to 1+ pedal edema up to ankles Pertinent Results: [2188-7-20] 09:37PM TYPE-ART TEMP-37.5 PEEP-5 O2-50 PO2-97 PCO2-65* PH-7.21* TOTAL CO2-27 BASE XS--3 INTUBATED-NOT INTUBA [2188-7-20] 07:53PM TYPE-ART TEMP-37.5 O2 FLOW-15 PO2-170* PCO2-77* PH-7.15* TOTAL CO2-28 BASE XS--3 INTUBATED-NOT INTUBA [2188-7-20] 07:28PM CK(CPK)-19* [2188-7-20] 07:28PM CK-MB-NotDone cTropnT-0.04* [2188-7-20] 06:19PM TYPE-ART TEMP-38.3 RATES-/12 PO2-204* PCO2-84* PH-7.11* TOTAL CO2-28 BASE XS--5 VENT-SPONTANEOU [2188-7-20] 03:55PM TYPE-ART TEMP-38.2 RATES-/17 TIDAL VOL-700 PEEP-8 O2-60 PO2-121* PCO2-57* PH-7.23* TOTAL CO2-25 BASE XS--4 VENT-SPONTANEOU COMMENTS-CPAP [2188-7-20] 01:05PM CK(CPK)-18* [2188-7-20] 01:05PM CK-MB-NotDone cTropnT-0.04* [2188-7-20] 10:48AM TYPE-ART PO2-82* PCO2-62* PH-7.20* TOTAL CO2-25 BASE XS--4 [2188-7-20] 10:48AM LACTATE-1.0 [2188-7-20] 06:05AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.013 [2188-7-20] 06:05AM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [2188-7-20] 06:05AM URINE RBC-0-2 WBC-[11-11]* BACTERIA-MOD YEAST-NONE EPI-0-2 [2188-7-20] 06:05AM URINE MUCOUS-FEW [2188-7-20] 04:15AM COMMENTS-GREEN TOP [2188-7-20] 04:15AM GLUCOSE-245* LACTATE-1.6 [2188-7-20] 04:00AM GLUCOSE-262* UREA N-44* CREAT-1.6* SODIUM-143 POTASSIUM-5.1 CHLORIDE-109* TOTAL CO2-24 ANION GAP-15 [2188-7-20] 04:00AM estGFR-Using this [2188-7-20] 04:00AM ALT(SGPT)-29 AST(SGOT)-25 CK(CPK)-21* ALK PHOS-414* AMYLASE-51 TOT BILI-0.2 [2188-7-20] 04:00AM ALT(SGPT)-29 AST(SGOT)-25 CK(CPK)-21* ALK PHOS-414* AMYLASE-51 TOT BILI-0.2 [2188-7-20] 04:00AM LIPASE-16 [2188-7-20] 04:00AM WBC-19.8# RBC-3.67 HGB-10.2* HCT-32.1* MCV-87 MCH-27.7 MCHC-31.6 RDW-16.3* [2188-7-20] 04:00AM NEUTS-95.1* BANDS-0 LYMPHS-2.9* MONOS-1.6* EOS-0.2 BASOS-0.1 [2188-7-20] 04:00AM PLT COUNT-388 [2188-7-20] 04:00AM PT-12.5 PTT-26.4 INR(PT)-1.1 . CXR [7-20]: Interval progression of now complete opacification of the left hemithorax likely represents a combination of a left-sided pleural effusion with collapse/consolidation of the left lung. Moderate/large pleural effusion has been present since the most remote chest radiograph available dated [2186-9-7]. If indicated, further evaluation with a CT could be considered. . CXR [2188-7-24]: Single bedside AP examination labeled "erect at 3 a.m." is compared with the study obtained some 10.5 hours earlier; allowing for differences in technique, the overall appearance is unchanged. There are persistent bilateral pleural effusions, left greater than right with dense left retrocardiac opacity, and pneumonic consolidation in this region cannot be excluded. There is right basilar subsegmental atelectasis. Heart remains enlarged with some pulmonary vascular congestion. Note that in comparison to the previous study, at 0400 H, the overall appearance is significantly improved, with the support tubes removed and the left subclavian central venous catheter, unchanged in position. . Swallow Study [2188-7-25]: VIDEO OROPHARYNGEAL SWALLOW. Mild oropharyngeal dysphagia. Evidence of silent aspiration and penetration. Please refer to the speech pathologist note for details and recommendations. Brief Hospital Course: 83 year old man with CAD and DM presented from nursing home with fevers, hypotension and respiratory failure. . # RESPIRATORY FAILURE: chronic left pleural effusion and RLL PNA on top of that which may explain his decompensation. He probably also has some chronic obstructive disease from his tobacco history. Initially admitted to ICU with intubation. He has been steadily improving since his extubation, and is now saturating well on 3.5 Lnc. He has completed 5 days of azithromycin, and finished 8day of vanco / zosyn. Central line dc'd and tip sent for culture on [2188-7-27]. Repeat CXR shows stable LLL effusion and decreased RLL opacity. Patient needs to be maintained with aspiration precautions. . # HYPOTENSION: SBP improved since admission- range nearly normal. Initially held home antihypertensives medications. Restarted lisopril after renal functions improved to baseline. Patient tolerated lisinopril well. f/u blood cultures were negative . # CAD: Cath in [2181] shows 2VD (LCX and RCA) and s/p stent to LCX. Subsequently no further symptoms or workup, although patient became more debilitated and rarely exerts himself. He has new RBBB since [5-/2187] but ruled out with cardiac enzymes. Patient was not placed on asa per urology recs in the past and was continued on plavix. . # PUMP: Wife does not remember any hx of CHF but remembers the patient taking lasix for peripheral edema at one point. He does not appear volume overloaded and was not continued on lasix. TTE on [7-28] showed nl LVEF. . # AFIB: No prior history of afib before this admission. Was in RVR to 130's in ED during acute respiratory distress when hypotensive. Metoprolol 2.5mg IV x 1 was given and he spontaneously converted back to sinus rhythm. He has remained in sinus ever since. Patient was continued on plavix while coumadin was not started per prior urology recs given history of hematuria. . # UTI: By UA in ED. No dysuria. Patient was already started on antibiotics as mentioned above for PNA which would have covered his UTI. . # chronic ear infection: Patient was placed on out patient antimicrobial drops. He was advised to make an out patient appointment with his PCP to follow up his ear infection. . # ARF: Baseline creatinine 1.1 to 1.5. Patient was discharged with baseline Creatinine. . # ANEMIA: Baseline hct of 30. Currently at baseline. Patient was continued on out patinet epo schedule and was given [Numeric Identifier 961] units on [7-30]. . # s/p CVA's: He was on coumadin and then aspirin at one time. These were discontinued for hematuria, with discussions with urology. Currently he is only on plavix. . # DM: Held his home glipizide and was placed on sliding scale insulin. . # FEN: -- thin, soft diet per nutrition recs . # PPX: -- prevacid -- sq heparin Medications on Admission: # Lisinopril 5 mg Daily # EPOGEN 10,000 unit/mL sq q 2wk # Multivitamin # Norvasc 5mg daily # Omeprazole 30 daily # Glipizide 10mg qAM, 5mg qPM # Cortisporin 2gtt L ear QID x 1 week # Ditropan XL 10mg daily # Iron 325mg daily # Zocor 20mg QHS # Claritin 10mg QHS # Augmentin 875mg q12H x 10 days, first day [7-1] # Levoquin 250mg dailt x 3 days, first day [6-24] Discharge Medications: 1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Neomycin-Polymyxin-HC 3.5-10,000-1 mg-unit/mL-% Drops, Suspension Sig: Four (4) Drop Otic TID (3 times a day). 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Ditropan XL 10 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day. 10. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Neomycin-Polymyxin-HC 3.5-10,000-1 mg-unit/mL-% Drops, Suspension Sig: Four (4) Drop Otic TID (3 times a day). 12. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 13. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital ] [Hospital ] Nursing Home - [Location (un) ] Discharge Diagnosis: Primary: 1. Pneumonia 2. Urinary tract infection Secondary: 1. Diabetes Mellitus type 2 2. Otitis media 3. Cerebrovascular accidents in the past 4. Hypertension Discharge Condition: Afebrile and hemodynamically stable. Discharge Instructions: You were evaluated and treated in the hospital for pneumonia. You were in the ICU for respiratory failure and went to the hospital floor once your condition improved. Your lung functions has improved to your baseline and you have no signs of active pneumonia. You need to follow up with your primary care doctor for your left ear infection. Please take all your medications as written to you. Please keep all your follow up appointments. Please call your regular doctor or return to the emergency department for any difficulty breathing, fevers greater than 101.5, chest pain, or any other concern. Followup Instructions: Please call your regular doctor to arrange follow up in the next week. Please continue your follow up with your urologist as recommended by him/her in the past. Completed by:[2188-7-30]	[ "511.9", "486", "427.32", "518.81", "382.9", "V44.2", "V10.51", "584.9", "250.00", "V45.82", "785.52", "530.81", "V12.59", "995.92", "428.0", "401.9", "414.01", "599.0", "V10.46", "V10.82", "556.9", "496", "038.9" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.04" ]	icd9pcs	[ [ [] ] ]	10267, 10361	5877, 8684	253, 266	10567, 10606	2539, 5854	11258, 11451	2014, 2019		9106, 10244		10382, 10546		8710, 9083			10630, 11235											2034, 2520																								193, 215													294, 1464																1486, 1890	1906, 1998
10,518	140,994	55340	Discharge summary	addendum	Name: [Known lastname 1529], [Known firstname 785] Unit No: [Numeric Identifier 1530] Admission Date: [2189-10-22] Discharge Date: [2189-10-25] Date of Birth: [2131-12-14] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is 57 year-old male with a history of metastatic renal carcinoma diagnosed in [2187-11-8] with known mets to his bone and lung presumed liver metastases, end stage renal disease on hemodialysis secondary to hypertension, congestive heart failure with an ejection fraction of 20 to 25% based on echocardiogram on [11-7], peptic ulcer disease was initially admitted to the MICU on the [11-22] for seizures and decreased responsiveness prior to his hemodialysis sessions thought secondary to hypoglycemia. The patient had a head CT in the Emergency Department demonstrating a presumed metastasis in his right parietal lobe. He had been evaluated neurosurgical and not deemed a surgical candidate, but was loaded on Dilantin for seizure prophylaxis with possible radiation therapy to his brain. The patient had remained on D10 for hypoglycemia during his Intensive Care Unit stay. On [10-24] the patient had discussions with his family and the MICU team and decided that he would not be interested in radiation therapy for his metastatic brain lesion and furthermore was no longer interested in hemodialysis and rather requested that he switch to a DNR/DNI and complete hospice and CMO care only. PAST MEDICAL HISTORY: 1. Renal cell carcinoma diagnosed in [11-7] with lung mets. 2. End stage renal disease on hemodialysis secondary to hypertension. 3. Congestive heart failure. EF of 20 to 25%. 4. Hypertension. 5. Peptic ulcer disease. 6. Barrett's esophagitis status post Nissen fundoplication. 7. Hyperparathyroidism status post resection. 8. Pancreatitis status post cholecystectomy. 9. Newly diagnosed metastatic brain lesion, liver disease [8-9], unclear etiology, but presumed metastatic disease. ALLERGIES: No known drug allergies. MEDICATIONS ON TRANSFER: 1. Morphine prn. 2. Decadron 4 q 6. 3. Dilantin 100 t.i.d. 4. Quinine 325 t.i.d. 5. Lactulose. PHYSICAL EXAMINATION: He is afebrile. Blood pressure 141/69. Pulse 98. Respiratory rate 20. On examination he is cachectic male appearing older then stated age, groaning with abdominal pain. He is alert and oriented times three. He is tachycardic with a systolic ejection murmur. His pulmonary is difficult to assess given his groaning. His abdominal examination is distended and tender throughout. HOSPITAL COURSE: The patient was transferred from the Intensive Care Unit to the Medicine Floor Acove Service on [10-24] after being requested for hospice CMO type care. He was placed on morphine prn and was maintained on his Dilantin and Decadron. On the early morning of [10-25] the patient developed increasing amounts of pain and was then placed on a morphine drip. The patient's family and attending physician was notified. The patient was pronounced dead at 10:20 a.m. on [10-25]. The attending physician [First Name8 (NamePattern2) ] [Name9 (PRE) ] and family were notified. The patient's family did not wish to pursue an autopsy at this point. [Name6 (MD) 116] [Last Name (NamePattern4) 1531], M.D. [MD Number(1) 1532] Dictated By:[Last Name (NamePattern1) 1533] MEDQUIST36 D: [2189-10-25] 01:00 T: [2189-10-27] 11:20 JOB#: [Job Number 1534]	[ "197.0", "251.2", "189.0", "403.91", "414.00", "780.39", "198.5", "428.0", "198.3" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]														2624, 3551																										2221, 2606																								281, 1508															2097, 2198	1530, 2072
63,200	180,193	53750	Discharge summary	report	Admission Date: [2118-3-30] Discharge Date: [2118-4-4] Date of Birth: [2042-5-23] Sex: F Service: MEDICINE Allergies: Penicillins / Ace Inhibitors / Iodine / Naprosyn Attending:[First Name3 (LF) 1253] Chief Complaint: Gastrointestinal bleeding Major Surgical or Invasive Procedure: none History of Present Illness: 75 y/o F hx CAD with ischemic cardiomyopathy s/p ICD, HTN, DM, CVA now transferred to [Hospital1 18] for further work-up of GIB. She presented to OSH on [2-26] with black tarry stools since Sunday. She also had N and coffee ground emesis X 2 (~ 2 cups dark brown fluid). She reportedly denied abd pain at the time, but had been taking aspirin and aleve [Hospital1 ] for arthritis pain. She was also c/o weakness and fatigue. She denied any CP, palpitations, BRBPR, hemetemesis, fevers. . At OSH, initial HCT was 18 although she was hemodynamically stable with BPs in 100's. R fem line was placed in OSH ED. NG lavage revealed yellow clear fluid with speckles of blood clots. She received sandostatin 100 mcg/hr, FFP X 2, 1U plts, and 6U PRBCs. EGD at [Hospital1 ] revealed some small esophageal varices and evidence of portal HTN gastropathy. No ulcers were seen. Also, Pt was found to have troponins which peaked at 18, CKMB 9. Creatinine was 1.5. Abd U/S revealed trace ascites, and liver described as fatty infiltration. Hepatitis panels were negative. . Upon transfer, she reports feeling very tired but otherwise denies any pain. She had been at Foxwoods and did not wish to leave which is why she waited 2 days to go to hospital. She reports that 10 yrs ago she had one episode of dark emesis and was told she had a bowel obstruction. Otherwise, she had never had other GIB. She had been taking Aleve 500 mg [Hospital1 ] and aspirin X 2 weeks for shoulder pain. Past Medical History: # CAD s/p MI [2102] # CHF EF 2--25% # Ischemic Cardiomyopathy s/p ICD # HTN # DM type 2 # s/p CVA [2098] with left sided weakness # Hypothyroidism # Dyslipidemia # gout # osteoarthritis # mild PVD # ? Sjogrens Social History: Married and lives with husdand. Retired Xray tech Smoking: none EtOH: rare social Family History: Father: CVA Mother CAD Physical Exam: On transfer from ICU to medicine floor Vitals: T: 98.7 BP: 108/56 P: 96 bpm R: 20 SaO2: 100% 3L NC I/O - 24 hrs - 1/1.4 General: Awake, alert, NAD, pleasant, appropriate, cooperative, modeerately tachypnic HEENT: NCAT, PERRL, EOMI, no scleral icterus, MMM, no lesions noted in OP Neck: supple, no bruits, JVP at 16 cm although some obscured by tachypnea Pulmonary: CRACKLES bilaterally 1/2 up Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or organomegaly noted Extremities: No edema, 2+ radial, DP pulses b/l Lymphatics: No cervical, supraclavicular, axillary or inguinal lymphadenopathy noted Skin: no rashes or lesions noted. Neurologic: No asterexis. Alert, oriented x 3. Able to relate history without difficulty. Cranial nerves II-XII intact. Normal bulk, strength and tone throughout. Pertinent Results: ======== Labs ======== . Hep B surface antigen Nonreactive, Hep C negative, Hep A IgM neg at OSH . Urine [2118-4-2] 11:22AM URINE Hours-RANDOM UreaN-1090 Creat-125 Na-25 [2118-4-2] 11:22AM URINE Eos-NEGATIVE . Serum [2118-3-30] 08:09PM BLOOD WBC-9.0 RBC-4.07* Hgb-12.0 Hct-34.3* MCV-84 MCH-29.5 MCHC-35.1* RDW-16.8* Plt Ct-110* [2118-3-31] 03:00AM BLOOD WBC-9.4 RBC-4.03* Hgb-12.4 Hct-35.1* MCV-87 MCH-30.7 MCHC-35.3* RDW-17.8* Plt Ct-89* [2118-4-1] 03:04AM BLOOD WBC-10.5 RBC-4.02* Hgb-12.4 Hct-35.6* MCV-89 MCH-30.9 MCHC-34.9 RDW-18.2* Plt Ct-100* [2118-4-2] 06:30AM BLOOD WBC-8.4 RBC-4.05* Hgb-12.5 Hct-36.6 MCV-91 MCH-30.8 MCHC-34.0 RDW-17.8* Plt Ct-90* [2118-4-3] 07:15AM BLOOD WBC-7.3 RBC-4.13* Hgb-12.6 Hct-37.4 MCV-91 MCH-30.5 MCHC-33.6 RDW-17.7* Plt Ct-88* [2118-3-30] 08:09PM BLOOD Glucose-184* UreaN-82* Creat-1.6* Na-147* K-3.9 Cl-115* HCO3-21* AnGap-15 [2118-3-31] 03:00AM BLOOD Glucose-163* UreaN-72* Creat-1.4* Na-149* K-4.0 Cl-118* HCO3-21* AnGap-14 [2118-3-31] 04:55PM BLOOD Glucose-158* UreaN-55* Creat-1.3* Na-149* K-4.1 Cl-118* HCO3-23 AnGap-12 [2118-4-1] 03:04AM BLOOD Glucose-113* UreaN-42* Creat-1.2* Na-149* K-4.0 Cl-120* HCO3-20* AnGap-13 [2118-4-1] 06:00PM BLOOD Glucose-141* UreaN-40* Creat-1.4* Na-142 K-4.6 Cl-111* HCO3-22 AnGap-14 [2118-4-2] 06:30AM BLOOD Glucose-164* UreaN-40* Creat-1.4* Na-137 K-4.1 Cl-105 HCO3-21* AnGap-15 [2118-4-2] 06:30AM BLOOD ALT-12 AST-25 AlkPhos-47 TotBili-1.5 [2118-3-30] 08:09PM BLOOD CK-MB-16* MB Indx-6.7* cTropnT-1.45* [2118-3-31] 03:00AM BLOOD CK-MB-12* MB Indx-6.2* cTropnT-1.75* [2118-3-30] 08:09PM BLOOD calTIBC-339 Ferritn-74 TRF-261 [2118-3-31] 03:01PM BLOOD AMA-NEGATIVE [2118-3-30] 08:09PM BLOOD [Doctor First Name ]-NEGATIVE [2118-3-30] 08:09PM BLOOD IgG-920 IgA-186 [2118-3-31] 03:01PM BLOOD CERULOPLASMIN-PND . ========== Radiology ========== Abdominal ultrasound [2118-3-31] 1. Marked splenomegaly measuring at least 12.5 cm. 2. Cholelithiasis and sludge without evidence of cholecystitis. 3. No focal liver lesion. 4. Small bilateral pleural effusions and trace perihepatic ascites. The study and the report were reviewed by the staff radiologist. ========= Cardiology ========= ECG [2118-3-30]: Sinus rhythm. Right axis deviation. Right bundle-branch block. Borderline left atrial abnormality. Non-diagnostic repolarization abnormalities. No previous tracing available for comparison. Brief Hospital Course: ## Upper GI bleed requiring blood transfusions: The patient presented with weakness and melena to OSH. Although the pt's HCT was 18 on arrival to the OSH, she was hemodynamically stable, suggesting a slow bleed. At the OSH she received 6 units pRBC's, FFP, PPI, ocreotide and Cipro - Cipro for GIB in the setting of possible cirrhosis. An EGD demonstrated gastropathy and ? small varices. Likely source is from gastritis versus esophageal varices versus HTN gastropathy. Although she has been taking NSAIDS and ASA, OSH EGD did not note ulcerations. As she had no hx of cirrhosis, she was transfered to the ICU here for furhter w/u. However, gastritis is also a possibility given recent NSAID use. On admission, here ASA and carvedilol were originally held. She was maintained on octreotide gtt for 36 hrs, changed to protonix IV BID after a day and was on Cipro for five days. Her HCT on arrival to [Hospital1 18] was 35 and remained around 35 during her stay. As she remained stable she was slowly restarted on carvedilol and lasix. She remained HD stable and required no blood transfusions in-house. Patient plans to have repeat EGD as outpatient, and if persistent varices may require initiation of nadolol. She was transitioned to an oral PPI prior to discharge. . ## New diagnosis of liver disease: Pt has no known history of liver disease, although OSH U/S reported fatty liver. Interestingly, U/S at [Hospital1 18] did not reveal fatty liver and LFTs have normalized. Transaminitis in the setting of UGIB and shock liver could potentially have caused transient rise in LFTs. Hep panel neg and no hx of EtOH abuse. Autoimmune work up negative. Ceruloplasmin PENDING at this time. Iron/TIBC 254/339 = 75% might be consistent with hemochromatosis but may be inaccurate in the setting of multiple units PRBC. Patient likely has some underlying compoenent of NASH, however her gastropathy, varices, and splenomegaly are more likely secondary to her her cardiac dysfunction and poor EF. Patient scheduled to follow up with Hepatology as an outpatient. She will need a repeat endoscopy. . ## Thrombocytopenia: Platelets 89 to 110 in house. Marked splenomegaly on ultrasound in setting of liver disease could be responsible for low platelet count. Cipro can cause low platelets, but this has not worsened since she has been on quinolone. . ## NSTEMI: Likely demand ischemia insetting of low HCT. CK trending down. Did have episode of asx NSVT in ICU, but patient was off betablocker. No significant events on tele on medicine floor. Patient was maintained on her home dose of Coreg once HD stable. She should restart daily ASA given this recent event, but at an 81mg daily rather than 325 mg daily dose. Patient also started on simvastatin 80mg daily and crestor discontinued. Gastroenterology agreed with this decision. Patient should follow up with her cardiologist as an outpatient and determine whether an outpatient stress test needed . ## Acute renal failure: No baseline Cr, but no hx of kidney disease. Fe urea of 150 consistent with intrisnic and possibly pre-renal process. Patient with slight anion gap metabolic acidosis. Most likely acidosis due to renal dysfunction. Patient likely has prerenal azotemia that has been exacerbated by Lasix administration. Hypernatremia has autocorrected with po intake. Restarted on home dose of lasix prior to discharge. Home [Last Name (un) ] and aldactone continue to be held at time of discharge. Patient should have electrolytes and kidney function rechecked within 1 week of discharge and PCP and cardiologist and determine when to restart [Last Name (un) ] and aldactone. . ## CHF: Ischemic cardiomyopathy. EF 25% s/p ICD. Patient initially hypervolemic in the setting of PRBC resuscitation, given hypoxemia, elevated JVP, and crackles, Patient markedly improved with lasix. Prior to discharge she was transitioned from 3 L of oxygen to saturating in the high 90s or room air. . ## DM2: Holding metformin in house. Plan to restart at discharge. Maintained on ISS while in house and blood sugars remained stable. . ## Gout: Allopurinol at home dose. . ## Access: PIV x2 Patient was a FULL code on this admission. Medications on Admission: ASA 325 Coreg 25 [Hospital1 ] Avapro 75 daily Lasix 20 daily Spironolactone 25 daily Allopurinol 300 daily Metformin 1000 mg [Hospital1 ] Glucosamine [Hospital1 ] Calcium MVI Crestor 10 daily Levoxyl 75 mcg every other day Naproxen 500 mg [Hospital1 ] Oxybutynin 2.5 mg [Hospital1 ] . Discharge Medications: 1. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:0 7. Multivitamin Capsule Sig: One (1) Capsule PO once a day. 8. Oxybutynin Chloride 5 mg Tablet Sig: 0.5 Tablet PO twice a day. 9. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 10. Glucosamine Oral 11. Calcium Oral 12. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 13. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) Discharge Disposition: Home Discharge Diagnosis: Primary: -Upper gastrointestinal bleeding -Non ST elevation MI -Acute renal failure Secondary: -Congestive heart failure -Ischemic Cardiomyopathy -Hypertension -Diabetes mellitus type II Discharge Condition: stable Discharge Instructions: You were here with a gastrointestinal bleeding. You were treated with blood transfusions. Your bleeding is most likely secondary to ibuprofen. It is important that you REFRAIN from taking ibuprofen or any NSAIDS (this includes alleve, naprosyn, etc). You were found to have varices (enlarged veins) on your prior endoscopy which maybe related to your heart failure. Please follow up with a GI doctor [First Name (Titles) 3] [Last Name (Titles) 8757]. In addition you were also found to have a small heart attack. You should follow up with your cardiologist. We have started you on a medication called protonix for bleeding in your stomach. We have also started you on a medication called simvastatin for your heart attack. We have stopped your crestor, since you will now be taking simvastatin. We have also stopped your aldactone and avapro for now. We suggest that you discuss restarting the aldactone and avapro with your PCP or cardiologist. You should take Aspirin 81 mg daily rather than 325mg daily given your recent bleeding. Please return to the ED if you have any of the following symptoms: Black stool, lightheadedness, loss of consciousness, shortness of breath, chest pain or any other serious concerns. Followup Instructions: It is important that you have another upper endoscopy as an outpatient. You are scheduled to see Dr. [First Name8 (NamePattern2) 1158] [Last Name (NamePattern1) ] office on [2118-5-4] at 11:00 am. Hi office phone number is ([Telephone/Fax (1) 16940] and is located at [Hospital1 18] [Hospital Ward Name 517], [Last Name (NamePattern1) ], [Hospital Unit Name 3269] [Location (un) ]. . Please call your PCP [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) ] [Telephone/Fax (1) 8572] to follow up with him in the next 2 weeks. . You need to make an appointment to follow up with your cardiologist within the next 1-2 weeks. This is very important given your recent heart attack. Completed by:[2118-4-4]	[ "425.4", "V45.02", "789.2", "428.22", "412", "729.89", "715.90", "535.41", "584.9", "276.0", "287.5", "410.71", "537.89", "456.21", "572.3", "244.9", "276.2", "272.4", "401.9", "438.89", "414.01", "428.0", "790.4", "443.9", "E935.9" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	11136, 11142	5630, 9816	334, 341	11373, 11382	3140, 5607	12666, 13464	2214, 2238		10171, 11113		11163, 11352		9842, 10148			11406, 12643											2253, 3121																								269, 296													369, 1858																1880, 2099	2115, 2198
52,076	109,131	1668	Discharge summary	report	Admission Date: [2112-6-26] Discharge Date: [2112-7-1] Date of Birth: [2043-4-18] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: Exertional dyspnea Major Surgical or Invasive Procedure: [2112-6-27] Aortic valve replacement (23mm St. [Male First Name (un) 923] Regent mechanical valve) History of Present Illness: 69 year old gentleman with a complex past medical history who has known coronary artery disease status post angioplasty and aortic stenosis followed by serial echocardiogram. He has recently noticed increased dyspnea on exertion. Echo earlier this year showed severe aortic stenosis with [Location (un) 109] 0.76cm2. He was referred for a cardiac catheterization which revealed no significant coronary disease and mild aortic stenosis. He presents now to see if his dyspnea is related to his aortic valve disease and if he should proceed with surgery. Of note, pulmonary function testing and a chest CT scan were not suggestive of any disease process which may be responsible for his exertional dyspnea. Past Medical History: Aortic stenosis Hypertension Dyslipidemia Diabetes type 2 Paroxysmal atrial fibrillation - Cardioversion x2 B cell lymphoma, chemo and xrt Prostate CA Herpes Zoster Lung CA Bursitis Urinary incontinence s/p artificial sphincter Spinal stenosis S/P right lower lobectomy [3-/2107] S/P fatty tumor removal from his back Prostate cancer, s/p resection and radiation; remission S/P resected bronchial carcinoid S/P left knee arthroscopy S/P Bilateral rotator cuff repair x 2 Social History: Race: Caucasian Last Dental Exam: Yesterday Lives with: Wife Contact: [Name (NI) ] Phone # [Telephone/Fax (1) 9640] Occupation: Semi-retired, Real estate Cigarettes: Smoked no [] yes [X] last cigarette [2089] Hx: Other Tobacco use: Denies ETOH: < 1 drink/week [X] [1-26] drinks/week [] >8 drinks/week [] Illicit drug use: Denies Family History: No Premature coronary artery disease-father died suddenly of an MI at age 83 Physical Exam: Pulse: 71 Resp: 16 O2 sat: 100% B/P Right: 125/74 Left: 125/75 Height: 5'[09] Weight: 220 General: Well-developed male in no acute distress Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur [X] grade [1-25] Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema/Varicosities: None Neuro: Grossly intact [X] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [Name (NI) 167]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: - Left: - Pertinent Results: [2112-6-27] 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. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50-55%). The remaining left ventricular segments contract normally. 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 severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results on this patient before surgical incision. POST-BYPASS: Intact thoracic aorta. Normal RV systolic function. LVEF 50%. No oovious wall motion abnormalities withl imited Midesophageal suboptimal views. The aortic valve is stable in position, both leaflets open and the residual mean gradient is 8 mm of Hg. Brief Hospital Course: Mr. [Known lastname 410] was admitted the day before surgery for pre-operative work-up and to be started on Heparin for history of atrial fibrillation. On the following day he was brought to the operating room where he underwent an aortic valve replacement. Please see operative note for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Later this day he was weaned from sedation, awoke neurologically intact and extubated. He was started on betablockers, statin therapy, ASA and ace-inhibitor and diuresed toward his pre-operative weight. He was transferred tot he stepdown unit for ongoing post-operative care. His chest tubes and temporary pacing wires were removed per protocol. His couamdin therapy was resumed for atrial fibrillation. On POD#5 he was cleared for discharge to home and all appointments and instructions were advised. Medications on Admission: Atenolol 100mg [Hospital1 ] Amlodipine 10mg daily Folic acid 2mg daily Lasix 20mg daily Novolog 11 units with breakfast, 20 units with dinner Levemir 55 units at bedtime Lisinopril 20mg daiy Simvastatin 40mg daily Coumadin 2.5mg alternating with 5mg Aspirin 325mg daily Vitamin D3 daily Discharge Medications: 1. Aspirin EC 81 mg PO DAILY RX Adult Low Dose Aspirin 81 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:1 2. Simvastatin 40 mg PO DAILY 3. Warfarin 2.5 mg PO DAILY16 3 day cycles: 2.5mg, x 2 days, then 5mg x 1 day, then repeat RX warfarin 2.5 mg [12-21] tablet(s) by mouth once a day Disp #60 Tablet Refills:1 4. Acetaminophen 650 mg PO Q4H:PRN pain/fever 5. NovoLOG NF (insulin aspart) 100 unit/mL Subcutaneous tid 11 units with breakfast 11 units with lunch 17 units with dinner 6. Multivitamins 1 TAB PO DAILY 7. Levemir NF (insulin detemir) 100 unit/mL Subcutaneous hs 55 units hs 8. Metoprolol Tartrate 75 mg PO TID Hold for HR < 55 or SBP < 90 and call medical provider. [Last Name (NamePattern4) 9641] metoprolol tartrate 25 mg 3 tablet(s) by mouth every eight (8) hours Disp #90 Tablet Refills:1 9. Oxycodone-Acetaminophen (5mg-325mg) [12-21] TAB PO Q4H:PRN pain RX oxycodone-acetaminophen 5 mg-325 mg [12-21] tablet(s) by mouth every four (4) hours Disp #65 Tablet Refills:0 10. Milk of Magnesia 30 ml PO HS:PRN constipation 11. FoLIC Acid 2 mg PO DAILY 12. Vitamin D 400 UNIT PO DAILY 13. Lisinopril 5 mg PO DAILY RX lisinopril 5 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:1 14. Furosemide 20 mg PO BID Duration: 7 Days then decrease to 20mg daily ongoing RX furosemide 20 mg 1 tablet(s) by mouth twice a day Disp #37 Tablet Refills:1 15. Potassium Chloride 20 mEq PO Q12H Duration: 7 Doses then decrease to once daily RX K-Tab 10 mEq 2 (Two) tablets by mouth twice a day Disp #42 Tablet Refills:1 Discharge Disposition: Home With Service Facility: [Location (un) 701] VNA Discharge Diagnosis: Aortic stenosis s/p Aortic valve replacement Past medical history: Hypertension Dyslipidemia Diabetes type 2 Paroxysmal atrial fibrillation - Cardioversion x2 B cell lymphoma, chemo and xrt Prostate CA Herpes Zoster Lung CA Bursitis Urinary incontinence s/p artificial sphincter Spinal stenosis S/P right lower lobectomy [3-/2107] S/P fatty tumor removal from his back Prostate cancer, s/p resection and radiation; remission S/P resected bronchial carcinoid S/P left knee arthroscopy S/P Bilateral rotator cuff repair x 2 Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Edema: 1+ lower extremity edema (left > right-chronically) Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours* Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) ] [Telephone/Fax (1) 170] on [2112-7-27] at 1:15pm in the [Hospital ] medical office building, [Doctor First Name ], [Hospital Unit Name ] wound check with cardiac surgery [Telephone/Fax (1) 170] on [2112-7-7] 10am in the [Hospital ] medical office building, [Doctor First Name ], [Hospital Unit Name ] Cardiologist: Dr. [Last Name (STitle) 7047] [Telephone/Fax (1) 8725] on [2112-7-19] at 8:45am Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) 3314] [Telephone/Fax (1) 3183] in [3-24] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR for Coumadin ?????? indication Mechican Aortic valve replacement Goal INR 2.5-3.0 First draw [2112-7-2] Results to Dr. [Last Name (STitle) 7047] phone [Telephone/Fax (1) 8725]; fax [Telephone/Fax (1) 8719] Completed by:[2112-7-7]	[ "272.4", "V45.82", "202.80", "V58.67", "401.9", "458.29", "V10.11", "416.8", "427.31", "185", "250.00", "424.1" ]	icd9cm	[ [ [] ] ]	[ "39.61", "35.22" ]	icd9pcs	[ [ [] ] ]	7090, 7148	4238, 5146	328, 436	7717, 7941	2853, 4215	8864, 9974	2060, 2138		5487, 7067		7169, 7214		5172, 5464			7965, 8841											2153, 2834																								270, 290													464, 1173																7236, 7696	1687, 2044
3,179	109,944	4550	Discharge summary	report	Admission Date: [2111-1-5] Discharge Date: [2111-1-10] Date of Birth: [2030-4-7] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 106] Chief Complaint: Weakness, shoulder/neck pain Major Surgical or Invasive Procedure: [2111-1-5]: right heart cath, pericardial tap, arterial puncture History of Present Illness: 80 yo M with HTN, who presents with weakness and shoulder/neck pain. Of note, he was recently observed in the [Hospital1 18] ED on [12-16] with similar complaints and had a MIBI that showed no reversible defect. He reports 4 weeks of gradually worsening weakness, waxing and [Doctor Last Name 688], without any sensory neurologic symptoms. On the day prior to presentation, he felt that he was unable to move at all prompting him to come to ED. He does also report neck/throat tightness with radiation to the shoulders for the last 5 days. It waxes and wanes, lasting 30-60 minutes, it's pleuritic without an exertional component. Patient does report SOB, palpitations, a "trembling chest", and five days' of a dry cough. . In ED: patient received ASA 325 on [12-4], Lasix 20 mg IV and 1 x SLNTG. EKG nsr @ 87, nl axis, IVCD, TWI in III, aVF; q in III - old; no new ST changes, no new Q waves. CE's flat x 2. A V/Q scan was low likelihood for pulmonary embolism. . On the floor, he developed progressively worsening dyspnea and hypoxia. He was noted to have a pulsus of 22 and a bedside echo showed RV collapse; he was taken urgently for pericardial drainage with removal of 400cc of serosanguinous fluid and drain placement. . ROS: No dysuria/hematuria, no abdominal pain, no back pain, no n/v/d, no diaphoresis. Does report transient lightheadedness this AM, with a headache that resolved. Patient denies any urinary retention or fecal incontence. He does report hematochezia x1 approx 2 wks ago after straining for a hard BM; denies known hx of hemorrhoids. Past Medical History: ?previous silent MI Incomplete LBBB Neuropathy with footdrop Hypertension Diverticulosis Esophageal ring Gout Social History: No smoking, occasional alcohol, no drug use. Family History: Non-contributory Physical Exam: T 100.4 BP 161/60 HR 83 RR 24 Sat 98% on NRBM GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions NECK: no supraclavicular or cervical lymphadenopathy, no carotid bruits, JVP approx 10cm RESP: CTA b/l; no w/r/r CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: trace [Name (NI) ] PT/DP pulses b/l; no c/c/e SKIN: no rashes/no jaundice NEURO: AAOx3. Cn II-XII intact. RECTAL: guaiac negative in ED Pertinent Results: V/Q scan ([1-5]): Low likelihood ratio for recent pulmonary embolism. . MRA Chest ([1-5]): No evidence of aortic dissection. Questionable area of wall thickening in the ascending aorta at the level of the main pulmonary artery. Although the finding is potentially artifactual, further assessment with a dedicated non-contrast chest CT is recommended to exclude an intramural hematoma. No evidence of aneurysm. Moderate pericardial effusion. Small bilateral pleural effusions with associated bilateral lower lobe atelectasis. . ECG ([2111-1-5]): ECG: nsr @ 87, nl axis, IVCD, TWI in III, aVF; q in III - old; no new ST changes, no new Q waves . Bedside TTE ([2111-1-5]): There is a moderate sized pericardial effusion. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. Left ventricular systolic function is grossly preserved. . Cardiac cath ([2111-1-5]): Resting hemodynamics were performed. The femoral arterial pressures had a pulsus of 41mmHg at the beginning of the procedure. The right sided filling pressures were significantly elevated (mean RA pressures were 25mmHg). The PCWP pressures were elevated at 25-30mmHg. The pericardial pressures were elevated at 20mm Hg. Successful pericardiocentesis was performed with appx 300cc of serosanguinous fluid removed. Drain left in place. Post pericardiocentesis, there was resolution of respiratory variation of the femoral arterial tracing. The right sided filling pressures were mildly elevated (mean RA pressures was 12mmHg). The left sided filling pressures have improved (mean PCW pressures were 21mmHg). The cardiac index improved to 3.2 l/min/m2. The pericardial pressures were appx 0mmHg. . Pericardial fluid cytology ([2111-1-5]): negative for malignant cells . CT Chest ([2111-1-6]): Tracheomalacia with narrowing of the main stem bronchi. Pericardial effusion. Bilateral pleural effusions. Increased pulmonary parenchymal density most likely representing mild edema. Compressive atelectasis. Hepatic cyst. . TTE ([2111-1-8]): The estimated right atrial pressure is 5-10 mmHg. There is symmetric left ventricular hypertrophy. The left ventricular cavity is small. Left ventricular systolic function is hyperdynamic (EF>75%). The right ventricular cavity is dilated. Right ventricular systolic function appears depressed. There is a small pericardial effusion subtending the lateral wall of the left ventricle. There are no echocardiographic signs of tamponade. . [2111-1-4] 09:15PM WBC-10.3 RBC-2.88* HGB-9.5* HCT-27.3* MCV-95 MCH-32.9* MCHC-34.7 RDW-14.7 [2111-1-4] 09:15PM GLUCOSE-172* UREA N-65* CREAT-3.1# SODIUM-136 POTASSIUM-5.2 CHLORIDE-103 TOTAL CO2-18* ANION GAP-20 [2111-1-4] 09:15PM CK-MB-NotDone proBNP-778 [2111-1-4] 09:15PM cTropnT-0.04* Brief Hospital Course: Shortly after admission to the floor for hypoxia, Mr. [Known lastname ] MRI from the ED was noted to show a moderate-sized pericardial effusion. Although his ECG did not show electrical alternans or low voltages, a pulsus was checked and found to be elevated at 22 mm Hg. An urgent cardiology consultation was obtained and a bedside TTE showed RV collapse and tamponade physiology. He was taken directly to cardiac catheterization where 400cc of serosanguinous fluid was removed and a pericardial drain was placed; he was sent to the CCU for further care. All studies (including Gram stain, culture, and cytology) returned as negative. He experienced relief of his dyspnea with the removal of this fluid but remained hypoxemic requiring 100% NRB facemask. . On hospital day 2, his percardial drain showed no fluid output and a followup TTE showed no evidence of reaccumulation so his drain was pulled. A chest CT showed no evidence of malignancy or any other pathology that could potentially explain his tamponade. . Due to a fever spike and concern for an infiltrate on his CXR, he was started on a 7-day course of empiric levofloxacin and metronidazole for suspected pneumonia. He was aggressively diuresed with a gradual decrease in his oxygen requirements over the course of his hospital stay. A V/Q scan in the ED was low probability for PE and LENIs were negative for DVT. A pulmonary consultation was obtained and agreed that his pneumonia and fluid overload were the most likely cause of his hypoxemia. By discharge, he was saturating 92-94% on room air. . Of note, on admission, he was found to be in acute-on-chronic renal failure, though to be secondary to renal hypoperfusion from his tamponade. His meds were renally-dosed, his [Last Name (un) ] was held, and his creatinine gradually improved with diuresis and improvement of his cardiac functioning. . He was also noted to have an acute-on-chronic anemia, though no source of acute bleeding could be identified. Iron studies were consistent with an anemia of chronic inflammation, although his very low serum iron also suggested some component of iron deficiency. He was started on iron repletion and further causes of anemia should be worked up as an outpatient. Medications on Admission: Omeprazole 20mg Proscar 5mg daily Felodipine 10mg daily Allopurinol 300mg daily Folic Acid 1mg daily Gabapentin 1200mg qhs at 7pm; 400mg prn for restless legs Mirapex 2.25mg qhs at 7pm Gemfibrozil 600mg twice daily Losartan 25mg daily Terazosin 10mg daily ASA 325mg daily Vit C 1000mg MVI Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Felodipine 5 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily). 4. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day. 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime) as needed for leg/foot pain. 7. Pramipexole 1 mg Tablet Sig: One (1) Tablet PO hs (). 8. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Terazosin 5 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. Disp:3 Tablet(s) Refills:0 13. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 days. Disp:9 Tablet(s) Refills:0 14. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 15. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. Disp:30 Tablet(s) Refills:0 16. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q8H (every 8 hours) as needed for SOB/wheezing. Disp:1 inhaler Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: pericardial effusion with tamponade . Secondary diagnosis: Hypoxia Acute on chronic renal failure Hypertension Coronary artery disease Neuropathy Gout Discharge Condition: Good, ambulatory, respiratory status stable off oxygen Discharge Instructions: Please take all medications as directed. You will be taking two antibiotics (levofloxacin and flagyl to complete a 7 day course). Your gabapentin dose has been decreased to 600mg by mouth at night. You should not take losartan due to your kidney function until your primary doctor or cardiologist tell you to restart it. . If you develop shortness of breath, chest pain, dizziness, fever, or any other symptom that concerns you, call your doctor or go to the emergency room. . Go to all of your follow up appointments. Followup Instructions: You have the following follow up appointments: Provider: [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. Phone:[Telephone/Fax (1) 250] Date/Time:[2111-1-16] 11:40 Call Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] to make an appointment for [1-22]. Phone:([Telephone/Fax (1) 5909]. Tell the office that Dr. [Last Name (STitle) ] said it was okay to double book. You will also need to call to make an appointment for an Echocardiogram prior to your visit with Dr. [Last Name (STitle) ]. The phone number is ([Telephone/Fax (1) 19380]. You will need a follow up chest CT in 2 months to evaluate lung parenchyma. CAT SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2111-3-10] 10:00. This is located in [Hospital Ward Name 23] [Location (un) ]. Do not eat or drink for 3 hours prior to this exam. You will need to have your doctor follow up on your cytology and pericardial cultures.	[ "428.0", "333.94", "584.9", "280.9", "403.90", "420.90", "355.8", "736.79", "274.9", "486", "426.3", "585.9", "799.02" ]	icd9cm	[ [ [] ] ]	[ "37.0", "88.55", "37.21" ]	icd9pcs	[ [ [] ] ]	9681, 9687	5634, 7885	341, 412	9901, 9958	2773, 5611	10527, 10550	2236, 2254		8224, 9658		9708, 9708		7911, 8201			9982, 10504											2269, 2754																								273, 303						10574, 11541							440, 2023			9786, 9880				9727, 9765									2045, 2157	2173, 2220
32,128	191,194	32612	Discharge summary	report	Admission Date: [2108-4-6] Discharge Date: [2108-4-16] Date of Birth: [2032-5-24] Sex: F Service: PLASTIC Allergies: Morphine Attending:[First Name3 (LF) 5667] Chief Complaint: SCC of the left eyebrow Major Surgical or Invasive Procedure: Left orbital exenteration and reconstruction with: 1. Radial forearm free flap to the left orbital region. 2. Fat grafting to the orbit. 3. Split-thickness skin graft measuring 2 inches x 9 cm to the right forearm. History of Present Illness: This patient has a history of squamous cell carcinoma in the region of the left brow and had previously been resected. She had perineural involvement. The patient subsequently underwent radiation treatment. The patient developed a new nodule in the region of the left brow. Biopsy confirmed squamous cell carcinoma and deeper biopsies showed extensive involvement of perineural spread along the nerve back into the orbit. In an effort to provide this patient with cure of this condition, a left orbital exenteration was recommended. The patient underwent a full ophthalmic evaluation and the right eye was noted to be normal. She was also seen by Dr. [First Name (STitle) ] for evaluation of reconstructive potential. She will be planning to undergo left orbital extenteration and reconstruction with a radial forearm flap Past Medical History: PMH: HTN, DM 2, Hyperlipidemia, hx of hypothyroidism, hx pancreatitis, reflux PSH: L hip replacement, partial colectomy (after perf from colonoscopy), several facial surgeries for SCC Physical Exam: At discharge: AVSS NAD HEENT: free flap over extenterated left orbit. Flap well perfused, good cap refill, warm. Some occassional serosanguinous drainage from previous penrose site at medial inferior suture line. RRR CTA b/l Right forearm: STSG intact, no hematoma, taking well. Dressed with xeroform and kerlex Right thigh: STSG donor site. Xeroform open to air, healing well, minimal drainage. Pertinent Results: Video swallow [4-13]: no evidence of aspiration Brief Hospital Course: Patient went to the OR on [2108-4-6] and underwent left orbital extenteration and reconstruction using a radial forearm flap and STSG from thigh to forearm. Post-op she went to the PACU initially, she was then transferred to the ICU secondary to some hypotension and EKG changes post-op. CARDIO: her blood pressure was managed with lopressor, initally IV and then PO. Immediately post-op she had some hypotension with some T wave changes. This resolved after repletion of electrolytes and some fluid resuscitation. Her enzymes were not elevated. Pulm: She remained intubated for several days secondary to a combination of airway edema and volume overload. She was given some steroids, and placed on a lasix drip. She was tolerating minimal vent support, but did not have a cuff leak. Once a few liters were taken off, she had a cuff leak, and was then extubated. Post-extubation she did well with no other problems. GI: Nutrition was started through her OG tube with standard tube feeds, these were advanced to goal. After extubation she was fed through a Dobhoff tube. A video swallow was done which showed that she had no aspiration, but did have some difficulty with solid foods. S & S recommended thin liquids and ground solids. Calorie counts were intiated. Her Dobhoff was removed prior to discharge and she was tolerating oral intake well. Heme: Her Hct did trend down in the post-op period in the ICU and she did receive 2 units of PRBC with an appropriate bump in her Hct. She was maintained on aspirin and SQH for DVT prophylaxis and flap patency. ID: she was continued on perioperative antibiotics until her drains were removed, they were then discontinued. WOUNDS: The wound vac on the right forearm was taken down after 5 days, the STSG looked healthy and was maintained with daily xeroform and kerlex dressing changes. Her donor site was maintained with a xeroform open to air that was not removed. Her JP drains were removed once they put out less than 30cc/day. Her free flap was monitored hourly in the ICU for doppler signals, perfusion, warmth etc. This was changed to Q2 checks, and then Q4 checks on the floor. The flap did well. Once the flap shrunk down some, and drainage from penrose decreased, then penrose drains were removed. PT: PT and OT were asked to evaluate the patient and make their recommendations. She would need rehab post-discharge Medications on Admission: lopressor, metformin, ASA, spironolactone, zetia, niaspan Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 3. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 4. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. 11. Insulin Regular Human 100 unit/mL Solution Sig: asdir Injection ASDIR (AS DIRECTED): see discharge instructions for sliding scale. 12. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: St. [Hospital 11042] Hospital Rehabilitation Discharge Diagnosis: aggressive and recurrent squamous cell carcinoma of the left brow with perineural involvement Discharge Condition: stable tolerating a oral diet Discharge Instructions: DIET: regular diet. Should encourage POs, supplement with BOOST shakes TID. Per speech and swallow her modifications should be: thin liquids and pureed solids until reevaluated by them and assessed safe for pure solid foods. . ACTIVITY: She is full weight bearing on both legs, should be encouraged to walk as much as possible with assistance and needs aggressive physical therapy to get back to her baseline. . MEDS: continue all your home meds. Should also continue pain medications as needed. Continue with daily aspirin to prevent flap thrombosis. . DRESSINGS: Right Arm->xeroform, 4 x 4, and kerlix and then place in resting splint. Change dressing daily. Right thigh->xeroform in place, open to air, do not change. If falls off then replace with xeroform. Flap over left orbit-> no dressing needed, may occassionaly drain serosanguinous fluid from old penrose site. [Month (only) 116] lightly tape a dry dressing just under flap to catch drainage if bothersome. . Perineal rash: Recommendations: Pressure relief per pressure ulcer guidelines Support surface: On Atmos Air, suggest First Step Select MRS [Last Name (STitle) ] low air loss and moisture control. Turn and reposition every 1-2 hours and prn side to side . PLEASE call if the patiet's flap begins to look more purple or more pale, becomes colder, has decreasing cap refill, increasing drainage. INSULIN SLIDING SCALE: Q6H Regular Glucose Insulin Dose 0-60 mg/dL [11-30] amp D50 61-120 mg/dL 0 Units 121-140 mg/dL 2 Units 141-160 mg/dL 4 Units 161-180 mg/dL 6 Units 181-200 mg/dL 8 Units 201-220 mg/dL 10 Units 221-240 mg/dL 12 Units 241-260 mg/dL 14 Units 261-280 mg/dL 16 Units 281-300 mg/dL 18 Units 301-320 mg/dL 20 Units > 320 mg/dL Notify M.D. Followup Instructions: please call to schedule an appt with Dr. [First Name (STitle) 7363] and Dr. [First Name (STitle) ] in the next 1-2 weeks.	[ "V43.64", "794.31", "173.3", "276.6", "244.9", "458.29", "272.4", "198.4", "250.00", "478.6", "401.9" ]	icd9cm	[ [ [] ] ]	[ "86.69", "96.72", "16.51", "99.04", "96.6", "86.63", "02.06" ]	icd9pcs	[ [ [] ] ]	5679, 5754	2092, 4495	291, 513	5892, 5924	2016, 2069	7866, 7999			4604, 5656		5775, 5871		4522, 4581			5948, 7843											1593, 1593																1607, 1997								228, 253													541, 1370																1392, 1578
15,740	135,087	18029	Discharge summary	report	Admission Date: [2102-3-13] Discharge Date: [2102-3-31] Date of Birth: [2024-2-25] Sex: F Service: ADMISSION DIAGNOSIS: Acute abdomen. DISCHARGE DIAGNOSES: 1. Superior mesenteric artery thrombosis. 2. Ischemic small bowel. 3. Status post superior mesenteric artery thrombectomy with vein patch angioplasty. 4. Status post small-bowel resection. HISTORY OF PRESENT ILLNESS: The patient is a 79-year-old woman transferred from [Hospital 1474] Hospital with abdominal pain beginning a few days ago. The abdominal pain progressed to bloody diarrhea. Of note, the patient had chronic atrial fibrillation secondary to bloody diarrhea and had stopped her Coumadin on [2102-3-10]. A computed tomography scan at [Hospital 1474] Hospital suggested the diagnosis of a superior mesenteric artery embolus, and the patient also arrived with a white blood cell count of 44,000; but no fever or acidosis. The patient was transferred to the General Surgery Service and Vascular Surgery Service for operative intervention. PAST MEDICAL HISTORY: 1. Chronic atrial fibrillation. 2. Hypertension. 3. Hypothyroidism. MEDICATIONS ON ADMISSION: (Home medications included) 1. Coumadin (last dose on [2102-3-10]). 2. Levoxyl. 3. Potassium. 4. Lasix. 5. Premarin. ALLERGIES: Allergy to CODEINE. PHYSICAL EXAMINATION ON PRESENTATION: Gentleman physical examination on admission revealed the patient was an elderly woman who was alert and with slurred speech. Vital signs revealed temperature was 97.9, heart rate was 130 (in atrial fibrillation), blood pressure was 127/69, and oxygen saturation was 94% on room air. Head, eyes, ears, nose, and throat examination revealed extraocular movements were intact. Pupils were equal, round, and reactive to light. Sclerae were anicteric. The throat was clear. Edentulous. The neck was supple with no masses or lymphadenopathy. Chest was clear to auscultation bilaterally. Cardiovascular examination revealed irregularly irregular with no murmurs, rubs, or gallops. The abdomen was significant for positive bowel sounds. There is significant tenderness diffusely through the abdomen with no guarding. Rectal examination was significant for guaiac-positive stool. Extremities were warm, with no cyanosis, and no edema times four. Neurologic examination was grossly intact; although it was difficult to assess with slurred speech. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on admission with a complete blood count which revealed 44, hematocrit was 42, and platelets were 397. Sodium was 136, potassium was 3.6, chloride was 93, bicarbonate was 25, blood urea nitrogen was 16, creatinine was 0.9, and blood glucose was 88. Arterial blood gas revealed pH was 7.47, PCO2 was 35, PO2 was 75, bicarbonate was 26. PERTINENT RADIOLOGY/IMAGING: Abdominal computed tomography was significant for the suggestion of an occluded superior mesenteric artery, also a dilated small bowel, and no free fluid. HOSPITAL COURSE: The patient was transferred for emergent management of probable superior mesenteric artery thrombosis or occlusion. The patient was taken to the operating room by the General Surgery Service and Vascular Surgery Service. In the operating room, the patient had superior mesenteric artery thrombectomy with a vein patch angioplasty and significant small-bowel resection. Please see the previously dictated Operative Reports for further details. In the postoperative period, the patient was managed in the Intensive Care Unit. She was initially kept intubated and sedated and was given total parenteral nutrition for parenteral nutrition. She was closely monitored, and as she began to mobilize her fluids she was then actively diuresed and subsequently extubated without event. The patient remained on a heparin drip for appropriate anticoagulation. This was done in consultation with the Neurology Service. She was also maintained on ampicillin, ceftriaxone, Flagyl for broad spectrum antibiotic coverage. Her atrial fibrillation was controlled using a combination of metoprolol and diltiazem. The patient was noted to have some vaginal prolapse which was quite severe and eventually became nonreducible. The Gynecology Service was consulted and recommended simple followup as an outpatient. As the patient's clinical status improved and bowel function returned, her diet was advanced as tolerated. She was felt to be an aspiration risk, and a bedside swallowing study revealed no acute risk of aspiration; although, did not have in her false teeth at that time. Eventually, the patient was transferred to the floor where she continued to do well. She did have multiple bowel movements per day and was Clostridium difficile negative times four. Ultimately, the patient was discharged on postoperative day 16. The patient was tolerating a regular diet with adequate pain control on oral pain medications. The patient was ambulating with assistance. The rest of this dictation will by issue/system: 1. NEUROLOGIC ISSUES: The patient came in with baseline slurred speech, and there was some concern for a cerebrovascular accident given her embolic event. The Neurology Service was consulted on postoperative day one, and a head computed tomography scan was obtained. The head computed tomography was consistent with a small subacute infarction in the right temporal lobe, left thalamus, and left insular cortex. No hemorrhage, or mass effect, and no shift. Neurology assessment stated the patient was back to baseline; although, she did continue to have slurred speech throughout her hospital stay. The Neurology consultation was obtained prior to surgery. Postoperatively, the patient was maintained sedated in the Intensive Care Unit until she could be weaned from her ventilator. After this, she had a few episodes of agitation which were controlled by Ativan. Otherwise, the patient was neurologically intact. 2. RESPIRATORY ISSUES: Postoperatively, the patient remained intubated. She initially had quite a bit of extra fluid volume on board, and the ventilator wean was very slow and prolonged due to this reason. It was felt that her airway was probably quite edematous, and that if the patient was extubated prematurely reintubation would be extraordinarily difficult. Thus, extubation was only done after the patient had automatically diuresed a significant amount. After this, the patient really had no respiratory issues. She never had pneumonia or pneumothorax by multiple central line placements. 3. CARDIOVASCULAR SYSTEM: The patient remained in chronic atrial fibrillation throughout her stay. Her heart rate was maintained using a combination of Lopressor and diltiazem. She was never seen to be back in a normal sinus rhythm. An echocardiogram was obtained which did rule out clot. Of note, the echocardiogram did show mild-to-moderate mitral regurgitation. For further details, please see the echocardiogram report of [2102-3-23]. The patient was maintained on a therapeutic heparin drip throughout her hospitalization until she was taking oral intake. At that time, she was begun on oral Coumadin. The heparin was discontinued after the INR became 2 or greater. 4. GASTROINTESTINAL ISSUES: The patient showed slow return of bowel function. She was begun on a clear liquid diet and advanced as tolerated. On at least one occasion she was seen to be choking on her clears, and a bedside swallow study was made. They could not definitively rule out the risk of aspiration and recommended ground foods with thin liquids. The patient seemed to do well this afterward; although, she did not take large amounts of oral intake. Of note, the patient did have multiple liquid stools after her oral diet was restored. She tested negative for Clostridium difficile times four. The patient was also begun on Questran in an attempt to slow her bowel movements. This was done because a significant portion of the ileum was removed, and it was thought that the patient may not be absorbing her bile salts. 5. INFECTIOUS DISEASE ISSUES: The patient was initially begun on broad spectrum triple antibiotic therapy with ampicillin, gentamicin, and Flagyl postoperatively. Her culture data was significant for methicillin-resistant Staphylococcus aureus growing from a right internal jugular central line catheter tip on [2102-3-19]. The patient was given levofloxacin for this, as this particular variety of methicillin-resistant Staphylococcus aureus was not resistant to levofloxacin. The patient had methicillin-resistant Staphylococcus aureus screens performed on [2102-3-20] and [2102-3-21] from nares and rectal swabs which were negative. The patient completed a 10-day course of Levaquin for the catheter tip culture and was seen to afebrile since then. 6. HEMATOLOGIC ISSUES: The patient's initial clinical problem began with a probable embolic event the superior mesenteric artery. Subsequent to her surgery, she was maintained on a therapeutic heparin drip at all times. She was eventually transitioned to Coumadin when she began taking oral intake, and the heparin drip was stopped when this was therapeutic. Otherwise, the patient was transfused appropriately around the time of surgery to maintain a hematocrit of 30 or greater. PHYSICAL EXAMINATION ON DISCHARGE: In general, the patient was in no acute distress. Vital signs were stable, afebrile. The chest was clear to auscultation bilaterally. Cardiovascular examination revealed irregularly irregular. The abdomen soft, nontender, and nondistended with a midline incision which was Steri-stripped. There was no erythema or exudate from the wound. The extremities were warm, no cyanosis, no edema times four. Neurologic examination was grossly intact. DISCHARGE DISPOSITION: To a rehabilitation facility. CONDITION AT DISCHARGE: Condition on discharge was good. DISCHARGE DIET: Diet is ad lib, supplemented with Boost or equivalent t.i.d. The patient will need encouragement in oral intake. Her oral intake will probably increase when she gets her teeth from her family. MEDICATIONS ON DISCHARGE: 1. Atenolol 100 mg p.o. q.d. 2. Diltiazem 30 mg p.o. q.d. 3. Questran 4 mg p.o. b.i.d. 4. Levothyroxine. 5. Coumadin (adjust for a goal INR of between 2 and 3). DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was to follow up with Dr. [Last Name (STitle) 468] in two weeks' time. 2. Encourage oral intake and supplement diet with Boost or equivalent t.i.d. 3. Physical therapy is necessary for conditioning and gait training. 4. The patient does have multiple loose stools per day. A Foley catheter is in place. The Foley catheter may be discontinued at any time and have a voiding trial. 5. The patient may also need to follow up with an OB/GYN of her choosing for her vaginal prolapse. [First Name8 (NamePattern2) 251] [Name8 (MD) ], M.D. [MD Number(1) 4984] Dictated By:[Last Name (NamePattern1) 5745] MEDQUIST36 D: [2102-3-30] 19:23 T: [2102-3-30] 20:50 JOB#: [Job Number 49885]	[ "427.31", "486", "557.0", "567.2", "996.62", "785.59", "276.3", "435.9", "244.9" ]	icd9cm	[ [ [] ] ]	[ "45.91", "99.15", "89.64", "45.41", "45.61", "38.93", "39.56", "96.72" ]	icd9pcs	[ [ [] ] ]	9868, 9909							190, 384				10198, 10365	1183, 3015	3033, 9381					10398, 11167																						153, 169		9924, 10172	9396, 9843																				413, 1062																1084, 1156
2,825	123,699	47070	Discharge summary	report	Admission Date: [2149-9-9] Discharge Date: [2149-9-11] Date of Birth: [2116-3-29] Sex: M Service: [Hospital Unit Name 196] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2074] Chief Complaint: Elective ICD placement Major Surgical or Invasive Procedure: ICD placement Intubation History of Present Illness: Pt is a 33 year old male with sarcoid, htn, obesity, hx NSVT and idiopathic DCM with EF 10-15%, who presents for elective ICD placement based on low EF. Pt became agitated during placement of ICD and required increased amounts of conscious sedation, finally becoming apneic and requiring intubation. He then recieved 2L NS after becoming hypotensive during general anesthesia administration with propofol. Past Medical History: CHF HTN Sarcoidosis Gout ?Irregular heart beat Obesity Meningitis as a baby [Name (NI) ] accident 2 years ago- broken ribs Allergies- NKDA, NKA Social History: Social history:- smoker since 18alcohol consumption - 1/wk * 12 yearsNo use of illicit drugsLives with wife and son Family History: Non-contributory Physical Exam: 96.5 109/72 85 18 100%RA Gen: NAD, morbidly obese, A&O X 3, pleasant gentleman. Heent: EOMI, PEERL, MMM Neck: difficult to assess JVP 2/2 habitus. Heart: RRR, normal S1 and S2, Could not palpate PMI. Lungs: Occasional end-exp wheezes, no rales. Abd: Obese. Soft, nt/nd. NABS. Ext: Trace pedal edema [12-31] way up shins (stable) Neuro: CN2-12 intact. Motor and sensation intact globally. Gait normal. Pertinent Results: [2149-9-11] 05:30AM BLOOD WBC-15.5* RBC-4.43* Hgb-10.0* Hct-33.3* MCV-75* MCH-22.6* MCHC-30.1* RDW-16.5* Plt Ct-239 [2149-9-11] 05:30AM BLOOD Neuts-83.7* Lymphs-9.5* Monos-6.1 Eos-0.6 Baso-0.1 [2149-9-11] 05:30AM BLOOD Hypochr-3+ Anisocy-1+ Microcy-2+ [2149-9-11] 05:30AM BLOOD Plt Ct-239 [2149-9-10] 03:45AM BLOOD PT-14.3* PTT-22.6 INR(PT)-1.3 [2149-9-11] 05:30AM BLOOD Glucose-149* UreaN-32* Creat-1.2 Na-136 K-4.5 Cl-103 HCO3-24 AnGap-14 [2149-9-11] 05:30AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.2 [2149-9-10] 06:43PM BLOOD Type-ART pO2-123* pCO2-39 pH-7.38 calHCO3-24 Base XS--1 Intubat-INTUBATED Brief Hospital Course: 1. Apnea: Pt became apneic during ICD placement and required intubation for apnea (likely from sedatives and pre-existing sleep apnea). Pt also became hypotensive during propofol administration, and was given 2L NS. 2. Volume overload/Acute pul edema: Pt recieved 2L NS resucitation for hypotension during intubation. He then developed pink, frothy sputum and displayed signs of acute pulmonary edema. He is quite fluid sensitive given his EF of [9-12]%. Pt was diuresed overnight with a IV lasix (40mg X 2 and 80mg X 1) and was successfully extubated on HD#2. He diuresed a total of 2L and was then 100% on RA and did not desaturate on ambulation. Pt will have CHF nursing dietary education prior to discharge. He will f/u with Dr.[First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. 3. Hypotension: The patient became hypotensive during propofol administaration. Fluid was given that increased his BP, but only transiently. He was also put on neosynephrine for total of 15 minutes and also required levophed for a short time (20 minutes). Given his history of long-term steroid use and sarcoidosis, he was given 2 doses of IV hydrocortisone which was then stopped. The etiology of his hypotension was likely vasodilation from propofol. He did not mount a reflex tachycardia from this probably because he was beta-blocked from his carvedilol which he takes at home. His BP normalized on HD#2 and his beta blocker and losartan were re-started without problem. 4. ICD placement: Post procedure chest films show the leads to be in the correct place. Device deemed to be functional by J.Conners N.P. 5. ARF: Pt's creatinine increased to 1.8 when he was volume overloaded. This was likely [12-30] decreased forward flow resulting in pre-renal azotemia. This corrected with diuresis and unloading of LV. Discharge Cr 1.2 (baseline). Medications on Admission: cozaar 50 mg po qD Lasix 40mg po QD Coreg 12.5 mg po BID ASA 325mg po QD Discharge Medications: 1. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 2. Losartan Potassium 50 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:30 Tablet(s) Refills:2 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 4. Lasix 20 mg Tablet Sig: Three (3) Tablet PO once a day: 60 mg po QD. Disp:90 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Apnea and volume overload requiring intubation during elective ICD placement. Discharge Condition: Good Discharge Instructions: Go to the ER or call your doctor if you have these symptoms: 1. shortness of breath 2. chest pain 3. dizziness 4. darkening vision 5. weight gain 6. fever >102 Take daily weights. If your wieght increases by 4 pounds from your baseline, take an extra dose of lasix. Followup Instructions: Provider: [Name10 (NameIs) 1571] BREATHING TESTS Where: [Hospital6 29] Phone:[Telephone/Fax (1) 5091] Date/Time:[2149-9-12] 11:15 Provider: [Name10 (NameIs) ] [Last Name (STitle) ]/DR [Last Name (STitle) ] Where: [Hospital6 29] MEDICAL SPECIALTIES Phone:[Telephone/Fax (1) 5091] Date/Time:[2149-9-12] 11:30 Provider: [Name10 (NameIs) 676] CLINIC Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 59] Date/Time:[2149-9-17] 9:30 Dr.[Last Name (STitle) ]: ([Telephone/Fax (1) 7179]. Please call and make an appointment. Completed by:[2149-9-11]	[ "458.29", "255.4", "276.2", "E947.8", "274.9", "428.0", "425.4", "997.5", "530.81", "518.5", "278.01", "584.9", "308.2", "427.1", "517.8", "135", "401.9", "305.1", "250.00" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.71", "37.94" ]	icd9pcs	[ [ [] ] ]	4722, 4728	2283, 4165	357, 383	4850, 4856	1632, 2260	5179, 5809	1141, 1159		4289, 4699		4749, 4829		4191, 4266			4880, 5156											1174, 1613																								295, 319													411, 819																841, 992	1023, 1125
57,381	187,931	49359	Discharge summary	report	Admission Date: [2181-2-23] Discharge Date: [2181-2-27] Date of Birth: [2112-6-29] Sex: M Service: CARDIOTHORACIC Allergies: Aleve / Morphine Attending:[First Name3 (LF) 1505] Chief Complaint: mitral regurgitation Major Surgical or Invasive Procedure: [2181-2-23] Mitral Valve Repair(30mm Annuloplasty Ring) History of Present Illness: This is a 68 year old male with history of mitral regurgitation who has been followed with serial echocardiograms. His most recent echocardiogram in [2180-11-19] revealed 4+MR [First Name (Titles) 151] [Last Name (Titles) 114]e to severe mitral valve prolapse. His symptoms are shortness of breath and palpitations. Prior to mitral valve surgery, he was referred for cardiac catheterization which revealed only a 40-50% stenosis in the mid left anterior descending artery. Past Medical History: -Hyperlipidemia -noninsulin dependent diabetes mellitus -Paroxysmal Atrial Fibrillation -Prostate carcinoma - s/p radioactive seed implantation [4-27] -Diverticulosis -Panic attacks -Cataracts -Hard of Hearing -Torn Left ACL-never repaired -s/p Disc surgery x2 -s/p Eye surgery -s/p Left inguinal hernia repair Social History: Race: Caucasian Last Dental Exam: Dental clearance in office Lives with: wife, has grown children Occupation: Retired from risk management Tobacco: denies ETOH: [1-20] glasses of wine daily Family History: Family History:Father s/p CABG in 50s, Brother with stroke in 50s Physical Exam: Admission: Pulse:63 Resp:18 O2 sat:100% RA B/P Right:144/74 Left: 135/58 Height:5'9" Weight:175 LBS General: WDWN in NAD Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] OP benign. Teeth in good repair. Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR, III/VI mid systolic blowing murmur Abd: Soft [X] non-distended [X] non-tender [X] bowel sounds +[X] Extremities: Warm [X], well-perfused [X] No Edema Varicosities: None Neuro: Grossly intact Pulses: Femoral Right:2 Left:2 DP Right:2 Left:2 PT [Name (NI) 167]:1 Left:1 Radial Right:2 Left:2 Carotid Bruit Transmitted murmur vs bruit. L>R Pertinent Results: Admission [2181-2-23] 12:31PM BLOOD WBC-10.8 RBC-3.28# Hgb-10.1# Hct-29.4# MCV-89 MCH-30.7 MCHC-34.3 RDW-13.5 Plt Ct-135 [2181-2-24] 02:31AM BLOOD WBC-14.4* RBC-3.57* Hgb-11.1* Hct-32.3* MCV-91 MCH-31.2 MCHC-34.5 RDW-13.7 Plt Ct-168 [2181-2-23] 01:33PM BLOOD PT-14.1* PTT-37.6* INR(PT)-1.2* [2181-2-23] 01:33PM BLOOD UreaN-17 Creat-1.0 Cl-109* HCO3-26 [2181-2-24] 02:31AM BLOOD Glucose-141* UreaN-15 Creat-1.0 Na-137 K-4.6 Cl-103 HCO3-26 AnGap-13 Discharge [2181-2-26] 05:15AM BLOOD WBC-10.0 RBC-3.69* Hgb-11.0* Hct-33.3* MCV-90 MCH-29.9 MCHC-33.0 RDW-13.3 Plt Ct-175 [2181-2-26] 05:15AM BLOOD Plt Ct-175 [2181-2-26] 05:15AM BLOOD Glucose-118* UreaN-22* Creat-1.1 Na-138 K-4.3 Cl-101 HCO3-30 AnGap-11 Mg-2.1 Radiology Report CHEST (PA & LAT) Study Date of [2181-2-25] 1:12 PM Final Report COMPARISON: [2181-2-24]. FINDINGS: Cardiomediastinal contours are stable in the postoperative period. Small amount of pneumopericardium remains. No pneumothorax. Bibasilar atelectasis is also slightly better. Small pleural effusions are demonstrated. Retrosternal gas on lateral view is likely related to recent surgery. IMPRESSION: Improving bibasilar atelectasis. Persistent small pleural effusions. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5785] Brief Hospital Course: Mr. [Known lastname ] was a same day admission for mitral valve repair by Dr. [Last Name (STitle) ]. For surgical details, please see operative note. In summary he had a mitral valve repair, triangular resection of the middle scallop of the posterior leaflet (P2) with an annuloplasty of the mitral valve with a 30 mm future CG annuloplasty ring. His bypass time was 65 minutes with a crossclamp of 46 minutes. He tolerated the operation well and following surgery, he was brought to the CVICU for invasive monitoring. He weaned and was extubated on the day of surgery and remained hemodynamically stable. On POD#1 his chest tubes were removed and he was transferred from the intensive care unit to the step-down floor. All other tubes lines and drains were removed per cardiac surgery protocol. Once on the floor he worked with nursing and physical therapy to improve ambulation strength and endurance. The remainder of his post-operative course was uneventful. On POD 4 he completed physical therapy conditioning and was cleared to be discharged home with visiting nurses. He will follow-up with Dr [Last Name (STitle) ] on [3-29]. Medications on Admission: Metoprolol Succinate 25mg po daily Simvastatin 40mg po daily Tamsulosin 0.4mg po every other day ASA 81mg po daily Cyanocobalamin 500mcg po daily MVI i tab 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. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Disp:30 Tablet(s) Refills:0 4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO QODHS (every other day (at bedtime)). Disp:15 Capsule, Sust. Release 24 hr(s) Refills:0 5. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO once a day for 5 days. Disp:10 Tablet Sustained Release(s) Refills:0 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days. Disp:5 Tablet(s) Refills:0 7. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Disp:40 Tablet(s) Refills:0 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 1110] VNA Discharge Diagnosis: Mitral Regurgitation s/p mitral valve Repair Chronic Systolic Congestive Heart Failure Hypertension Dyslipidemia Type II Diabetes Mellitus Mild to Moderate Aortic Insufficiency Parosxymal Atrial Fibrillation Mild Coronary Artery Disease Discharge Condition: Alert and oriented x3, nonfocal Ambulating, gait steady Sternal pain managed with percocet prn Sternal incision healing well, no drainage or erythema Alert and oriented x3, nonfocal Ambulating, gait steady Sternal pain managed with percocet prn Alert and oriented x3, nonfocal Ambulating, gait steady Sternal pain managed with percocet prn Sternal incision healing well, no drainage or erythema Alert and oriented x3, nonfocal Ambulating, gait steady Sternal pain managed with percocet prn Sternal incision healing well, no drainage or erythema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Surgeon Dr. [Last Name (STitle) ] on [3-29] @1PM ([Telephone/Fax (1) 170]) Please call to schedule appointments below: Primary Care Dr. [Last Name (STitle) 71779] in [1-20] weeks ([Telephone/Fax (1) 103387]) Cardiologist Dr. [Last Name (STitle) ] in [1-20] weeks Wound check appointment - [Hospital Ward Name 121] 6 ([Telephone/Fax (1) 3071]) - your nurse will schedule before discharge Completed by:[2181-2-27]	[ "401.9", "V10.46", "427.31", "428.22", "272.4", "424.0", "250.00", "414.01", "562.10", "458.29", "428.0" ]	icd9cm	[ [ [] ] ]	[ "39.61", "38.93", "35.12" ]	icd9pcs	[ [ [] ] ]	6073, 6132	3597, 4749	304, 366	6413, 6963	2228, 3574	7504, 7962	1463, 1515		4962, 6050		6153, 6392		4775, 4939			6987, 7481											1530, 2209																								244, 266													394, 881																903, 1220	1236, 1432
47,035	176,239	5389	Discharge summary	report	Admission Date: [2146-2-13] Discharge Date: [2146-2-15] Date of Birth: [2071-10-9] Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 5790] Chief Complaint: respiratory failure Major Surgical or Invasive Procedure: [2146-2-14] 7.0 [Last Name (un) 295] adjustable tracheostomy tube and PEG tube placement. [2146-2-15] Bronchoscopy History of Present Illness: The patient is a 74-year-old woman with respiratory insufficiency who presents from rehab for elective tracheostomy tube and peg placement Past Medical History: Past Medical History: Appendectomy DM2 Hyperlipidemia HTN Cholecystectomy Hernia Repair H/o melanoma TAH/BSO Carpal tunnel OA Vitamin D deficiency Hypothyroid Restrictive lung disease [2-10] obesity Social History: Lives with husband, at rehab Family History: Noncontributory Physical Exam: Tcurrent: 36.6 ??????C (97.8 ??????F) HR: 83 BP: 116/49(63) RR: 22 SpO2: 97% General: laying with eyes closed, drowsy HEENT: dry MM, EOMI Neck: obese CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: good breath sounds BL, scattered rhonchi at bases Abdomen: soft, NT, obese, +BS, fecal tube with liquid stool, no rebound/guarding GU: foley Ext: warm, well perfused, 3+ edema of all extremities, non-warm firm erythema of BL lower extremities c/w chronic venous stasis, does not look cellulitic Skin: cherry hemangiomas and sebarrheic keratosis Neuro: CNIII-XII intact, moving all extremities spontaneously, normal DTRs Pertinent Results: [2146-2-13] 06:31PM WBC-7.4 RBC-3.66* HGB-8.7* HCT-30.8* MCV-84 MCH-23.9* MCHC-28.4* RDW-19.8* [2146-2-13] 06:31PM PLT COUNT-226 [2146-2-13] 06:31PM CALCIUM-9.8 PHOSPHATE-2.7 MAGNESIUM-2.1 [2146-2-13] 06:31PM GLUCOSE-114* UREA N-24* CREAT-0.7 SODIUM-145 POTASSIUM-3.9 CHLORIDE-97 TOTAL CO2-44* ANION GAP-8 [2146-2-14] CXR : Moderately severe pulmonary edema has worsened, and severe cardiomegaly and moderate right and small left pleural effusion persists. Tracheostomy tube is canted anteriorly and has a relatively short vertical excursion. There is no pneumothorax or mediastinal widening Brief Hospital Course: Mrs. [Known lastname 1001] was admitted to the ICU for full evaluation prior to undergoing elective tracheostomy and PEG tube placement. She was taken to the Operating Room on [2146-2-14] for the above mentioned procedures and tolerated it well. She returned to the ICU sedated on Propofol and on full mechanical ventilation. Her vent settings and mode was adjusted on multiple occasions due to hypercarbia and she alternated between MMV and A/C. Her most recent ABG revealed a Ph of 7.33 PO2 59 PCO2 90 and HCO3 16. Her chest Xray this morning was more opacified on the right side and an bronchoscopy was done which showed but there was no significant plugging. A post bronch cehst xray showed better aeration with the same right effusion. The Nutrition service recommended replete w/ fiber at a goal of 45 cc/hr w/ 42 Gm beneprotein daily. These feeding can be started after she arrives at rehab. Currently she is on no sedation and is responding to voice and commands. She received a dose of Lasix 20 mg this AM for possible fluid overload in light of her xray and diamox was also started. From a surgical standpoint she is doing well. Her trach flange sutures can be removed on [2146-2-24]. If there are any questions or concerns regarding the trach or PEG please call Dr. [Last Name (STitle) ] at 6[Telephone/Fax (1) 21905]. Medications on Admission: 2. buspirone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 4. Celexa 20 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. 6. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once a day. 7. fenofibrate 150 mg Capsule Sig: One (1) Capsule PO once a day. 8. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. methylphenidate 10 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 10. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 5 days. 11. Seroquel 25 mg Tablet Sig: One (1) Tablet PO at bedtime. 12. Diovan 160 mg Tablet Sig: One (1) Tablet PO once a day. 13. oxybutynin chloride 10 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 14. Humalog 100 unit/mL Solution Sig: Per sliding scale . Subcutaneous . 15. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. buspirone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 5. enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) mg Subcutaneous DAILY (Daily). 6. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. methylphenidate 10 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 9. Morphine Sulfate 2-4 mg IV Q2H:PRN pain 10. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 11. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 13. AcetaZOLamide 250 mg IV Q12H Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Hypercarbic respiratory failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: * You were transferred to [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1675] for placement of a feeding tube and a tracheostomy tube to help with breathing. * You have recovered well and are now ready to transfer back to your rehab. * The feeding tube can be used starting today. * If you develop any redness or drainage around the PEG tube or the trach tube please call Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 2348]. Followup Instructions: Call Dr.[Name (NI) 2347] office at [Telephone/Fax (1) 2348] if follow up is needed. Completed by:[2146-2-15]	[ "V10.82", "518.83", "276.69", "V85.43", "401.9", "278.01", "416.8", "514", "276.3", "244.9", "278.03", "327.23", "250.00", "272.4" ]	icd9cm	[ [ [] ] ]	[ "33.24", "43.11", "31.1", "96.6", "96.71" ]	icd9pcs	[ [ [] ] ]	5785, 5851	2254, 3617	318, 448	5927, 5927	1608, 2231	6580, 6703	906, 923		4741, 5762		5872, 5906		3643, 4718			6103, 6557											938, 1589																								259, 280													476, 616										5942, 6079						660, 843	859, 890
48,794	197,366	10693	Discharge summary	report	Admission Date: [2175-11-15] Discharge Date: [2175-11-17] Date of Birth: [2115-1-29] Sex: F Service: MEDICINE Allergies: lisinopril Attending:[First Name3 (LF) 3984] Chief Complaint: Chief Complaint: My face was tingling and swollen . Reason for MICU transfer: Concern for andioedema, airway obstruction Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 60 y/o F with a PMH of HTN, DM, dyslipidemia, CAD s/p LAD stent and ETOH abuse who presnted to the ED [11-15] with a CC of "Facial Swelling" since 6AM this morning. Upon ED arrival swelling was on the left side and lips and progressed to include the right side over a course of hours. The patient has no allergic history to foodstuffs or drugs but has been taking lisinopril for years. The patient has never experienced a similar episode before. There were no recent medication changes or new illnesses. In the ED inital vitals were, 97.4 71 125/88 16 100% RA. The patient was treated for suspected ACEI angioedema with Solu-Medrol, famotidine, Benadryl. The patient was treated for hyperkalemia of 5.3 with kayexalate. The EKG was reassuring and showed sinus rythm of 72 with LBBB QTc 469 not meeting Sgarbossa criteria for MI. Labs were notable for Na 132 and nrew onset Cr 1.4. At no point since symptom onset has the patient experienced wheezing, sensation of throat closing or shortness of breath. The patient was admitted to the ICU for worsening angioedema. In the ICU the patient was found to be in no distress with improved facial swelling and no respiratory compromise. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Cath on [2173-4-22] POBA diagonal for 70% stenosis, in stent restenosis of 40% h/o CAD s/p DES to LAD in [2170] Type II Diabetes Hypertension Hyperlipidemia GERD Gastric h. pylori s/p treatment Osteoporosis Bipolar d/o Anxiety h/o tobacco use - quit in [2160] 1.5 pk x 30 yrs prior to that H/o EtOH and cocaine abuse Hyponatremia Social History: She lives alone. She is retired, but had worked in an electronic company previously. She does not currently smoke but previously had a 40-50 pack year history and quit in [2160]. She also has a history of ethanol and cocaine abuse. She reports being drug free since [2160]. She does not have a history of IVDU. Relapsed 3 years ago with EtOH. - Tobacco: non smoker Hx 50 pack years - Alcohol: + for abuse 1 pint hard etoh [First Name8 (NamePattern2) ] [Last Name (un) 7295] 5 days sober - Illicits: cocaine [2154] Family History: Her mother and father are both alive and healthy in their 80s. Grandfather had stomach cancer. Her aunt and grandmother [Name (NI) 35029] problems in their 50s. Physical Exam: On Admission General: Alert, oriented, no acute distress HEENT: Sclera anicteric, large left orbital ecchymoses, MMM, oropharynx clear without visible edema; symmetric subcutaneous edema of lower face Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, [3-12] ejection murmur, 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 neurological: No cerebellar sign, not tremulous On Discharge: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, large left orbital ecchymoses, MMM, oropharynx clear without visible edema; symmetric subcutaneous edema of lower face Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, [3-12] ejection murmur, 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 neurological: No cerebellar sign, not tremulous Pertinent Results: On Admission: [2175-11-15] 01:50PM GLUCOSE-159* UREA N-23* CREAT-1.4* SODIUM-132* POTASSIUM-5.3* CHLORIDE-94* TOTAL CO2-25 ANION GAP-18 [2175-11-15] 01:50PM ALT(SGPT)-15 AST(SGOT)-25 ALK PHOS-120* [2175-11-15] 01:50PM TSH-1.3 [2175-11-15] 01:50PM C3-148 C4-41* [2175-11-15] 01:50PM WBC-8.3 RBC-3.68* HGB-10.5* HCT-32.2* MCV-87 MCH-28.4 MCHC-32.5 RDW-15.1 [2175-11-15] 01:50PM NEUTS-76.5* LYMPHS-18.7 MONOS-3.0 EOS-1.4 BASOS-0.4 [2175-11-15] 01:50PM PLT COUNT-306 [2175-11-15] 01:50PM SED RATE-49* Pertinent labs: [2175-11-16] 05:23AM BLOOD WBC-6.6 RBC-3.28* Hgb-9.7* Hct-28.5* MCV-87 MCH-29.4 MCHC-33.9 RDW-15.8* Plt Ct-294 [2175-11-17] 04:39AM BLOOD WBC-8.7 RBC-2.96* Hgb-8.8* Hct-26.0* MCV-88 MCH-29.5 MCHC-33.7 RDW-16.1* Plt Ct-290 [2175-11-16] 05:23AM BLOOD Glucose-262* UreaN-22* Creat-1.1 Na-131* K-4.7 Cl-96 HCO3-18* AnGap-22* [2175-11-17] 04:39AM BLOOD Glucose-168* UreaN-19 Creat-1.0 Na-138 K-3.9 Cl-103 HCO3-27 AnGap-12 [2175-11-16] 03:21PM BLOOD Calcium-9.1 Phos-3.5 Mg-2.7* [2175-11-17] 04:39AM BLOOD Calcium-8.5 Phos-3.4 Mg-1.8 [2175-11-16] 04:12PM BLOOD Lactate-2.1* [2175-11-17] 05:08AM BLOOD Lactate-1.2 Urine: [2175-11-16] 05:23AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.004 [2175-11-16] 05:23AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [2175-11-16] 05:23AM URINE Eos-NEGATIVE [2175-11-16] 05:23AM URINE Hours-RANDOM UreaN-187 Creat-17 Na-66 K-4 Cl-54 [2175-11-16] 05:23AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG EKG [11-16] Normal sinus rhythm. Left bundle-branch block. No change compared to tracing #1 EKG [11-15] Normal sinus rhythm. Left bundle-branch block. No significant change compared to the previous tracing of [2175-11-10]. Brief Hospital Course: Principle Reason for Admission: 60 y/o F with a PMH HTN, DM, dyslipidemia, CAD s/p LAD stent and ETOH abuse who presents with acute onset facial swelling suggestive of angioedema. Active problems #. Angioedema: Admitted through [Hospital1 18] ED with concern for worsening facial swelling due to angioedema. Received benadryl, solumedrol, and famotidine. Patient arrived to the ICU without significant facial swelling and was never in respiratory distress. Home lisinopril was discontinued. C3 and C4 levels were measured and were unremarkable. Recommended avoidance of ACE inhibitor until further evaluation, and provided with epinephrine injectable prescription. # Decreased HCO3. Patient noted to have HCO3 of 18 morning after admission. Corrected to 27 prior to dishcarge without significant intervention. #.Increased Cr: Baseline Cr near 1.0. 1.4 on admission. Home HCTZ was held and lisinopril discontinued. Creatine returned to 1.0 by day of discharge. Of note, FEUrea measured at 70% #. Hyperkalemia. K 5.3 on admission and received dose of kayexalate. Decreased to 3.9 by discharge and had no EKG changes. #. Hyponatremia. 132 on admission, and 131 morning after admission. Suspect hypovolemia as corrected to 138 prior to discharge following IVF challenge. CHRONIC PROBLEMS # Diabetes: Home metformin held, and patient controlled with ISS during stay. # Bipolar: Continued home fluoxetine and ativan prn. # HTN: Continued home amlodipine and metoprolol. HCTZ held and lisinopril DC'd as above. #. Alcoholism: Recent traumatic injury [11-10] during intoxicated episode. Decided to enter rehab at that time, now 5 days sober. Patient without s/s of withdrawal. Continued home folate PO and B12 thiamine PO OUTSTANDING STUDIES -None TRANSITIONAL ISSUES -DC'd ACEI. Consider addition of [Last Name (un) ] -HCTZ dose decreased to 25 mg daily -DC'd with EpiPen and appointment to see allergist. -Recheck Cr to eval resolution of [Last Name (un) ]. Medications on Admission: metformin 850 TID omeprazole 20 [Hospital1 ] amlodipine 5mg QD Folic Acid simvastatin 40mg HCTZ 50mg QD aspirin 81 QD Lisinopril 40 QD Metoprolol 50 QD Fluoxetine 20 QD Lorazepam 1mg TID daily vitamin Discharge Medications: 1. metformin 850 mg Tablet Sig: One (1) Tablet PO three times a day. 2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 5. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. metformin 850 mg Tablet Sig: One (1) Tablet PO three times a day. 9. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 10. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 11. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 12. multivitamin Tablet Oral 13. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) injection Intramuscular once a day as needed for allergic reaction with wheezing, difficulty breathing, or facial swelling. Disp:1 pen Refills:3 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis angioedema hyponatremia acute kidney injury Secondary Diagnosis hypertension type II diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [Known lastname 28942], You were admitted with swelling in your face concerning for angioedema. This can be a dangerous condition that can progress to swelling in your throat and difficulty breathing. We think that this was likely a reaction to your blood pressure medication, lisinopril. Do NOT take this medication again without consulting with your physician. [Name10 (NameIs) ] should see an allergist to ensure that there was no other cause for this reaction. You were also found to have some kidney injury and low sodium that resolved with intravenous fluid resuscitation. Please note the following changes to your medications: STOP lisinopril DECREASE HCTZ to 25mg daily START EpiPen as needed for severe allergic reactions causing facial swelling, difficulty breathing or wheezing. Followup Instructions: Department: BIDHC [Location (un) ] When: TUESDAY [2175-11-21] at 11:15 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] NP [Telephone/Fax (1) 608] Building: 545A Centre St. ([Location (un) 538], MA) [Location (un) ] Campus: OFF CAMPUS Best Parking: Department: DIV OF ALLERGY AND INFLAM When: MONDAY [2175-12-18] at 7:00 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 9703], RNC [Telephone/Fax (1) 9316] Building: One [Location (un) ] Place ([Location (un) ], MA) [Location (un) 895] Campus: OFF CAMPUS Best Parking: Parking on Site Department: NEUROLOGY When: TUESDAY [2175-12-19] at 4:30 PM With: DRS. [Name5 (PTitle) ] & TARULLA [Telephone/Fax (1) 44] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438]	[ "303.90", "276.1", "426.3", "414.01", "V45.82", "250.00", "733.00", "530.81", "E942.9", "272.4", "276.7", "995.1", "296.80", "584.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	9892, 9898	6461, 8442	397, 403	10055, 10055	4547, 4547	11038, 12080	3046, 3213		8698, 9869		9919, 10034		8468, 8675			10206, 10828											3228, 3876																	3890, 4528			10857, 11015	1657, 2105			252, 359													431, 1638								4562, 5094		10070, 10182			5110, 6438			2127, 2471	2487, 3030
49,036	127,912	38136	Discharge summary	report	Admission Date: [2178-8-14] Discharge Date: [2178-8-26] Date of Birth: [2109-6-14] Sex: M Service: SURGERY Allergies: Dicloxacillin Attending:[First Name3 (LF) 1390] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [2178-8-14] EXPLORATORY LAPAROTOMY, SMALL BOWEL RESECTION, CHOLECYSTOSTOMY, G TUBE PLACEMENT History of Present Illness: 69 M with stage 4 melanoma diagnosed [5-/2178] with metastases to liver, lung, stomach, brain and spleen p/w sharp lower abd pain since this morning. His pain began 2 days ago but was minimal at that time. It has progressed to sharp, diffuse [10-18] pain. He has had PO intolerance and nausea without emesis. He had a dark black BM yesterday and is guaiac positive. He denies fevers, chills, night sweats. He has had fatigue and weight loss associated with his aggressive malignancy. Past Medical History: PMH: melanoma metastatic to liver, lung brain and spleen. Nephrolithiasis 15 to 20 years ago. PSH: L axillary tumor removal (diagnostic for his melanoma) Social History: Retired, previously self-employed owner of a motel but has since left work after his recent diagnosis of cancer. He is a retired fifth grade teacher. Previous 2PPD smoker, quit this year in [Month (only) 116]. Denies EtOH. Married with four children. Family History: Maternal aunt with CA (does not remember what kind). Otherwise non-contributory Physical Exam: PHYSICAL EXAMINATION: upon admission [2178-8-14] Temp:96.7 HR:111 BP:150/89 Resp:20 O(2)Sat:97 normal Constitutional: Pale, ill-appearing HEENT: Anicteric Oropharynx within normal limits Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, tachycardic, Normal first and second heart sounds Abdominal: Diffuse tenderness to palpation with guarding Rectal: Heme Positive, dark green stools, no melena GU/Flank: No costovertebral angle tenderness Extr/Back: Warm, well perfused Neuro: Expressive aphasia (at baseline per pt/family), symmetric strength/sensation Pertinent Results: [2178-8-13] 07:55PM BLOOD WBC-14.5* RBC-3.06* Hgb-8.8* Hct-27.3* MCV-89 MCH-28.7 MCHC-32.2 RDW-18.2* Plt Ct-402 [2178-8-14] 06:28AM BLOOD WBC-11.5* RBC-4.05# Hgb-11.8# Hct-36.2# MCV-89 MCH-29.0 MCHC-32.5 RDW-17.0 Plt Ct-344 [2178-8-15] 02:18AM BLOOD WBC-12.5* RBC-2.82* Hgb-8.5* Hct-24.9* MCV-89 MCH-30.0 MCHC-33.9 RDW-16.9* Plt Ct-235 [2178-8-16] 02:25AM BLOOD WBC-13.5* RBC-2.67* Hgb-7.7* Hct-24.0* MCV-90 MCH-29.0 MCHC-32.2 RDW-16.6* Plt Ct-206 [2178-8-17] 03:20AM BLOOD WBC-10.1 RBC-2.64* Hgb-7.8* Hct-23.2* MCV-88 MCH-29.6 MCHC-33.6 RDW-16.3* Plt Ct-222 [2178-8-18] 04:41AM BLOOD WBC-6.9 RBC-3.15* Hgb-9.2* Hct-28.0* MCV-89 MCH-29.2 MCHC-32.8 RDW-16.3* Plt Ct-214 CT Abd/Pelvis [2178-8-14]: IMPRESSION: 1. Focal small bowel wall thickening and mesenteric edema in the left mid abdomen with microperforation. The imaging features suggest venous ischemia, with arterial ischemia less likely. Infection is felt even less likely but not excluded. Markedly enlarged centrally necrotic lymph node along the supplying mesentery. 2. New stone or sludge in the gallbladder, otherwise no CT evidence of acute cholecystitis. Correlation with clinical data advised. 3. Overall progression of metastatic disease. Probable new metastatic lesion in the L1 vertebral body. Brief Hospital Course: The patient presented with a small bowel obstruction. After discussion with patient and his family the decision was made to proceed with surgery despite his diagnosis of metastatic melanoma. [8-14] - He was taken to the operating room the next day for an exploratory laparotomy, small bowel resection, cholecystostomy tube placement and G-tube placement (see operative report for full details). He was transfused 2u PRBC. He was admitted to the unit afterwards and did well other than profound delirium. He was maintained on Cipro and Flagyl. Hem/Onc was consulted to assist in his management. Per their recommendations he was started on dexamethasone, which was tapered, for his brain metastases. After much discussion with hem/onc, and his family it was determined to make him DNR/DNI. 8/7-8 - The patient continued to be delirious but improving. Palliative care was consulted for assistance in controlling the patient's pain. He was maintained on morphine and olanzapine per their recommendations. He otherwise did well. [8-17] - He was transfused 1u PRBC for a Hct of 23.7. TF were started at a rate of 10 to advance to a goal of 50cc/hr. [8-18] - Patient was fit to transfer out of the ICU and to the floor. Since his transfer to the floor and after further discussions with patient and his family pertaining to quality of life issues the decision was made to allow patient to eat any foods that he desires. His diet was progressed to regular for which he is tolerating and his tube feedings stopped. He did have difficulty with increased sleepiness and dosing on Zyprexa and oxybutynin were changed; he is more awake and alert. His cholecystectomy tube is to gravity drainage with green drainage and his PEG is clamped. A family/team meeting took place to discuss disposition issues and it was decided that the family wished for patient to go to a rehab facility in order to regain some functional abilities closer to his previous baseline. Physical therapy was consulted and recommendations for [Hospital1 1501] were made. Medications on Admission: Temodar 250' QD for five days repeated every 28 days; Sennosides 8.6 2 tabs', Spiriva with HandiHaler 18 mcg inh', Nystatin 100,000 u oral susp, Lorazepam 0.5 TID prn, Furosemide 20', Dexamethasone 4'''', Omeprazole 20'', Prochlorperazine Maleate 10 Q6H prn nausea, Tramadol 50 Q6H prn, Docusate Sodium 100'', Oxycodone 5 Q4H prn, MVI' Discharge Medications: 1. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [1-10] Puffs Inhalation Q6H (every 6 hours). 2. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for bladder spasm. 3. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours) as needed for chronic pain. 4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Puff Inhalation Q4H (every 4 hours) as needed for wheeze. 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 7. Morphine 10 mg/5 mL Solution Sig: 2.5-5 ml PO Q2H (every 2 hours) as needed for pain: hold for resp. rate <10. Discharge Disposition: Extended Care Facility: [Location (un) 582] - [Location (un) 7658] Discharge Diagnosis: necrotic perforated bowel Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive. Discharge Instructions: Regular diet as tolerated Bed to chair with assistance Dry steril dressing to PEG and cholecystoscopy tube, clean site with 1/2 st hydrogen peroxided if crusted Cholecystoscopy tube to gravity drainage PEG clamped Followup Instructions: Follow up in [Hospital 2536] clinic in [1-10] weeks, call [Telephone/Fax (1) 600] for an appointment. Follow up with your primary care providers aftr discharge from rehab. Completed by:[2178-8-26]	[ "198.5", "V10.82", "575.2", "197.8", "196.3", "197.4", "348.5", "197.7", "557.0", "197.0", "569.83", "560.89", "198.3", "293.0", "575.10" ]	icd9cm	[ [ [] ] ]	[ "51.03", "45.62", "96.6", "43.19" ]	icd9pcs	[ [ [] ] ]	6636, 6713	3411, 5474	289, 388	6783, 6783	2087, 3388	7129, 7344	1385, 1467		5861, 6613		6734, 6762		5500, 5838			6890, 7106											1482, 1482													1504, 2068											234, 251													416, 915										6798, 6866						937, 1093	1109, 1369
14,039	154,496	48425	Discharge summary	report	Admission Date: [2127-2-6] Discharge Date: [2127-2-12] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1556] Chief Complaint: MVA, car vs tree Major Surgical or Invasive Procedure: None History of Present Illness: 88 year old man in high speed motor vehicle collision with tree, unrestrained. +bilat airbag deployment, large front end damage to vehicle. +LOC with Right chest and sternal pain, worse with movement/inspiration Past Medical History: HTN, DM, ?afib ex lap after gsw in WWII Social History: Lives alone, wife and sons live nearby etoh: 1 drink per day Family History: Non-contributory Physical Exam: VS: T-99.7 HR-80 BP-120/60 RR-20 O2sat: 100% on 4L nc HEENT: 1cm bleeding lac to left temporal scalp Perrl chest: decreased breath sounds bilat, chest and sternum tender to palpation heart: irregularly irregular ABD: soft, non-tender Rectal: normal tone, no gross blood, trace heme + ext: no sign of trauma Neuro: alert, agitated sensation grossly intact DTRs normal moving all extremities Pertinent Results: [2127-2-6] 09:39PM BLOOD WBC-5.3 RBC-3.01* Hgb-9.6* Hct-28.9* MCV-96 MCH-31.8 MCHC-33.1 RDW-16.1* Plt Ct-189 [2127-2-6] 09:39PM BLOOD PT-12.9 PTT-27.7 INR(PT)-1.1 [2127-2-6] 09:39PM BLOOD Fibrino-433* [2127-2-6] 09:39PM BLOOD UreaN-40* Creat-1.5* [2127-2-6] 09:39PM BLOOD CK(CPK)-96 Amylase-35 [2127-2-7] 03:30AM BLOOD CK-MB-18* MB Indx-3.2 cTropnT-0.03* [2127-2-7] 03:30AM BLOOD Calcium-8.0* Phos-3.5 Mg-2.2 [2127-2-6] 09:39PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2-6] CT C-spine: C7 pedicle fx extending from spinolaminar junction into spinous process as well and right inferior and left superior articular facet. C6/C7 widening, C4/5 arthrolithesis (?ligamentous injury). [2-6] CT-Chest: Transverse manubrial frx. RML and RLL contusion. R rib frx [1-14]. L rib frx 3,5,6. Scattered opacities ?aspiration vs. infection vs. contusions. [2-6] CT-head: Soft tissue contusion anterior to left frontal bone with single focus of subcutaneous emphysema. No fx. [2-6] CT abdomen: ? jejunal thickening. No other solid organ injury [2-10] chest x-ray:Area of increased density is seen on the lateral view which may represent lower lobe pneumonia possibly on the right side. Overall improvement from prior x-ray Brief Hospital Course: [2-6] HD #1 Admitted to the Trauma service. His scalp laceration was sutured. He underwent CT imaging which showed bilateral rib fractures, sternal fracture, pulmonary contusion and C7 pedicle fracture with possible ligamentous injury at C3-C4. Seen and evaluated by Neurosurgery who recommended non operative intervention with use of a c-collar with thoracic extension ([Location (un) 36323] brace). [2-7] HD #2 Seen by the acute pain service because of his rib fractures. An epidural catheter was placed (Dilaudid)for pain control. His diet was slowly advanced. [2-8] HD #3 He was transferred to the floor. Tolerating his diabetic diet. Pain controlled, pulmonary hygiene continues. He was transfused 1 unit of PRBCs for low Hct; post transfusion Hct 28.1. Seen and evaluated by PT & OT, they have recommended short term rehab to improve overall functioning. [2-9] HD #4 In the evening, when the RN was cleaning under the brace, the patient refused to have the brace replaced. He became increasingly agitated and a psych emergency was called. Episode was felt to be related to delirium per Psychiatry who was consulted, caused by sedatives that patient had previously received during the acute hospital phase. He subsequently was placed on sitters; sedatives were stopped. His behavior improved significantly and the sitters were able to be discontinued. [2-10] HD#5 His brace was adjusted by the Orthotics company for a more comfortable fit. [Last Name (un) ] Diabetes Center was also consulted due to elevated blood sugars; glargine added and his sliding scale was adjusted. Epidural catheter discontinued and he was transitioned to oral pain medications. Ho pain overall was in much better control at this time. [2-11] HD#6 Pt continu ed to improve, pt made aware of importance of keeping brace on, and patient agreed, via russian translator, to do so. Sitter d/c'd in preparation for rehab. [2-12] HD#7 Pt cleared for discharge to rehab with brace. Follow up instructions discussed with patient. Need to keep brace on discussed with patient. Patient agrees to plan anf follow up. Medications on Admission: Detrol 4, Flomax 0.4, Flonase 50, iron 18''', lisinopril 20, nifedipine 60, omeprazole 20, Paxil 20 mg, MVI, doxepin cream 5%, ASA 81, trazodone 50, Zyrtec 10, salsalate 750''' 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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:60 Tablet(s) Refills:0 3. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 4. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 5. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). Disp:60 Tablet Sustained Release(s) Refills:2 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:30 Capsule, Sust. Release 24HR(s) Refills:2 7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2) Spray Nasal [Hospital1 ] (2 times a day). Disp:1 bottle Refills:2 9. Salsalate 750 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 11. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:25 Tablet(s) Refills:0 14. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 15. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 16. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 17. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. 18. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed) as needed for sore throat. Disp:30 Lozenge(s) Refills:0 19. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital6 1643] Center Discharge Diagnosis: s/p Motor vehicle crash C7- pedicle fracture Pulmonary contusion Bilateral multiple rib fractures Discharge Condition: Stable Discharge Instructions: You must continue to wear your brace as instructed by Neurosurgery. Followup Instructions: Follow up with your Primary Physician for the incidental finding of a nodule in your chest. You will need to call for an appointment. Follow up with Dr. [Last Name (STitle) 739], Neurosurgery, in 1 week. Call [Telephone/Fax (1) 77038] for an appointment. Inform the office that you will need a repeat CT scan of your spine for this appointment. Additional appointments that were scehduled prior to your hospitalization include the following: Provider: [Last Name (NamePattern4) ]. [First Name (STitle) 5376] [Doctor Last Name ] Phone:[Telephone/Fax (1) 463] Date/Time:[2127-3-10] 1:30 Provider: [First Name8 (NamePattern2) 11136] [Last Name (NamePattern1) ], [Name Initial (NameIs) ].D. Date/Time:[2127-3-18] 10:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 11771], M.D. Phone:[Telephone/Fax (1) 26488] Date/Time:[2127-3-18] 2:30	[ "401.9", "E816.0", "805.07", "250.00", "292.81", "600.00", "331.83", "807.08", "E937.9", "861.21", "873.0" ]	icd9cm	[ [ [] ] ]	[ "03.90", "86.59" ]	icd9pcs	[ [ [] ] ]	6941, 6995	2454, 4594	277, 284	7137, 7146	1130, 2431	7263, 8183	682, 700		4822, 6918		7016, 7116		4620, 4799			7170, 7240											715, 1111																								221, 239													312, 525																547, 588	604, 666
26,956	117,914	31582+57752	Discharge summary	report+addendum	Admission Date: [2157-8-2] Discharge Date: [2157-8-8] Date of Birth: [2102-1-21] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2969] Chief Complaint: new onset cough and chest pain w/ fever Major Surgical or Invasive Procedure: none History of Present Illness: He presents now with a one day history of productive cough that has steadily increased in frequency and is associated with mild dyspnea. Patient states that he does not believe that he has had a fever during this time and as recently as two days ago, claims that his PCP did not find anything amiss with his oxygen sats. or on physical exam. However, upon his condition worsening this morning, he went again to his PCP and chest xrays were performed that showed evidence of a multifocal pneumonia. Admitted for w/u. Past Medical History: Esophageal ca, history of aspiration pneumonia, COPD, OSA (CPAP), GERD, lipids, s/p back fusion, h/o diverticuli, pain, diabetes Social History: lives w/ wife and children 40 pk year smoker- quit 8 mos ago. No ETOH Family History: non contributory Physical Exam: general: Obese male in NAD VS: 98.4, 92, 132/54, 18, 94% on room air HEENT: unrenarkable Chest: course breath sounds bilat. COR: RRR S1, S2 abd: obese, soft, round, NT, +BS extrem: no LE edema neuro: intact Pertinent Results: cxr [8-2] Cardiomediastinal contours are unchanged. There are bilateral perihilar consolidations, left greater than right, with air bronchograms. Scattered airspace opacities are also seen at the right apex, and left base. There is no definite pleural effusion. Pulmonary vascularity is normal. There is no pneumothorax. IMPRESSION: Bilateral perihilar consolidations, and scattered additional airspace opacities, most consistent with multifocal pneumonia vs other etiologies. Video swallow [8-4] VIDEOFLUOROSCOPIC SWALLOWING EVALUATION: In collaboration with speech and pathology department, a speech and swallow evaluation was performed. Barium of various consistencies was administered to the patient during continuous videofluoroscopic imaging. ORAL PHASE: Bolus formation and AP tongue movements are within normal limits. There is a mild amount of premature spillover seen before the swallow. PHARYNGEAL PHASE: A mild delay in pharyngeal swallow initiation is seen. Palatal elevation, laryngeal elevation, and epiglottic deflection are within functional limits. However, laryngeal valve closure was mildly reduced. A trace amount of residue is seen within the vallecula and piriform sinuses. 13- mm barium tablet passes freely to the stomach. ASPIRATION/PENETRATION: Penetration was seen with thin and nectar-thick liquids, secondary to premature spillover and swallow delay. Aspiration of thin liquids was also seen, and was noted to be silent. IMPRESSION: Mild oropharyngeal dysphagia, with penetration and an episode of aspiration seen. For further details, please refer to speech and pathology report from the same day. Brief Hospital Course: Pt was admitted and taken to the SICU for hypoxia requiring continuous O2 sat monitioring and 100% non-rebreather. Kept NPO for suspetced aspiration PNA. Hydrated and placed on broad spectrum IVAB unasyn and vanco pending sputum culture. Speech and swallow pathology was re- consulted and a video swallow was perform - see results section- essentially-exam unchnaged from previous intermittent,trace aspiration and aspiration was eliminated with thickened liquids and the chin tuck. He is admittedly not 100% compliant at home w/ his swallowing precautions. With aggressive pul tiolet and IVAB, his oxygenation improved and was transferred from the ICU to the general floor. IVAB were changed to augmentin and bactrim per ID recommendations- sputum cultures were contaminated and therefore unrevealing. ON HD# 5 pt developed abd discomfort and distention. A KUB was done and showed large amounts of stool. After bowel regimen was increased, pt passed stool and symptoms improved and was [Last Name (un) 1815] reg diet. On HD#7 developed left sided back pain w/ coughing which was reproduceable w/ palpation. Appears to be muscle strain from coughing. Given toradol and placed on motrin regimen w/ some relief. Medications on Admission: Lipitor 80mg QD Celebrex 200mg QD Relpax 20mg prn Tricor 48mg QD Fioricet prn Ativan 1mg QD Diazepam 2mg prn Albuterol Prilosec Roxicet Zoloft 100mg QD Oxycontin 40mg [Hospital1 ] Metformin 1000mg QD. Discharge Medications: 1. Sertraline 50 mg Tablet [Hospital1 ]: Two (2) Tablet PO DAILY (Daily). 2. Oxycodone 40 mg Tablet Sustained Release 12 hr [Hospital1 ]: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 3. Hydrocodone-Acetaminophen 5-500 mg Tablet [Hospital1 ]: One (1) Tablet PO Q6H (every 6 hours) as needed for breakthrough pain. 4. Guaifenesin 100 mg/5 mL Syrup [Hospital1 ]: 5-10 MLs PO Q6H (every 6 hours) as needed. 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 6. Lipitor 80 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day. 7. Celebrex 200 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO once a day. 8. Ativan 1 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day as needed. 9. Diazepam 2 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day as needed. 10. Amoxicillin-Pot Clavulanate 500-125 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times a day) for 14 days. Disp:42 Tablet(s) Refills:0 11. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO BID (2 times a day) for 14 days. Disp:56 Tablet(s) Refills:0 12. Ranitidine HCl 150 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO HS (at bedtime). Disp:60 Tablet(s) Refills:2 13. Ibuprofen 600 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q8H (every 8 hours). Disp:90 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Esophageal ca, history of aspiration pneumonia, COPD, OSA (CPAP), GERD, lipids, s/p back fusion, h/o diverticuli, pain, diabetes PSH: transhiatal esophagectomy, pyloroplasty, hiatal herniorrhaphy and feeding jejunostomy in [9-18] Discharge Condition: good Discharge Instructions: Call Dr.[Doctor Last Name 4738] office [Telephone/Fax (1) 170] if experience: -Fever > 101 or chills -Difficulty swallowing Complete all the antibiotics. Followup Instructions: Follow-up with Dr. [Last Name (STitle) ] as needed [Telephone/Fax (1) 170] Follow-up with your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 10740] [Telephone/Fax (1) 40144]- call for an appointment to be seen in 2 weeks. Completed by:[2157-8-8] Name: [Known lastname 12266],[Known firstname ] E Unit No: [Numeric Identifier 12267] Admission Date: [2157-8-2] Discharge Date: [2157-8-8] Date of Birth: [2102-1-21] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 9814] Addendum: clarification- pt had recurrent aspiration PNA. Discharge Disposition: Home [First Name11 (Name Pattern1) 3549] [Last Name (NamePattern1) 9816] MD [MD Number(2) 9817] Completed by:[2157-9-1]	[ "507.0", "250.00", "276.6", "496", "V10.03", "327.23" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	7328, 7494	3098, 4313	359, 365	6372, 6378	1427, 3075	6588, 7305	1167, 1185		4569, 6065		6115, 6351		4339, 4546			6402, 6565											1200, 1408																								280, 321													393, 910																932, 1063	1079, 1151
54,348	128,820	48092	Discharge summary	report	Admission Date: [2164-11-2] Discharge Date: [2164-11-14] Date of Birth: [2106-2-11] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4691] Chief Complaint: neck pain Major Surgical or Invasive Procedure: 1. Inferior vena cavogram. 2. Inferior vena caval filter placement. History of Present Illness: 58M fell down stairs ? 2 days ago complaining of neck pain shortness of breath and rigth knee pain. Pt is on Coumadin for PE of unclear etiology. Pt drinks 2 [2-10] pints of liquor day. Past Medical History: Polysubstance abuse (heroin, cocaine, ETOH). Detoxed following admission to an inpatient facility about 3 years ago. Currently in [Hospital1 ] suboxone program. Hepatitis C Depression Social History: Lives in [Location ] alone. Had been homeless earlier in the year. Drinks 2 pints of Whiskey per day. Distant heroin/cocaine abuse. Family History: Father died of lung cancer in mid 70s, alcohol abuse, hypertension. Mother died of lung cancer in mid 70s. Three siblings; two brothers, one sister, all in good health. Physical Exam: Temp 97.5 BP 106/70 HR 100 RR20 O2 Sat 100% RA HEENT PERRLA Multiple superficial abrasions on forehead Neck Cervicle collar in place, non tender Chest Slear, no deformity COR RRR Abd soft , non tender, hematoma right buttock Ext abrasion over right knee Neuro Strength 5/5 upper and lower extremities Pertinent Results: [2164-11-2] 07:30PM PT->150* PTT-55.1* INR(PT)->20.2* [2164-11-2] 07:30PM PLT COUNT-428 [2164-11-2] 07:30PM NEUTS-67.3 LYMPHS-23.4 MONOS-4.7 EOS-3.5 BASOS-1.0 [2164-11-2] 07:30PM GLUCOSE-96 UREA N-20 CREAT-1.1 SODIUM-132* POTASSIUM-7.0* CHLORIDE-91* TOTAL CO2-17* ANION GAP-31* [2164-11-2] 10:20PM GLUCOSE-101 UREA N-18 CREAT-0.8 SODIUM-137 POTASSIUM-2.9* CHLORIDE-95* TOTAL CO2-23 ANION GAP-22* [2164-11-2] C Spine CT : 1. Displaced fracture of the right C5 spinous processes with extension intothe right C5 lamina. 2. Multilevel degenerative changes, as above, including small posterior osteophytes. If clinical concern for ligamentous or spinal cord injury, MRI is more sensitive. 3. Scattered areas of focal osseous lucency, which may relate to degenerative change or osteopenia. However, if patient has history of malignancy, these would be of more concern, and further evaluation with MRI or bone scan could be obtained. 4. Suggestion of hypodensity in the inferior right lobe of the thyroid, for which further evaluation with ultrasound can be obtained. [2164-11-2] Head CT : No acute intracranial process. [2164-11-2] CXR : 1. Suboptimal examination due to patient motion and exclusion of the right costophrenic angle. 2. Small amount of fluid seen in the azygos lobe fissure. 3. 4-mm rounded density in the right mid lung, as above, not clearly seen on prior radiographs or on prior chest CT. Consider further evaluation with chest CT. [2164-11-3] MR [First Name (Titles) ] [Last Name (Titles) 1093] : 1. Findings indicative of injury to the C4-5 interspinous ligaments and the ligamentum flavum at disc level likely secondary to extension injury with fracture of the C5 spinous process. 2. Subtle signal change in the anterior portion of C5-6 disc could be secondary to trauma to the disc from extension injury. 3. Prevertebral hematoma in the upper cervical region from C1-C4 level. 4. Degenerative changes as described above. 5. No evidence of abnormal signal within the spinal cord to indicate spinal cord trauma. No intraspinal hematoma. Brief Hospital Course: Mr. [Known lastname 15716] was admitted to the Trauma ICU with an INR of 20 and received 5 units of FFP and 1 unit of blood. His lowest hematocrit was 20 and stabilized after that at 25. He did have some neck pain and right shoulder pain which was controlled with Percocet. He did have some episodes of agitation and impulsive behavior and for that reason was placed on the CIWA protocol which was effective. Atrial fibrillation was a problem during his hospitalization and his pre admission Diltiazem was resumed and lopressor was started. He converted to NSR at a rate of 76 BPM and has been able to maintain regularity. His C spine injury was further reviewed with an MRI which indicated ligamentous injury of C [5-13] and the recommendations by the Neurosurgery service were to wear a hard collar for 6 weeks and then return to the Clinic for follow up xrays. Mr. [Known lastname 15716] had a temperature of 101 early in his hospitalization and 1 set of blood cultures was positive for coag negative staph ([2164-11-5]). His echo in [Month (only) 216] showed tricuspid valve endocarditis and he was treated with 6 weeks of antibiotics. He was placed on Linazoilid pending repeat cultures as he is VRE positive from his last admission. While blood cultures were pending he had a TEE which showed no vegetations and trace tricuspid regurgitation. His repeat cultures were negative and his antibiotics were discontinued. He remained afebrile for the remainder of his hospitalization. Following the assurance of no bacteremia he had an IVC filter placed uneventfully on [2164-11-6]. He subsequently started Coumadin and was transitioned off Lovenox. His INR's were monitored carefully and will be followed by the [Hospital 18] [Hospital3 ]. Medications on Admission: Seroquel 50", Omeprazole 20', Gabapentin 100, Diltiazem HCl, Coumadin -- Unknown Strength Discharge Medications: 1. Acetaminophen 325 mg Tablet [Hospital3 ]: Two (2) Tablet PO every six (6) hours as needed for pain. 2. Quetiapine 25 mg Tablet [Hospital3 ]: One (1) Tablet PO BID (2 times a day). 3. Oxycodone-Acetaminophen 5-325 mg Tablet [Hospital3 ]: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [Hospital3 ]: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 5. Diltiazem HCl 60 mg Tablet [Hospital3 ]: One (1) Tablet PO QID (4 times a day). 6. Metoprolol Tartrate 25 mg Tablet [Hospital3 ]: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 7. Warfarin 5 mg Tablet [Hospital3 ]: One (1) Tablet PO once a day: Take as directed by [Hospital 197] Clinic. Discharge Disposition: Home Discharge Diagnosis: 1. C5 fracture. 2. Recent pulmonary embolism. 3. Deep venous thrombosis. Discharge Condition: 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, or Ibuprofen etc. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Call Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 2359] for a follow up appointment in 2 weeks Call Dr. [Last Name (STitle) 1007] at [Telephone/Fax (1) 1228] for a follow up appointment in 6 weeks with flexion and extension Xrays. Call Dr. [Last Name (STitle) 4427] for a follow up appointment in [2-10] weeks Your Coumadin dose will be regulated by the [Hospital 3052]. Call [Telephone/Fax (1) 2173] with any questions. Completed by:[2164-11-14]	[ "415.19", "285.1", "453.41", "070.54", "E880.9", "805.05", "427.31", "311" ]	icd9cm	[ [ [] ] ]	[ "38.7", "88.51", "38.93" ]	icd9pcs	[ [ [] ] ]	6446, 6452	3649, 5435	325, 395	6569, 6578	1504, 3626	7549, 8040	998, 1168		5576, 6423		6473, 6548		5461, 5553			6602, 7526											1183, 1485																								276, 287													423, 615																637, 827	843, 982
71,871	191,197	49001	Discharge summary	report	Admission Date: [2128-7-13] Discharge Date: [2128-7-16] Date of Birth: [2064-5-25] Sex: F Service: MEDICINE Allergies: Atorvastatin Attending:[Last Name (NamePattern4) 290] Chief Complaint: dark stool and fatigue Major Surgical or Invasive Procedure: EGD Colonoscopy Capsule Endoscopy History of Present Illness: This is 64 female with a past medical history significant for breast CA, HTN, CAD s/p 1v CABG, severe AS s/p AVR, Afib on ASA presenting with 4 days of melena. She was referred to the ED for decreased Hct (from 37 last year to 28 at PCP [Name Initial (PRE) 3726]). She reports that she has been anemic for some time and was on iron supplementation after a car accident approximately 4 weeks ago. She reports that she has been fatiged since the MVA. She reports that she has felt increasingly weak over the past few weeks, and recently had a an episode of diarrhea 4 days ago it was darker than usual. She reports that she did not think this was notable that time because her stools are typically very dark on iron, but that this was darker than usual. She was reports that she has had these darker than usual stools persist since. She reports that she was scheduled for a outpatient colonoscopy tomorrow due to her anemia. She denies fever, chills, nausea, vomiting, and dysuria. Denies chest pain, shortness of breath, and headache. In the ED, her initial vitals were: 99.6 86 82/42 18 100% RA. She was given 1L of NS. She was started on a protonix gtt and 2 18-gauge PIV were placed. A NG lavage was negative for blood. She was being transfered her first unit of pRBC as she was being transfered to the ICU. Past Medical History: CARDIAC VALVE REPLACEMENT (TISSUE) S/P CABG TO PDA LCIS, BREAST BILATERAL OOPHORECTOMY HYPERTENSION HYPERCHOLESTEROLEMIA VENTRICULAR HYPERTROPHY, LEFT RIGHT BUNDLE BRANCH BLOCK OBESITY REMOTE H/O TOBACCO USE OSTEOPENIA SCIATICA ALLERGIC RHINITIS ASTHMA OSTEOARTHRITIS H/O REMOTE TOBACCO USE Social History: Occupation: receptionist at psych hospital Drugs: denies Tobacco: never Alcohol: 2pack x 20years, stop 30 years ago Other: has a daughter who is 8 month pregnant. Family History: father died of sudden death @37 years old Physical Exam: Admission Exam: VS: 97.8, 84, [10/2086], 17, 99%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: Regular rate and rhythm, normal S1 + S2, [2-17] C-D sytolic murmur heard in 2nd ICS, [1-19] holosystolic murmur heard along R sternal board. Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, obese, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . DISCHARGE EXAM (from MICU) Vitals: Tm: 98.5 Tc: 98.5 HR: 72 BP: 144/71 RR: 20 SpO2: 96% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: Regular rate and rhythm, normal S1 and S2, III/VI sytolic murmur heard in 2nd ICS, II/VI systolic murmur loudest at the right sternal border without radiation, no rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: obese, soft, non-tender, non-distended, normoactive bowel sounds present, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: grossly intact Pertinent Results: ADMISSION LABS: [2128-7-13] 07:20PM BLOOD WBC-10.0 RBC-2.42# Hgb-7.9# Hct-24.2# MCV-100* MCH-32.4* MCHC-32.4 RDW-13.7 Plt Ct-213 [2128-7-13] 07:20PM BLOOD Neuts-70.9* Lymphs-21.6 Monos-4.3 Eos-2.8 Baso-0.4 [2128-7-13] 07:20PM BLOOD PT-11.2 PTT-24.8* INR(PT)-1.0 [2128-7-13] 07:20PM BLOOD Glucose-103* UreaN-31* Creat-1.1 Na-139 K-4.0 Cl-100 HCO3-27 AnGap-16 [2128-7-13] 07:33PM BLOOD Lactate-1.2 REPORTS: EGD [2128-7-14] The Z-line was noted to be irregular Grade 2 esophagitis in the lower third of the esophagus Normal mucosa in the whole stomach. No fresh or old blood was seen. Otherwise normal EGD to third part of the duodenum COLONOSCOPY [2128-7-15] Polyps in the colon Grade 2 internal hemorrhoids Normal mucosa in the colon Otherwise normal colonoscopy to cecum ECG [2128-7-13] Sinus rhythm. Non-specific junctional ST segment depression. Compared to the previous tracing of [2125-9-28] no diagnostic interim change. DISCHARGE LABS: [2128-7-16] 04:05AM BLOOD WBC-11.3* RBC-2.99* Hgb-9.7* Hct-29.8* MCV-100* MCH-32.4* MCHC-32.6 RDW-15.8* Plt Ct-220 [2128-7-16] 04:05AM BLOOD Glucose-119* UreaN-9 Creat-1.0 Na-142 K-3.8 Cl-107 HCO3-25 AnGap-14 [2128-7-15] 03:53AM BLOOD ALT-41* AST-124* AlkPhos-43 TotBili-0.4 [2128-7-16] 04:05AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.1 Brief Hospital Course: 64 yo F with past medical history significant for breast cancer, HTN, CAD s/p 1v CABG, severe AS s/p AVR and MR, Afib on ASA presenting with melena and hematocrit drop. # Upper GI bleed- pt has been passing [First Name9 (NamePattern2) 102875] [Doctor Last Name 3945] prior to admission with a drop in her HCT from 28.8-->24.3 over a couple of days hwich was already down from her baseline of 37. She was symptomatic with this hct drop. NG lavage was negative in the ED and she was transferred to the MICU for monitoring if she were to require emergent EGD overnight. She was seen by GI in the emergency room who felt that she was stable to undergo an EGD within 24 hours. She was bolused with PPI in the ED and started on a drip with bowel movements taht were brown and guiac negative. She was transfused 2U of pRBC and fluid resuscitation with NS. She underwent an EGD which showed the Z-line at the GE junction was noted to be irregular and grade 2 esophagitis was present in the lower third of the esophagus. As a result of this equivocal EGD in the setting of melanotic stools, the decision was made to pursue a colnoscopy which showed Polyps in the colon, Grade 2 internal hemorrhoids, Normal mucosa in the colon, Otherwise normal colonoscopy to cecum. She then underwent a capsule endoscopy on [2128-7-16], the results of which are pending. She was encouraged to avoid NSAIDs given her recent bleeding. An oral PPI was initiated and she was discharged with a prescription for this medication. She will resume Aspirin on [2128-7-20]. . #. hypotension- Patient was hypotensive in the setting of an UGIB, she was volume resuscitated with 2 liters of NS and 2 units pRBC, but her blood pressure fluctuated drastically. She would frequently have SBP in 90s but with repeat measurements in the 100s-110s within 5 minutes. Throughout this time, she was asymptomatic and without any changes in mental status. . #. HTN- In the setting of acute blood loss, decision was made to hold blood pressure medications on admission to the ICU. She should follow up with her PCP and [Name9 (PRE) ] her medications after having her blood pressure checked. . #. HLD- Decision made to hold statin in the setting of acute GI bleed. . #. Breast CA- chronic condition without acute exacerbation. Continued on tamoxifen. . TRANSITIONAL ISSUES: - PCP should follow up to restart BP meds - Aspirin can re-started on [2128-7-20] - Follow-up with GI and PCP as noted in DC Planning Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze 2. Fluoxetine 40 mg PO DAILY 3. Fluticasone Propionate 110mcg 2 PUFF IH [Hospital1 ] 4. Fluticasone Propionate NASAL 1 SPRY NU [Hospital1 ] 5. Furosemide 20 mg PO DAILY 6. Lisinopril 5 mg PO DAILY 7. Metoprolol Succinate XL 50 mg PO DAILY 8. OxycoDONE (Immediate Release) 5 mg PO Q4-6H PRN pain 9. Potassium Chloride 20 mEq PO QD ON MONDAY, WEDNESDAY, FRIDAY Duration: 24 Hours Hold for K > 4.5 10. Simvastatin 20 mg PO DAILY 11. Tamoxifen Citrate 20 mg PO DAILY 12. Aspirin 81 mg PO DAILY 13. coenzyme Q10 NF 100 mg Oral qd 14. Centrum Silver NF (multivitamin-minerals-lutein;<br>mv with min-lycopene-lutein;<br>mv-min-folic acid-lutein) Oral qd 15. Fish Oil (Omega 3) 1000 mg PO BID 16. tolnaftate NF 1 % Topical qd Discharge Medications: 1. Fluoxetine 40 mg PO DAILY 2. Fluticasone Propionate 110mcg 2 PUFF IH [Hospital1 ] 3. Fluticasone Propionate NASAL 1 SPRY NU [Hospital1 ] 4. Tamoxifen Citrate 20 mg PO DAILY 5. Pantoprazole 40 mg PO Q24H RX pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 6. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze 7. Amoxicillin [2115] mg PO PREOP before dental procedures 8. Centrum Silver NF* (multivitamin-minerals-lutein;<br>mv with min-lycopene-lutein;<br>mv-min-folic acid-lutein) 0 ORAL QD 9. coenzyme Q10 NF 100 mg Oral qd 10. Fish Oil (Omega 3) 1000 mg PO BID 11. Lisinopril 5 mg PO DAILY 12. Metoprolol Succinate XL 50 mg PO DAILY 13. OxycoDONE (Immediate Release) 5 mg PO Q4-6H PRN pain 14. Potassium Chloride 20 mEq PO QD ON MONDAY, WEDNESDAY, FRIDAY Duration: 24 Hours Hold for K > 4.5 15. Simvastatin 20 mg PO DAILY 16. tolnaftate NF 1 % Topical qd Discharge Disposition: Home Discharge Diagnosis: GI Bleed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [Known lastname ], You were admitted to the hospital because you had a gastrointestinal bleed. The loss of blood caused you to have low blood pressure. You were given intravenous fluid and two units of blood to replace the blood that you lost. At the time of discharge from the hospital, your blood counts (hemoglobin and hematocrit) had increased and your blood pressure returned to [Location 213]. You had three tests to look for the source of bleeding: an upper endoscopy, a colonoscopy, and a capsule study. The upper endoscopy was normal. The colonoscopy did not find a source of bleeding, but did find polyps in your colon, which will need to be removed. The capsule study is in progress and you will need to follow up with your gastroenterologist for the results. You will need to follow up with your primary care doctor and a gastroenterologist. We have made those appointments for you. It was a pleasure to participate in your care. Followup Instructions: Department: BIDHC [Location (un) ] When: THURSDAY [2128-7-22] at 10:30 AM With: [First Name8 (NamePattern2) 1037] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 3329] Building: [Location (un) 3966] ([Location (un) 55], MA) [Location (un) 551] Campus: OFF CAMPUS Best Parking: Free Parking on Site This is a follow up appointment for your hospitalization. You will be reconnected with your primary care provider after this visit. Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [2128-7-28] at 2:00 PM With: [First Name8 (NamePattern2) ] [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 [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292*]	[ "V42.2", "233.0", "211.3", "272.0", "401.9", "V45.81", "427.31", "285.1", "276.52", "V15.82", "455.0", "V58.66", "530.19", "578.9" ]	icd9cm	[ [ [] ] ]	[ "45.13", "45.19", "45.23" ]	icd9pcs	[ [ [] ] ]	9205, 9211	4857, 7185	303, 339	9264, 9264	3501, 3501	10397, 11402	2197, 2240		8281, 9182		9232, 9243		7371, 8258			9415, 10374				4488, 4834							2255, 3482																		7206, 7345						241, 265													367, 1683						3517, 4472				9279, 9391						1705, 1999	2015, 2181
17,413	128,695	20231+57133	Discharge summary	report+addendum	Admission Date: [2135-9-21] Discharge Date: [2135-9-27] Date of Birth: [2082-2-7] Sex: M Service: MICU HISTORY OF PRESENT ILLNESS: The patient is a 63-year-old Spanish-speaking gentleman with a history quadriparesis following a cervical crush injury approximately 10 years ago, history of tracheostomy at time of cervical crush injury, history of decannulation of tracheostomy, history of interstitial lung disease times 10 to 15 years of unknown etiology, and chronic obstructive pulmonary disease who was transferred from [Hospital 1562] Hospital on [2135-9-21] to the [Hospital1 69]. The patient was in a good state of health until approximately 10 years ago when he had a crush injury to his neck resulting in quadriparesis. At that time, he was working underneath a motor vehicle when its support slipped. This resulted in quadriparesis with a prolonged hospital course, prolonged ventilation dependence necessitating tracheostomy placement. Shortly after his original injury, the patient's tracheostomy was decannulated, and he was able to breathe independently. In the intervening years, he had a history of multiple recurrent pneumonias and bronchial infections. He was recently admitted to [Hospital 1562] Hospital on [2135-9-11] with a chief complaint of neck pain and abdominal pain. The patient has a history of chronic constipation requiring Fleet enemas every other day. Secondary to his abdominal pain and bloating, he is unable to tolerate his oral pain medication for his chronic neck pain. During that admission, he also developed bronchitis resulting in a chronic obstructive pulmonary disease flare. For the bronchitis, he was started on clindamycin, ciprofloxacin, and prednisone. A sputum sample from [9-9] also showed yeast. The patient was started on Diflucan. On [2135-9-12], the patient had an episode of respiratory distress while at [Hospital 1562] Hospital resulting in decreased oxygen saturations on 3 liters nasal cannula oxygen to the low 80s. He was transferred from the Medicine floor to the Intensive Care Unit at [Hospital 1562] Hospital where he was intubated for hypercapnic respiratory failure. Prior to intubation, the patient's chronic opiate use was attempted to be reversed with Narcan with only transient improvement in his respiratory status. Arterial blood gas at the time of intubation was a pH of 7.27, PCO2 of 62, PO2 of 115, and bicarbonate of 28. During his Intensive Care Unit admission, he completed a 7-day course of ciprofloxacin and clindamycin. However, at [Hospital 1562] Hospital, the Intensive Care Unit staff felt it difficult to wean the patient from the ventilator. This was felt to be multifactorial in nature secondary to the patient's history of hypercapnia from chronic obstructive pulmonary disease flare, neuromuscular weakness from his underlying quadriparesis, as well as poor lung reserve from his history of interstitial lung disease. Therefore, he underwent tracheostomy and percutaneous endoscopic gastrostomy tube placement on [2135-9-19]. During the [Hospital 228] hospital course at [Hospital 1562] Hospital, the Pulmonary staff noted abnormalities on his chest x-rays including bilateral pleural effusions. A chest computed tomography was performed at [Hospital 1562] Hospital with evidence of pleural thickening and loculated pleural effusions bilaterally. Also noted was calcified lung parenchyma seen in the apices with retraction consistent with chronic lung disease. In light of these abnormalities, the patient's case was discussed with Dr. [First Name4 (NamePattern1) 951] [Last Name (NamePattern1) 952] (a thoracic surgeon a [Hospital1 1444]). Therefore, the patient was transferred to [Hospital1 69] on [2135-9-21] in order to undergo open lung biopsy. The end goal was to establish a diagnosis or etiology for his interstitial lung disease. PAST MEDICAL HISTORY: 1. Cervical spine injury at level C5; resulting in quadriparesis approximately 10 years ago (status post cervical crush injury). 2. Chronic obstructive pulmonary disease. 3. Interstitial lung disease times 10 to 15 years; etiology never characterized. 4. Chronic pain; status post crush injury with intrathecal pump containing morphine, baclofen, and clonidine. 5. Hypertension. 6. Gastritis. 7. Depression. 8. History of recurrent bronchial and pneumoniae infections. 9. History of tracheostomy; status post initial cervical spine injury. 10. Sleep apnea (on [Hospital1 ]-level positive airway pressure at night). 11. Neurogenic bladder requiring suprapubic Foley. 12. Chronic constipation. MEDICATIONS ON ADMISSION: (Medications prior to admission included) 1. Elavil 75 mg by mouth at hour of sleep. 2. Fleet enemas every other day. 3. Zoloft 200 mg by mouth once per day. 4. Trazodone 100 mg by mouth once per day. 5. OxyContin 40 mg by mouth twice per day as needed (for pain). 6. Oxygen 2 liters via nasal cannula. 7. Prednisone (admits to being tapered). 8. Albuterol meter-dosed inhaler. 9. Atrovent meter-dosed inhaler. 10. Flovent 110-mcg inhaler 2 puffs inhaled twice per day. 11. Intrathecal pump containing morphine, baclofen, and clonidine. ALLERGIES: The patient has a reported allergy history of ORAL BACLOFEN; however, please noted that baclofen is a component of his intrathecal pump and he tolerates this without a reaction. SOCIAL HISTORY: The patient is a former 40-pack-year tobacco smoker. He quit smoking in [2118]. His is primarily Spanish-speaking. He is married. He is confined to a chair and is dependent in all of his activities of daily living. CODE STATUS: The patient is a full code. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination upon admission revealed the patient's temperature was 97.2 degrees Fahrenheit, his blood pressure was 128/63, and his heart rate was 66. Ventilator setting on continuous positive airway pressure with pressure support tidal volume was 480 to 550, his respiratory rate was 14 to 19, and his oxygen saturation was 97% to 100% on these settings with a pressure support of 12, positive end-expiratory pressure of 5, FIO2 of 0.40. General appearance revealed the patient was a well-developed obese gentleman who was depressed in appearance with a flat affect. In no acute distress. Head, eyes, ears, nose, and throat examination revealed left internal jugular central venous line was in place. No erythema, edema, or purulent discharge from the internal jugular site. Right neck with multiple ecchymotic lesions. Otherwise, normocephalic and atraumatic. Pupils were equal, round, and reactive to light and accommodation. The oral mucosa were moist. The neck was supple. No masses or lymphadenopathy. Lung examination revealed coarse breath sounds anterolaterally with scattered rhonchi. Cardiovascular examination revealed a regular rate and rhythm. Normal first heart sounds and second heart sounds were auscultated. No murmurs, rubs, or gallops. The abdomen was obese, soft, nontender, and nondistended. Quiet bowel sounds. Positive percutaneous gastrostomy tube site. No evidence of erythema, edema, or purulent discharge around percutaneous endoscopic gastrostomy tube site. Genitourinary examination revealed positive suprapubic Foley catheter was in place. Extremity examination revealed 2+ pitting edema to the mid thighs bilaterally. PERTINENT LABORATORY VALUES ON PRESENTATION: Pertinent laboratories revealed complete blood count on admission with a white blood cell count of 8.1, his hemoglobin was 10.6, his hematocrit was 32.2, and his platelets were 351. Coagulation profile revealed his prothrombin time was 13.6, his partial thromboplastin time was 24.1, and his INR was 1.2. Serum chemistry revealed the patient's sodium was 136, potassium was 3.5, chloride was 97, bicarbonate was 34, blood urea nitrogen was 14, creatinine was 0.1, and blood glucose was 148. Calcium was 8.1, phosphorous was 4.2, and magnesium was 2.4. Liver function tests revealed his ALT was 98, his AST was 35, his alkaline phosphatase was 74, his amylase was 69, his lipase was 80, and his total bilirubin was 1. His total protein was 5.5. Albumin was 3.1. Globulin was 2.4. Urinalysis showed large blood, trace ketones, and 4+ urobilinogen. Negative leukocyte esterase and nitrites. Microanalysis revealed 3 to 5 red blood cells, 0 to 2 white blood cells, and occasional bacteria. Urine culture grew greater than 100,000 enterococcus. PERTINENT RADIOLOGY/IMAGING: Studies available from [Hospital 1562] Hospital included an abdominal x-ray from [2135-9-11] with very few air/fluid levels present within nondilated small bowel loops. No free air was identified. No abnormal masses or abnormal calcification was seen. A chest computed tomography without contrast on [2135-9-5] at [Hospital 1562] Hospital showed pleural thickening with loculated pleural fluid present bilaterally. Calcified lung parenchyma seen in both apices with retraction; consistent with chronic lung disease. Diffuse air space and interstitial changes in both lungs could represent a combination of acute or acute-on-chronic changes. There were multiple enlarged mediastinal lymph node, the largest of which pretracheal at 1.5 cm. Electrocardiogram from [2135-9-12] revealed a normal sinus rhythm at 80 beats per minute, normal axis, and a right bundle-branch block. There was a Q wave noted in lead III. No ST-T wave changes when compared to [2135-9-6] study. CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: 1. RESPIRATORY FAILURE ISSUES: It was felt that the patient's respiratory failure and prolonged ventilator dependence was likely multifactorial in nature. Namely, this was most likely contributed to by his hypercapnia secondary to his chronic obstructive pulmonary disease flare, his neuromuscular diminished strength secondary to his cervical spine injury, as well as poor lung reserve secondary to his interstitial lung disease. His airway mechanics were assessed via upright and supine studies. Upright, his negative inspiratory force was negative 32 and his vital capacity was 410. Supine his negative inspiratory force was negative 42 with a vital capacity of 500. The patient was slowly weaned from ventilation; primarily via decrease in his level to pressure support. He was continued wit aggressive pulmonary toilet and Atrovent and albuterol meter-dosed inhalers. He was admitted on high-dose steroids which were initiated at the outside hospital. These were tapered during this hospitalization. He was able to tolerate weaning to a tracheostomy collar mask on [2135-9-25]. A venous blood gas on tracheostomy collar mask showed adequate oxygenation and ventilation. In light of the patient's history of persistent bilateral pleural effusions, an echocardiogram was ordered to assess for a possible cardiac component to his pulmonary edema. At the time of this dictation, the results of this study were still pending. 2. INTERSTITIAL LUNG DISEASE ISSUES: On original admission, we were unable to get a full occupation, travel, and social history on the patient secondary to his depressed state and flat affect and nonparticipation in the history and physical. His occupational history was discussed with his wife who reported that the patient had previously worked as a chemical and insecticide sprayer. However, it was unclear if this contributed to his development of interstitial lung disease. Although the differential diagnosis for interstitial lung disease is extremely broad, the patient's chest imaging was highly suggested of a upper lobe predominant process. This is more commonly due to sarcoid, silica, or coal exposure. Ideally, the patient should undergo high-resolution computed tomography scanning when he is stable off the ventilator. In light of his underlying quadriparesis, it was felt that pulmonary function tests would not be revealing as the patient would likely have evidence of an obstructive process secondary to longstanding quadriparesis. In order to rule out a rheumatologic cause of his interstitial lung disease, antinuclear antibody and rheumatoid factor laboratory values were evaluated. These were both negative. The presence of the ground-glass, in addition to fibrotic and calcified changes on his computed tomography scan, were highly suggestive of an acute-on-chronic process. In light of the presence of both ground-glass as well as fibrotic and calcified changes on his computed tomography scan, it was felt that the patient was most likely suffering from an acute-on-chronic process in terms of his interstitial lung disease. Therefore, there a possibility that an open lung biopsy; particularly a biopsy of an acutely inflamed or active area, could contribute much to understanding the etiology of his interstitial lung disease. Therefore, the patient underwent an open lung biopsy on [2135-9-23]. The patient tolerated the procedure quite well. He was readmitted to the Medical Intensive Care Unit with a chest tube drain in place. He was able to have the chest tube removed on [2135-9-26]. He tolerated this well. At the time of this dictation, the tissue biopsy sample showed a Gram stain with 2+ polymorphonuclear leukocytes, no antineutrophil cytoplasmic antibody organisms. Tissue culture had no growth. Anaerobic culture was still pending. An acid-fast smear was negative for acid-fast bacilli. Acid-fast culture was still pending. A fungal culture showed no fungus isolated. Additionally, there were no fungal elements on potassium hydroxide smear. Studies for Legionella were negative. Immunofluorescent staining for pneumocystis carinii pneumonia were also negative. Further discussion of the patient's laboratory and imaging findings with the Pulmonary staff led us to the opinion that the patient's interstitial lung disease was most likely secondary to silicosis; however, this was a clinical diagnosis, and ultimately the final pathology should be followed up on. 3. DELIRIUM ISSUES: Status post biopsy, the patient had a waxing and [Doctor Last Name 688] mental status. A Psychiatry consultation was obtained. They felt the patient's presentation was consistent with delirium. He was evaluated with a head computed tomography which was negative for any acute intracranial bleed or other intracranial process. Thyroid-stimulating hormone levels were checked and were normal. The patient's outpatient psychiatric medications including Zoloft, trazodone, and Elavil were held. These can be reinstituted once his mental status is stable at his baseline. At the time of this dictation, the patient's mental status was much improved. 4. HYPERTENSION ISSUES: Upon admission, the patient was on a regimen on clonidine patch, hydralazine, and captopril. Due to the effects of rebound hypertension with clonidine and hydralazine, the patient's clonidine and hydralazine were discontinued while he was in a monitored Intensive Care Unit setting. His captopril dose was increased and should be titrated up further as needed for adequate blood pressure control. 5. GASTRITIS ISSUES: The patient was continued on his outpatient proton pump inhibitor dose. 6. CHRONIC PAIN ISSUES: The patient was continued on his intrathecal pump as well as morphine sulfate for breakthrough pain. 7. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient was tolerating tube feeds at goal. He was fitted with a Passey Muir valve by the Speech and Swallow Department. In light of previous Speech and Swallow evaluations at [Hospital 1562] Hospital, the patient will be undergoing a video swallow examination on [2135-9-27]. The results of that evaluation were still pending. 8. INFECTIOUS DISEASE ISSUES: The patient had a low-grade temperature on [2135-9-26]. He was pan-cultured. The results of this culture was pending at the time of this dictation. The patient's left internal jugular central venous line was removed. Intravenous access was reestablished with a right femoral line. He was not started on any antibiotic therapy. The results of his cultures will be followed up by the accepting Medicine team. 9. CODE STATUS ISSUES: The patient is a full code. 10. COMMUNICATION ISSUES: The patient's plan of care was discussed extensively with his wife [First Name8 (NamePattern2) 1787] [Name (NI) 21006]). She serves as his primary health care decision maker when the patient is unable to make decisions for himself. The remainder of the patient's Discharge Summary including his condition on discharge, discharge status, discharge diagnoses, discharge medications, as well as follow-up plans will be dictated as a separate Addendum to this report. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8037], M.D. [MD Number(2) 8038] Dictated By:[Last Name (NamePattern1) 54337] MEDQUIST36 D: [2135-9-27] 16:01 T: [2135-9-27] 16:06 JOB#: [Job Number 54338] Name: [Known lastname 10104], [Known firstname 10105] Unit No: [Numeric Identifier 10106] Admission Date: [2135-9-21] Discharge Date: [2135-10-3] Date of Birth: [2082-2-7] Sex: M Service: [Location (un) 571] CONCISE SUMMARY OF HOSPITAL COURSE SINCE PREVIOUS DISCHARGE SUMMARY: 1. Pulmonary: On transfer to the general medicine floor from the MICU the patient was completely stable from a pulmonary standpoint. He was maintained on a trach mask over his trach collar and demonstrated good oxygen saturations with a gradual wean in his FIO2. He was maintained on his nebulizer treatments. His lung biopsy results returned with an increased number of intra-alveolar macrophages and focal foreign body giant cell reaction to foreign material with mild focal interstitial fibrosis, which was considered consistent with silicosis interstitial lung disease. The patient's Solu-Medrol was switched to Prednisone 40 mg po q day and it is anticipated that the patient will undergo a two week taper of oral steroids. 2. Infectious disease: The patient was noted to have a fever to 102.2 on the morning following his transfer to the general medicine floor. The patient had blood cultures positive for two out of four bottles with gram positive cocci that eventually grew coag negative staph. He received a three day course of intravenous Vancomycin, but given subsequent blood cultures were negative the coag negative staph and two out of four blood culture bottles was considered to be likely contaminate. Once the patient's Vancomycin was stopped the patient's fever curved decreased and he was afebrile for four days prior to discharge. In addition to the coag negative staph in his blood cultures the patient was also noted to have enterococcus in his urine culture as well as on his femoral line that was pulled on [9-28]. Given that the patient was afebrile off antibiotics and showed no signs of symptoms of infection no antibiotics were started and the patient was monitored throughout the rest of his hospital course. 3. Neurology: On the morning following the [Hospital 1325] transfer to the medicine floor the patient had an episode of unresponsiveness in which he was noted to have roaming eye movements as well as a laceration of his tongue thought suffered secondary to tongue biting. Given the concern for seizure the patient had an electroencephalogram, which was read as negative for seizure focus. The patient had no further episodes of unresponsiveness throughout the remainder of his hospital course and reported that this episode was secondary to his typical panic attacks that he suffers when he is left alone. 4. .cardiovascular: The patient was noted to be hypertensive in the MICU and had his antihypertensive regimen changed to Captopril 25 mg t.i.d. The patient was hemodynamically stable throughout his stay on the general medicine floor. He was noted to have somewhat low blood pressures in the 90s to low 100s/50s and his Captopril dose was cut in half. He was otherwise noted to be stable from a cardiovascular standpoint. 5. Gastrointestinal: The patient was maintained on his proton pump inhibitor throughout his hospital stay. He had frequent regular bowel movements. 6. FEN: A speech and swallow evaluation was obtained on transfer to the medicine floor, which showed no evidence of aspiration, but fatigue with swallowing. . the patient was therefore started on a thin liquid pureed solid diet in addition to his tube feeds. It is hoped that the patient's diet will be gradually increased to regular food though it is likely that the patient's tube feeds will be required for some time. DISCHARGE CONDITION: Good. DISCHARGE STATUS: The patient is discharged to a pulmonary rehabilitation center where he will continue all medications as listed. DISCHARGE DIAGNOSES: 1. Interstitial lung disease, secondary to silicosis. 2. Quadriplegia status post C spine fracture. 3. Status post respiratory failure. 4. Chronic obstructive pulmonary disease. 5. Chronic pain. 6. Hypertension. 7. Depression/panic attacks. 8. Obstructive sleep apnea. DISCHARGE MEDICATIONS: 1. Albuterol one to two puffs q 4 hours prn. 2. Lansoprazole 30 mg po q day. 3. Captopril 12.5 mg po t.i.d. 4. Polyvinyl alcohol 1.4% one to two drops prn. 5. Miconazole powder b.i.d. 6. Colace 150 mg per 15 milliliters 10 ml b.i.d. 7. Lorazepam 0.5 mg and 0.25 to one tablet po q 4 to 6 hours prn anxiety. 8. Ipratropium 18 micrograms two puffs q.i.d. 9. Fluticasone 110 micrograms two puffs b.i.d. 10. Heparin 5000 units subq q 8 hours. 11. Acetaminophen 325 one to two tablets q 4 to 6 hours prn. 12. Morphine sulfate 1 to 5 mg intravenously or IM q one hours prn. 13. Prednisone 20 mg po q day times four days, then 10 mg po q day times four days, then 5 mg po q day times three days. FOLLOW UP: The patient will be followed by physicians at his pulmonary rehabilitation center. His wife is encouraged to call his primary care physician [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 10107] at [Telephone/Fax (1) 10108] to schedule an outpatient appointment. [First Name11 (Name Pattern1) 904] [Last Name (NamePattern4) 1369], M.D. [MD Number(1) 1370] Dictated By:[Last Name (NamePattern1) 10109] MEDQUIST36 D: [2135-10-3] 07:38 T: [2135-10-3] 07:49 JOB#: [Job Number 10110]	[ "907.2", "344.00", "V44.0", "502", "518.81", "599.0", "996.69", "491.21", "515" ]	icd9cm	[ [ [] ] ]	[ "96.72", "33.28", "97.23", "96.6", "34.21", "97.41", "38.93", "33.39", "34.04" ]	icd9pcs	[ [ [] ] ]				20897, 21037				21058, 21336	21359, 22062				4733, 5482																							22074, 22677		9663, 20875																										164, 3966																3989, 4706	5499, 9628
62,733	166,015	38439	Discharge summary	report	Admission Date: [2130-1-28] Discharge Date: [2130-2-4] Date of Birth: [2072-10-21] Sex: M Service: [Year (4 digits) 662] Allergies: Haldol Attending:[First Name3 (LF) 2195] Chief Complaint: AMS Major Surgical or Invasive Procedure: intubation History of Present Illness: 57 year old male with history of insulin dependent diabetes mellitus, Hepatitis C s/p IVDU, Bipolar disorder, PTSD, hypertension, hypothyroidism who was found at home by his girlfriend altered, diaphoretic. Per records, girlfriend reported patient had slept all day yesterday, had not taken his insulin or any other medications recently. [Month (only) 116] have taken more morphine than he was supposed to and had run out of percocet. BS111. The patient was taken to [Hospital1 18] [Location (un) 620] where CT head non-contrast was negative, CXR showed infiltrates bilaterally. Patient was in respiratory distress and acute on chronic renal failure (Cr 5.2 up from baseline Cr2.0) so was transferred to [Hospital1 18] ED for V/Q scan to rule out pulmonary emboli, given the acuity of his symptoms and desaturations to 86%. He was given Vancomycin/Levofloxacin prior to transfer. . Of note, patient had a biopsy/removal of right lower extremity growth two weeks ago. And has a large erythematous, tender and indurated region on his left buttocks. . In the ED initial vital signs were not documented as patient reportedly combative. Patient was in respiratory distress and desaturating to 88% on nasal cannula. He responded somewhat better nonrebreather. Given the infiltrates on CXR, V/Q scan was not felt to be useful at this time. The patient underwent a repeat CXR which confirmed bilateral infiltrates; urine culture was sent and the patient was given Flagyl for ?aspiration and clindamycin for possible cellulitis/nec fasc. Surgery evaluated the patient's buttock induration and RLE biopsy site, felt there was low likelihood of nec fasc. ?ABG in the ED was 7.21/49/76/21 and lactate 1.0. Prior to transfer to the [Hospital1 18] [Hospital Ward Name 516], patient became extremely combative, did not respond to Haldol 5/Ativan 2, requiring four security guards to restrain and was ultimately intubated, on Fentanyl/Versed initially and switched to Propofol but resumed on Fent/Versed when he became hypotensive. He received 1L lactated ringers en route. . On arrival, patient intubated, sedated but opens eyes to noxious stimuli . Review of Systems: (+) Per HPI (-) Unable to obtain as patient intubated. . Past Medical History: Past Medical History (per OMR): * Type II diabetes mellitus * Hepatitis C s/p IVDU, treated 12 years ago with ?interferon * Hperosmolar hyperglycemia with likely pancreatitis in [6-/2129] * Bipolar disorder * Depression * Hypertension * Gout * Hypothyroidism * COPD, early mild per PFTs [2129-3-1] * Chronic back pain * h/o Brain abscess, s/p treatment in [2119] * Psoriasis * Lichenoid keratosis of right thigh, biopsy confirmed * newly diagnosed liver [Male First Name (un) ] concerning for HCC * Cirrhosis Social History: Diabetes . Family History: 1ppd smoker X 20 years, heavy alcohol abuse in [2123] - ?unsure currently. No active IVDU, last used 12 years ago. Moved from [Location (un) 2848] to [Location (un) 86] area this year. Previously worked in roofing. . Physical Exam: Physical Exam on admission . GEN: NAD VS: T100.3, HR96, BP123/75, RR24, 92% on NRB --> Afebrile, HR86, BP99/55, RR24 --> 15, 100% on Assist Control, FiO2100%, PEEP 5, RR14, TV 500 HEENT: MMM, no nasopharynx lesions, neck is soft/supple, no cervical LAD CV: Regular rate and rhythm, normal S1/S2, no murmurs/gallops/rubs PULM: Bibasilar crackles, intubated, no wheezing/rhonchi/rales ABD: BS+, soft, NTND, no masses or HSM, no stigmata of chronic liver disease, obese and distended LIMBS: No LE edema, no tremors or asterixis, no clubbing; psoriatic plaques on bilateral arms, left hand > right. Tattoo on left upper extremity. Also with erythematous, warm, scarred over lesion on right thigh, borders marked. NEURO: CNII-XII nonfocal, strength 5/5 of the upper and lower extremities, reflexes 2+ of the upper and lower extremities, toes down bilaterally . On ICU discharge: . General: A+OX3, pleasant and cooperative, full insight into his medical condition HEENT: pupils 1mm bilaterally, MMM Neck: supple, no JVD, no LAD CV: RRR, no m/r/g appreciated Resp: clear to auscultation bilaterally Abd: distended but soft, +BS, mild RUQ tenderness on deep palpation, no R/G, neg [Doctor Last Name ]??????s , no palpable HSM Ext: wwp, no LE edema, DP 2+, nail pitting Skin: psoriatic lesions on dorsum of hands Neurologic: no gross deficit Pertinent Results: Admission Labs: Na 135, K 4.9, Cl 100, Bicarb 20.8, BUN81, Cr 5.2 WBC 15.5 H/Hct 11.8/34.4 . ALT 462 ALT 109 AP 142 TBili 1.46 Lipase 63 INR 1.1 . UTox + aspirin, negative APAP . pH7.19/pCO2 46/pO2118/HCO318 Assist control, FiO2 100%, Rate 14, TV 500, PEEP 5 . EKG: Sinus tachycardia, HR92, left axis, normal intervals, QTc 434, poor Rwave progression. Poor baseline but no ST elevations or Twave inversions. TWF in aVF. . Discharge Labs: [2130-2-4] 06:15AM WBC-6.6 RBC-3.34* Hgb-10.7* Hct-31.8* MCV-95 Plt Ct-185 [2130-2-4] 06:15AM Glucose-93 UreaN-25* Creat-1.5* Na-137 K-3.8 Cl-102 HCO3-26 [2130-2-1] 04:43AM ALT-90* AST-147* LD(LDH)-483* AlkPhos-104 TotBili-1.2 Imaging: CXR [2130-1-28]- Compromised secondary to diminished lung volume. Cephalization but no frank interstitial edema. Mediastinum grossly unremarkable. Cardiac size likely normal but appears exaggerated due to low lung volumes. No effusion, no pneumothorax. CXR [2130-1-29] - ETT now in place, ~3cm above carina, orogastric feeding tube also in place. Cephalization with some interstitial edema still present. CXR [2130-1-31]: New right upper lobe and right basilar infiltrates, suspicious for infection. Microbiology: [2130-1-31] Blood Cultures: Pending, no growth to date at time of discharge [2130-1-28] Sputum Culture: Pan-sensitive E.coli [2130-1-31] Wound Culture: Rare growth of S.aureus and CoNS Brief Hospital Course: 57 year old male with history of Type II diabetes, Hepatitis C s/p IVDU, recently diagnosed liver [Male First Name (un) ] concerning for HCC, recent lower extremity excisonal biopsy for melanoma, Bipolar disorder, PTSD, hypertension, hypothyroidism, who was found at home by his girlfriend altered, diaphoretic, hypoxic. . # Altered mental status: Initially likely multifactorial from hypoxemia + intoxications. Patient was on multiple centerally acting medications at home. Per his PCP he has chronic pain syndrome since an MVA years ago and has lately required increasing opiate doses d/t abdomninal pain attributable to newly diagnosed liver [Male First Name (un) ]. Per his PCP and per the patient no recent history of alcohol or other substance abuse. Pt has known cirrhosis but his liver functions were stable and he had no asterexis thus hepatic encephalopathy was not thought likely. He did present with acute on chronic renal failure but degree of uremia was not thought sufficient to cause encephalopathy. Pt has known hypothyroidism and TSH = 11 on admission but had no other features of myxedema. RPR was negative. Serotonin syndrome was considered in view of pt's home meds but thought unlikely in the lack of impressive regidity. Pt was intubated and sedated on admission d/t hypoxia responsive to non-rebreather mask in the setting of severe combativeness. He became severely agitated after weaning from sedation and extubation on [1-31] with little response to IV Diazepam or precedex. Thiamin was started. Psychiatry was consulted in view of patient's [Doctor First Name ] psychiatric history and agreed with diagnosis of delirium, and per their recs thorazine was started with excellent response with subsequent complete resolution of his delirium. Thorazine was then discontinued and Seroquel 25/25/100 and Celexa 20 were started. These medications should continue to be titrated up in the outpatient setting. . # Respiratory distress: CXR on admission more suggestive of volume overload than infectious process. BNP was elevated. Pt was diuresed with lasix. Echo was limited but showed no gross evidence of HF. Patient had leukocytosis with mild left shift which later resolved. He has a known malignancy, likely HCC, and is thus at risk for thromboembolic disease but did not have signs of DVT or EKG suggestive of right heart strain. Pt was intubated on admission d/t hypoxia and combativeness, andlevofloxacin was started for possible pneumonia on [1-29]. He was Extubated [1-31] in AM, and later became hypoxic and febrile with repeat CXR showing new upper and lower infiltrates on the right. Given fever, SOB, and new findings on CXR, Levofloxacin was stopped and he was started on empiric coverage with Vanc/Cefepime. Sputum culture grew pan-sensitive E.Coli. Pt subsequently well saturated on room air and afebrile. He was transitioned back to Levofloxacin and completed an 8 day course prior to discharge. . # Right thigh cellulitis s/p biopsy: Per pathology specimen from shin consistent with malignant melanoma in situ with extension to biopsy margins. Most recent biopsy from thigh notes only lentiginous growth. Patient had a prior wound swab with heavy pan-sensitive Staph Aureus growth and was on Keflex prior to admission. Swab [1-31] showed only rare growth. Patient was initially treated with Clindamycin, which was stopped when Vancomycin was started for VAP as above. This was transitioned back to Clindamycin on [2130-2-3], and he will need to complete a total of ten days of antibiotics, last day=[2130-2-7]. Wound in right thigh significantly improved with reduction of swelling, erythema and warmth. Patient will need close post-dicharge follow up for his melanoma, which he prefers to pursue at [Hospital1 18]. . # Acute on Chronic renal failure: Cr = 2.0 at baseline. 3.5 on admission. Likely ATN vs. pre-renal process [3-8] reduced CO in the setting of volume overload vs. tubular injury from rhabdomyolisis per elevated CPK on admission. Pt was treated with lasix and adequate urine output was maintained. Creatinine improved from 3.5 to 1.5 on ICU discharge. Calcitriol was continued and all meds were renally dosed. . # Hypothyroidism: Stable as of [2129-7-5] although patient known to be non-compliant. TSH on this admission 11. Levothyroxine was increased to 200mcg. Will need recheck TSH in the outpatient setting. . # Elevated CPK: Rhabdomyolisis from lying on the floor for a long time prior to being found down. NMS or Serotonin Syndrome less likely as per discussion above. CPK subsequently trended down. . # Macrocytic anemia: Patient denies recent alcohol abuse as does his PCP. [Name Initial (NameIs) ] [3-8] underlying liver disease as elevated PT/INR with elevated LDH also indicate underlying liver disease. B 12/folate normal. . # Hepatitis C s/p IVDU,k suspected HCC: Reportedly treated 12 years ago, unclear duration and type of medications. Per imaging has cirrhosis and suspected [Male First Name (un) ], likely HCC given elevated AFP. Has hypoalbuminemia, mildly elevated INR also concerning for ongoing liver disease. No ascites per US. Pt will need oncology follow-up post discharge. . # Tinea cruris in buttock: Treated with topical miconazole cream . # Type II diabetes mellitus: Patient was treated with an insulin sliding scale alone while in-house, with blood sugars <200. He was not discharged on Lantus as a result. He was instructed to check his blood sugars at home and call his [Last Name (un) ] doctor, Dr.[First Name (STitle) ], when blood sugars rise above 200 so that this medication can be re-started. . # Bipolar disorder/Depression: Seroquel and Celexa re-started at reduced doses as above. Further titration per outpatient psychiatry. . # Gout: Stable, no acute flare, allopurinol re-started on discharge. . # Hypertension: All medications re-introduced after discharge from the ICE and continued at discharge. . # Psoriasis: Stable, visualized on hands . # Chronic pain: In the ICU did not complain of back pain. Did have RUQ pain attributed to his liver [Male First Name (un) ]. Home ultram and flexeril were held d/t AMS. Got IV Morphine PRN for pain. On ICU discharge day started on Acetaminophen 325 mg PO/NG Q6H:PRN pain, OxycoDONE (Immediate Release) 5 mg PO/NG Q4H:PRN pain which he did well with. He is being discharged on Percocet alone. . # DVT ppx: Heparin SQ # Communication: With girlfriend [First Name5 (NamePattern1) 8513] [Name (NI) 20179] [Telephone/Fax (1) 85578]) Medications on Admission: med rec'ed with PCP: . - percocet 325 TID:PRN pain - Lantus 42 units QD - Flexeril 10mg TID - Tramadol 100mg QD - Calcitriol 0.25 mcg [Hospital1 ] - Amlodipin 10mg QD - Carisoprodol 350mg TID:PRN muscle spams - SEROQUEL 150 XR QD - Lisinopril 40mg QD - Trazodone 100mg [2-5] Tab QHS:PRN sleep - Morphine Sulphate XR 15mg [Hospital1 ] - Atenolol 100mg QD - Levoxil 150 mcg once daily - Allopurinol 100mg QD - HCTZ 25mg QD - Flomax 0.4mg QD - Celexa 40mg QD Discharge Medications: 1. levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): In the morning and at noon. Disp:60 Tablet(s) Refills:2 4. quetiapine 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 8. clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 4 days. Disp:32 Capsule(s) Refills:0 9. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 10. atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day. 11. allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day. 12. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 13. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [7-12] hours as needed for pain. Disp:40 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Pneumonia Cellulitis Delirium (confusion caused by medical problems) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the ICU with somnolence and trouble breathing, as well as a skin infection on your right thigh. You were intubated for a short period of time and received medications for agitation. You were also treated with antibiotics for a pneumonia and a cellulitis on your right leg. Your psychiatry medications were changed to a lower dose of Seroquel and a lower dose of Celexa, which you tolerated well. You will need to follow-up closely with your outpatient psychiatrist so that your Celexa can be increased back up to your usual dose. You received your last dose of antibiotics for your pneumonia today. You will need to continue to take Clindamycin until [2130-2-7]. If you develop diarrhea while taking this medication please call your primary care doctor immediately. You did not require long-acting insulin while you were on the general [Year/Month/Day ] floor, and you should not resume your home dose of Lantus when you go home. Your blood sugars will likely begin to increase when you go home, though, so you should continue to check your blood sugars regularly and call Dr.[First Name (STitle) ] when your sugars increase above 200. You were on multiple pain medications when you came into the hospital, which may have contributed to your somnolence. You are being discharged on Percocet alone; your long-acting Morphine, Flexeril, and Tramadol have been held. Please talk to your primary care doctor [First Name (Titles) ] [Last Name (Titles) 9457] this medication. The dose of your thyroid medication was changed during this hospital stay. Followup Instructions: Please follow-up with your primary care doctor within 2-3 days of discharge; his contact information is below. Also follow-up closely with your psychiatrist to adjust your medications. PCP: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. Location: [Hospital1 ] [First Name (Titles) 3860] [Last Name (Titles) 662]-[Location (un) ]/[Location (un) ] Address: [State 21595],STE LL2, [Location (un) ],[Numeric Identifier 9310] Phone: [Telephone/Fax (1) 17753]	[ "E879.8", "584.5", "250.00", "V58.67", "070.70", "285.9", "348.31", "571.5", "682.6", "496", "724.2", "338.29", "728.88", "428.21", "486", "401.1", "309.81", "296.80", "V49.87", "428.0", "110.9", "998.59", "518.81", "244.9" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.04" ]	icd9pcs	[ [ [] ] ]	14467, 14473	6202, 6540	288, 301	14585, 14585	4764, 4764	16349, 16872	3160, 3391		13287, 14444		14494, 14564		12794, 13264			14735, 16326				5204, 6179							3406, 4745																					2507, 2566			245, 250													329, 2488						4780, 5188				14600, 14711						2588, 3115	3131, 3144
52,249	139,181	35698	Discharge summary	report	Admission Date: [2164-1-3] Discharge Date: [2164-1-11] Date of Birth: [2084-7-29] Sex: M Service: MEDICINE Allergies: Ambien Attending:[First Name3 (LF) 2745] Chief Complaint: melena Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy [2164-1-3] History of Present Illness: 79 y/o M with PMHx of Afib & CAD s/p AVR with St. [Male First Name (un) 1525] mechanical on coumadin who was discharged from [Hospital1 18] surgical service on [2163-12-29] presented to [Hospital ] hospital on [2164-1-2] with GI bleed. Pt initially presented in [12-9] to [Hospital ] hospital with abd distension, CT revealed extraluminal intraperitoneal air consistent with duodenal perforation communicating with his common bile duct. Repeat imaging on [12-11] demonstrated midepigastric collection 11.5 x 11 cm tracking into the porta hepatis. Pt underwent a CT-guided abscess drainage by IR on [12-13] and pigtail catheter was left in place. He was transferred to [Hospital1 18] on [12-21] for further management. Pt underwent ERCP on [12-26] that was non-diagnostic and fluoro imaging revealed that pigtail catheter had migrated into subcutaneous tissue of the intra-abdominal wall. Pigtail catheter was removed and pt was discharged home with lovenox bridge to coumadin with plan for follow up abd CT in 3 wks. Pt returned home with VNA and was tolerating po without any abdominal pain. However, he reported multiple episodes of loose black stools and lightheadedness to his VNA who sent him into [Hospital ] Hosp for evaluation on [2164-1-2]. . Pt described multiple loose black stools with assoc lightheadedness and diaphoresis. Per OSH notes, BP was 90s/60s with HR in 60s and was mentating appropriately. He was guaic positive and initial hct was 28 and INR of 2.2. He received 2u FFP for elevated INR and was receiving first unit of prbcs on transfer. Per report, he was admitted to ICU where he underwent EGD that revealed CBD bleeding that was treated with local epinephrine injection. Pt was discussed with [Hospital1 18] GI & overnight intensivist before transfer to [Hospital1 18] for further management. . On arrival, pt was denying chest pain, shortness of breath, abd pain, N/V, palpitations, weakness, lightheadedness. Pt reports two days with 3-4 episodes of loose black stools with some associated lightheadedness, diaphoresis, nausea and one episode of non-bloody emesis. Last dose of lovenox on [2164-1-2] and po Coumadin on [2164-1-1]. . Review of sytems: (+) Per HPI (-) Denies fever, chills, cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, abdominal pain. No dysuria. Denied arthralgias or myalgias. Past Medical History: CAD s/p St. [Male First Name (un) 1525] mechanical valve placement [2146] HTN PUD AFib LBBB Hyperlipidemia Gout BPH Social History: Lives with wife in [Name (NI) 14663], MA. Retired fisherman. Remote history of smoking <5 yrs. Rare ETOH. Walks with a cane or walker. Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM Vitals: T: 97.1 BP: 119/50 P: 60 R: 20 O2: 98% on 2L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: RRR, muliple PVCs, harsh gr 2-3 SEM over LSB with prominent S2 Abdomen: soft, non-tender, non-distended, hyperactive bowel sounds, no rebound tenderness or guarding Ext: Warm, well perfused, 2+ pulses, no edema Guaic+ maroon stool in vault Pertinent Results: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2164-1-11] 06:55AM 30.0* [2164-1-10] 07:20AM 7.3 3.41* 10.6* 29.6* 87 31.1 35.9* 16.0* 300 [2164-1-9] 07:20AM 7.4 3.44* 10.5* 29.7* 86 30.5 35.2* 16.2* 272 [2164-1-8] 07:35AM 6.8 3.43* 10.4* 29.9* 87 30.3 34.7 16.5* 265 [2164-1-7] 08:15AM 5.8 3.43* 10.8* 30.0* 87 31.5 36.0* 16.5* 240 [2164-1-6] 04:56AM 5.9 3.25* 10.3* 28.4* 87 31.5 36.2* 16.9* 226 [2164-1-5] 10:00PM 28.5* [2164-1-5] 07:30AM 7.2 3.24* 10.2* 28.2* 87 31.5 36.2* 16.5* 209 [2164-1-4] 04:38PM 28.3* [2164-1-4] 05:00AM 6.3 3.13# 9.8# 27.0* 86 31.4 36.3* 16.3* 200 Source: Line-peripheral [2164-1-3] 11:23PM 27.4* [2164-1-3] 05:12PM 25.7* [2164-1-3] 11:03AM 25.6* 1 OF 4 Q6 [2164-1-3] 03:20AM 8.0 2.45# 7.8# 21.4#1 87 31.7 36.4 16.0* 230 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [2164-1-11] 06:55AM 26.4* 82.9* 2.6* [2164-1-10] 07:20AM 300 [2164-1-10] 07:20AM 22.8* 75.4* 2.2* [2164-1-9] 07:20AM 272 [2164-1-9] 07:20AM 19.4* 71.5* 1.8* [2164-1-8] 07:35AM 265 [2164-1-8] 07:35AM 17.3* 75.4* 1.6* [2164-1-7] 08:15AM 240 [2164-1-7] 08:15AM 16.2* 78.7* 1.5* [2164-1-6] 07:30PM 16.1* 76.2* 1.4* heparin dose: 1050 [2164-1-6] 12:45PM 16.5* 75.3* 1.4* [2164-1-6] 04:56AM 226 [2164-1-6] 04:56AM 17.3* 55.6* 1.6* [2164-1-5] 10:00PM 17.2* 28.7 1.6* [2164-1-5] 03:20PM 18.3* 81.3* 1.7* heparin dose: 1050 [2164-1-5] 07:30AM 209 [2164-1-5] 07:30AM 18.7* 141.31 1.7 [2164-1-4] 11:54PM 20.3* 91.0* 1.9* [2164-1-4] 04:38PM 19.1* 29.2 1.8* [2164-1-4] 05:00AM 200 Source: Line-peripheral [2164-1-4] 05:00AM 18.6* 30.3 1.7* Source: Line-peripheral [2164-1-3] 11:23PM 17.9* 30.5 1.6* [2164-1-3] 05:12PM 18.3* 31.5 1.7* [2164-1-3] 11:03AM 19.4* 32.9 1.8* [2164-1-3] 03:20AM 230 [2164-1-3] 03:20AM 20.9* 35.3* 2.0* . ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [2164-1-4] 05:00AM 35 38 230 58 63 1.0 Source: Line-peripheral [2164-1-3] 05:12PM 83 [2164-1-3] 11:03AM 62 [2164-1-3] 03:20AM 30 33 [Telephone/Fax (2) 81213].7 OTHER ENZYMES & BILIRUBINS Lipase [2164-1-4] 05:00AM 47 CPK ISOENZYMES CK-MB cTropnT [2164-1-3] 05:12PM 0.09 [2164-1-3] 11:03AM 0.10 [2164-1-3] 03:20AM 0.07 . [2164-1-10] 7:20 am SEROLOGY/BLOOD FINAL REPORT [2164-1-11] HELICOBACTER PYLORI ANTIBODY TEST (Final [2164-1-11]): POSITIVE BY EIA. (Reference Range-Negative). . Cardiology Report ECG Study Date of [2164-1-3] 4:33:48 AM Atrial fibrillation with mean ventricular rate 49. Left bundle-branch block with secondary repolarization abnormalities. Compared to the previous tracing of [2163-12-25] multiple abnormalities persist without major change. . [2163-12-26] ERCP: A single diverticulum was found at the major papilla. Major papilla was normal otherwise. Successful superficial cannulation of the biliary duct using a sphincterotome was performed using a free-hand technique. Deep cannulation of the common bile duct was unable to be accomplished after multiple attempts. Traction pre-cut sphincterotomy was performed, and again deep biliary cannulation was unsuccessful. Contrast medium was injected resulting in partial opacification. A 0.035in in diameter glidewire was unable to be advanced deep into the common bile duct. The common bile duct and common hepatic duct were opacified completely. The intraampullary portion of the common bile duct had a sharp S shape. A partial narrowing of the common hepatic duct was noted The right hepatic duct, left hepatic duct, and intrahepatic ducts were not obtained The cystic duct and gallbladder were opacified. . [2164-1-3] PORTABLE CXR Cardiomediastinal silhouette is stable including post-sternotomy, CABG. There is interval development of pulmonary edema, which is currently mild-to-moderate and may be related to the patient's history of multiple blood transfusions. There is small amount of left pleural effusion, although minimal amount of right pleural fluid cannot be excluded. . [2164-1-3] TTE: The left atrium is moderately dilated. The right atrium is moderately dilated. The estimated right atrial pressure is 10-20mmHg. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. There appears to be a sinus of Valsalva aneurysm. The ascending aorta is moderately dilated. The aortic arch is mildly dilated. A mechanical aortic valve prosthesis is present and generally appears well seated. The transaortic gradient is normal for this type of prosthesis. Trace 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 borderline pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. IMPRESSION: Normal left ventricular systolic function without regional wall motion abnormality. Moderate left ventricular hypertrophy. Well-seated bileaflet aortic valve replacement. Moderate mitral regurgitation. Probable sinus of Valsalva aneurysm. Comparison with prior echocardiographic studies is recommended (none available here). . [2164-1-3] EGD The previous sphincterotomy site was evaluated with a side-viewing scope. Evidence of previous sphincterotomy seen at the major papilla. A diverticulum was noted adjacent to the major papilla with a blood clot. No evidence of active bleeding was seen. 6 cc.Epinephrine 1/[Numeric Identifier 961] was injected at the sphincterotomy site for hemostasis with success. A gold probe was applied at the apex of sphincterotomy for hemostasis successfully. No evidence of active bleeding from the stomach. No evidence of active bleeding from the esophagus. Evidence of previous sphincterotomy seen at the major papilla. A diverticulum was noted adjacent to the major papilla with a blood clot. No evidence of active bleeding was seen. The site was injected with epinephrine and gold probe was applied at the apex of sphincterotomy for hemostasis successfully. Brief Hospital Course: #Acute blood loss anemia - Duodenal bleed referred from CBD s/p sphincterotomy. Hct 21.4% on admission. Coumadin was held and 3 units FFP given. Transfused a total of 4 units PRBC. Treated with octreotide gtt x 5 hours and IV PPI [Hospital1 ]. Underwent EGD [2164-1-3] and source treated with local epinephrine injection. Remained hemodynamically stable without recurrence of bleeding and with Hct stabilizing at ~30% despite resuming anticoagulation. He was stable for floor transfer on HD#2. Will continue on twice daily PPI and complete a 2-week course of augmentin/biaxin for + H.Pylori IgG as outpatient. Will have repeat Hct and INR 2 days after discharge. . #Mechanical AVR - The patient was seen in consultation by cardiology and heparin gtt was started on HD#2 after the source of UGIB was treated endoscopically. Coumadin was resumed on HD#3 after consulting with the GI team. Goal INR was targeted at 2.5-3.0 given his mechanical AVR and comorbid AFib and LV dysfunction. Heparin overlap was continued for 12 hours following achievement of a therapeutic INR. . #Troponin leak - The patient had an asymptomatic troponin leak (peak 0.10) on HD#1 without associated CK elevation or ishemic changes on EKG. Telemetry revealed known slow AFib with LBBB. TTE revealed normal left ventricular systolic function without regional wall motion abnormality, moderate LVH, well-seated bileaflet aortic valve replacement, and moderate mitral regurgitation. Troponin leak was attributed to demand ischemia in the setting of profound anemia. Consulting GI team approved starting aspirin 7 days after EGD but the patient refused, stating that his cardiologist had recommended that he not take ASA. He was instructed to discuss the risks and benefits of ASA therapy with his outpatient providers. . #Atrial fibrillation - Digoxin was discontinued in the setting of asymptomatic bradycardia. Per discussion with the patient's outpatient cardiologist, his bradycardia was a longstanding issue from which he has never been symptomatic. Anticoagulation was achieved with heparin and coumadin, as above. . #Gout - Allopurinol was continued. Flare in the right elbow and MCP's was treated effectively with colchicine and tylenol. . #Hypertension - Diazide was held initially in the setting of acute GIB and was not restarted upon discharge due to normotension. . #Hyperlipidemia - Atorvastatin was continued. Medications on Admission: Lipitor 10mg po daily Allopurinol 300mg daily Digoxin 125mcg daily Furosemide 20mg daily Omeprazole 20mg daily Biaxin 250mg [Hospital1 ] Augmentin 875mg [Hospital1 ] Coumadin 4 mg daily Lovenox 90mg sc BID Colchicine 0.6mg daily Diazide daily Discharge Medications: 1. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day. 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days. Disp:10 Tablet(s) Refills:0 4. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 5 days. Disp:10 Tablet(s) Refills:0 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:0 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day as needed for gout pain. Disp:30 Tablet(s) Refills:2 9. Warfarin 1 mg Tablet Sig: Five (5) Tablet PO once a day: Please have your coumadin level (INR) checked on Friday, [1-13] and await instructions from your physician about any change in dose. Disp:50 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Company 1519]/[Hospital1 8] VNA Discharge Diagnosis: 1) Acute blood loss anemia 2) Mechanical aortic valve replacement 3) Atrial fibrillation 4) H. Pylori gastritis 5) Gout 6) Hyperlipidemia Discharge Condition: Asymptomatic with stable vital signs. Discharge Instructions: You were admitted to the hospital with GI bleeding possibly related to the ERCP procedure on [12-26]. You had an upper endoscopy on [1-3] during which the source of bleeding was identified and treated. We recommended that you begin taking a low-dose aspirin to protect your heart, but you recalled having been told not to take aspirin. Please discuss the risks and benefits of aspirin therapy with your primary care physician and cardiologist. The following medication changes were recommended: 1) Please continue taking warfarin (coumadin) at a dose of 5 mg daily until instructed by your physician to change the dose. Please have your coumadin level (INR) checked on Friday, [1-13]. 2) Lovenox was discontinued due to bleeding. 3) Omeprazole was increased to twice daily due to the recent episode of bleeding. 4) Please continue taking clarithromycin (biaxin) and augmentin through Monday, [1-16]. 5) Digoxin was discontinued due to a low heart rate. 6) Diazide was discontinued due to normal blood pressure. Please have your coumadin level (INR) and red blood cell count (hematocrit) checked on Friday, [1-13], with the results to be faxed to the office of Dr. [Last Name (STitle) 78054] [Name (STitle) 78055] at [Telephone/Fax (1) 81214]. Please follow up with Dr. [Last Name (STitle) 78054] [Name (STitle) 78055] on Tuesday, [1-17] at 11:00 AM. Please call [Telephone/Fax (1) 79219] if you need to reschedule. Please follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 8573] on Wednesday, [1-18] at 3:30 PM. His office phone number is [Telephone/Fax (1) 58158] if you need to reschedule. Please call your physician or return to the Emergency Department if you experience fever, chills, sweats, dizziness, lightheadedness, chest pain, palpitations, cough, shortness of breath, abdominal pain, vomiting, diarrhea, bloody or dark stools, or leg swelling. Followup Instructions: Please have your coumadin level (INR) and red blood cell count (hematocrit) checked on Friday, [1-13], with the results to be faxed to the office of Dr. [Last Name (STitle) 78054] [Name (STitle) 78055] at [Telephone/Fax (1) 81214]. Please follow up with Dr. [Last Name (STitle) 78054] [Name (STitle) 78055] On Tuesday, [1-17] at 11:00 AM. Please call [Telephone/Fax (1) 79219] if you need to reschedule. Please follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 8573] on Wednesday, [1-18] at 3:30 PM. His office phone number is [Telephone/Fax (1) 58158] if you need to reschedule. Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2164-1-27] 10:15 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2832], MD Phone:[Telephone/Fax (1) 2833] Date/Time:[2164-1-27] 11:00 Completed by:[2164-1-12]	[ "426.3", "274.9", "427.31", "401.9", "041.86", "411.89", "272.4", "285.1", "V58.61", "518.83", "V45.81", "535.50", "V43.3", "E878.8", "998.11", "600.00" ]	icd9cm	[ [ [] ] ]	[ "44.43" ]	icd9pcs	[ [ [] ] ]	14218, 14289	10404, 12809	273, 317	14471, 14511	3678, 10381	16509, 17453	3108, 3126		13111, 14195		14310, 14450		12835, 13088			14535, 16486											3141, 3657																								227, 235					2599, 2788								345, 2581																2810, 2936	2952, 3092
24,785	174,027	46491	Discharge summary	report	Admission Date: [2167-10-20] Discharge Date: [2167-10-22] Date of Birth: [2087-10-1] Sex: M Service: SURGERY Allergies: Percocet Attending:[First Name3 (LF) 2777] Chief Complaint: Fall on BKA site Major Surgical or Invasive Procedure: none History of Present Illness: 80 year old male well known to our service who was recently discharged after getting a Right Below the knee amputation after he had a failed right lower extremity bypass graft with onset of ischemic rest pain and gangrene of his forefoot. Today during dialysis he had fallen out of bed. The fall that was unwitnessed. He also has been hypotension over the last 48 hours. The first episode of hypotension was during dialysis and his blood pressure medications have been held. Past Medical History: 1. CHF: diastolic & systolic HF with CRI, EF 40-45% in [1-13] and [5-14] 2. CAD s/p 2V-CABG [2161] 3. CVA: ([2154]) 3-4 days of slurred speech and right facial droop without residual symptoms. s/p CEA (documented however patient without memory of this procedure) 4. HTN 5. Hyperlipidemia 6. IDDM (retinopathy, nephropathy, neuropathy) 7. NSVT 8. Afib 9. PVD s/p R fem-[Doctor Last Name ] ([2154]), R 2nd toe amputation, gangrene L 1st toe s/p amp ([10-11]), angio with L SFA stenosis & ratty AT ([12-11]), CABG x 2, LLE AT angioplasty ([6-2]) 10. CRI (b/l around 2.9-3.1) 11. Colon ca s/p hemicolectomy 12. H/o diverticulosis 13. H/o angioectasia in stomach w/UGIB [3-/2161] and again [7-/2166] 14. Prostate ca (dx'd [2150]): s/p orchiectomy ([2150]), TURP ([2153]) & pelvic XRT ([2155]) with radiation 'proctopathy'. 15. Iron deficiency anemia on bone marrow aspirate ([2157]) 16. Interstitial lung disease w/mediastinal LAD & a negative CMA. (Differential diagnosis included burned out sarcoidosis versus interstitial pulmonary fibrosis versus malignancy.) s/p flexible bronchoscopy and cervical mediastinoscopy with biopsies ([5-9]) 17. Left cataract surgery [77]. UGIB [2-7] angioectasia ([3-8], [7-13], [5-14]) 19. CEA 20. Cervical mediastinoscopy with biopsies ([5-9]) Social History: Social history is significant for the absence of current tobacco use; he has a remote history of tobacco use but quit in his 20s. There is no history of alcohol abuse or illicit drug use. Patient is widowed and transferred from [Hospital3 1186]. He is a retired foreman for [Company 2676]. Family History: Father: DM, alcohol related death Mother: DM,passed away giving birth to 22nd child Daughter: macular degeneration Physical Exam: Physical Exam Vital Signs: T 97.0 HR 88 BP 121/95 RR 16 O2 Sat 97% on 2L NC General: No Acute distress Cardiovascular: Regular rate and rhythm Lung: clears to ausculation bilaterally Abdomen: soft nontender, nondistended Extremities: Right Below the knee amputation site: no oozing seen at this time but there are old dressings that was sucked with blood, No wound seen, no hematoma felt and sutures are still in place. Left lower extremity: palpable femoral, dopplerable DP, no PT found (which is his baseline) Pertinent Results: [2167-10-22] 05:55AM BLOOD WBC-7.1 RBC-3.07* Hgb-8.1* Hct-26.0* MCV-85 MCH-26.5* MCHC-31.4 RDW-20.4* Plt Ct-36* [2167-10-21] 06:55AM BLOOD PT-17.6* PTT-34.2 INR(PT)-1.6* [2167-10-22] 05:55AM BLOOD Glucose-76 UreaN-23* Creat-2.9* Na-139 K-4.1 Cl-103 HCO3-29 AnGap-11 [2167-10-21] 06:55AM BLOOD CK(CPK)-85 [2167-10-22] 05:55AM BLOOD Calcium-7.5* Phos-2.9 Mg-1.5* [2167-10-21] 06:55AM BLOOD Digoxin-0.8* Brief Hospital Course: pt admitted for fall on [10-20] on BKA site Admit for observations overnight. Monitor for hematoma formation of BKA site. There was no sequele from fall. Transfuse one unit of packed red blood cells for his anemia. HVT stable on DC at 26 One dose of IV antibiotics, prophylactic. No antibiotics on dc. Ne fevres or white count during this hosptial stay. Pt did recieve HD as scheduled. renal consulted PO lopressor and digoxin was initially held for low BP after HD. This will be restarted at Rehab. On Dc pt sable F/U arranged Medications on Admission: [Last Name (un) 1724]: Albuterol nebs prn, Amiodarone 200', Digoxin 0.0625 QOD, Colace 100", Gabapentin 300 QHS, Gabapentin 100", Glargine 9 QHS, HISS, Atrovent nebs prn, Metoprolol 25", Omeprazole 20', Simvastatin 10', Nephro 1', Tylenol prn, Dulcolax prn, Nitroglycin prn, tramadol 25mg PO Q6 hours prn pain Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Digoxin 125 mcg Tablet Sig: 0.5 tabs Tablet PO once a day: Total dose 0.0625 daily. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at [Last Name (un) 21013]). 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Insulin Insulin SC (per Insulin Flowsheet) Sliding Scale & Fixed Dose Fingerstick QACHS Insulin SC Fixed Dose Orders Dinner Glargine 9 Units Insulin SC Sliding Scale Breakfast Lunch Dinner [Last Name (un) ] Humalog Glucose Insulin Dose 0-60 mg/dL [1-7] amp D50 61-159 mg/dL 0 Units 0 Units 0 Units 0 Units 160-179 mg/dL 2 Units 2 Units 2 Units 0 Units 180-199 mg/dL 4 Units 4 Units 4 Units 2 Units 200-219 mg/dL 6 Units 6 Units 6 Units 4 Units 220-239 mg/dL 8 Units 8 Units 8 Units 6 Units 240-259 mg/dL 10 Units 10 Units 10 Units 8 Units 260-280 mg/dL 12 Units 12 Units 12 Units 10 Units > 280 mg/dL Notify M.D. 11. Lantus 100 unit/mL Cartridge Sig: One (1) 9 units Subcutaneous at [Month/Day (2) 21013]: with SSI humulog. 12. Tramadol 50 mg Tablet Sig: 0.5 tabs Tablet PO three times a day: prn. 13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day: hold for SBP less then 100 / HR less then 60. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: s/p fall on Amputation site CRI - On HD CHF chronic systolic IDDM neuropathy, CAD, CHF EF 50%, HTN, hyperlipidemia, Fe def anemia, Discharge Condition: good Discharge Instructions: DISCHARGE INSTRUCTIONS FOLLOWING TRANSMETATARSAL / ABOVE KNEE OR BELOW 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 for 4-6 weeks. You should keep this amputation site elevated when ever possible. You may use the heel of your amputation site for transfer and pivots. But try not to exert to much pressure on the site when transferring and or pivoting. If possible avoid using the heel of your amputation site when transferring and pivoting. 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). New pain, numbness or discoloration of your foot or toes. 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. No heavy lifting greater than 20 pounds for the next 14 days. 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 [Hospital6 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 HD as scheduled Followup Instructions: Provider: [Name10 (NameIs) 251] [Last Name (NamePattern4) 1490], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2167-11-4] 10:15 Completed by:[2167-10-22]	[ "V58.67", "250.40", "250.60", "428.42", "403.91", "V49.75", "285.21", "272.4", "997.69", "V10.05", "250.50", "428.0", "V10.46", "357.2", "E884.4", "V45.81", "583.81", "585.6", "362.01" ]	icd9cm	[ [ [] ] ]	[ "39.95", "99.04" ]	icd9pcs	[ [ [] ] ]	6431, 6497	3656, 4197	287, 294	6673, 6680	3196, 3633	12191, 12366	2529, 2645		4561, 6408		6518, 6652		4223, 4538			6704, 8558											2660, 3177																								231, 249										8571, 11477	11501, 12168		322, 800																822, 2195	2211, 2513
10,106	133,283	6048	Discharge summary	report	Admission Date: [2161-9-14] Discharge Date: [2161-9-19] Date of Birth: [2097-12-16] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 348] Chief Complaint: headache, fever, neck pain Major Surgical or Invasive Procedure: lumbar puncture cerebral angiogram History of Present Illness: 63 y/o man with prior bacterial meningitis with several day slowly pregressive HA, neck ache, photophobia with fever and chills. Denies mental status change. Developed nausea and vomiting 1 day PTA to OSH. AT OSH had head CT neg for bleed., but LP showed large amounts RBC with negative bacterial gram stain and culture. Transferred here for SAH w/u. REpeat LP confirmed RBC with xantho and lymphocytic pleocytosis. Cerebral angiogram negative for aneurys and dissection. Received acyclovir, rochephin, ampicillin, vancomycin. Rocephin was d/c'd. . Reports salmonella meningitis in [2158] following nerve blocks and epidural injections for chronic back pain (symptoms began within 3 days of last injection). Followed by Dr. [Last Name (STitle) 1774] in Infectious Disease. Past Medical History: chronic pancreatitis s/p whipple's c/b liver lac with infected liver fluid collection HTN asthma salmonella meningitis DM-2 chronic back pain s/p steroid injections Social History: current smoker, alcoholic with markedly decreased alcohol since Whipple procedure reporting single drink every [Holiday ]. lives with wife at home. Family History: noncontributory Physical Exam: VS: T 99.7, BP 150/80, P100, rr 16, 96% RA Gen: nontoxic, nard HEENT: (+) nuchal rigidity, negative Kernig's, negative Bradzinski, emoi, perrla Lungs: CTAB Cor: reg s1/s2, tachycardic, no m/r/g ABd: flat, soft, nttp, nabs, surgical scars well healed Ext: no c/c/e Neuro: alert and orient x3, answers ? appropriately cn 2-12 intact motor [3-25] sensation intact light touch DTR 2+, Babinski equivocal Pertinent Results: Labs: WBC= 4.4, 7.7, 5.1 Cr 1.0 BUN 11 K 4 _ CSF fluid analysis HSV PCR (+) tube 1 WBC 60, RBC 1110, lymph 92% tube 2 protein 88, glucose 95 tube 4 WBC 80, RBC 6850 lymph 91% bacterial culture No Growth Lyme, VDRL, eastern equine, and west [Doctor First Name ] pending _ Blood Cultures - no growth _ Head MRI w/gadolinium 1. Mild small vessel ischemic infarcts of chronic nature. 2. no evidence of AVM or vascular disease _ HEAD MRA 1. Fetal posterior cerebral artery on the right. Absence of posterior communicating artery on the left. Otherwise, unremarkable study. _ HRI neck w/ and w/o contrast: 1. no evidence of soft tissue infection. _ Cerebral Angiogram: no evidence of AVM, vascular disease, aneurysm, or dissection. Brief Hospital Course: 63 y/o man admitted for meningeal signs in setting of aseptic meningitis vs. subarachnoid bleed. He was admitted to the ICU under the Neurosurgery service where he underwent extensive workup for intracranial bleed including Head CT, Head and Neck MRI w and w/o contrast, Cerebral angiogram, and repeat LP. Imaging studies showed no evidence of bleed. Repeat LP demonstrated xanthocromia and persistent RBC with lyphocytic pleocytosis. He initially received Ampicillin, Ceftriaxone 2g, and acyclovir. Neurology felt that given his past history of meningitis, neurosyphilis, TB, lyme, and HSV were possible agents. However, his prior episode of meningitis was due to salmonella in the setting of instrumentation of his spine. Amp and Ceftriaxone were discontinued when gram stain and bacterial cultures were negative. HSV PCR returned positive and it was felt that the patient had HSV menigoencephalitis given the presence of blood on LP. He underwent PICC line placement and d/c home on a 2 week course of IV acyclovir 800mg q8h. He continued to complain of headaches but were improving at the time of discharge. It could be argued that the xanthrochromia was secondary to a traumatic tap on his initial LP and that encephalitis was not present given the patient's normal mental status throughout his illness. However given the serious nature of HSV encephalitis, a more aggressive course was taken. He will follow up with his infectious disease docotr, Dr. [Last Name (STitle) 1774] at [Hospital1 18]. His blood pressure was noted to be moderately controlled on his home regimen. His ACEi dose was increased and he was sent home with controlled BPs. Blood sugars were noted to be elevated as well and he was started on metphormin 800mg [Hospital1 ]. He will need to be followed up by his PCP for management of his hyperglycemia and hypertension. Medications on Admission: moexipril 5mg qd protonix 40mg qd advair 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. Moexipril HCl 7.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Acetaminophen-Caff-Butalbital [Medical Record Number 3668] mg Tablet Sig: [11-21] Tablets PO Q4-6H (every 4 to 6 hours) as needed for 7 days. Disp:28 Tablet(s) Refills:0 4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 5. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 6. Acyclovir Sodium 800 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 10 days. 7. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for 3 days. Disp:18 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 5065] Healthcare Discharge Diagnosis: herpes viral meningoencephalitis Discharge Condition: stable to home with IV antibiotics Discharge Instructions: contact your physician if you develop fevers, worsening headache, neck pain, weakness or numbness. meet with IV home nurses for treatment. continue your antibiotics, acyclovir, for 10 more days. We made the following medication changes: 1) we started metformin (glucophage) - this is for your diabetes. 2) we increased your blood pressure medication. Followup Instructions: follow up with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 3183], PCP, [Name Initial (NameIs) 176] 2-4 weeks of your discharge call Dr. [First Name8 (NamePattern2) 3403] [Last Name (NamePattern1) 1774], your Infectious Disease doctor, phone: ([Telephone/Fax (1) 4170] to schedule an appointment within 2-4 weeks.	[ "493.90", "250.00", "054.3", "303.90", "401.9" ]	icd9cm	[ [ [] ] ]	[ "88.41", "38.93", "03.31" ]	icd9pcs	[ [ [] ] ]	5664, 5725	2774, 4648	342, 379	5802, 5838	2019, 2751	6240, 6618	1563, 1580		4739, 5641		5746, 5781		4674, 4716			5862, 6082											1595, 2000																							6102, 6217	276, 304													407, 1190																1212, 1378	1394, 1547
71,564	197,372	36714	Discharge summary	report	Admission Date: [2199-8-5] Discharge Date: [2199-8-15] Service: MEDICINE Allergies: Penicillins / Horse/Equine Product Derivatives / Ragweed / Tetanus Attending:[First Name3 (LF) 1990] Chief Complaint: hemoptysis, hypoxic respiratory failure Major Surgical or Invasive Procedure: bronchoscopy History of Present Illness: Mr. [Known lastname 83028] is a [Age over 90 ] year-old male transferred from OSH for hypoxia and hemoptysis. PMH significant for HTN, prior MI, GERD, pAF, severe COPD and prior asbestosis exposure with lung damage and patient is home oxygen dependent at baseline on 1.5L NC continuously. History limited as patient is sedated on arrival to ICU and no family present. Per OSH notes, the patient initially presented yesturday afternoon to OSH ED complaining of left ankle and tibial pain and bruising after hitting his leg on the car door. He was then d/c from ED and told to hold his usual home Coumadin dose last night as INR was 3.7, but per reports the patient still took usual 2.5mg daily dose. He returned to OSH ED later in the night with hypoxia, coughing and hemoptysis. Repeat INR then 2.7 per OSH notes after he received 2 units of FFP at OSH. . He became hypoxic into the 70s on usual 1.5L and again into 70s on NRB. He was intubated and then transferred to [Hospital1 18] ED for additional workup. CK and trops at OSH negative. In ED here, vitals were temp 98.8F, HR 65, BP 145/64, RR 18, O2 Sat 100%. he was intubated, on AC mode, VT set 550, RR set 16, PEEP 5, FiO2 100%. He had persistent dark bloody drainage, about 20cc, from NGT despite lavage. GI was consulted. Patient was given Protonix 40 mg IV and 500mg azithromycin x1 and additional 2L NS IVFs. CT scan of chest showed large plaques and questionable aspiration which is what prompted azithromycin coverage. . Patient on Sotolol and Coumadin therapy for paroxysmal atrial fibrillation history. He is sedated currently so PMH confirmation is limited. Despite concern for GI bleeding vs. hemoptysis his Hct appears stable with Hct yesturday 42, then 38--> now 36 this morning. This morning INR 2.1, PT 22.2, PTT 31.6. On arrival to ICU he appeared sedated and in NAD with HR 60s, BP 157/68, MAP 80s, AC vent (Tv550, RR 14, PEEP 5, FiO2 100%). Past Medical History: COPD, h/o abstestos exposure, on home O2 at 1.5-2.5L continuous NC HTN GERD CAD s/p MI paroxysmal atrial fibrillation On coumadin for pAF Social History: Formerly worked in ship yard in [Location 27256] Navy Yard and was exposed to asbestos. Smoked 3PPD x 30 years and quit ~35 years ago. No ETOH or illicit drug use. He had been living at home alone in [Location (un) 3146]. Family History: unknown and unobtainable as patient sedated and no family present at time of admission; assumed noncontributory Physical Exam: GEN:intubated, sedated, in NAD HEENT: No head/neck trauma noted, no scleral icteris, pupils sluggish but equal and reactive ( 2mm) to light bilaterally CVS: RRR, S1 & S2 reg, no murmurs/rubs/gallops RESP: Bilateral rales noted at bases bilaterally and rhonchi at upper anterior lungs ABD: soft, nondistended, normoactive BS throughout, no whincing or signs of pain with palpation but exam limited [3-11] sedation Rectal: brown stool, no BRBPR, normal sphincter tone NEURO: sedated, EOMI, withdraws to basic pain stimulus SKIN: no rashes, small ecchymosis over LLE tibial region ( 2") and at heel EXT: left lower leg with bruising and 1+ edema, 2+ pedal pulses bilaterally Pertinent Results: [2199-8-5] 04:45AM PT-22.2* PTT-31.6 INR(PT)-2.1* [2199-8-5] 04:45AM PLT COUNT-257 [2199-8-5] 04:45AM WBC-10.4 RBC-4.15* HGB-12.2* HCT-36.7* MCV-88 MCH-29.3 MCHC-33.1 RDW-14.2 [2199-8-5] 04:45AM UREA N-18 CREAT-1.0 [2199-8-5] 04:54AM freeCa-1.04* [2199-8-5] 04:54AM HGB-14.0 calcHCT-42 O2 SAT-80 CARBOXYHB-3 MET HGB-0 [2199-8-5] 04:54AM GLUCOSE-130* LACTATE-1.5 NA+-140 K+-4.7 CL--101 TCO2-26 [2199-8-5] 05:07AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-7.0 LEUK-NEG CT CHEST W/CONTRAST OSH - Extensive bilateral pleural plaques, and interstitial lung changes most c/w asbestosis. Marked volume loss and architectural distortion in RUL, with rightward tracheal deviation. Large hiatal hernia. Small centrilobular nodules at right lung base may represent aspiration or infection. . EKG: NSR, rate 60s, LAD, RBBB with LAFB, 1st degree AV prolongation noted, V1 ST depression, no ST elevations . CXR: ETT properly placed, small bilateral effusions ( left>right),pleural thickening and RML fissure territory with increased markings and questionable scarring. Overall decreased volumes bilaterally. Brief Hospital Course: [Hospital Unit Name 153] Course: [Age over 90 ] year-old male with PMH significant for HTN, severe COPD, CAD ( s/p prior MI) who presented to OSH with hypoxic episode with likely aspiration event in setting of hemoptysis. The patient was intubated at OSH and transferred to [Hospital1 18] for further workup. After arrival to the [Hospital Unit Name 153], the pt was noted to have increased peak pressures on the vent--suctioning produced a large clot that was partially occluding the endotracheal tube. INR was noted at 2.1, coumadin held. Subsequent bronchoscopy identified a possible bleeding source in the posterior segment of the RUL, culture grew MSSA. Antibiotic coverage with Vancomycin, Azithromycin and Ceftriaxone was selected for broad coverage of CAP, although pt was afebrile with no leukocytosis. Additionally, a steroid taper was started to treat a likely COPD exacerbation. Eight day antibiotic course was completed. . Initially, the patient was bradycardic and hypotensive while venitilated. He was given fluid boluses with minimal response. His hypotension and bradycardia improved with decreasing sedation and discontinuation of fentanyl. The patient's blood pressure then became highly labile and labetolol gtt was started while sedation with propofol was titrated. During this time, the patient's respiratory failure improved and he was weaned from the vent and extubated on [8-10]. Post extubation, the patient had 1 x complaint of chest pain on [8-11]--CK and troponins were negative, no changes on EKG, ASA held due to concern for bleeding. Additionally, he had 1 x bloody return on suction that prompted team to revers his INR with FFP and vitamin K. Prior to transfer to the floor, labetolol gtt was discontinued and PO captopril and labetolol were started. While in the unit, The patient recieved total 1 unit PRBCs and 4 FFP. Hematocrit was monitored and stable post transfusion through to end of [Hospital Unit Name 153] stay. On transfer to floor, pt was stable, saturating 88-95% on 4L O2NC. This was considered baseline for patient secondary to severe underlying pulmonary status. . The above represents the ICU course, and was written by the ICU physicians. The following represents the medical [Hospital1 ] course and was written by Dr. [Last Name (STitle) ]: Pt. stable on arrival to floor. Foley removed, voided clean yellow urine, no hematuria seen. Pt. had slight pink discoloration of sputum on one occasion, but no overt hemoptysis. Pt. was discharged to rehab hospital with the instructions below. Medications on Admission: -Lisinopril 5mg daily -Advair Diskus 250/50 1 puff [Hospital1 ] -Spiriva 18mcg daily INH -Prilosec 20mg daily -Sotalol 40mg [Hospital1 ] -Warfarin 2.5mg daily -ASA 81mg daily -Albuterol INH /.083% Nebs qid PRN -continuous 1.5L O2 via NC -Lasix 20mg daily -Potassium 10meq daily -Mucinex 600mg x2 [Hospital1 ] Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 4. Prednisone 20 mg Tablet Sig: One (1) Tablet PO daily () for 1 days: on [2199-8-16]. 5. Prednisone 10 mg Tablet Sig: One (1) Tablet PO daily () for 3 days: [Date range (1) 83029]. 6. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed for sob, wheezing. 9. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) cap, inhaled Inhalation [Hospital1 ] (2 times a day). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day: ONLY begin once sputum has cleared (no longer pink or blood tinged); observe for evidence of hemoptysis - if this recurs, stop this medication, if severe - transport back to the [Hospital1 ] emergency room for evaluation. 15. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: ONLY begin once sputum is no longer blood tinged or pink in color - observe closely for evidence of recurrent hemoptysis. If this occurs, stop this medication. If severe, transport back to [Hospital1 ] Emergency Room for evaluation. Discharge Disposition: Extended Care Facility: [Hospital6 ] at [Location (un) 246] Discharge Diagnosis: hemoptysis Discharge Condition: Stable Discharge Instructions: Return to the [Hospital1 ] emergency room for: coughing up of blood, shortness of breath Followup Instructions: Pt will need f/u in regards to the etiology of his hematuria if it recurs (? cystoscopy). Also recommend f/u imaging to rule out underlying malignancy in the context of new endobronchial bleed. With primary care doctor within one month - call for appointment.	[ "412", "786.3", "414.01", "401.9", "518.81", "427.31", "V46.2", "041.11", "501", "530.81", "486", "V58.61", "599.70", "491.21", "799.02", "276.1", "286.9" ]	icd9cm	[ [ [] ] ]	[ "96.72", "38.91", "99.04", "38.93", "99.07", "33.24" ]	icd9pcs	[ [ [] ] ]	9709, 9779	4754, 7352	313, 327	9834, 9843	3540, 4731	9984, 10250	2714, 2828		7723, 9686		9800, 9813		7378, 7700			9867, 9961											2843, 3521																								234, 275													355, 2287																2309, 2449	2465, 2698
32,367	101,033	24492	Discharge summary	report	Admission Date: [2146-2-7] Discharge Date: [2146-2-24] Date of Birth: [2078-3-18] Sex: M Service: MEDICINE Allergies: Amitriptyline / Norvasc Attending:[First Name3 (LF) 613] Chief Complaint: lethargy x 4-5 days Major Surgical or Invasive Procedure: - Intubation [2146-2-17] - Extubation [2146-2-18] - PICC placement [2146-2-18] - PICC removal [2146-2-21] History of Present Illness: 67 y/oM with PMH CAD, afib, DM, spinal cord atrophy who presented to the ED with lethargy x 4-5 days and was found to be hypoxic with presumed multifocal PNA and afib in RVR. For the past 4-5 days, patient has been complaining of fatigue with decreased PO intake. Also developed wet cough productive of clear sputum. On the day prior to admission, his caregiver found him unable to get off the commode and tilting to the left. Today, he was too tired to get out of bed so his partner [Name (NI) 4662] him to the [Name (NI) ]. In the ED, initial VS: 13 98.8 104 139/98 32 86% 4L NC. He triggered for hypoxia and was placed on 100%NRB with sats rising to 100%. CXR revealed multiple patchy opacities in left lung, blood and urine cultures were drawn and patient was given dose of vancomycin/ levofloxacin. Neurology was consulted given trunchal ataxia on exam and did not feel that presentation was consistant with an acute intracranial event, recommending treating underlying illness. ED course c/b development of afib with RVR with HR in the 160-180s. Despite 50mg total of diltiazem IV, HR did not improve significantly. Given hemodynamic instability, patient admitted to the ICU for further monitoring. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness. Denies chest pain, chest pressure, palpitations. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: # CAD s/p PCI x 2 with a history of MI and angioplasty 12 years ago. His most recent cardiac catheterization was in [Month (only) 216] of [2140] at [Hospital6 1708] which revealed non-flow limiting three-vessel disease and no intervention was performed at that time # Atrial flutter/atrial tachycardia status post ablation in [2140-9-5] with breakthrough atrial tachycardia and atrial flutter # Type 2 diabetes on insulin-followed by Dr.[Doctor Last Name 4849]- [2145-4-20] visit A1C 7.5 # PVD followed by Dr. [First Name (STitle) ] # Colon Ca -- s/p partial colectomy [2125], no radiation or chemotherapy # Neuropathy -- progressing to R arm now; legs unchanged, uses wheelchair # Spinal stenosis -- MRI performed [5-/2141], no emergent issues, but some retrolisthesis of L4-5, status post laminectomy at L4-L5. # Alcohol abuse # History of mechanical falls. Social History: - Retired and lives at [Hospital1 1426]/[Location (un) ] with friend/partner [Name (NI) 61893] [Name (NI) ] ([Telephone/Fax (1) 61891]). - He is disabled and wheelchair bound. - Reports consuming 1-2 drinks/day for years. Denies problems with alcohol, but concern for abuse per previous notes. No h/o withdrawal, DTs or seizure. - Smokes 1 [2-6] PPD for 60 pack-year smoking history. - Reports remote marijuana. Family History: No history of premature cardiac disease. Physical Exam: Physical Exam Vitals: T: 96.5 BP: 78/61 P: 135 R: 23 O2: 95% on 100% NRB General: cachextic elderly male; drowsy, oriented HEENT: Sclera anicteric, dry oral mucosa, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: tachycardia, irregular Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: 2+ pulses, no clubbing, cyanosis or edema Neuro: difficult to assess given mental status, moving all extremities. Decreased sensation in LE b/l Physical Exam on Discharge: VS: HR 80, RR 20, 92% on 2L General: well-appearing, NAD, comfortable HEENT: sclera anicteric, pale conjunctivae, mucous membrane dry Neck: supple Lung: CTAB in anteriorly but crackles posteriorly up to mid-lung field CV: irregularly irreguar, non-tachycardic, no m/r/g Abd: soft, NT, ND, no guarding, BS present Extremities: no cyanosis or edema, 2+ dorsalis pedis pulses bilaterally GU: mild edematous only on posterior aspect of distal shaft and non-erythematous foreskin, glans appear well-perfused and non-cyanotic, minimal pain with palpation, no catheter, no rash Neuro: awake, alert and oriented to place ([Hospital1 18]), time ([2146-2-24]), person (president [Last Name (un) 2753]) Skin: small 1x1cm ulcer on the left buttock, clean without drainage or erythema around Pertinent Results: Admission Labs [2146-2-7] 04:00PM BLOOD WBC-5.3# RBC-4.61# Hgb-14.9# Hct-43.3# MCV-94 MCH-32.2* MCHC-34.3 RDW-13.1 Plt Ct-324 [2146-2-7] 04:00PM BLOOD Neuts-62 Bands-5 Lymphs-22 Monos-5 Eos-0 Baso-0 Atyps-4* Metas-2* Myelos-0 [2146-2-7] 04:00PM BLOOD PT-12.0 PTT-24.0 INR(PT)-1.0 [2146-2-7] 04:00PM BLOOD Glucose-272* UreaN-21* Creat-0.8 Na-130* K-4.4 Cl-95* HCO3-22 AnGap-17 [2146-2-7] 04:00PM BLOOD ALT-6 AST-11 CK(CPK)-22* AlkPhos-88 TotBili-0.8 . Pertinent Labs [2146-2-7] 04:00PM BLOOD CK-MB-2 [2146-2-7] 04:00PM BLOOD cTropnT-<0.01 [2146-2-8] 03:43AM BLOOD cTropnT-<0.01 [2146-2-9] 12:02AM BLOOD TSH-1.1 [2146-2-7] 04:00PM BLOOD Cortsol-55.9* [2146-2-8] 03:43AM BLOOD Cortsol-19.5 [2146-2-7] 04:00PM BLOOD Digoxin-0.7* [2146-2-7] 06:17PM BLOOD Lactate-1.7 . [2146-2-7] 04:30PM URINE RBC-0-2 WBC-0 Bacteri-OCC Yeast-NONE Epi-0-2 [2146-2-7] 04:30PM URINE Blood-SM Nitrite-NEG Protein-75 Glucose-250 Ketone-15 Bilirub-SM Urobiln-1 pH-5.0 Leuks-NEG [2146-2-7] 04:54PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG Microbiology [2146-2-7] Urine culture: negative [2146-2-7] Blood culture x2: negative [2146-2-7] MRSA screen: negative [2146-2-7] Urine legionella antigen: negative [2146-2-8] Influenza A and B antigens: negative [2146-2-9] Sputum culture: contaminated. Legionella culture negative [2146-2-17] Sputum culture: >25 PMNs and <10 epithelial cells/100X field. No microorganisms seen. Commensal flora absent. 2 morphologies of yeast. Imagings CXR ([2146-2-7]): Markedly limited study. There is suggestion of a dense consolidation of the left lower and mid lung zones. This may represent pneumonia. If clinically feasible, consider PA and lateral views in the radiology suite for better characterization. CT Head ([2146-2-7]): 1. Prominent ventricles, non-[Last Name (LF) 61910], [First Name3 (LF) ] represent normal pressure hydrocephalus in the appropriate clinical setting. Clinical correlation recommended. 2. No other acute intracranial process identified. TTE ([2146-2-9]): Mild symmetric LVH with normal regional and global biventricular systolic function. Moderate tricuspid regurgitation. Mild pulmonary artery systolic hypertension. CXR ([2146-2-10]): Worsening right upper lobe and left mid and lower lung opacities, consistent with worsening pneumonia. CXR ([2146-2-18]): As compared to the previous radiograph, there is minimal improvement of the pre-existing mainly perihilar and left lateral parenchymal opacities. The extent of the retrocardiac atelectasis, potentially combined with a small pleural effusion, is unchanged. On the right, the parenchymal opacities have apparently decreased in extent. No evidence of newly appeared parenchymal opacities. Unchanged size of the cardiac silhouette. Unchanged position of the endotracheal tube and the nasogastric tube. Brief Hospital Course: 67 year old male with coronary artery disease s/p PCI, atrial tachycardia s/p failed ablation, diabetes mellitus type II complicated by neuropathy leading to spinal cord atrophy who presented to the ED with lethargy x 4-5 days and was found to be hypoxic with presumed multifocal PNA and atrial fibrillation/tachycardia with RVR. # Hypotension, resolved: BP on arrival to ICU was 70/50 in the setting of likely multifocal pneumonia seen on CXR and volume depletion in the setting of poor oral intake. Bedside echo showing hyperdynamic ventricles and respiratory variation in IVC filling pressures on admission consitent with hypovolemia. He was aggressively fluid resuscitated by early goal directed protocol with MAP > 65. He was started on Levaquin for community acquired pneumonia and cefepime for Gram negative coverage in setting of chronic aspiration. He was ruled out for ACS with three sets of enzymes. Random and am cortisol showed appropriate adrenal function. His hypotension resolved with fluid resuscitation and never needed pressors. He was normotensive off medications. # Hypoxia, resolved: Persistent hypoxia to mid-80s on RA in the ED, likely [3-9] underlying multifocal PNA which is visualized on CXR. Hx of recurrent PNA suggestive of repeat aspiration events. Alternatively, patient with risk factors, peripheral neuropathy and multiple bacterial infections is also at risk of HIV which was sent. He was started on levaquin for CAP and cefepime for gram negative coverage in setting of chronic aspiration. Pt improved and was called out to the floor on [2-9]. On the floor he maintained his blood pressure and heart rate but required continued oxygen with saturations in the low to mid 90's on 3L NC. On [2-10], he triggered for mental status changes with orientation to self. He had significant rhonchi on exam at that time and respiratory was called; deep suction removed large amounts of mucous which were sent for culture. Later that evening, the patient was noted to have worsnening oxygen requirement with 93% oxygen on 5 liters and 97% on a nonrebreather. Deep suction was attempted but the patient had desaturation in this context. Received zydis 2.5 mg for agitation and paranoia. ABG 7.48/25/71. Transferred back to MICU for respiratory evaluation. On [2-11], he continued to require deep suctioning for large amount of secretions. He continued to get chest physical therapy with deep suctioning for large amount of secretions on [2-12] as well. On [2146-2-16], he was noted to have increased requirement in his venti mask from 50% to 100% with whiteout of left lung bases concerning for mucous plug. He was intubated for respiratory distress on [2146-2-17]. He was extubated on [2146-2-18] when goals of care were changed to comfort measures only (see below). Since then, he has been on minimal oxygen and morphine intermittently for comfort and maintaining O2 saturation in mid 90% on RA. # Leukocytosis: His WBC increased on [2-11] and continued to rise on [2-12]. He was started on vancomycin/flagyl while levaquin and cefepime were continued as he was clinically getting worse. IV Vancomycin/flagyl/levaquin and cefepime were discontinued on [2146-2-19] when he was made CMO # Delirium. Resolving. He was noted to be agitated and paranoid while being transferred back to the MICU. Likely secondary to hypoxia, improved with deep suctioning and respirator stabilization. His agitation has been managed by olanzepine rapid disintegrating tab. He has not had episodes of agitation since being on olanzepine. Upon discharge, he is oriented to person, place, and time. # Atrial fibrillation with RVR: on initial arrival to ICU, HR in 150-160s and irregular. Underlying process of pneumonia is likely the driving force for it. Patient was on anticoagulation alone with aspirin and plavix given history of multiple falls. He was started on amiodarone and over the next few days was weaned off metoprolol and digoxin. TTE was performed which showed LVH and no clots. Amiodarone IV changed to PO on [2-9], and then changed to home metoprolol. He remained stable in AFib without RVR. He was noted to have RVR on [2-11] and was restarted on amiodarone while metoprolol was discontinued. On [2-12], he continued to be in RVR with rates in 120s so metoprolol was added for rate control with amiodarone. However, because he was made CMO, his AFib medications were discontinued. His HR has been mostly < 100 per minute off of medications. # Truncal ataxia: per ED evaluation, patient persistently leaning towards left. CT head was negative. Per neurology, there was no acute process. # H/o CAD: He denied angina. EKG was without acute ST changes. Cardiac enzymes were negative x 3. Initially, he was continued on aspirin, Plavix, and metoprolol as mentioned above. However, after he was made CMO, these medications were held. # H/o ETOH abuse. There was no h/o withdrawal seizures. He did not have evidence of active withdrawal while in the hospital. # Type II DM: No evidence of DKA by labs. Patient was managed by insulin sliding scale. However, with CMO status, finger stick and insulin administration were held. # Malnutrition: Albumin of 2.1. Per speech and swallow, NPO with crushed meds in apple sauce with concern for chronic aspiration and will need to be reevaluted once off of face mask for oxygen. NG tube placed on [2146-2-9] and tube feeds started with nutritions help. Tube feeds held on [2-10] in the setting of desaturation and copious secretions, due to concern for aspiration. Restarted [2-11] as it seemed that secretions were mucous and not gastric contents. However, with CMO status, patient resumed regular diet per his preference and nutritional supplement was added. # Left buttock ulcer. 1 cm x 1 cm. Area does not appear to be infected. This should continue to be monitored with regular repositioning every 2 hours and daily wound care. # Comfort measures only: On [2146-2-19] after extensive discussion with his health care proxy, it was decided to make the patient comfort measures only and was extubated on [2146-2-19]. Antibiotics were discontinued. He was transitioned to narcotics as needed for shortness of breath and pain. He was discharged on oral morphine solution as his Foley catheter and PICC were removed on [2146-2-20] and [2146-2-21] respectively. He will be followed by hospice. It will be important to continue the discussion of Do Not Hospitalize with patient and his health care proxy. Medications on Admission: levothyroxine 25 mcg daily amlodipine 5 mg daily metoprolol succinate 50 mg daily bupropion 150 mg daily lisinopril 10 mg daily ipratropium-albuterol (duoneb) [Hospital1 ] allopurinol 100 mg [Hospital1 ] advair 250-50 q12h tylenol 1000 mg [Hospital1 ] simethicone 1 tablet [Hospital1 ] gabapentin 300 mg TID ASA 81 mg daily fluticason 2 sprays each nostril daily artificial tears at bedtime docusate 200 mg qhs miralax 17 g qhs prn senna 2 tabs qhs Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:30 neb Refills:0 2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain or fever. 3. bisacodyl 5 mg Tablet Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:0 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 5. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:30 neb Refills:0 6. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO once a day. Disp:30 Tablet, Rapid Dissolve(s) Refills:0 7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation. Disp:30 packet Refills:0 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:60 Tablet(s) Refills:0 9. morphine 10 mg/5 mL Solution Sig: Five (5) mL PO Q1-2 hour as needed for pain or shortness of breath. Disp:1000 mL Refills:2 10. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily) for 3 weeks: Continue for another two weeks before tapering to 14 mg/24 hour patch. Disp:21 Patch 24 hr(s) Refills:0 Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) 3504] [Last Name (NamePattern1) ] Rehabilitation & Nursing Center - [Location (un) 538] Discharge Diagnosis: Primary diagnoses: - Multifocal pneumonia - Atrial fibrillation with rapid ventricular rate Secondary diagnoses: - Delirium - spinal atrophy 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 6955], It was a pleasure to take care of you at [Hospital1 827]. You were admitted to the hospital for pneumonia and fast irregular heart rate. You were treated with antibiotics for the pneumonia as well as medications to help controlling your heart. Because of your worsening breathing, you were on a ventilator (a machine that help to breath for you) for a short period of time. After a discussion between your health care proxy and your intensive care team, it was decided that you would prefer to live with dignity and would prefer not to have invasive procedures done such as a PEG tube (feeding tube) or a tracheostomy (more permanent breathing tube). You did very well after they remove the ventilator and required minimal oxygen. The medical team discussed with you about hospice. You and your health care proxy both decided that you want to ultimately be home with hospice. Hospice nurse and social workers came and explored with you regarding your options and necessary support that you may need. While resources at home get set up, it is thought that you can go to inpatient hospice for a period of time. Please note the following changes in your medications: - Please START Tylenol 325 mg tab, 1-2 tabs, every 6 hours as needed for pain or fever - Please START albuterol nebulizer, 1 neb, every 4-6 hours as needed for shortness of breath or wheeze - Please START bisacodyl 10 mg, 1 tab, by mouth, once a day as needed for constipation - Please START docusate 100 mg, 1 tab, by mouth, twice a day to soften your stool - Please START ipratropium neb, 1 neb, every 4-6 hours as needed for shortness of breath or wheeze - Please START Miralax, 1 packet, by mouth, once a day as needed for constipation - Please START morphine 10mg/5mL, 5mL, by mouth, every 1-2 hours as needed for pain or shortness of breath. - Please START olanzapine zydus 5 mg, 1 tab, by mouth, once a day in the evening. - Please START senna, 1 tab, by mouth, once a day as needed for constipation - Please DISCONTINUE mirtazipine 30 mg at night prior to bed time - Please DISCONTINUE Flomax 0.4 mg once a day - Please DISCONTINUE Plavix 75 mg once a day - Please DISCONTINUE calcium carbonate with vitamin D 600 mg-400 units - Please DISCONTINUE Humulin 70/30 insulin - Please DISCONTINUE Aspirin 325 mg once a day - Please DISCONTINUE digoxin 125 mcg once a day - Please DISCONTINUE Megace 20 mL once a day - Please DISCONTINUE metoprolol 75 mg three times a day - Please DISCONTINUE macrodantin 100 mg twice a day - Please DISCONTINUE flunase 50 mcg 2 sprays twice a day - Please DISCONTINUE gabapentin 300 mg 4 times a day - Please DISCONTINUE multivitamin once a day - Please DISCONTINUE folic acid once a day Followup Instructions: Please call your primary care physician [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 131] at [Telephone/Fax (1) 133] to set up an appointment for follow-up of the recent hospitalization. You can also reach your hospice nurse by calling [Telephone/Fax (1) 61911]. You can also call your hospice social work by calling [Hospital 3005] Hospice [Telephone/Fax (1) 61912] or Toll Free [Telephone/Fax (1) 61913]. Their fax number is [0-0-]. Their website is [URL 61914] Department: CARDIAC SERVICES When: WEDNESDAY [2146-3-23] at 2:20 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: NEUROLOGY When: THURSDAY [2146-4-28] at 2:30 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 19249], MD [Telephone/Fax (1) 44] Building: [Hospital6 29] [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617] Completed by:[2146-2-24]	[ "414.01", "357.2", "V45.82", "486", "250.60", "V58.67", "507.0", "427.89", "427.31", "263.9", "038.9", "V10.05", "305.01", "780.09", "443.9", "518.81", "605", "V49.86", "412", "305.1", "276.1", "E912", "707.22", "781.3", "995.92", "933.1", "348.30", "336.8", "707.03" ]	icd9cm	[ [ [] ] ]	[ "38.93", "96.6", "96.71", "96.04" ]	icd9pcs	[ [ [] ] ]	16515, 16669	7898, 14500	302, 426	16855, 16855	4919, 7875	19803, 21122	3419, 3461		15015, 16492		16690, 16783		14526, 14992			17038, 19780											3476, 4080		16804, 16834													4108, 4900						1698, 2030			243, 264													454, 1679										16870, 17014						2052, 2949	2965, 3403
81,303	172,869	50771	Discharge summary	report	Admission Date: [2133-8-13] Discharge Date: [2133-8-20] Date of Birth: [2069-10-17] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Vicodin Attending:[First Name3 (LF) 1406] Chief Complaint: Coronary Artery Disease Major Surgical or Invasive Procedure: [2133-8-13]: Coronary artery bypass grafting x4 with a left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to the posterior descending artery, obtuse marginal artery, and ramus intermedius artery History of Present Illness: 63M with h/o hypertension, Diabetes and ESRD (on PD x 3 yrs). He is undergoing evaluation for renal transplant. Stress test was abnormal. He denies chest pain or shortness of breath. Cath shows 2 vessel and left main CAD. He is referred for surgical evaluation. Past Medical History: Coronary Artery Disease mild Aortic Stenosis Diabetes (since age 17, on Insulin pump) Hypertension ESRD (PD at night) Iron defeciency anemia AVM at pyloris (cauterized in [2131]) Orthostatic hypotension IgG lambda monoclonal gammopathy Past Surgical History: Bilateral hand surgeries for Dupuytrens Contractures PD catheter LASER surgery to retina bilateral cataract surgery Social History: Smokes 1 PPD for 30 years. Rare alcohol use. Occasional marijuana use. Married. Realtor. Family History: His mother is alive and well. His father died of a stoke. Physical Exam: Physical Exam on admission: Pulse: 63SR Resp: 12 O2 sat: 99%RA B/P Right: Left: 209/82 Height: 6' Weight: 165lb General: NAD Skin: Dry [x] intact [x] HEENT: PERRLA [] EOMI [x] s/p cataract surgery- pupils reactive but unequal (L>R) Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade __2/6 syst._ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] PD Catheter Extremities: Warm [x], well-perfused [x] early venous stasis changes Edema [] __trace pedal edema_ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left:2+ DP Right: 1+ Left:1+ PT [Name (NI) 167]: 1+ Left:NP Radial Right: cath Left: 2+ no carotid bruits Pertinent Results: [2133-8-19] 06:00AM BLOOD WBC-7.8 RBC-2.96* Hgb-9.2* Hct-28.5* MCV-96 MCH-31.1 MCHC-32.3 RDW-13.7 Plt Ct-316 [2133-8-19] 06:00AM BLOOD Plt Ct-316 [2133-8-20] 05:35AM BLOOD Glucose-52* UreaN-58* Creat-12.3* Na-133 K-5.1 Cl-92* HCO3-33* AnGap-13 [2133-8-16] 02:48AM BLOOD ALT-24 AST-23 AlkPhos-86 TotBili-0.1 Brief Hospital Course: On [8-13] Mr. [Known lastname 105606] was taken to the operating room and underwent coronary artery bypass grafting x4 with a left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to the posterior descending artery, obtuse marginal artery, and ramus intermedius artery with Dr.[Last Name (STitle) ]. Please see the operative report for further details. He tolerated the procedure well and was transferred to the CVICU intubated and sedated for invasive monitoring. The renal service was consulted for peritoneal dialysis recommendations. He awoke neurologically intact and weaned to extubate. He required atrial pacing initially to augment his cardiac output. He remained hemodynamically stable and A pacing was stopped. All lines and drains were discontinued per protocol. He was placed on aspirin, statin and Beta-blocker was initiated once his blood pressure and heart rate could tolerate it. PD cycles began on postop night. He remained on an insulin drip until transitioning to his pump was accomplished on post-operative day two. He transferred to the step down unit for further monitoring. Physical therapy was consulted for evaluation of his strength and mobility. He continued to have glucose highs and lows and [Last Name (un) ] was consulted. He remained in the hospital for further observation due to his glucose control. On post-operative day six a scant amount of cloudy sternal discharge was expressed. He was placed on prophylaxis antibiotics, renally dosed as discussed with pharmacy. By the time of discharge on post-operative day seven, he was ambulating, his glucose was under tight control, and his sternum without erythema. His sternum was stable. He was discharged to home with VNA services. All follow up appointments were advised. Medications on Admission: 1. Fludrocortisone Acetate 0.05 mg PO DAILY 2. Lactulose 15 mL PO DAILY:PRN constipation 3. Lisinopril 40 mg PO DAILY 4. Temazepam 30 mg PO HS:PRN insomnia 5. traZODONE 50 mg PO HS 6. Diltiazem Extended-Release 240 mg PO DAILY:PRN htn 7. Atenolol 25 mg PO DAILY:PRN htn 8. Atorvastatin 10 mg PO DAILY 9. Cinacalcet 30 mg PO DAILY 10. flaxseed oil NF unknown Oral daily 11. Lanthanum 1000 mg PO TID W/MEALS 12. sevelamer CARBONATE 2400 mg PO TID W/MEALS 13. sildenafil NF unknown Oral prn prn 14. Aspirin 81 mg PO DAILY 15. folic acid-B complex & C no.10 NF 1 mg Oral daily 16. Doxercalciferol 1.5 mcg PO 3X/WEEK (MO,WE,FR) Discharge Medications: 1. Aspirin EC 81 mg PO DAILY RX aspirin [AsperDrink] 81 mg one tablet(s) by mouth daily Disp #30 Tablet Refills:2 2. Atorvastatin 10 mg PO HS RX atorvastatin 10 mg one tablet(s) by mouth daily at night Disp #30 Tablet Refills:2 3. Cinacalcet 30 mg PO DAILY 4. Doxercalciferol 1.5 mcg PO 3X/WEEK (MO,WE,FR) 5. Lactulose 15 mL PO DAILY:PRN constipation 6. Lanthanum 1000 mg PO TID W/MEALS 7. sevelamer CARBONATE 2400 mg PO TID W/MEALS 8. Temazepam 30 mg PO HS:PRN insomnia 9. traZODONE 50 mg PO HS 10. Docusate Sodium 100 mg PO BID 11. Insulin Pump SC (Self Administering Medication)Insulin Lispro (Humalog) Basal rate minimum: 0.8 units/hr Basal rate maximum: per pt home scale units/hr Bolus minimum: per prearranged PT/[Last Name (un) ] plan units Bolus maximum: per prearranged PT/[Last Name (un) ] plan units Target glucose: 80-180 Fingersticks: QAC and HS MD acknowledges patient competent MD has completed competency 12. Levofloxacin 250 mg PO Q24H x 10 days RX levofloxacin 250 mg one tablet(s) by mouth daily Disp #10 Tablet Refills:2 13. Metoprolol Tartrate 12.5 mg PO BID hold HR < 55 SBP < 95 RX metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth twice a day Disp #30 Tablet Refills:2 14. Mupirocin Cream 2% 1 Appl TP DAILY PD cath site resume Pts home regimen 15. Nephrocaps 1 CAP PO DAILY 16. flaxseed oil NF 1 unit ORAL DAILY resume home medication 17. Fludrocortisone Acetate 0.05 mg PO DAILY 18. folic acid-B complex & C no.10 NF 1 mg Oral daily 19. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN Pain RX hydromorphone 2 mg [12-1] tablet(s) by mouth every four hours Disp #40 Tablet Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Coronary Artery Disease mild Aortic Stenosis Diabetes (since age 17, on Insulin pump) Hypertension ESRD (PD at night) Iron defeciency anemia AVM at pyloris (cauterized in [2131]) Orthostatic hypotension IgG lambda monoclonal gammopathy Past Surgical History: Bilateral hand surgeries for Dupuytrens Contractures PD catheter LASER surgery to retina bilateral cataract surgery Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - 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* Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office [Telephone/Fax (1) 170], [2133-8-25] at 10:45a Surgeon Dr. [Last Name (STitle) ] [Telephone/Fax (1) 170], [2133-9-17] at 2:15p Cardiologist Dr. [Last Name (STitle) ]/ [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2003], [MD Number(3) 1240]:[Telephone/Fax (1) 62] Date/Time:[2133-9-2] 11:30 Provider: [Name10 (NameIs) 2105] [Name11 (NameIs) 2106], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2133-9-3] 8:40 Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] TRANSPLANT SOCIAL WORK Date/Time:[2133-9-3] 10:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 6050], MD Phone:[Telephone/Fax (1) 8770] Date/Time:[2134-7-5] 10:30 Please call to schedule the following: Primary Care Dr. [Last Name (STitle) 105607],[First Name3 (LF) ] C. [Telephone/Fax (1) 81883] in [3-5] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Completed by:[2133-8-20]	[ "V53.91", "280.9", "403.91", "250.81", "414.01", "250.41", "424.1", "V45.11", "273.1", "585.6", "458.29" ]	icd9cm	[ [ [] ] ]	[ "36.15", "54.98", "36.13", "39.61" ]	icd9pcs	[ [ [] ] ]	6764, 6822	2594, 4412	313, 561	7245, 7363	2247, 2571	8151, 9337	1382, 1441		5094, 6741		6843, 7083		4438, 5071			7387, 8128									7106, 7224		1456, 1470																								250, 275													589, 856								1484, 2228								878, 1118	1275, 1366
433	163,523	47329	Discharge summary	report	Admission Date: [2164-8-13] Discharge Date: [2164-8-17] Date of Birth: [2112-11-10] Sex: F Service: MEDICINE Allergies: Codeine Attending:[Last Name (NamePattern1) 495] Chief Complaint: cardiac arrest Major Surgical or Invasive Procedure: Arterial line CVVHD History of Present Illness: 51 yo female with MMP including h/o PE (s/p permanent IVC filter), PVD (fem/[Doctor Last Name ] BPGs), ESRD ([3-2] gent), valv dz (AI, MR - not [Doctor First Name ] cand) and endocarditis, PVD, DVT, narc abuse, admitted to the ICU s/p cardiac arrest at home. Apparently, as relayed by pt's husband, pt has been SOB x 1 days. Pt went to bathroom said that "she felt she was going to die" and collapsed. , Documentation from EMS mostly absent, so story per husband and [Name (NI) ] reconds. Apparently, pt was complaining of worsening sob over thpast day, went to go to bathroom and said she felt like she was dying and then collapsed. Husband called EMS, EMS arrived approx 8 min later and found the patient in asystole. Pt intubated in field, CPR started, total 8 rounds of epi, 3 of atropine, Got BP of started cpr given 6 rounds of epi, 3 of atropine and 1 Nabicarb. had bp of 90/p at one point. total field code time was 30 minutes. Lost BP short time later, HR on monitor read to be 140s with no pulses. When rolling into the ED, bounding femoral pules felt, with hr of 130's. bp then 130/p. Total coding time about 30 mins. . In ed femoral catheter placed, ? arterial placement but line gas and abg from radial artery obviously different lab results so appears to be in appropriate vein. CTA was not ordered [3-2] high PTT in the EDs and IVC filter placed. Pt never really hypotensive per ED records with lowerst BP recorded as 99/33. . Of note, seroquel was recently increased to 50mg [Hospital1 ] by [Name8 (MD) 3782] NP on [2164-8-6] and dilaudid 2mg to be taken tid was prescribed during this visit too due to poor pain control . Unable to obtain ROS as patient is intubated and unresponsive. . . In the ED, VS returned HR 110-130s; BP 110/50. Past Medical History: 1. CHF--AR and MR [First Name (Titles) 767] [Last Name (Titles) 100137] endocardidtis ([2162]) with medical tx, not surgical candidate for valve repair. Echo [2162-10-1] showed LAE, dilated RV/LV, LVEF >60% (intrinsic depression given regurg). 4+ AR, 3+ MR, 2+ TR. PA systolic HTN. Known Veg Ao valve, coronary cusp--stable since [2163] 2. ESRD on HD qT, R, Sat --due to mixed gent and contrast-induced nephrotoxicity 3. Chronic PE s/p IVC filter [11-2] on lifelong coumadin 4. PVD s/p fem-post tib nonreversed saphenous vein graft [11-2]-- c/b wound hematoma --> exploration /evacuation, IVC filter placed; chronic venous stasis ulcers 5. HBV and HCV 6. Hypothyroidism 7. OA s/p bilateral TKR ([2157]) c/b R septic joint --> redo 8. Multiple psych issues including bipolar d/o with psychosis, narcotic dependence, anxiety d/o 9. Hx of pericardial effusion with tamponade [2-3] - resolved 10. MRSA carrier 11. Prior aspiration events. 12. Deep ulcers L leg 13. Atrial fibrillation on anti-coagulation/rate control 14. multiple MICU admissions to the MICU for respiratory depression due to overnarcotizing 15. multiple aspiration pneumonias Social History: Lives at home in [Location (un) 669] with her boyfriend, who spends his time taking care of her. She is on SSI. She is not able to walk, is transported in wheelchair by her husband, whom she cites as a strong support. No alcohol or drugs. [1-31] ppd x 40 years tobacco. Recently DC'd from [Hospital3 ] rehab Family History: NC Physical Exam: VS: T 98.3 (not recorded in other ED documentation), Tc 98.6; BP 132/49; HR 100-120; RR 16-32; O2 sat 100% on ABG: 7.28/31/348. AC 55016, FIO2 of 1.00; PEEP 5. GEN: intubated, unresponsive. HEENT: PERRLA, sclera icteric, scleral edema. R EJ in place. Fast, rhythic jaw fasiculations. rigid platysma. no JVP CV: regular, nl s1, s2,3+systolic murmur, 2+diastolic murmur. LV heave. PULM: CTAB, coarse inspiratory breath sounds ABD: soft, obese, multiple scars, +BS. no organomegaly. EXT: RLE. no edema. weak dopp pulses. No pulses dopplerable LLE. multiple ulcers on the LLE, some down to the bone. necrotic tissue present. NEURO: intubated, unresponsive without sedation. does not withdraw to pain. Pertinent Results: Labs: [2164-8-13] 12:58PM BLOOD WBC-9.4 RBC-3.63 Hgb-11.2* Hct-38.6 MCV-106# MCH-30.8 MCHC-28.9 RDW-21.2* Plt Ct-155 [2164-8-17] 04:19AM BLOOD WBC-9.7 RBC-3.34* Hgb-10.3* Hct-33.4* MCV-100* MCH-30.9 MCHC-31.0 RDW-22.3* Plt Ct-84* [2164-8-13] 12:58PM BLOOD Neuts-78* Bands-0 Lymphs-18 Monos-3 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 NRBC-8* [2164-8-13] 12:58PM BLOOD PT-22.5* PTT-150* INR(PT)-2.2* [2164-8-13] 12:58PM BLOOD Glucose-182* UreaN-26* Creat-3.7# Na-131 K-4.7 Cl-92* HCO3-15* AnGap-29* [2164-8-17] 04:19AM BLOOD Glucose-102 Na-132* K-4.5 Cl-97 HCO3-20* AnGap-20 [2164-8-13] 12:58PM BLOOD CK(CPK)-33 [2164-8-13] 07:25PM BLOOD ALT-29 AST-58* LD(LDH)-348* CK(CPK)-92 AlkPhos-277* Amylase-65 TotBili-1.1 [2164-8-16] 02:36AM BLOOD ALT-1066* AST-1522* AlkPhos-220* TotBili-2.4* [2164-8-13] 07:25PM BLOOD Lipase-22 [2164-8-13] 07:25PM BLOOD CK-MB-NotDone cTropnT-0.21* [2164-8-15] 04:00AM BLOOD CK-MB-16* MB Indx-1.6 cTropnT-0.72* [2164-8-13] 07:25PM BLOOD Albumin-3.8 Calcium-9.3 Phos-5.1* Mg-1.7 [2164-8-13] 07:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2164-8-13] 02:22PM BLOOD Type-ART Tidal V-550 FiO2-100 pO2-478* pCO2-33* pH-7.19* calTCO2-13* Base XS--14 AADO2-201 REQ O2-42 -ASSIST/CON Intubat-INTUBATED [2164-8-13] 02:30PM BLOOD Rates-16/0 Tidal V-550 PEEP-5 FiO2-100 pO2-57* pCO2-65* pH-7.04* calTCO2-19* Base XS--14 AADO2-590 REQ O2-97 -ASSIST/CON Intubat-INTUBATED Comment-GREEN TOP [2164-8-13] 01:13PM BLOOD Glucose-167* Lactate-8.6* Na-130* K-5.7* Cl-96* calHCO3-18* . CXR on admission: no acute cardiopulm process . EKG on admission: Aflutter 150, regular, borderline qt, leftward axis, ST-T changes laterally. . EKG on floor: sinus arrythmia, rate 102. q's in III. Leftward axis. QTc 0.51 . CT head: 1. No hemorrhage. 2. Poor differentiation of the grey-white matter may be seen in the setting of anoxic brain injury. Correlate clinically. Brief Hospital Course: 51F ESRD on HD, PVD, valvular heart disease admitted to the micu s/p asystolic arrest of unknown etiology. . #s/p asystolic arrest: The patient was found down at home; 8 mins until CPR and then at least 30 mins until return of circulation. [Last Name (un) ] etiology. Differential includes arrythmia (hyperkalemia, prolonged qt), large PE, overnarcosis, MI. Cardiac enzymes are elevated but more likely demand than ACS. Serum and urine toxicology screens were negative. Based upon her neuro status, in discussion with her family, the patient was made CMO after >72 hrs of observation. She expired shortly after extubation. . #Neuro: Unresponsive. s/p prolonged downtime (~8mins) with long resuscitation (30 min). Evidence of severe anoxic brain injury on examination and head CT with loss of grey-white differentiation. Neurology was consulted and recommended repeat examinations at initial time point and 72 hours after presentation given renal failure, fevers, and possibly effects of narcotics. There was no improvement and thus the prognosis for any neurologic recovery was extremely grim. . #Respiratory: Intubated due to asystolic arrest. Overbreathing the vent due to acidosis. Continue mechanical ventilation until terminally extubated. . #CV: . Ischmemia: No CP per witness but did c/o SOB which may be anginal equivalent. +trops but s/p CPR (no shocks), and ST changes laterally when going 150 (? rate related). No cath in our system but abnormal stress test. Cardiac enzymes were trended and troponin leak likely from hypotension during arrest rather than ruptured plaque. . Pump: Preserved EF. Known chronic aortic valve vegetation but not a surgical candidate per multiple evaluations. . Rhythm: h/o Afib on anticoagulation. Patient was in sinus arrhythmia at presentation with long QT. Initial arrest may have been due to torsades and notably she is on seroquel and topamax as an outpatient. Maintained K>4, Mg>2. Avoided QTc prolonging drugs. . #PVD: Multiple non-healing chronic LLE wounds. Wound care team was consulted. . #ID: ? infected ulcers given elevated WBC count and fevers. Colonized by MRSA and ESBL kliebsiella. Also with UTI and likely aspirated during arrest. She was treated with vanco/ceftriaxone for broad spectrum coverage. . #Hematology: Anticoagulated with coumadin for PE and chronic aortic valve vegetation. She was therapeutic on admission and then became supratherapeutic likely due to severe hepatic failure. Coumadin was held. . #Endocrine: RISS. Continued IV levothyroxine. . #renal: ESRD on HD [3-2] contrast/toxin nephropathy. Renal was consulted and she was placed on CVVHD for management of anion gap lactic acidosis due to hypoperfusion. Her pH on admission was 7.19 and normalized. She was removed from CVVHD given the stability of her metabolic status, poor prognosis due to severe brain injury, and decision to make CMO by family. . # Contact: [Name (NI) 38972] [Name (NI) ] (Daughter/HCP) [Telephone/Fax (3) 100193] #Dispo: Expired Medications on Admission: warfarin 2.5 mg PO HS folic acid qday synthroid 150mcq q am trazadone 150mg qhs thiamine 100 qd topamax 100 qd cymbalta 30mg qd Colace 100 mg [Hospital1 ] asa 81mg qd lopressor 50mg tid seroquel 50mg [Hospital1 ] oxycodone 20mg [Hospital1 ] oxycodone 5mg q 4 hrs flovent 220mcg 2puffs [Hospital1 ] combivent 2puffs quid senna prn Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Cardiac arrest Hypoxic brain injury End stage renal disease Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: None	[ "V58.61", "348.1", "070.54", "707.15", "V12.51", "428.0", "396.3", "427.31", "070.32", "585.6", "427.5" ]	icd9cm	[ [ [] ] ]	[ "96.71", "38.93", "96.6" ]	icd9pcs	[ [ [] ] ]	9871, 9880	6427, 9445	291, 312	9983, 9992	4435, 6034	10048, 10055	3692, 3696		9842, 9848		9901, 9962		9471, 9819			10016, 10025											3711, 4416																								237, 253													340, 2137		6263, 6404						6096, 6254								2159, 3339	3355, 3676
11,162	169,701	22924	Discharge summary	report	Admission Date: [2161-5-6] Discharge Date: [2161-5-12] Date of Birth: [2107-6-10] Sex: F Service: MEDICINE Allergies: Demerol Attending:[First Name3 (LF) 30] Chief Complaint: Torn medial meniscus shortness of breath bronchospasm Major Surgical or Invasive Procedure: Medial meniscus repair. Intubation and mechanical ventilation. Central venous line placement. History of Present Illness: Ms. [Known firstname 17937] [Known lastname 6633] is a 53 yo female with PmHx of asthma, colon cancer s/p resection, HTN, osteoarthritis who was admitted for elective R knee arthroscopy [2161-5-6]. Ms. [Known lastname 6633] [Last Name (Titles) 1834] R knee arthroscopy, with repeat partial posterior [Doctor Last Name 534] medial meniscectomy, partial lateral meniscectomy. Although she appeared to tolerate her surgery well, her immediate post-op course was complicated by diffuse wheeze and hypercarbic respiratory failure of unclear etiology (?bronchospastic adverse durg reaction) shortly after the LMA was removed, necessitating intubation. She had received 1L of crystalloid, Decadron 10 mg and albuterol MDI x2 in the OR. Medications administerd in the PACU included ketoralac, albuterol nebulizers, racemic epi neb, terbutaline 0.5 SC, lidocaine IV, ketamine, propofol peri-intubation. Her pre-intubation ABG revealed: 7.26/59/113. Of note, her post-intubation chest film did not reveal any infiltrates. . Ms. [Known lastname 6633] has recured MICU care from [5-6] - [5-11]. Her MICU course was notable for several complications, as follows. . 1) respiratory failure. She was maintained on empiric steroids, initially prednisone -> methylprednisolone, and then transitioned back to prednisone [5-11], as well as frequent nebs and inhaled steroids. She was successfully extubated [5-8] and has demonstrated improved respiratory status. . 2) She was noted to have a lactic acidosis, with lactate up to 11 [5-6], perhaps secondary to adverse reaction to propofol versus ?albuterol. Her propofol was dicontinued, and switched to fentanyl/versed for sedation, and albuterol was also held. Her lactate rapidly returned to baseline by [5-7]. . 3) She complained of L-sided CP, and was noted to have T wave flattening in the lat leads. She was given ASA, started on captopril, and was briefly on a nitroglycerin drip, later transitioned to isosorbide dinitrate. Serial cardiac enzymes were negative. An echo revealed an EF of 65%, with nl LV thickness and wall motion, and [1-25]+ MR. . 4) ?GIB - after placement of an NG tube shortly after admission, she was noted to have ?coffee grounds. A lavage cleared shortly after infusion of saline. GI was consulted, who felt that her coffee grounds may have been secondary to stress gastritis in the setting of high-dose steroids, and she was begun on frequent PPI. Her HCT has remained stable. . 5) HTN - patient has been noted to have significant HTN, with SBPs in the low 200s associated with mild HA. It is not clear what her pre-admission BP regimen was, though outpatient notes indicate lisinopril alone (?dose). She was begun on captopril -> lisinopril 20mg, HCTZ 25, and metoprolol, with improved control. A renal aretry u/s was obtained today for workup of ?secondary HTN. Past Medical History: Asthma htn knee OA S/p R knee arthroscopy in [10-27] obesity colon resection Social History: [Date Range 8003]-speaking only. Lives 1 hour from [Location (un) 86] in a 2 floor home. Eight children No tobacco No alcohol No illicit drug use. Unable to exercise. Physical [Location (un) ]: Gen: patient appears stated age, found sitting up in bed, in NAD HEENT: Sclera anicteric, conjunctiva uninjected, PERL, EOMI, MMM, no sores in OP, no evidence of thrush Neck: no JVD, no LAD, nl ROM Cor: RRR nl S1 S2 II/VI HSM at apex Chest: inspiratory, bibasilar crackles R>L. Abd: soft, obese, NT/ND, +BS. No HSM appreciated. EXT: no calf tenderness. No edema. 2+DP/PT pulses. R knee sutures intact, and knee is without evidence of inflammation (no fluctuance, warmth, or tenderness to palpation) Neuro: MS [First Name (Titles) ] [Last Name (Titles) ], CN II-XII in tact, UE/LE strength 5+ bilaterally, nl cerebellar [Last Name (Titles) ]. Gait not tested. Pertinent Results: [2161-5-6] 03:05PM GLUCOSE-170* NA+-143 K+-3.7 CL--103 TCO2-28 [2161-5-6] 03:05PM O2-40 PO2-113* PCO2-59* PH-7.26* TOTAL CO2-28 BASE XS--1 INTUBATED-NOT INTUBA COMMENTS-COOL NEB [2161-5-6] 04:09PM TYPE-ART RATES-[4-4] TIDAL VOL-500 PO2-424* PCO2-71* PH-7.21* TOTAL CO2-30 BASE XS--1 INTUBATED-INTUBATED [2161-5-6] 04:48PM PT-13.1 PTT-23.7 INR(PT)-1.1 [2161-5-6] 04:48PM PLT COUNT-145* [2161-5-6] 04:48PM NEUTS-85.2* LYMPHS-13.4* MONOS-1.0* EOS-0.2 BASOS-0.2 [2161-5-6] 04:48PM WBC-8.3 RBC-4.01* HGB-12.1 HCT-35.2* MCV-88 MCH-30.3 MCHC-34.5 RDW-12.7 [2161-5-6] 04:48PM CALCIUM-8.9 PHOSPHATE-3.5 MAGNESIUM-1.7 [2161-5-6] 05:25PM LACTATE-5.8* [2161-5-6] 08:53PM PLT COUNT-161 [2161-5-6] 08:24PM TYPE-ART PO2-158* PCO2-39 PH-7.27* TOTAL CO2-19* BASE XS--8 [2161-5-6] 08:53PM NEUTS-85* BANDS-6* LYMPHS-7* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2161-5-6] 08:53PM WBC-10.9 RBC-4.15* HGB-12.6 HCT-36.7 MCV-88 MCH-30.4 MCHC-34.4 RDW-12.7 [2161-5-6] 08:53PM ALBUMIN-3.9 CALCIUM-9.3 PHOSPHATE-2.5* MAGNESIUM-1.8 [2161-5-6] 08:53PM CK-MB-3 cTropnT-<0.01 [2161-5-6] 08:53PM ALT(SGPT)-13 AST(SGOT)-29 LD(LDH)-241 CK(CPK)-58 ALK PHOS-100 AMYLASE-88 TOT BILI-0.5 [2161-5-6] 08:57PM PT-13.6 PTT-24.5 INR(PT)-1.2 [2161-5-6] 09:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2161-5-6] 09:00PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.020 [2161-5-6] 09:06PM LACTATE-11.2* [2161-5-6] 11:06PM LACTATE-10.3* K+-3.6 [2161-5-6] 09:06PM TYPE-[Last Name (un) ] [2161-5-6] 11:06PM TYPE-ART TEMP-35.6 RATES-22/ TIDAL VOL-500 PEEP-5 O2-40 PO2-117* PCO2-39 PH-7.31* TOTAL CO2-21 BASE XS--6 INTUBATED-INTUBATED Brief Hospital Course: 53 yo female with h/o asthma s/p elective R knee arthroscopy [5-6], who developed hypercarbic respiratory failure requiring intubation [Date range (1) 59224], now recovering well on empiric steroids and nebulizers. . Respiratory failure: likely [2-25] asthma flare possibly from instrumentation vs. adverse medication reaction vs. aspiration. Continued to do well since being successfully extubated [2161-5-8]. Received solumedrol taper and was converted to prednisone. -rapid prednisone taper -MDIs -outpatient pulmonary workup, including PFTs. . Lactic Acidosis: Resolved on hospital day 2. Felt to be either [2-25] propofol or less likely albuterol. . CP: Currently chest pain free. Prior lateral T wave flattening, ?etiology given serially negative cardiac enzymes. However, it is noteworthy that the CP occurred in the setting of coffee-ground emesis, and may actually have been GI in origin. -continue empiric ASA. -BP control as below -consider d/c of empiric nitrates -recommend outpatient ETT if has not been previously performed by outpatient cardiologist. . HTN: Managed by Dr. [Last Name (STitle) 35852] ([Telephone/Fax (1) 59225]), affiliated with [Hospital1 2025]). -Continued lisinopril 20 mg daily -continued metoprolol, titrate dose (though given asthma flare, preferred to increase ACE rather than b-blocker) -Continued HCTZ . s/p arthroscopy: Wound was healing well and eventually tolerated weight bearing with physical therapy. Will need [Hospital1 ] follow-up and suture removal. . Gastritis: Suspect coffee grounds were secondary to stress gastritis as above. -Continued pantoprazole. -Outpaient EGD . Anemia: HCT stably low with HCT ~31. With normal iron and ferritin. Suspect anemia of chronic dz. . Hyperglycemia: Steroid induced, continue RISS . Occult Bacteremia: 1/4 bottles with Staph epi. in culture [5-10] likely a contaminant. No intercurrent fevers or leukocytosis. . FEN: Maintained on cardiac diet . Access: CVL (L subclavian). Attempt PIV, and then d/c CVL. . Comm: [Name (NI) ], daughters, and [Name2 (NI) ] interpreter. Daughter phone [Telephone/Fax (1) 59226]. . Code: Full. . Dispo: Patient was afebrile with stable vital signs on the day of discharge. She was not dyspneic and was able to speak in full sentences without distress. She had no further comnplaints and was able to bear weight on her knee s/p arthroscopy. She was without wheezing or rales on physical [Telephone/Fax (1) ] and was euvolemic. She was discharged home in stable condition on a rapid prednisone rapid taper with PCP, [Name10 (NameIs) ], and GI follow-up. . Follow-up: With PCP for asthma management during rapid prednisone taper, management of anemia, and for exercise tolerance testing or pharmacological stress (as limited by asthma). With GI for outpatient EGD for possible stress gastroenteritis). Medications on Admission: lisinopril flovent oxycodone albuterol prednisone x 5days in [Month (only) ] ultram Discharge Medications: 1. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). Disp:1 inhaler Refills:2 2. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual ASDIR (AS DIRECTED) as needed for pain: please let 1 tablet every 5 minutes for persistant chest pain. Call your doctor if you need to take this medication. Disp:30 Tablet, Sublingual(s) Refills:0 3. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for wheeze. Disp:1 inhaler Refills:0 4. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for indigestion. Disp:500 ML(s) Refills:0 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. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). Disp:240 Tablet(s) Refills:2 8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 9. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 10. Prednisone 10 mg Tablet Sig: see instructions below Tablet PO DAILY (Daily): [5-13]: 3 tablets daily [2079-5-13]: 2 tablets daily [Date range (1) 59227]: 1 tablet daily. Disp:12 Tablet(s) Refills:0 11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: [1-25] Disk with Devices Inhalation [Hospital1 ] (2 times a day). Disp:1 Disk with Device(s) Refills:2 12. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:20 Tablet(s) Refills:0 13. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO once a day. Disp:90 Tablet Sustained Release 24HR(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital6 ] Discharge Diagnosis: Torn medial meniscus, asthma flare, respiratory failure requiring intubation and mechanical ventilation Discharge Condition: Stable. Discharge Instructions: Please take prednisone as directed: On [5-13] take 30 mg (3 tablets) once each day. On [2078-5-13], and 23 take 20 mg (2 tablets) once each day. On [2081-5-16], and 26 take 10 mg (1 tablet) once each day. After [5-19], you are finished taking the prednisone. . Please see Dr. [Last Name (STitle) ] to follow up about your knee on [5-18] at 10:50 am. . Please take all the medications as listed by the prescriptions; you will be taking some new medications. . Physical therapy will be assisting you at home. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 10486], MD Where: [Hospital6 29] ORTHOPEDICS Phone:[Telephone/Fax (1) 1228] Date/Time: [2161-5-18], 10:50	[ "836.1", "836.0", "584.9", "715.16", "530.81", "493.92", "518.81", "285.9", "276.2", "E928.9", "278.00", "401.9", "V10.05", "790.6", "535.41" ]	icd9cm	[ [ [] ] ]	[ "38.93", "80.6", "96.04", "96.71" ]	icd9pcs	[ [ [] ] ]	11311, 11358	6211, 9098	319, 415	11506, 11515	4368, 6188	12094, 12291			9236, 11288		11379, 11485		9124, 9213			11539, 12071																																			226, 281													443, 3345																3367, 3449	3465, 4349
26,401	100,247	50366+50367	Discharge summary	report+report	Admission Date: [2144-12-27] Discharge Date: [2145-1-6] Date of Birth: [2086-10-17] Sex: F Service: ADMISSION DIAGNOSIS: [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Dictator Info ] MEDQUIST36 D: [2145-1-6] 15:16 T: [2145-1-6] 15:54 JOB#: [Job Number ] Admission Date: [2144-12-27] Discharge Date: [2145-1-8] Date of Birth: [2086-10-17] Sex: F Service: ADMISSION DIAGNOSIS: 1. Cardiogenic shock 2. Upper gastrointestinal bleed DISCHARGE DIAGNOSIS: 1. Coronary artery disease 2. Mitral regurgitation 3. Upper gastrointestinal bleed 4. Mitral valve prolapse 5. Status post coronary artery bypass graft times two and mitral valve repair 6. Episodic atrial fibrillation 7. Left ventricular outflow obstruction HISTORY OF PRESENT ILLNESS: The patient is a 58 year old woman who was admitted to the [Hospital3 3834] on [2144-12-26] with complaints of shortness of breath. She denied chest pains or palpitations at that time. She was hypotensive and a chest x-ray was consistent with congestive heart failure. Computerized tomography scan was obtained to rule out pulmonary embolism given the history of breast cancer. The patient had a history of allergy to Shellfish and computerized tomography scan was ultimately negative for pulmonary thrombosis, but the patient became acutely more short of breath and bronchospastic. She was presumed to have an allergic reaction to the intravenous contrast dye and was treated with epinephrine, Solu-Medrol as well as Benadryl. Despite this the patient became hypoxic and was intubated and transferred to the Intensive Care Unit. Dopamine drip was started and Swan-Ganz monitoring was used. Dobutamine was started for presumed cardiogenic shock although there was no specific etiology. Heparin drip was also begun and the patient's PTT went to 170. The patient subsequently developed a 300 cc bloody emesis via nasogastric tube. Hematocrit dropped from 41.6 to 34.4. She was transfused 2 units of packed red blood cells and a repeat hematocrit was 38.3. Heparin was discontinued. The patient was also started on broad-spectrum antibiotics, Levaquin, Vancomycin and Flagyl. The patient was then transferred to the [Hospital6 1760] for catheterization. PAST MEDICAL HISTORY: 1. Bronchitis; 2. Asthma; 3. Status post right lumpectomy for breast cancer; 4. Fibromyalgia; 5. Hypertension; 6. Increased cholesterol; 7. Mitral valve prolapse; 8. Palpitations. ALLERGIES: Penicillin, shellfish, Demerol, Percocet. MEDICATIONS: Medications at home were Atenolol 25 mg q.d., Lipitor, Amitriptyline. PHYSICAL EXAMINATION: Intubated, alert, moves all extremities and follows commands. Vital signs, temperature 100.0, heartrate 100, blood pressure 102/66, respirations 12, 100% oxygenation. Cardiovascular, tachycardiac, S1 and S2, II/VI systolic ejection murmur at the apex. Chest is significant for rales in the right mid lung field. Abdomen is soft, nontender, nondistended and obese. Extremities are warm, noncyanotic, nonedematous times four. Neurological was grossly intact. The patient has a right internal jugular Swan-Ganz catheter, left radial arterial line, intubated with nasogastric tube, Foley catheter and two peripheral intravenous lines. LABORATORY DATA: Complete blood count 22.9/31.9/217 with neutrophils 88%. Chemistry 137/4.2/103/22/25/0.9/147/ 8.2/4.9/3.2. Arterial blood gases 7.42/35/115 on 40% fIO2. Creatinine kinase 108, MB 4 and troponin 2.0. Chest x-ray reveals mild congestive heart failure with question of a right middle lobe infiltrate. There was some small left pleural effusion. Electrocardiogram is sinus rhythm, ST depression in V3 and 4 with T wave flattening in the lateral leads. HOSPITAL COURSE: The patient was admitted with the presumptive diagnosis of cardiogenic shock, possibly from transient ischemia. She has also had upper gastrointestinal bleed. Leukocytosis with lowgrade temperatures, also indicated the possibility of a lung infection. From a gastrointestinal standpoint, the patient had an esophagogastroduodenoscopy performed on [2144-12-28] which revealed blood in the fundus and multiple small lesions are actively bleeding. It was felt that those lesions probably represented arteriovenous malformations. Gastroenterology recommendations were to avoid non-steroidal anti-inflammatory drugs, transfuse prn and avoid nasogastric tube suction. The patient is also to begin proton pump inhibitors, Protonix 40 mg b.i.d. The patient was extubated on hospital day #2 without difficulty. Her saturations remained above 95% on face mask. The patient was premedicated for cardiac catheterization given her possible allergic reaction to intravenous dye. Cardiac catheterization revealed 3 to 4+ mitral regurgitation with an ejection fraction of 65%. There was some anterior hypokinesis. The coronary system was right dominant and there was noted to be 70% occlusion of obtuse marginal 1 and 60% of the mid right coronary artery. Intra-aortic balloon pump was placed at that time. Cardiology also recommended coronary artery bypass graft and mitral valve repair. The patient also had an episode of supraventricular tachycardia with a rate of 200 and then converted back to sinus rhythm with a total of 10 mg of intravenous Lopressor. Cardiac surgery consultation was obtained on hospital day #3 which agreed with operative repair. On [2144-12-30], the patient then underwent coronary artery bypass graft times two with saphenous vein graft to the descending right coronary artery and saphenous vein graft to the obtuse marginal as well as mitral valve repair with a 26 mm [Doctor Last Name 405] [Doctor Last Name ] annuloplasty band. Postoperatively, the patient was taken to the Intensive Care Unit for closer monitoring. The patient was subsequently extubated that evening. Postoperatively, the patient did well in the Intensive Care Unit. Intra-aortic balloon pump was discontinued on postoperative day #2. She was also transfused 1 unit of packed red blood cells. The patient was transferred to the floor on postoperative day #3 and seemed to be doing well. Her chest tubes and wires were discontinued. On the evening of postoperative day #3, the patient went into rapid atrial fibrillation and was given 20 mg of intravenous Lopressor as well as 150 mg of Amiodarone. The patient's rate remained uncontrolled and blood pressure began to drop. The patient was transferred back to the Intensive Care Unit for closer monitoring. The patient received an additional Amiodarone 150 mg intravenous bolus as well as Amiodarone drip. The patient subsequently converted back into normal sinus rhythm. On postoperative day #5 the patient was transferred back to the floor. She continued to work with physical therapy and did well with this. On postoperative day #6, the patient went into a second episode of rapid atrial fibrillation at approximately 1:30 AM. The patient remained asymptomatic throughout without chest pain or shortness of breath. She did complain of subjective palpitations. Heartrate was between 120 and 150 with a blood pressure maintained in the 100s/60s. Saturations were 97% on room air. The patient converted back to normal sinus rhythm with 15 mg of intravenous Lopressor and 2 gm of Magnesium Sulfate given. Lowest blood pressure drop was 80/60. Subsequent to this, Electrophysiology was consulted. They recommended outpatient [Doctor Last Name ] of Hearts monitoring as well as Amiodarone taper regimen. They also recommended obtaining echocardiogram prior to discharge to assess the left ventricular function as well as mitral valve function. Echocardiogram was obtained on [2145-1-6] which revealed still some mild to moderate mitral regurgitation as well as significant left ventricular outflow obstruction due to the mitral leaflets. Left ventricular function remained greater than 60%, the effect was hyperdynamic. The patient was kept in house for closer monitoring as well as increasing of beta blockade. The goal was to decrease the patient's heartrate down below the 70s and hopefully into the 50s. The patient tolerated this and had no further disease. The patient was discharged to home on postoperative day #9 tolerating a regular diet and given adequate pain control and p.o. pain medications. Anticoagulation was not begun due to her history of gastrointestinal bleeds and probable arteriovenous malformations. DISCHARGE MEDICATIONS: 1. Colace 100 mg b.i.d. 2. Tylenol #3 prn 3. Amiodarone 200 mg t.i.d. times one week, 200 mg b.i.d. times two weeks, 200 mg q.d. 4. Captopril 12.5 mg t.i.d. 5. Lopressor 100 mg b.i.d. 6. Aspirin 325 mg q.d. 7. Lipitor 10 mg q.d. 8. Albuterol/Ipratropium inhaler DISCHARGE CONDITION: Good. DISPOSITION: To home. DISCHARGE INSTRUCTIONS: Diet is cardiac. The patient is discharged with [Doctor Last Name ] of Hearts monitor for arrhythmias. She should follow up closely with Dr. [Last Name (STitle) 911] of Cardiology. The patient should follow up in six weeks with Dr. [Last Name (STitle) 70]. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Last Name (NamePattern1) 5745] MEDQUIST36 D: [2145-1-10] 00:20 T: [2145-1-10] 07:16 JOB#: [Job Number ]	[ "427.31", "428.0", "785.51", "997.1", "411.1", "537.83", "174.9", "416.0", "424.0" ]	icd9cm	[ [ [] ] ]	[ "88.56", "36.12", "96.71", "37.61", "44.43", "37.22", "88.53", "39.61", "35.12" ]	icd9pcs	[ [ [] ] ]				8980, 9011					8687, 8958		669, 935			3944, 8664		9036, 9608																								2815, 3926	592, 648																							964, 2441																2464, 2792
76,275	161,171	13351	Discharge summary	report	Admission Date: [2168-4-30] Discharge Date: [2168-5-4] Date of Birth: [2092-6-1] Sex: F Service: SURGERY Allergies: Vioform Attending:[First Name3 (LF) 2836] Chief Complaint: Right wrist and right heel pain Major Surgical or Invasive Procedure: [2168-5-2] ORIF right intra-articular distal radius fracture, 3 or more fragments. History of Present Illness: Patient is a 75 y/o RHD woman who was the restrained driver in a single vehicle MVA - car vs. tree - who was transferred from [Hospital6 3105] with a R distal radius fracture and a R calcaneus fracture in addition to multiple bilateral rib fractures (R [3-16], L 1), sternal fracture with small anterior medistinal hemorrhage, L1 and L3 transvers process fractures, and a possible L lower sacral fracture. The patient was driving her 4 grandchildren home when she had a syncopal episode, lost control of the car at 60 mph and hit a tree. 3 of the children were intubated and flown to a local hospital. She had a GCS of 15 in the field. She was boarded and collared and taken to [Hospital6 3105] where CT head/neck were negative. The remainder of the work-up was remarkable for multiple bilateral rib fractures, sternal fracture with mediastinal hemorrhage, L1 and L3 transverse process fracture, R distal radius fracture, R calcaneus fracture, and a possible L minimally displaced sacral fracture. Given the mediastinal hemorrhage she was transferred to [Hospital1 18] for further care. Past Medical History: PMH: hypothyroid, HLD, NIDDM . PSH: L TKA, Tonsillectomy, Cholecystectomy, Cervical cone procedure, Multiple R foot procedures - [Hospital1 15309] neuroma excision, bone spur excision Social History: Lives with daughter [Name (NI) ] [Last Name (NamePattern1) 1139] none ETOH none Family History: non contributory Physical Exam: HR:80 BP:180/p Resp:12 O(2)Sat:One percent Normal Constitutional: Uncomfortable HEENT: Normocephalic, atraumatic, Pupils equal, round and reactive to light, Extraocular muscles intact Oropharynx within normal limits Chest: Clear to auscultation chest tender to palpation midline and right left chest Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nontender Extr/Back: No cyanosis, clubbing or edema rectal calcaneal pain Skin: No rash Neuro: Speech fluent Pertinent Results: [2168-4-30] 02:16AM WBC-10.4 RBC-3.92* HGB-10.1* HCT-32.1* MCV-82 MCH-25.8* MCHC-31.5 RDW-15.5 [2168-4-30] 02:16AM NEUTS-85.7* LYMPHS-7.9* MONOS-6.1 EOS-0.1 BASOS-0.2 [2168-4-30] 02:16AM PLT COUNT-261 [2168-4-30] 02:16AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2168-4-30] 02:16AM GLUCOSE-287* UREA N-24* CREAT-0.5 SODIUM-136 POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-25 ANION GAP-14 [2168-4-30] 2:30 am URINE Site: CATHETER FINAL REPORT [2168-5-2] URINE CULTURE (Final [2168-5-2]): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 1 S [2168-4-30] CT Right lower extremity: 1. Comminuted fracture of the calcaneus as described above, involving posterior subtalar joints, superior, dorsal and plantar surfaces of the calcaneus, calcaneocuboid joint and anterior process of talus. Suspected fracture at the posterior margin of the talus. 2. No other acute discrete fracture is identified in the mid foot. 3. Old fracture deformity of the distal tibia and fibula with superimposed osteoarthritis, and old osteochondral lesion of the superomedial talar dome. 4. Chronic Achilles thickening. 5. Suspected fracture of plantar calcaneal enthesophyte, plantar fasciitis, age indeterminate. [2168-4-30] Right wrist fracture: Distal radial fracture in near anatomic alignment. Focal defect in the mid scaphoid waist is concerning for a scaphoid fracture. Evaluation of the carpi is limited due to overlying cast. [2168-4-30] Right tib/fib xray: Chronic deformity of the distal tibia and fibula. Tricompartmental osteoarthritis of the right knee. Communited calcaneal fracture is partially imaged [2168-4-30] CT C spine : 1. No evidence of acute intracranial abnormalities. 2. Cervical spine CT demonstrates no evidence of fracture. Degenerative change is seen with mild spinal canal narrowing at C6-7 level. [2168-5-3] Cardiac echo : The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no left ventricular outflow obstruction at rest or with Valsalva. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. [2168-5-3] Carotid duplex scan : < 40% stenoses B/L ICA's Brief Hospital Course: Mrs. [Known lastname ] was evaluated by the Trauma team in the Emergency Room along with the Ortho Trauma service for her multiple broken bones. Her right wrist fracture was initially reduced in the Emergency Room with plans for operative repair when she was medically stable. She was then admitted to the hospital for further management of her injuries. Her accident was possibly caused by a syncopal episode therefore she needed a cardiac echo and carotid duplex scan to rule out any abnormalities. Her Cardiac echo revealed a normal EF, no wall motion abnormalities and no significant valvular disease. Her carotid studies showed a < 40% stenoses in bilateral ICA's. She was placed on telemetry and had no arrhythmias. Her blood pressure was on the high side but after her pain was controlled and her routine antihypertensives were resumed she was in better control. She remained free of any dizziness, palpitations or chest pain during her admission. Her hematocrit was stable in the 23-24 range without any blood transfusions. On [2168-5-2] she was taken to the Operating Room for ORIF of the right distal radial fracture. She tolerated the procedure well and returned to the PACU in stable condition.. She maintained stable hemodynamics and her pain was well controlled. Following transfer to the Trauma floor she continued to make good progress. Her diet was resumed and well tolerated. her blood sugars were elevated but in better control after resuming her diabetic medications. The Physical Therapy service evaluated her to try to increase her mobility although her weight along with her activity restrictions were limiting. Her right upper extremity in non weight bearing though she can bear weight through the right forearm. Her right lower extremity in non weight bearing as well. Hopefully time spent in rehab will help her increase her mobility safely. Medications on Admission: Metformin 1000 [Hospital1 ] Synthroid 125 mcg daily Diovan 320 mg daily Metoprolol XL 75 mg daily Januvia 100 mg daily Glimepizide 4 mg daily Provastatin 20mg daily Flonase 2 sprays daily ProAir 90 mcg 1-2 puffs q 4-6 hrs prn Serovent 50 mcg 1 inh daily Spiriva 18 mcg daily Meclizine 25 mg daily prn ASA 81mg Buproprion CL 100 mg [Hospital1 ] FeSO4 325 mg daily Discharge Medications: 1. nitrofurantoin macrocrystal 50 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) for 3 days: thru [2168-5-5]. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 4. tramadol 50 mg Tablet Sig: 0.5 Tablet PO QID (4 times a day). 5. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. glimepiride 4 mg Tablet Sig: One (1) Tablet PO daily (). 8. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): Hold for SBP < 110, HR < 60. 10. valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Hold for SBP < 110. 11. Januvia 100 mg Tablet Sig: One (1) Tablet PO daily (). 12. insulin regular human 100 unit/mL Solution Sig: 4-10 units Injection four times a day as needed for per sliding scale. 13. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 14. salmeterol 50 mcg/dose Disk with Device Sig: One (1) Inhalation Q12H (every 12 hours). 15. aspirin 81 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 17. bupropion HCl 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 19. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. FeSO4 325 mg daily Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) 8957] Discharge Diagnosis: S/P MVC car v. pole 1. Right rib fractures [3-16] 2. Left 3rd rib fracture 3. Non displaced sternal fracture 4. Tiny mediastinal hematoma 5. Left L1 & L3 transverse process fracture 6. Right intra articular distal radial fracture 7. Right calcaneal fracture 8. Enterococcal UTI Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair, right upper and lower extremities are NON weight bearing Discharge Instructions: * You were admitted to the hospital after your car accident with multiple broken bones, some requiring surgery. * Your rib fractures can be painful so make sure that you take enough pain medication to be comfortable. You will need to cough, deep breath and use your incentive spirometer to prevant pneumonia. * Constipation can be a problem with narcotic pain medication and iron therefore make sure that you take a stool softener and/or gentle laxative to stay regular. * Continue to eat a regular diabetic diet and stay well hydrated. * Follow ypour blood sugars and continue your diabetic medications as stated below. * You CANNOT bear weight on your right hand or right leg but may bear weight through the right forearm. You can weight bear as tolerated on the left leg. * If you develop any fevers, shortness of breath or any other symptoms that concern you, please call your doctor or return to the Emergency Room. Followup Instructions: Call the Acute Care Clinic at [Telephone/Fax (1) 600] for a follow up appointment in [3-10] weeks. Call the [Hospital ] Clinic at [Telephone/Fax (1) 1228] for a follow up appointment in 2 weeks. Completed by:[2168-5-4]	[ "805.4", "250.00", "807.08", "244.9", "E816.0", "599.0", "041.04", "862.29", "780.2", "807.2", "813.41", "272.4", "825.0" ]	icd9cm	[ [ [] ] ]	[ "79.02", "79.32", "38.91" ]	icd9pcs	[ [ [] ] ]	9555, 9629	5643, 7532	297, 386	9955, 9955	2417, 5620	11134, 11376	1858, 1876		7953, 9532		9650, 9934		7558, 7930			10188, 11111											1891, 2398																								226, 259													414, 1525										9970, 10164						1547, 1737	1753, 1842
16,454	188,598	26400	Discharge summary	report	Admission Date: [2168-12-26] Discharge Date: [2169-1-20] Date of Birth: [2120-2-22] Sex: M Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 148] Chief Complaint: pancreatitis Major Surgical or Invasive Procedure: ERCP History of Present Illness: 40 y/o M presents with 12 hours of epigastric chest pain. He states that he was discharged home from the hospital with his fifth episode of pancreatitis in the past 12 months on [2168-12-22], 4 days prior to presentation. The pain is the same pain he gets when he has pancreatitis. Past Medical History: 1. Recurrent pancreatitis x5 since [12-22] with unclear etiology. Has had numerous RUQ U/S which have been negative for cholelithiasis, MRCP in [3-22] that was negative reportedly, nl triglycerides, no sig EtOH history. Some notes mention ?relation to RA. 2. Chronic tophaceous gout x 5-7 years, on chronic prednisone as outpatient of at least 20 mg although has been increased many times in the last year for flares as well as allopurinol as outpatient, recently stopped at OSH given worsening renal failure and acute flare 3. ?Rheumatoid arthritis - seronegative per notes ([Doctor First Name ] and RF checked in [3-22]) but has mention of this on various notes; never been on DMARD therapy 4. HTN 5. Hypercholesterolemia 6, H/o LGIB ?colonic ulcer secondary to NSAID use in [12-22]. 7. h/o ARF secondary to acute pancreatitis while on diuretics, fluid responsive 8. Fatty liver on CT scan in [12-22] 9. Chronic lower back pain 10. Skin cancer ?basal cell CA resected off lumbar spine 11. Last echo [2167] with nl LV [Last Name (LF) ], [First Name3 (LF) ] 55%, 1+AI. Stress test done for unclear reasons which was neg. 12. h/o nephrotic syndrome dxed at age 19 per the patient Social History: smoked occasional cigars but quit 15 years ago, no cigarette use. Social drinker in the past but no significant alcohol use currently. Separated from his wife, has 2 grown children. On disability. Family History: noncontributory with no h/o cancer, DM, CAD; mother had gout in her 60s, no other family h/o rheumatic diseases Physical Exam: Vitals: 97.8 77 114/83 rr 20 96% on RA Gen: NAD Neuro: AAOX3, MAE HEENT: PERRL, EOMI, anicteric, neck supple Chest: LCTA CV: RRR, no murmurs, 2+ distal pulses Abd: diffusely tender to palp, no guarding or rebound, no flank or back pain Ext: no edema, + gouty deformity of b/l hands and halluxes Pertinent Results: [2168-12-26] 04:40PM PLT COUNT-327 [2168-12-26] 04:40PM WBC-22.7# RBC-3.94 HGB-12.5* HCT-35.5* MCV-90 MCH-31.7 MCHC-35.2* RDW-15.2 [2168-12-26] 04:40PM ALBUMIN-3.3* CALCIUM-7.7* PHOSPHATE-3.3 MAGNESIUM-1.0* [2168-12-26] 04:40PM LIPASE-145* [2168-12-26] 04:40PM ALT(SGPT)-36 AST(SGOT)-17 ALK PHOS-61 AMYLASE-134* TOT BILI-0.6 [2168-12-26] 04:40PM GLUCOSE-82 UREA N-21* CREAT-2.7# SODIUM-143 POTASSIUM-3.4 CHLORIDE-106 TOTAL CO2-25 ANION GAP-15 [2168-12-26] 04:47PM LACTATE-1.8 [2169-1-19] 05:51AM BLOOD Hct-24.2 [2169-1-14] 05:30AM BLOOD WBC-10.4 RBC-3.13* Hgb-8.9* Hct-25.7* MCV-82 MCH-28.4 MCHC-34.6 RDW-15.3 Plt Ct-410 [2169-1-18] 07:33AM BLOOD Plt Ct-412 [2169-1-18] 07:33AM BLOOD Glucose-84 UreaN-20 Creat-0.7 Na-142 K-3.9 Cl-108 HCO3-26 AnGap-12 [2169-1-16] 06:00AM BLOOD Glucose-110* UreaN-22* Creat-0.7 Na-140 K-4.4 Cl-108 HCO3-27 AnGap-9 [2169-1-18] 07:33AM BLOOD ALT-65* AST-25 LD(LDH)-186 AlkPhos-180* Amylase-57 TotBili-0.2 [2169-1-18] 07:33AM BLOOD Lipase-99* [2169-1-18] 07:33AM BLOOD Albumin-2.3* Calcium-7.7* Phos-3.2 Mg-1.6 [2169-1-11] 11:55AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEG IgM HBc-NEG IgM HAV-NEGATIVE [2169-1-11] 11:55AM BLOOD HCV Ab-NEGATIVE [2168-12-26] 04:47PM BLOOD Lactate-1.8 [2169-1-17] 11:20AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.013 [2169-1-13] 08:49PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.012 [2169-1-17] 11:20AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-7.0 Leuks-NEG RADIOLOGY Final Report CHEST (PORTABLE AP) [2169-1-17] 10:08 AM CHEST (PORTABLE AP) Reason: assess for cardiopulmonary pathology [Hospital 93] MEDICAL CONDITION: 48 year old man with pancreatitis, spiking fevers REASON FOR THIS EXAMINATION: assess for cardiopulmonary pathology HISTORY: Pancreatitis and spiking fevers. COMPARISON: [1-10] and 27, [2168]. FINDINGS: AP upright portable view of the chest. Heart and mediastinal contours are stable. There is no pulmonary edema. A left basilar opacity is again seen, unchanged and probably representing atelectasis. There are no new pulmonary opacities. There is no effusion. The right PICC is in unchanged position. IMPRESSION: Stable left basilar opacity, probably representing atelectasis. RADIOLOGY Final Report CT ABD W&W/O C [2169-1-10] 11:25 AM CT ABD W&W/O C; CT PELVIS W/CONTRAST Reason: please give po and IV contrast Field of view: 40 Contrast: OPTIRAY [Hospital 93] MEDICAL CONDITION: 48 year old man with recurrent pancreatitis, possible rupture of cyst, hemorrhage--hypotensive, tachycardic REASON FOR THIS EXAMINATION: please give po and IV contrast CONTRAINDICATIONS for IV CONTRAST: None. CT OF THE ABDOMEN AND PELVIS There is a comparison study from [2169-1-1], most recently and an MRCP from [2169-1-5]. CLINICAL HISTORY: Recurrent pancreatitis of unclear etiology, evaluate changes since prior exam. TECHNIQUE: Axial MDCT images of the abdomen and pelvis were obtained pre- and post-IV contrast enhancement. CT ABDOMEN FINDINGS: Images of the lower thorax demonstrate a small left pleural effusion. It is not significantly changed since the prior exam. There is subsegmental atelectasis. Pre-contrast images of the abdomen demonstrate aortic atherosclerosis. Post-contrast images demonstrate normal appearance of the liver and spleen. Two splenules are present. Again noted is atrophy of the pancreas. Low-density structures are present in the uncinate process and pancreatic neck and tail. These are not significantly changed since the prior exam or from [2168-1-7]. A recent MRCP suggests that these represent intraductal papillary mucinous tumor. Since the prior exam there are increased inflammatory changes in the pancreatic tail, as evidenced by increased stranding in the fat surrounding the pancreatic tail. The large cystic structure in the lesser sac measures 8.0 x 15.6 cm on the current study compared to 5.6 x 13.9 cm on the previous study. The pancreatic duct is not dilated. There is no biliary dilatation. Again noted are multiple low densities in the kidneys bilaterally, most suggestive of renal cysts, these were seen in [2167-12-19] and are not significantly changed. The splenic vein is normal. No splenic artery aneurysms are visualized. There is no lymphadenopathy. Images of the pelvis demonstrate a cystic structure with an enhancing rim, just anterior to the rectum. This measures 2.6 x 2.2 cm. On the previous examination fluid was noted at this location and in the more anterior pelvis. There is atherosclerosis of multiple arteries in the pelvis. There is a peripherally calcified rounded lesion anterior to the rectum, which likely represents calcification of previously necrosed fat. Bone windows demonstrate sclerotic lesions in the femoral heads bilaterally consistent with avascular necrosis. IMPRESSION: 1. The large cystic lesion in the lesser sac has not ruptured, it has increased in size since the previous exam. 2. Increased inflammatory changes in the region of the pancreatic tail. While all these changes may be related to pancreatitis, the underlying cause of the pancreatitis may be secondary to an underlying lesion. The recent MRI suggested that IPMT is present in the pancreas. On the CT from an outside institution dated [2168-1-7], there is a low-density lesion in the pancreatic tail. Possible etiologies include mucinous cystadenoma or cystadenocarcinoma. Previous biopsies for cytology apparently have been negative. Consider a repeat biopsy. 3. New loculated enhancing fluid collection in the pelvis at the location of a previously noted collection of free fluid. This may represent a pseudocyst or abscess in the correct clinical scenario. 4. Findings in the femoral heads are consistent with avascular necrosis, which was seen in [2167]. RADIOLOGY Final Report MRCP (MR ABD W&W/OC) [2169-1-5] 4:09 PM MRCP (MR ABD W&W/OC); MR CONTRAST GADOLIN Reason: ?obstruction?stone Contrast: MAGNEVIST [Hospital 93] MEDICAL CONDITION: 48 year old man with recurrent pancreatitis, now w/persistent abdominal pain and new fluid collection REASON FOR THIS EXAMINATION: ?obstruction?stone HISTORY: Recurrent pancreatitis of unknown etiology, now with persistent abdominal pain and a new fluid collection. COMPARISON: Previous CT scans performed between [2168-12-21] and [2169-1-1]. TECHNIQUE: Multiplanar imaging of the abdomen with focus on the liver, bile duct, and pancreas was performed at 1.5 Tesla utilizing T1-weighted and T2- weighted sequences, including dynamic gadolinium-enhanced images with subtractions for each phase of enhancement. Multiplanar reformatted images were generated on a 3D workstation. FINDINGS: The pancreas is mildly atrophic. It demonstrates minimally diminished signal on precontrast T1-weighted images. It enhances normally without evidence of necrosis. There is an 8 mm cystic lesion in the pancreatic head, a 9 mm cystic lesion in the pancreatic tail, and two adjacent cystic lesions in the pancreatic body with the largest lesion measuring 10 mm. These cystic lesions communicate with the main pancreatic duct, consistent with dilated pancreatic duct side branches. There is irregular narrowing of the pancreatic duct in the neck, between the cystic lesions in the head and body, consistent with a stricture. There is no evidence of a pancreas divisum. There is a fluid collection arising at the pancreatic tail, which extends superiorly along the left flank and enters the lesser sac, where it communicates with a 5.1 x 7.0 x 9.0 cm pseudocyst. The pseudocyst contents demonstrate heterogeneous signal intensity. The pseudocyst compresses the inferior aspect of the stomach. There is no evidence of splenic vessel pseudoaneurysm or splenic vein thrombosis. There is a small fluid collection in the left lower quadrant of the abdomen, which fluctuates in size compared to several preceding CT scans. It appears slightly smaller than on the most recent CT scan of [2169-1-1]. The common bile duct is normal in contour and caliber, without evidence of wall thickening. Intrahepatic bile ducts are also normal in appearance. Focal adenomyomatosis is noted in the gallbladder fundus. The liver, spleen, and adrenal glands appear unremarkable. Several splenules are noted. Multiple cysts are present in both kidneys. Multiplanar reformatted images were generated on a 3D workstation, and they were essential in delineating the anatomy of the peripancreatic fluid collections as well as the pancreatic duct. Findings were discussed with Dr. [Last Name (STitle) ] in the morning of [2169-1-6]. IMPRESSION: 1. Multifocal dilatation of pancreatic duct side branches, consistent with multi focal side branch IPMT. 2. Pancreatic duct stricture at the level of the neck. 3. Fluid collection arising from the pancreatic tail and extending superiorly along the left flank into the lesser sac, where it communicates with a large pseudocyst. 4. Fluctuating small fluid collection in the left lower quadrant. 5. Focal adenomyomatosis in the gallbladder fundus. Brief Hospital Course: Pt was admitted to the SICU for observation. He was made NPO, put on IVF, and started on Dilaudid SC for pain control. Cultures were sent, and CXR and CT were obtained. The CT demonstrated increased peripancreatic stranding and multiple pseudocysts. Pt was maintained on conservative treatment and improved. On HD2 pt was transferred to the floor. He continued to have intermittent abdominal pain, somewhat improved from admission. On HD3 he was started on TPN in anticipation of a prolonged course of NPO. A right PICC line was placed in interventional radiology for anticipated home TPN. He was maintained on TPN with intermittent increases in abdominal pain, most pronounced in his LUQ. He was given iv Dilaudid with some relief. On HD7, patient had an acute increase in his abdominal pain. He became hypertensive and tachycardic. An abdominal CT scan demonstrated a new large 13 x 5 cm fluid collection in his anterior abdomen. At this time, he was transferred to the VICU for closer management. He was given Lopressor and nitropaste for his blood pressure and started on a Dilaudid PCA with some relief of his pain. Patient continued to improve and was transferred to the regular nursing floor. Patient was kept NPO and was subsequently started on TPN supplementation. On [1-5] patient underwent an MRCP which showed a multifocal dilatation of pancreatic duct side branches, consistent with multi focal side branch IPMT, pancreatic duct stricture at the level of the neck, a fluid collection arising from the pancreatic tail and extending superiorly along the left flank into the lesser sac, where it communicates with a large pseudocyst, a fluctuating small fluid collection in the left lower quadrant, and focal adenomyomatosis in the gallbladder fundus. At this point it was decided that patient will require an ERCP. On [1-13] patient underwent an ERCP that showed extravasation from the main pancreatic duct at the body of the pancreas. This pancreatic leak most likely explains the recent increase in size of the pancreatic cyst. Otherwise, the pancreatogram was normal. Because of issues with sedation, the procedure was terminated prior to placement of a pancreatic stent and was rescheduled for a future date with general anesthesia. Repeat ERCP on [1-16] showed a normal common bile duct and common hepatic duct. Because of the sharp turns/ansa loop of the main pancreatic duct, we were unable to advance the wire to place a pancreatic stent. A single stricture was seen at the body of the pancreas. Proximal to the stricture, a small, round cystic lesion connected to the main pancreatic duct was seen--this was previously thought to be extravasation, however with prolonged views under anesthesia, there was no extravasation. Patient continued to do well post ERCP. Although his pain never completely subsided and would flare, he was fairly well controlled with PO pain medications. Given the failed ERCP stenting, patient is being discharged home on TPN and will follow-up with Dr. [Last Name (STitle) ] in 3 weeks with a CT scan. Patient was discharged to a rehabilitation facility in stable condition with instructions for follow-up. Medications on Admission: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for muscle spasm. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 6. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 8. Prednisone 10 mg Tablet Sig: 2.5 Tablets PO qd () for 4 doses. Disp:10 Tablet(s) Refills:0 9. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every 4-6 hours. Disp:15 Tablet(s) Refills:0 Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Octreotide Acetate 100 mcg/mL Solution Sig: One (1) Injection Q8H (every 8 hours). 5. Nitroglycerin 2 % Ointment Sig: One (1) Transdermal Q6H (every 6 hours) as needed for HTN, give for sustained sbp>150. 6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 7. Hydromorphone 2 mg Tablet Sig: 2-3 Tablets PO Q2H (every 2 hours) as needed. 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 9. Hydromorphone 4 mg/mL Syringe Sig: One (1) Injection Q4-6H (every 4 to 6 hours) as needed for breakthrough pain. 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Hydromorphone 2 mg/mL Syringe Sig: One (1) Injection Q3-4H (Every 3 to 4 Hours) as needed. 13. Nutrition-TPN [Known lastname 3240],[Known firstname ] [Numeric Identifier 65286] Non-Standard TPN For Date: [2169-1-19] Order marked as pumpedVolume(ml/d) Amino Acid(g/d) Branched-chain AA(g/d) Dextrose(g/d) Fat(g/d) [Telephone/Fax (2) 65287]0 50 Trace Elements will be added daily Standard Adult Multivitamins NaCL NaAc NaPO4 KCl KAc KPO4 MgS04 CaGluc 90 100 40 30 15 0 30 5 Heparin(units) Insulin(units) Zinc(mg) 5000 30 10 Total volume of solution per 24 hours. Rate of continous infusion determined by pharmacy-See Label 14. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - Acute Rehab Discharge Diagnosis: Acute recurrent pancreatitis Tophaeous gout Discharge Condition: Stable Discharge Instructions: Please come to the emergency room if you have persistent or worsening abdominal pain, nausea/vomiting, dizziness or weakness or shortness of breath. Call if your PICC line site becomes red or painful, or if you develop fever. Please continue your TPN as directed. Do not drive while taking pain medications. Followup Instructions: Please follow up with Dr. [Last Name (STitle) ] in approximately 3 weeks with a CT scan. Call [Telephone/Fax (1) 1231] for an appointment.Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2832], MD Phone:[Telephone/Fax (1) 2833] Date/Time:[2169-2-10] 10:00 Completed by:[2169-1-21**]	[ "272.0", "285.9", "577.0", "274.0", "577.2", "401.9" ]	icd9cm	[ [ [] ] ]	[ "51.10", "38.93", "99.15" ]	icd9pcs	[ [ [] ] ]	17755, 17828	11794, 14972	284, 291	17916, 17924	2528, 4291	18280, 18610	2078, 2191		16003, 17732	8693, 8795	17849, 17895		14998, 15980			17948, 18257											2206, 2509																								232, 246	8824, 11771												319, 608																630, 1847	1863, 2062
3,078	195,782	21244	Discharge summary	report	Admission Date: [2175-10-19] Discharge Date: [2175-10-22] Date of Birth: [2128-2-22] Sex: M Service: MEDICINE Allergies: Vitamin K Attending:[First Name3 (LF) 30] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: placement of a foley catheter by urology service ([10-22]) History of Present Illness: History of Present Illness: 47 year old man with cirrhosis (EtOh, hep C), ESRD on HD, with altered mental status. He was recently discharged ([10-16]) for transplant surgery after hospital stay for umbilical hernia weeping complicated by anaphylactic arrest after iv vitamin K. He was admitted with altered mental status on [10-19] after missing dialysis and notably taking dilaudid and tylenol at home for pain. No f/c/n/v at home. In the ED VS: T 97.4, HR 80 BP 113/43 RR 16 O2Sat 96% 2L (89% RA). He became unresponsive during a head CT in the ED and was therefore admitted to the MICU. It was presumed that his altered mental status was due to a combination of narcotics, missing HD, and non-compliance with lactulose. He was treated with naloxone and lactulose with improvement in mental status. He was also started on ceftriaxone for empiric SBP treatment (pt has had an elevated WBC count but no fever). An US-guided beside paracentesis was attempted but aborted [2-17] loops of bowel moving in front of the needle and he was dialyzed with 2.4L off. . Mr. [Known lastname ] also complains of wheezing and chronic cough. He does report history of asthma for which he uses and albuterol inhaler. Of note he did have an anaphylactic reaction to IV vit K on last hospitalization requiring chest compressions. . ROS: He notes dry mouth; denies fevers, chills, cough, SOB, CP, abdominal pain, nausea, vomitting, diarrhea, constipation, melena, BRBPR, hematemesis, dysuria. He feels much better today with no complaints. . Past Medical History: Past Medical History: * Cirrhosis - hep C, EtOH abuse - c/b esophageal varices s/p banding in [12-26] - EGD [2175-4-28]: 4 cords of grade II varices, nonbleeding GE jctn ulcer - has not been treated for hepatitis C - has nodular lesions on US -> no MRI to eval for HCC, AFP 4.3 - h/o SBP in [9-21], ? SBP during hospitalization (empiric) [8-22] * ESRD on HD T/Th/Sat * Anemia of chronic disease * Left Lower extremity abscess [8-22] * h/o major depression * schizotypal personality disorder * asthma (as per pt, not in chart) Social History: Social History: Lives with wife. Denies tobacco, ETOH, or drug use currently. Heavy ETOH use in the past, prior IV drug use in early 80s (last reportedly [4-21]). Family History: Family History: Maternal aunt with DM Physical Exam: VS: T: 98.4 rectal HR: 82 BP: 121/69 RR: 15 Sat: 99% on ra Gen: alert and oriented, massive [Location (un) ]-sarca, no distress HEENT: NCAT, PERRL, sclera mildly icteric with pingueculae and mild scleral edema, OP clear, mm slightly dry, no photophobia, + tongue fasiculations Neck: Supple, no LAD, JVD 7cm CV: RRR, no m/r/g, 1+ DP puleses (difficult to appreciate given edema Resp: Bibasilar crackles, wheezy, occasional inspirational clicking sound. Abdomen: Protuberent, distended, +BS, NT, + easily reducible umbilical hernia, + fluid wave Ext: 3+ PE bilateral LE, + asterixis Neuro: A + O x 2 ([Hospital1 ], 199-, self), CN II-XII grossly intact, Motor [5-20] both upper and lower extremities, sensation grossly intact to light touch Skin: Multiple ecchymosis: anterior chest, bilateral UE in area of BP cuff, multiple head/chest spider angiomas, mild erythema without warmth LLE (? area of infection in [8-22]), no palmar erythema, no jaundice Pertinent Results: [2175-10-19] 10:27PM COMMENTS-GREEN TOP [2175-10-19] 10:27PM LACTATE-2.3* K+-5.5* [2175-10-19] 10:20PM GLUCOSE-80 UREA N-73* CREAT-8.7* SODIUM-127* POTASSIUM-7.8* CHLORIDE-96 TOTAL CO2-21* ANION GAP-18 [2175-10-19] 10:20PM estGFR-Using this [2175-10-19] 10:20PM ALT(SGPT)-46* AST(SGOT)-147* ALK PHOS-178* AMYLASE-67 TOT BILI-4.0* [2175-10-19] 10:20PM LIPASE-73* [2175-10-19] 10:20PM ALBUMIN-2.7* CALCIUM-8.9 PHOSPHATE-9.2* MAGNESIUM-3.0* [2175-10-19] 10:20PM AMMONIA-149* [2175-10-19] 10:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-7.8 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2175-10-19] 10:20PM NEUTS-76.8* LYMPHS-11.9* MONOS-7.1 EOS-3.9 BASOS-0.3 [2175-10-19] 10:20PM PLT COUNT-121* . . UA with 21-50 WBC, mod LE, neg Nit. . WBC 17.4 . Imaging: . CXR:There are no short acute interval changes. Bibasilar atelectasis greater in the left side, minimal in the right are unchanged. The upper lobes are clear. There is no pneumothorax or pleural effusion. Cardiomediastinal contour is unchanged. Right internal jugular vein catheter remains in standard position. . . CT Head [10-20]: Prelim read no intracranial hemorrhage, mass effect, hydrocephalus, or shift of normally midline structures. . ECG [10-19]: NSR (74), normal axis, intervals, no acute ST-T segment changes, no acute changes. Brief Hospital Course: Assessment: 47 year old man with cirrhosis, admitted with altered mental status with periods of apnea, hyponatremia, CKD on HD, thrmobocytopenia, anemia. . # Altered mental staus: Likely secondary to dilaudid and lactulose noncompliance in the setting of renal failure and hepatic failure. Improved with naloxone, dialysis, and lactulose. Other possible causes on the DDx include SBP, so a radiology-guided paracentesis was performed, which showed no evidence of SBP. On the night of [10-22] pt complaining of insomnia and was given ambien, and pt was lethargic for much of the following morning. In the future all sedating medications should be avoided since pt's compromised liver function will cause high levels and could precipitate worsening encephelopathy. On [10-22] the pt signed out AMA, before either PT or Social work could see him. Discussed with patient risks of leaving, in particular the risks of cardiac arrhythmias from not receiving dialysis on a regular basis, worsening of liver failure and encephalopathy, and hydronephrosis from urinary retention. Patient stated his understanding and appeared to have competency and decision making capacity. Patient signed AMA paperwork prior to discharge. Foley catheter removed. Discussed with Dr. [Last Name (STitle) ]. . # Liver failure: LFT's around baseline, coags mildly elevated. Continued nadolol, rifaxamin, lactulose, folate, thiamine. . # Pleuritic chest pain: likely from chest compressions + asthma. Given nebs with improvement. AP&Lat CXR showed only bibasilar atelectasis. . # Acidemia on admission: resolved; probably from ESRD + respiratory depression . # Positive UA: No complaints of dysuria but elevated WBC count, so pt started on CTX on admission. When culture with >100K yeast ABX were d/ced and no antifungals started because likely represents colonization of foley in pt with low urine output [2-17] ESRD. Elevated WBC count appears to be chronic on OMR. . # Urinary retention: After pt had foley catheter removed following MICU stay there was some concern for urinary retention because bedside bladder scan showed 700 cc urine. Straight catheter and foley catheter were attempted to be placed, but without return of urine, so balloon was no filled and catheters were removed. Due to concern for urinary retention Urology was called, who placed a foley catheter with little urine return. they felt that bladder scan results were likly [2-17] artifact from ascites, and that pt infact did not have urinary retention. Urology recommended an Abdominal US to evaluate foley placement and bladder distention, but pt signed out AMA before this could be performed. The risks of urniary retention were explained to him, and he accepted these risks. . # Umbilical Hernia: No further weeping, easily reducible, no new issues. . # Hyponatremia on admission: Likely secondary to cirrhosis. Recent baseline high 120's-low 130's, resolved during hospital stay with discharge Na = 134. . # Chronic Kidney Disease: Pt missed dialysis before admission, which likely contributed to mental status changes. He was dialyzed in house and continue sevelamer and added nephrocaps while in house. Pt did not recieve perscription for nephrocaps prior to leaving AMA. . # Thrombocytopenia: likely [2-17] splenic sequestration with cirrhosis, heparin sc initially given but then held. Discharge platlelets = 56. . # Anemia: Recent baseline approx. 30, iron studies [6-22] c/w AOCD, hct remained stable at baseline. . # Leukocytosis: Was elevated on recent admit [9-22] so not clearly elevated from recent baseline. UA was positive so ceftriaxone started, but with UCx showing yeast and a US guided paracentesis ruling out SBP ceftriaxone was d/ced (as described above). . # Communication: With patient, wife: [Name (NI) 553] [Name (NI) 19419], [Telephone/Fax (3) 56229]. . # Dispo: Pt left AMA as described above, and [Telephone/Fax (3) 4030] in OMR note. Medications on Admission: Rifaximin 400 mg TID Nadolol 20 mg PO DAILY Lactulose 45 ML PO QID Thiamine 100 mg PO DAILY Folic Acid 1 mg PO DAILY Sevelamer 1600 mg TID W/MEALS Pantoprazole 40 mg PO Q24H Hydromorphone 1 mg PO Q6H as needed tylenol Discharge Medications: 1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 2. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lactulose 10 g/15 mL Syrup Sig: Sixty (60) ML PO QID (4 times a day). 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: hepatic encephalopathy cirrhosis seconday to hepatitic C, EtOH ESRD on HD T/Th/Sat anemia of chronic disease h/o major depression schizotypical personality disorder asthma Discharge Condition: against medical advice, afebrile, ambulatory Discharge Instructions: You were admitted with mental status changes secondary to dilaudid and hepatic encephalopathy. You were treated in the MICU, and your mental status improved after receiving Narcan and lactulose. You also were found to have urinary retention, for which you had a foley catheter placed. The hepatology service was following you for your liver disease. You should continue to take your medications as prescribed. Please follow up with your PCP [Name9 (PRE) ] your doctor for any abdominal pain, confusion, fever, chills, or any other concerning symptoms. Followup Instructions: please follow up with your PCP within two weeks Provider: [Name10 (NameIs) ] [Last Name (NamePattern4) 2424], MD Phone:[Telephone/Fax (1) 2422] Date/Time:[2176-2-29] 11:30	[ "070.44", "553.1", "301.22", "493.90", "276.1", "285.21", "276.2", "348.39", "571.2", "287.5", "585.5", "296.20" ]	icd9cm	[ [ [] ] ]	[ "39.95" ]	icd9pcs	[ [ [] ] ]	10029, 10035	5126, 6702	292, 357	10252, 10299	3746, 5103	10906, 11098	2721, 2744		9370, 10006		10056, 10231		9127, 9347			10323, 10883											2759, 3727																								231, 254													413, 1933								7986, 9101								1977, 2504	2536, 2689
44,890	150,042	25757	Discharge summary	report	Admission Date: [2129-5-21] [Month/Day/Year ] Date: [2129-5-28] Date of Birth: [2055-10-28] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2817] Chief Complaint: s/p Arrest Major Surgical or Invasive Procedure: Endotracheal Intubation Mechanical Ventilation History of Present Illness: 73 yoM w/ a h/o DM, recent h/o diabetic foot ulcer / osteo, recent C diff infection, PUD, presenting following an arrest. The patient called EMS on the day of admission not feeling well. EMS arrived and during transport the patient reportedly lost his pulse, CPR was initiated, AED with "no shock advised" and with CPR alone the patient regained his pulse prior to arriving at the hospital. Per the son the patient has been fatigued, dehydrated, having persistent diarrhea which he states was unresponsive to the flagyl he was taking, had decreased urine output for 4 days. He had decreased PO intake x 2 days and slight nausea. No vomiting but dry heaves x 1. No abdominal pain, no chest pain, shortness of breath. No focal weakness. No other complaints per son. Also per the son the patient has a h/o ETOH abuse, but the patient has told his son he has not drank for 60 days. However, the son states that he often lies about his drinking. In the ER his initial VS were: T 100.2, HR 123, BP 145/93 RR 14 O2 95% The patient underwent an IJ placement and given 4L IVF. He was intubated and sedated. He withdrew to painful stimuli. Given low GCS and reperfusion after arrest he was started on the cooling protocol. Guaiac negative in the ER. Also given vanc, levofloxacin and flagyl. Of note the patient had a recent admission to the medicine floor for recurrent C diff as well as VRE and coag negative staph bacteremia (presumed PICC line infection). His C diff was treated with PO flagyl with a course to continue until [2129-5-25] (as he would stop dapto for VRE on [2129-5-18]. His VRE had grown from PICC line cultures (1/2 bottles) from [2129-5-2] and his PICC line was pulled, he had no + peripheral blood cultures, he started dapto on [2129-5-5]. In addition on [5-3] he had coag negative staph from PICC line 1/4 bottles. The patient was discharged to rehab on [5-6], he stayed for 4 days and signed out AMA. He only rec'd 5 days of daptomycin IV. He reportedly was continuing to take his PO flagyl. Past Medical History: 1. CAD: s/p MI in [2120] w/ stent (aspirin stopped [3-10] due to massive GIB) 2. CRI: baseline Cr 1.5-2.2 3. PUD with massive GI bleed [3-10] requiring 10 units PRBCs. Pt underwent EGD showing esophageal and stomach ulcers. Colonoscopy with diverticulosis. Pt was unable to swallow a capsule for capsule study. Tagged RBC scan no source of active bleeding. 4. Chronic R foot ulcerations/infections: s/p R metatarsal head resection on [2125-12-13], followed by podiatry 5. DM 2: c/b neuropathy, nephropathy, and chronic R foot infections. h/o microalbuminuria 6. h/o DVT w/ L filter 7. PVD 8. h/o squamous cell CA of left posterior auricular area (s/p removal by derm) 9. EtOH abuse w/ alcoholic hepatitis 10. h/o CVA [2122] with residual left foot weakness; MRI in [2125] Likely small acute cortical infarcts involving the right frontal lobe. Extensive chronic small vessel infarcts. Old right cerebellar infarct. 11. Odontoid fracture in [2125] with traumatic Horner syndrome L Social History: Pt denies EtOH use for past 80 days. Previously drank 4 oz of vodka every night, 2ppd x60 years, retired builder. Patient has never had DTs, seizures, or passed out as a result of drinking. He left rehab facility against medical advice and states he lives alone. Takes medications on his own with assistance of his visiting nurse. Patient has assistance from a woman who lives upstairs in his building who checks in once a day. Does not speak with his son who was previously involved in his care. Per previous notes patient does not want son [Name (NI) 653] as his son "wants him in a nursing home." Family History: DM-mother, stroke-mother, [Name (NI) 64167] Physical Exam: VITAL SIGNS: HR 69 BP 108/81 RR 14 O2 100% on AC 550 x 18, PEEP 5, FiO2 50% GEN: NAD, intubated, sedated HEENT: Pupils small, PERRL, + corneals, withdraws to pain CHEST: CTAB CV: RRR, no m/r/g ABD: soft, NT, ND, no masses or organomegaly EXT: wwp, no c/c/e NEURO: cooled, intubated, sedated, PERRL, + corneals, withdraws to pain DERM: no rashes Pertinent Results: Blood culture x 2 [2129-5-21]: pending C diff + on [2129-5-4] Blood culture [5-3]: 1/2 bottles S epi Catheter Tip IV (PICC Line)- negative Blood culture [2129-5-2]: VRE 1/2 bottles. u/a [2129-5-21]: 0-2 WBC, mod bacteria, trace leuk esterase, neg nitrites, [5-11] hyaline casts. STUDIES: CT head [2129-5-21]: No acute intracranial hemorrhage CT abd / pelvis w/ contrast, CTA chest [2129-5-21]: Striated appearance of both kidneys with stranding, concerning for renal infarcts given provided history. No PE or dissection. Severe emphysema in the lungs. CXR [2129-5-21]: Extensive chronic appearing interstitial disease. Tubes in appropriate position. Please correlate with CTA chest performed subsequently. CXR [2129-5-21] post line plcmt: In comparison with the earlier study of this date, there has been placement of a right internal jugular catheter that extends to the upper portion of the SVC. No evidence of pneumothorax or change from prior study. EKG: sinus tach rate 110, LAD LAFB, normal intervals, incomplete RBBB, LAE, no new Q waves, early R wave progression, no ST T wave changes. No significant changes from prior [3-10]. Brief Hospital Course: SUMMARY [5-26] back to MICU ============ 73 yoM w/ a h/o PVD, DM, CAD and recent C diff presenting with PEA arrest following 4 days of general malaise. #. PEA arrest: Likely secondary to dehydration secondary to severe clostridium difficile infection. The patient had a recent admission for c. diff and VRE / S epi bacteremia. Hct was stable. CTA was negative for PE. MI was ruled out. No major electrolyte abnormalities. The patient was initially started on cooling protocol but then stopped as it was deemed unnecessary. Empiric daptomycin, cefepime, ciprofloxacin, po vancomcyin, IV flaygl were started. The patient was cultured and lactate trended. He improved and it was felt that this was likely hypovolumeia that led to PEA arrest. His daptomycin, ciprofloxacin, cefepime were all discontinued. He continued on po vancomycin and IV flagyl for C. difficle infection. He was then transferred to the regular medical floor and continued on oral Vancomycin and IV Flagyl with improvement in his diarrhea. # NSTEMI: On [5-25] patient was noted to have an unresponsive episode with normal hemodynamics at that time. This was thought to possibly be due to a seizure versue vaso-vagal syncope. During this episode, and EKG was obtained that revealed new T-wave inversions in his lateral leads. Cardiac enzymes revealed an elevated troponin I to 0.46. Given his co-morbid conditions, he was medically managed with beta blockade, aspirin PR and high dose statin (though this was only partially administered as patient developed swallowing difficulties). He was also transfused given his Hematocrit < 30 and evidence of end organ ischemia. Troponin remained stable and was trended for 24 hours. The following day, he was transferred to the MICU in the setting of new onset hypotension to SBP 80s. An Echo was obtained [5-26] that revealed decreased EF = 10% and biventricular dysfunction consistent with cardiogenic shock. # Respiratory failure: Secondary to PEA arrest. The patient was intubated and ventilated. He was rapidly weaned off the vent on [2129-5-22]. He continued to do well s/p extubation. # Oliguria / Renal failure: Patient was admitted with hypotension after PEA arrest. Also with chronic renal insufficience with baseline Cr of 1.7. After transfer from the MICU [5-24], patient was noted to have minimal urine output, approximately 10cc/hr. This was attributed to dehydration (given diarrhea and NPO with swallowing difficultie) and possible ATN given low pressure upon admission. He was fluid resuscitated with only minimal improvement over the next 48 hours. Renal was consulted on [5-26]. Patient became anuric on the morning of transfer to ICU and continued to be anuric throughout his stay. # Unresponsive Episodes: On [5-25] patient suddenly became unresponsive though hemodynamically stable on telemetry. He was then confused and with poor swallowing ability. Given these constellatin of symptoms, seizure was suspected. His care provider and son were able to corroborate that he had had similar episodes at home in the last several weeks but that they lasted less than 1 minute. CT head was obtained and did not reveal an acute intracranial process. Neurology was consulted and recommended EEG. EEG was obtained [5-26] showing global encephalopathy without evidence of epileptiform complexes, Neurology felt neurologic dysfunction could be from recrudecenc of old infarct deficits. # Alcohol Abuse: The patient has history of alcohol abuse. Placed on CIWA. Thiamine, folate, and MVI supplementation were given. # Bilateral renal infarcts: Seen on imaging. Cr at baseline was intially at baseline. Intial Echo [5-23] did not show vegetations that could account for renal infarcts. Creatinine was trended with renal function as described below. # CAD: Has a history of MI in [2120] s/p stent. Patient intially with negative cardiac enzymes, but then with NSTEMI as above on [2129-5-25]. # Anemia: Acute hematocrit drop with OG lavage without gross blood but gastroocult +. Guiaic negative. Despite this, he did not require transfusions during his intial MICU stay as his hematocrit was stable. During his floor course, he was transfused as above in the setting of NSTEMI. He was then transferred to the ICU for hypotension [5-26]. # DM: HISS, last A1C was 6% in [7-9] # COPD: Standing atrovent and placed on prn albuterol to avoid tachycardia # Foot wound: Consulted podiatry who recommended dry dressings to wound. Antibiotics were not intially continued for this given his wound did not appear infected and he had treated his treatment course for osteomylitis. # Recent GI hemorrhage: Patient with recent admission for massive GI hemorrhage of unclear source (EGD x 2 with ulcerations, no source on colonoscopy, tagged RBC negative) requiring 10u PRBC. Continued on PPI without evidence of further GI bleeding. #On morning of [5-28] patient became acutely tachycardic, tachypnic and hypotensive. Physican was called to bedside and found patient without radial pulse and only weakly palpable femoral pulse. Discussion with patients HCP determined [Name2 (NI) ] measure should be pursued. Mr. [Known lastname ] was pronounced dead at 1229pm. Medications on Admission: Atorvastatin 20 mg po daily Trazodone 25mg po qhs Multivitamin po daily Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL 15-30mL po qid B-Complex with Vitamin C po daily Sucralfate 1 gram po qid Heparin 5000 units sc tid Acetaminophen prn Pantoprazole 40 mg po q12 hours Metoprolol Tartrate 12.5mg po bid Metronidazole 500 mg po q8hrs Calcium Carbonate 500 mg po qid Ferrous Sulfate 325 mg po daily [Known lastname ] Medications: n/a [Known lastname ] Disposition: Expired [Known lastname ] Diagnosis: n/a [Known lastname ] Condition: Deceased [Known lastname ] Instructions: n/a Followup Instructions: n/a	[ "276.2", "305.01", "008.45", "584.9", "585.9", "357.2", "276.52", "250.60", "785.59", "518.81", "785.51", "427.5", "492.8", "348.30", "414.01", "410.71" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.04", "38.93" ]	icd9pcs	[ [ [] ] ]		5791, 11074	339, 387		4580, 5768	11725, 11731	4146, 4195						11100, 11702														4210, 4561																								289, 301													415, 2471																2493, 3503	3519, 4130
7,473	174,542	9158	Discharge summary	report	Admission Date: [2121-12-5] Discharge Date: [2121-12-9] Service: CCU HISTORY OF PRESENT ILLNESS: The patient is an 86 year old male with a history of coronary artery disease, status post myocardial infarction times two, remote percutaneous transluminal coronary angioplasty on medical regimen, who presented to the hospital with chest pain and shortness of breath which was progressively worsened over the past two months. The patient describes increasing dyspnea on exertion but denied any orthopnea or paroxysmal nocturnal dyspnea. An electrocardiogram at the outside hospital demonstrated atrial fibrillation with a ventricular rate in the 100s which was a new rhythm for this patient. The patient was admitted for congestive heart failure exacerbation and new atrial fibrillation. Catheterization at the outside hospital demonstrated 75% left main disease with diffuse three vessel disease including diffuse left anterior descending, nonsignificant circumflex, 70% medial, ejection fraction 20%, 3+ mitral regurgitation, wedge increased at 29, cardiac output 3.5. The patient was then transferred to [Hospital1 1444] for further catheterization intervention. Catheterization results at [Hospital1 188] demonstrated 75% left main disease with diffuse three vessel disease. The right coronary artery was 80% occluded with a stent placed to the proximal right coronary artery with percutaneous transluminal coronary angioplasty and Rotablator distally. There was a 50% residual. The patient experienced hypotension episode with percutaneous transluminal coronary angioplasty requiring transient Dopamine which was further complicated by prolonged bleeding of the left groin site. The patient received a total of 320 ccs of nonionic dye. The patient was admitted to the CCU for observation and medical therapy for significant left main disease and severe systolic left ventricular dysfunction. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post myocardial infarction times two with remote percutaneous transluminal coronary angioplasty on medical regimen. 2. Congestive heart failure with an ejection fraction of 15 to 20%. 3. Hypertension. 4. Arthritis. 5. Benign prostatic hypertrophy. 6. Urticaria. 7. History of urinary tract infection. 8. Herniorrhaphy. 9. Status post laminectomy. ALLERGIES: Erythromycin, Penicillin. MEDICATIONS ON ADMISSION: 1. Lasix 40 mg p.o. q.d. 2. Lipitor 5 mg p.o. q.d. 3. Imdur 30 mg p.o. q.d. 4. Atenolol 50 mg p.o. q.d. 5. Prilosec 20 mg p.o. q.d. 6. Altace. 7. DDAVP. 8. Aspirin 325 mg p.o. q.d. 9. Vioxx 25 mg p.o. q.d. 10. Benadryl 25 mg p.o. q6hours p.r.n. SOCIAL HISTORY: The patient has a remote tobacco history but quit in [2082]. PHYSICAL EXAMINATION: Heart rate 84, blood pressure 136/64, respiratory rate 18, oxygen saturation 99% on four liters nasal cannula. In general, the patient is comfortable in no acute distress. Head, eyes, ears, nose and throat examination - The oropharynx is clear. Extraocular movements are intact. The neck is supple, brisk carotid upstroke, no jugular venous pressure could be visualized. Cardiovascular - normal S1 and S2, no S3 or S4, soft systolic murmur at the left upper sternal border. Lungs -good aeration anteriorly. Abdomen - positive bowel sounds, soft, nontender, nondistended. Extremities - no edema, 1+ dorsalis pedis and posterior tibial bilateral lower extremities. Groin - no bruit on auscultation, femoral line placed on the left. LABORATORY DATA: At outside hospital, white blood cell count 6.5, hematocrit 34.8, platelets 226,000. Sodium 135, potassium 4.9, chloride 98, bicarbonate 27, blood urea nitrogen 25, creatinine 1.2. Calcium 8.7. At [Hospital1 69], white blood cell count 10.7, hematocrit 29.2, platelets 190,000. Prothrombin time 14.3, partial thromboplastin time 60.0, INR 1.4. Sodium 133, potassium 4.4, chloride 101, bicarbonate 23, blood urea nitrogen 18, creatinine 1.1, glucose 187, ALT 13, AST 11, CK 33, alkaline phosphatase 79, total bilirubin 0.9, albumin 3.7, calcium 8.1, magnesium 1.7, phosphorus 3.0. Postcatheterization electrocardiogram revealed frequent premature ventricular contractions, question of normal sinus rhythm, normal axis, minimal ST depressions laterally with T wave inversions in aVL. HOSPITAL COURSE: The patient is an 86 year old white male with a history of coronary artery disease, status post catheterization with 75% left main and three vessel disease, increased wedge at 29, ejection fraction 20%, cardiac output of 35, transferred to [Hospital1 69] for intervention to right coronary artery. 1. Cardiovascular - The patient had his right coronary artery stented with distal right coronary artery with rotablation with a 50% residual. A decision was made for further medical management of the patient's diffuse coronary artery disease. He was continued on Aspirin, Lipitor and Pravachol and was started on Plavix. Chest x-ray demonstrated evidence of left sided failure although the patient felt comfortable as this was most likely secondary to compensated chronic heart failure. The patient was continued on Metoprolol and his Captopril was increased to 25 mg t.i.d. The patient was diuresed approximately two liters over the first hospital day with significant increase in his oxygen saturation and comfort level. Over the next few hospital days, further gentle diuresis resulted in decrease of the patient's jugular venous distention and pulmonary edema until the patient was titrated back down to his usual daily dose of Lasix. The patient was noted to remain in atrial fibrillation over the course of the hospital stay. Therefore, he was started on a Heparin drip and Coumadin once his femoral bleeding site had coagulated appropriately. The plan at this point is to anticoagulate the patient over the next few weeks and readdress the issue of cardioversion as an outpatient. The patient remained hemodynamically stable over the course of the hospital stay and was transferred to the floor without complications. He ruled out for myocardial infarction with negative CKs. The patient is to follow-up with his primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 2912], for further management of his atrial fibrillation. 2. Pulmonary - The patient had significant crackles on pulmonary examination and chest x-ray evidence of heart failure at the time of admission. The patient was diuresed over the course of the hospital with significant improvement in his symptoms and decreased oxygen needs. The patient's Lasix was titrated back down to his usual daily dose of 40 mg p.o. q.d. 3. Renal - The patient had a mildly elevated blood urea nitrogen and creatinine at the time of admission of 25 and 1.2. He demonstrated excellent urine output over the course of the hospital stay and his creatinine remained stable at 1.0. The patient had no further renal issues. 4. Hematology - The patient had an initial groin bleed on his left side secondary to catheterization. This eventually halted with significant pressure applied to the site for long periods of time. The patient did experience a decrease in his hematocrit and was therefore transfused one unit of packed red blood cells in order to maintain his hematocrit over 30.0. Once adequate coagulation had been obtained at the site, the patient was started on Heparin drip and was started on Coumadin therapy for appropriate anticoagulation given his new diagnosis of atrial fibrillation. The plan is to anticoagulate the patient with an INR of 2.0 to 3.0 for the next few weeks and then consideration of cardioversion. The patient left femoral site remained without bruit and with good peripheral pulses and his ecchymosis began to resolve over the course of his hospital stay. 5. Prophylaxis - The patient was maintained on Protonix and Heparin drip as prophylaxis during the hospital stay. CONDITION ON DISCHARGE: The patient was discharged to rehabilitation in stable condition. MEDICATIONS ON DISCHARGE: 1. Aspirin 325 mg p.o. q.d. 2. Plavix 75 mg p.o. q.d. times thirty days. 3. Protonix 40 mg p.o. q.d. 4. Lipitor 5 mg p.o. q.d. 5. Lasix 40 mg p.o. q.d. 6. Zestril 10 mg p.o. q.d. 7. Tylenol 650 mg p.o. q6hours p.r.n. 8. Metoprolol 50 mg p.o. b.i.d. 9. Coumadin 5 mg p.o. q.h.s. (with INR checks daily over the next few days). 10. Heparin drip at 1150 units per hour (with partial thromboplastin time checks q6hours over the next few hours, to be discontinued when therapeutic INR of 2.0 to 3.0 is obtained). DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Status post myocardial infarction. 3. Congestive heart failure with an ejection fraction of 15%. 4. Hypertension. 5. Arthritis. 6. Benign prostatic hypertrophy. 7. History of urinary tract infection. 8. Herniorrhaphy. 9. New atrial fibrillation. [First Name8 (NamePattern2) 2053] [Last Name (NamePattern1) 2052], M.D. [MD Number(1) ] Dictated By:[Name8 (MD) 8860] MEDQUIST36 D: [2121-12-8] 13:43 T: [2121-12-8] 13:51 JOB#: [Job Number 31519]	[ "414.01", "427.31", "600.0", "790.6", "458.2", "998.11", "412", "428.0", "424.0" ]	icd9cm	[ [ [] ] ]	[ "36.01", "88.57", "36.06", "99.20" ]	icd9pcs	[ [ [] ] ]								8613, 9163				8074, 8592	2413, 2668	4342, 7956																										2774, 4324																								118, 1934																1956, 2387	2685, 2751	7981, 8048
690	124,988	5745+55698	Discharge summary	report+addendum	Admission Date: [2188-4-17] Discharge Date: [2188-4-18] Date of Birth: [2109-9-24] Sex: M Service: MEDICINE Allergies: Morphine / Codeine / Chocolate Flavor Attending:[First Name3 (LF) 3561] Chief Complaint: hypotension Major Surgical or Invasive Procedure: None History of Present Illness: HPI: This is a 78 yo M w/ multiple medical problems, including ESRD on HD, DM, CAD s/p CABG [2182], PVD and recent osteomyelitis from foot ulcers, who presents with hypoT after HD. Following HD, felt "woozy" and had blurred vision, particularly on standing; his BP at this time was 80/50 and he was brought to the ED. Denies associated chest pain, shortness of breath, or nausea. Denies any recent illness. . In ED, he was afebrile (Tmax 99) with an initial BP of 78/38 and HR of 88. He received 2 L NS an BP initial increased to 121/54, however subsequently fell to 61/31. Lactate 2.5. Received Vanco/Levo/Flagyl empirically in the ED. . He reports that in the past he has developed similar symptoms when his blood pressure has been low after dialysis. . Symptoms resolved after treatment in the ED. Admitted to ICU for refractory hypotension. Past Medical History: ESRD Type 2 diabetes mellitus ('[76]) PVD, s/p R [Doctor Last Name ]-dp BPG Neuropathy HTN Hypercholesterolemia Chronic anemia Hiatal hernia CAD, s/p CABG lima-lad, SVG RCA, OM [3-27] Lower back pain s/p surgery for ?disk herniation Social History: The patient lives in [Location 38] with his wife who is his primary caregiver. [Name (NI) ] is an ex-smoker (approx 40yrs), quit 22 years ago. Used to drink socially, no longer drinks. Family History: The patient's mother died of MI at 89, father had DM, ?heart dz died at 79, paternal GM had DM. He reports other family members with heart disease. Physical Exam: T: 98.5 HR: 71 BP: 107/47 RR: 19 O2 Sat: 98% RA Gen: NAD, speaking in full sentences HEENT: aniecteric, EOMI, no JVD CV: regular rhythm, 70s, +III/VI SEM radiating to carotids Resp: CTAB no wheezes or crackles Abd: Soft, NT, no organomegaly Ext: +palpable thrill over L forearm AV graft. Open wound on L heel, with granulation tissue at base. Lesions on toes bilaterally and [Initials (NamePattern4) ] [Last Name (NamePattern4) ] l. Normal cap refill distally. Diminshed bulk L Neuro/Psych: A&Ox3. Pertinent Results: [2188-4-18] 04:23AM BLOOD WBC-8.1 RBC-3.80* Hgb-13.1* Hct-40.4 MCV-106* MCH-34.4* MCHC-32.4 RDW-17.0* Plt Ct-173 [2188-4-17] 06:35PM BLOOD Neuts-57.1 Lymphs-31.2 Monos-8.8 Eos-2.5 Baso-0.5 [2188-4-17] 06:35PM BLOOD Anisocy-1+ Macrocy-3+ [2188-4-18] 04:23AM BLOOD Plt Ct-173 [2188-4-18] 04:23AM BLOOD PT-12.9 PTT-25.7 INR(PT)-1.1 [2188-4-18] 04:23AM BLOOD Glucose-75 UreaN-24* Creat-3.3* Na-140 K-3.7 Cl-100 HCO3-27 AnGap-17 [2188-4-18] 04:23AM BLOOD Calcium-9.3 Phos-3.3 Mg-1.8 Brief Hospital Course: 78 M p/w hypotension following HD. Pt did not exhibit any evidence of infection (no leukocytosis, fever or chills). Blood cultures were drawn and remained no growth, but these will need to be followed up on as an outpt. He responded nicely to 3L NS with resolution of normotension of 110/50 and remained normal at this level. He was guiac negative and his hct was stable at 36. Troponin was 0.16 but he denied SSCP and he had no ECG changes; this was [Month/Day/Year 2771] to previous myocardial damage and decreased clearance of troponin. He will need to be dialyzed tomorrow; Saturday [4-19]. His dialysis center should be aware of his sensitivity to volume shifts . Medications on Admission: Zetia 10 mg PO daily Protonix 40 mg PO daily Lopressor 25 mg PO daily Epogen 8000 units at dialysis glyburide 2.5 mg PO daily ASA 81 mg daily gemfibrozil 600 mg PO BID zocor 40 mg daily heparin 5000 units SC TID darvon 65 mg PO Q6 hours prn pain lactulose 30 cc PO BID calcitrol 0.75 mcg PO daily Flonase 0.05% 1 spray/nostril daily nephrocaps 1 tap PO daily multivitamin daily metamucil colace nephro supplement 1 can PO daily simethicone Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:2 4. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1) Spray Nasal [Hospital1 ] (2 times a day). Disp:qs Refills:2 7. Niacin 500 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO BID (2 times a day). Disp:60 Capsule, Sustained Release(s) Refills:2 8. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. Disp:qs Tablet, Chewable(s) Refills:0 10. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 Discharge Disposition: Extended Care Facility: [Location (un) 38] Manor - [Location (un) 38] Discharge Diagnosis: Hypotension Discharge Condition: Good Discharge Instructions: If you have these symptoms, call your doctor: fevers, chills, shortness of breath, nausea or vomiting, bloody stool, melanic stools If you feel woozy or lightheaded or experience any [Location (un) ] changes, call your doctor or go to the ED Followup Instructions: Provider: [Name10 (NameIs) 6131] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 253] Date/Time:[2188-6-3] 2:30 Provider: [Name10 (NameIs) ] FIELD SCREENING Phone:[Telephone/Fax (1) 253] Date/Time:[2188-6-3] 3:00 Please keep all of your outpt appointments. Completed by:[2188-4-18] Name: [Known lastname 3877],[Known firstname 133] R. Unit No: [Numeric Identifier 3878] Admission Date: [2188-4-17] Discharge Date: [2188-4-18] Date of Birth: [2109-9-24] Sex: M Service: MEDICINE Allergies: Morphine / Codeine / Chocolate Flavor Attending:[First Name3 (LF) 2969] Addendum: Pt was seen by podiatry prior to leaving to address several wound issues. For his right herel he has a decubitus ulcer. This should be treated with daily wet to dry dressings. For his Left plantar surgical incision he needs daily dry dressing changes. For his eschar toes he needs daily application of betadine. While walking he should use surgical shoes. And while in bed he should use the multi-podus boots. Discharge Disposition: Extended Care Facility: [Location (un) ] Manor - [Location (un) ] [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2970] MD [MD Number(2) 2971] Completed by:[2188-4-18]	[ "V45.81", "285.21", "403.91", "458.21", "250.60", "707.07", "585.6", "357.2" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	7041, 7274	2926, 3611	310, 317	5611, 5618	2396, 2903	5914, 7018	1698, 1848		4102, 5452		5576, 5590		3637, 4079			5642, 5891											1863, 2377																								259, 272													345, 1201																1223, 1469	1485, 1682
63,537	105,106	29427	Discharge summary	report	Admission Date: [2159-4-21] Discharge Date: [2159-5-15] Date of Birth: [2083-5-13] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2071] Chief Complaint: Fatigue for one week. Transferred to CCU with hypoxic distress in context of AF with RVR, developed PNA and transferred to MICU with stabilized AF. Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. [Known lastname 70654] is a 75M with a history of coronary artery disease s/p CABG x3 ([University/College ] Presbyterian NY, [2145]), PTCA x2 stents (DES: proximal LAD and SVG to PDA, [2156]) as well as assymptomatic PAF on coumadin who presented to [Hospital1 18] on [2159-4-21] with fatigue for the last 5 days. He did not endorse shortness of breath or chest pain, only generalized fatigue. Other ROS were negative and notable for the absence of fevers, chills, productive cough, sick contacts, recent travel or other complaints. In the ED, initial vitals: 97.8 65 132/78 16 97. CXR showed a small new right pleural effusion. EKG showed atrial fibrillation at a rate of 114, and ST depression II, III, AVf, V4-V6. He was given Aspirin and placed on Oxygen. Cardiac biomarkers were negative x 3. He was loaded with dofetilide for chemical cardioversion of his a fib and went into NSR after the first dose. The following morning he developed worsening dyspnea and was found to be hypoxic with O2 sats in the 70s on RA. He triggerred for hypoxia and was found to have expiratory wheezes and crackles at the base. Chest x-ray showed severe scoliosis and opacities within both lower lobes. VBG showed pH 7.42, pO2 53, pCo2 30. He was placed on a non-rebreather with O2 sats that returned to 92%. The team felt that his symptoms were either CHF versus pneumonia, with CHF more likely because he did not have a white count or fever at the time. He was diuresed with 20 mg IV lasix x 3 and had 2 L of urine output. He remained on the non-rebreather throughout the afternoon despite the diuresis. He was given nebulizers and ordered doxycycline and augmentin for possible community acquired pneumonia (although he did not receive antibiotics). At 6:30 pm nightfloat came to evaluate the patient and was concerned. An ABG showed pH 7.42 pO2 66 and pCO2 54. Vanc and cefipime were started and the CCU was called to evaluate the patient. The patient was found to be tachypneic and uncomfortable, using increase work of breathing. He was sating 92% on the non-rebreather. He was transferred for hypoxic respiratory distress. In the CCU he endorsed chills, but denied fever, chest pain, palpitations, nausea, cough, abdominal pain, HA, dysuria, myalgias, melena. Respiratory status continued to be tenuous in the CCU requiring face mask during the day, and BiPap overnight. Patient was not intubated due to concerns about ability to wean from the vent. He was treated empirically with broad spectrum. CCU course notable for increasing respiratory distress requiring BiPap for comfort. Initially used overnight only with face mask during the day but increasingly requiring BiPap. Was seen by his outpatient pulmonologist who agreed with current plan, and felt patient likely to be difficult to wean from the vent if intubated. +6L LOS (not counting insensible losses). Admission weight 53.1kg, currently weighs 56.1 kg(but unreliable as bed weight with sheets etc). Patient had intermittent A. Fib with RVR requiring boluses of diltiazem for rate control. Past Medical History: 1. coronary artery disease -CABG in [2145]: SVG to RPDA; SVG sequentially to diagonal and OM; no LIMA graft -Cath in [2156] notable for occlusion of a vein graft to the right PDA treated with a DES and a subsequent elective native vessel LAD PCI 2. PAF: rate controlled with atenolol and on warfarin 3. Dyslipidemia 4. Hypertension 5. OSA on BiPAP 11cm insp and 9cm exp pressures 6. Tuberculosis as a child, status post left upper lobe lobectomy 7. BPH 8. Severe kyphoscoliosis 9. Chronic sinususitis Social History: - Married, Lives in [Location 745] with Wife, Three Children - Holocaust survivor - Retired child psychologist at [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Location (un) ] in NY - Tobacco history: Denies - ETOH: Denies - Illicit drugs: Denies Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. - Father: Killed during Holocaust - Mother: Died in 90s, no known medical history - Sister: [Name (NI) ] [Name (NI) 3730], 50s. Physical Exam: Gen: Pleasant. NAD. Oriented x3. Mood, affect appropriate. HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with full EJ and JVP slightly above clavicle CV: normal S1, S2. No m/r/g. Chest: Sever Kyphoscoliosis. Patient appeared uncomfortable breathing, increased work, + accessory muscle use, + expiratory wheezes and decreased breath sounds on right and left bases. + egophony and + fremitus on right base. Abd: Soft, NTND. No HSM or tenderness. Ext: 1+ Pedal/Ankle Edema Bilaterally. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: Lab Data on Admission [2159-4-21] 08:50AM BLOOD WBC-6.3 RBC-3.91* Hgb-12.2* Hct-36.9* MCV-94 MCH-31.2 MCHC-33.0 RDW-15.0 Plt Ct-141* [2159-4-21] 08:50AM BLOOD Neuts-67.3 Lymphs-24.0 Monos-5.5 Eos-2.6 Baso-0.6 [2159-4-21] 08:50AM BLOOD PT-28.1* PTT-37.9* INR(PT)-2.8* [2159-4-21] 08:50AM BLOOD Glucose-120* UreaN-34* Creat-1.2 Na-142 K-4.3 Cl-102 HCO3-33* AnGap-11 [2159-4-21] 08:50AM BLOOD ALT-41* AST-36 LD(LDH)-211 CK(CPK)-70 AlkPhos-140* TotBili-0.4 [2159-4-21] 08:50AM BLOOD CK-MB-NotDone cTropnT-<0.01 proBNP-3733* [2159-4-21] 08:50AM BLOOD TSH-2.6 Pertinent Labs from During the Admission [2159-4-22] 05:30AM BLOOD Calcium-8.9 Phos-3.0 Mg-1.9 [2159-4-23] 03:43AM BLOOD VitB12-728 Folate-19.0 [2159-4-23] 03:43AM BLOOD ASA-NEG Acetmnp-10.0 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2159-4-22] 06:45PM BLOOD Lactate-1.2 [2159-4-23] 04:00AM BLOOD freeCa-1.13 Blood Gas, Lactate, Cardiac Enzymes [2159-4-21] 08:50AM BLOOD CK-MB-NotDone cTropnT-<0.01 proBNP-3733* [2159-4-21] 08:50AM BLOOD cTropnT-<0.01 [2159-4-21] 01:07PM BLOOD CK-MB-NotDone cTropnT-<0.01 [2159-4-21] 09:18PM BLOOD CK-MB-NotDone cTropnT-<0.01 [2159-4-22] 07:24PM BLOOD CK-MB-3 cTropnT-<0.01 [2159-4-23] 03:43AM BLOOD CK-MB-3 cTropnT-<0.01 [2159-4-23] 03:15PM BLOOD CK-MB-4 cTropnT-<0.01 [2159-4-24] 03:57AM BLOOD CK-MB-3 cTropnT-<0.01 [2159-4-27] 05:30AM BLOOD proBNP-4224* [2159-4-22] 01:13PM BLOOD Type-[Last Name (un) ] Temp-37.0 pO2-30* pCO2-53* pH-7.37 calTCO2-32* Base XS-3 [2159-4-22] 06:45PM BLOOD Type-ART pO2-66* pCO2-34* pH-7.42 calTCO2-23 Base XS--1 [2159-4-23] 04:00AM BLOOD Type-[Last Name (un) ] Temp-38.4 pO2-60* pCO2-59* pH-7.40 calTCO2-38* Base XS-8 Intubat-NOT INTUBA [2159-4-23] 05:19PM BLOOD Type-[Last Name (un) ] Temp-36.3 Rates-/25 FiO2-80 O2 Flow-12 pO2-42* pCO2-53* pH-7.40 calTCO2-34* Base XS-5 AADO2-495 REQ O2-81 Intubat-NOT INTUBA Comment-NEBULIZER [2159-4-24] 02:14PM BLOOD Type-ART Temp-36.6 pO2-51* pCO2-42 pH-7.48* calTCO2-32* Base XS-6 Intubat-NOT INTUBA [2159-4-24] 03:37PM BLOOD Type-ART Temp-36.6 Rates-/26 O2 Flow-12 pO2-54* pCO2-43 pH-7.45 calTCO2-31* Base XS-4 Intubat-NOT INTUBA Comment-NON-REBREA [2159-4-26] 05:03PM BLOOD Type-[Last Name (un) ] pO2-30* pCO2-57* pH-7.33* calTCO2-31* Base XS-1 [2159-4-27] 05:33AM BLOOD Type-[Last Name (un) ] pO2-49* pCO2-57* pH-7.31* calTCO2-30 Base XS-0 [2159-4-22] 06:45PM BLOOD Lactate-1.2 [2159-4-23] 04:00AM BLOOD Lactate-2.1* [2159-4-23] 05:19PM BLOOD Lactate-1.4 [2159-4-24] 02:14PM BLOOD Lactate-1.6 [2159-4-26] 05:03PM BLOOD Lactate-0.9 Other Reports EKG [2159-4-21] Atrial fibrillation with premature ventricular contractions and uncontrolled ventricular response. Compared to tracing #2 the heart rate is faster. Rate PR QRS QT/QTc P QRS T 114 0 104 330/424 0 16 -164 CXR [2159-4-21] COMPARISON: Multiple prior chest radiographs from [2157-1-5], [2157-3-2], and [2159-1-17]. CTA chest was performed on [2157-3-10]. CHEST RADIOGRAPH, PA AND LATERAL VIEWS: The patient is status post median sternotomy, CABG, and coronary artery stenting. Severe scoliosis of the thoracolumbar spine, with deformity of the left rib cage, again limits evaluation. Left lung volume is chronically small. Left pleural thickening with calcification is as before. On the right, there is small pleural effusion which is new since [2159-1-17]. There may be subtle ill-defined opacity in the right lung base. No overt pulmonary edema is seen. Cardiac enlargement is unchanged. IMPRESSIONS: Evaluation limited by spine and ribcage deformity. New small right pleural effusion and subtle opacity in the right lung base, which could represent aspiration, atelectasis, and/or developing consolidation. Echo [2159-4-23] The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with infero-lateral hypokinesis. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([1-13]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [2158-6-13], no definite change. CARDIAC CATH performed on [2156-10-4] demonstrated: 1. Coronary angiography in this right dominant system demonstrated a normal LMCA with collaterals to RPL. The LAD had a 90% proximal lesion with competitive flow. The LCX system had an occluded OM. The RCA was not selectively engaged. 2. Graft angiography showed a patent SVG to diagonal and OM. The SVG to RPDA had a 99% proximal stenosis. 3. Limited resting hemodynamics as detailed above revealed mildly elevated filling pressures. 4. PCI of SVG-RPDA with 3.5 X 28 mm Cypher DES and no residual stenosis or complications (see PTCA comments for detail). FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Patent SVG-diagonal-OM graft. 3. Proximal stenosis of SVG-RCA, successful PCI with Cypher drug-eluting stent. CARDIAC CATH performed on [2156-10-6] demonstrated: 1. Successful stenting of the proximal LAD with 2.5 X 13 Cypher [Name Prefix (Prefixes) ] [Last Name (Prefixes) 7930] to 3.0 with no residual stenosis. 2. Distal LAD myocardial bridge with compression during systole but normal flow at diastole. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Successful stenting of the proximal LAD with Cypher DES. CXR [2159-4-22] IMPRESSIONS: FINDINGS: Comparison is made to prior study from [2159-4-21]. Study is markedly limited due to patient positioning and the severe scoliosis. Allowing for this, however, there appears to be opacities within both lower lobes which are worrisome for consolidation or pneumonia. The consolidations on the right side are much more apparent than on the study from yesterday. Aspiration cannot be excluded. CXR [2159-4-27] FINDINGS: As compared to the previous radiograph, the volume of the right hemithorax has decreased. As a consequence, there is increased crowding of the right perihilar vessels. However, there is no clear evidence of pneumonia (the film strongly resembles the examination performed on [2159-4-24], 8:03 a.m.). Unchanged marked asymmetry of the chest wall given the extreme scoliosis. Unchanged size of the cardiac silhouette. CT chest [2159-4-28] 1. Moderate right pleural effusion with adjacent telectasis/consolidation. 2. Scattered ground-glass opacities with enlarged heart. These findings are most likely representative of pulmonary edema. 3. Calcified left pleural plaques consistent empyema. 4. Prominent abdominal vessels are limited due to lack of intravenous contrast but suggestive of varices. Clinical correlation is recommended. 5. Marked thoracic cage distortion due to scoliosis. Pleural fluid [2159-4-29] NEGATIVE FOR MALIGNANT CELLS. CXR [2159-5-10] As compared to the previous radiograph, the lung volumes are unchanged. Presence of a minimal right-sided pleural effusion cannot be excluded. Minimally increased diameters of the pulmonary vessels in the right upper lobe could indicate mild overhydration. Unchanged size of the cardiac silhouette. Unchanged aspect of the left lung. DISCHARGE LABS: [2159-5-15] WBC-7.7 RBC-3.72* Hgb-11.2* Hct-35.0* MCV-94 Plt Ct-335 [2159-5-15] PT-29.5* PTT-37.2* INR(PT)-2.9* [2159-5-15] Glucose-94 UreaN-44* Creat-1.2 Na-142 K-4.1 Cl-96 HCO3-38* [2159-5-15] Calcium-9.3 Phos-3.8 Mg-2.1 Brief Hospital Course: Brief Hospital Course Professor [Known lastname 70654] is a 75 YOM with paroxysmal atrial fibrillation and coronary artery disease who presented with 5 days of fatigue and was found to be in Atrial fibrillaton with RVR. Patient was admitted to the cardiology service and dofetilide was initiated given atrial fibrillation. On HD#1 patient develope hypoxic respiratory distress reguiring transfer to the CCU where he was treated for community acquired pneumonia with Vancomycin, Cefepime, and Doxycycline given concern for QT prolongatoin. During his stay in the CCU he was intermittently in atrial fibrillation with RVR and would intermittently develop respiratory distress reguiring BiPap. Patient was eventually transferred to the MICU for more intensive management of his pulmonary issues. There the patient completed his course of antibiotics and was diuresed. Slowly the patients breathing improved and on [5-4] was transfered to the general medical floor. Hypoxic Respiratory Distress: On presentation to the hospital patient was at baseline pulmonary status. Initial CXR with question of RLL opacity. On HD#1 patient developed hypoxic respiratory failure which [Hospital 70655] transfer to the CCU and broad spectrum antibiotics to treat RLL pneumonia visualized on CXR. Further patient became febrile prior to transfer. Initially patient was thought to have RLL infiltrate c/w pneumonia and high fever. Patient was treated for probable RLL pneumonia with Vancomycin, Cefepime, and Doxycycline completing an 8 day course. On transfer to the MICU the patient appeared to have superimposed pulmonary edema from volume resuscitation as evidenced by LOS fluid balance, interval weight, and clinical exam. MICU attempted low dose lasix overnight [4-27] for diuresis and monitored respiratory status, with 700cc out and no worsening in creatinine. Non-contrast CT showed moderate right sided pleural effusion. Based upon patient's respiratory distress, he underwent a 1.5L thoracentesis on [4-29] with interval improvement in respiratory status. Patient has limited reserve given prior pneumonectomy and severe kyphoscoliosis and may not tolerate small volumes of fluid. A Urine legionella was negative. Blood cultures negative (finalized). Sputum cultures contaminated. Pleural fluid appeared transudative and cultures NGTD. The patient was maintained on nebulizers as needed. The patient underwent aggressive diuresis with IV lasix and was negative approximately 6 liters for his MICU stay (though even from admission weight). The patient initially required BiPap around the clock. He was weaned to a shovel mask and eventually to a nasal cannula with diuresis. He continued on BiPap at night with his home settings. Based upon radiographic images, there was concern that patient may be aspirating. He was evaluated by speech and swallow who cleared the patient for solids and thin liquids; pills whole with puree. After diuresis patient continued to improve, no longer needing BiPAP during the day. Patient was transferred to the general medical floor where diuresis was continued. The patient was maintained on nasal cannula 1-2L for a week, and finally weaned down to RA, satting mid90s on discharge. The patient was discharged on Lasix and Aldactone. Atrial fibrillation: On admission to the hospital patient was found to be in atrial fibrillation. With therapeutic INRs for the past two months. Decision was made to start dofetilide. Patient initially converted to sinus rhythm prior to transfer to CCU. During CCU stay patient was paroxysmally in atrial fibrillation which was intermittently controlled with diltiazem. The patient was continued on dofetilide per EP recommendations, and daily EKGs were initially obtained to monitor for QT prolongation. The patient's diltiazem was up-titrated as tolerated. At the time of leaving the MICU, he was on Diltiazem Extended Release 240mg PO BID. He was in sinus rhythm. On the floor, the patient was intermittently in afib. He was started on Metoprolol 25mg PO BID for better heart rate control. He was intermittently in afib and junction rhythm (rate 60s-80s). Dofetilide was discontinued on [5-14]. He was discharged on Dilt 240mg PO BID, Metoprolol 25mg PO BID. Metabolic alkalosis: Thought to be secondary to aggressive diuresis with lasix (contraction alkalosis). Correction may help respiratory status by preventing compensatory hypoventilation. On his last day in the MICU, he was started on acetazolamide 250 mg [Hospital1 ]. Junctional Bradycardia: Likely secondary to beta-blockers. The patient was started on Metoprolol, as recommended by EP. The patient was noted to be in a junctional rhythm, but was not bradycardic. Coronary artery disease: post CABG and [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] 2. ST depressions on EKG (stable, but worsened with tachycardia to 150s). No active chest pain. Cardiac enzymes negative. The patient was continued on aspirin 81 mg and his home dose Lipitor. Hypernatremia: The patient was intermittently hypernatremic while in the MICU, most recently with Na 146 on [5-4] free water deficit of 1.4L. He intermittently received D5W X 1000 cc and PO intake was encouraged. OSA: Continued Home BiPAP Hyperlipidemia: Continued Atorvastatin Medications on Admission: (per DC Summary [2159-1-18]) 1. Atenolol 50 mg Once Daily 2. Atorvastatin 20 mg Once Daily 3. Fluticasone 50 mcg One Nasal Spray Daily 4. Lorazepam 0.5 mg 1-2 Tablets PO Once Daily PRN anxiety, insomnia. 5. Mirtazapine 7.5 mg PO HS 6. Nifedipine 60 mg Once Daily 7. Nitroglycerin 0.3 mg SL PRN Chest Pain 8. Risedronate 35 mg once weekly 9. Warfarin 5 mg Tablet Once Daily 10. Aspirin 325 mg Tablet Once Daily 11. Os-Cal 500 + D 500 mg(1,250mg) -400 unit, Twice Daily 12. Lactobacillus Rhamnosus One Capsule PO Once a Day 13. Bipap Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 3. Lactobacillus Rhamnosus (GG) 10 billion cell Capsule Sig: One (1) Capsule PO once a day as needed for constipation. 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for Insomnia/anxiety. Disp:60 Tablet(s) Refills:0 6. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO BID (2 times a day). Disp:120 Capsule, Sustained Release(s) Refills:0 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 8. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO 2X/WEEK ([Doctor First Name ],TU). 9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO 4X/WEEK (MO,WE,TH,FR,SA). 10. Os-Cal 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO twice a day. 11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for rash for 10 days. Disp:1 container Refills:0 12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 13. Aldactone 25 mg Tablet Sig: 0.5 Tablet PO once a day. Disp:15 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary: Diastolic Heart Failure Paroxysmal Atrial [Hospital 9343] Health care Associated Pneumonia Restrictive Pulmonary Disease secondary to kyphoscoliosis CAD HTN HLD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 70654], . It was a pleasure caring for you while you were hospitalized with fatigue and shortness of breath. During your stay your breathing became extremely labored [Hospital 70656] transfer to the Intensive Care Unit were you were treated with antibiotics for pneumonia. While in the ICU your breathing was slow to improve so you were also diuresed with IV diuretics (lasix). Slowly your breathing improved and you were transfered to regular medical floor. Throughout this time your heart rate was in and out of atrial fibrillation. Electrophysiology recommended Diltiazem and Metoprolol for good rate control. You were also on Dofetilide which was stopped since it did not keep you in a normal heart rhythm. . Please take all your medications as prescribed and keep all of your follow up appointments. Weigh yourself every morning, and call your physician if your weight goes up more than 3 lbs. You should also have lab work checked at your visit on [2159-5-18] to ensure your kidney function and electrolytes are normal. . The following changes were made to your medication regimen: #. CHANGE Atenolol to Metoprolol 25mg by mouth twice daily #. STOP Nifedipine #. START Diltiazem 240mg by mouth twice daily #. START Miconazole powder twice a day as needed for you groin rash #. Start Lasix 20mg daily on [2159-5-17] (Call PCP and stop if you feel lightheaded or dizzy) #. Start Aldactone 12.5mg daily on [2159-5-17] )Call PCP and stop if you feel lightheaded or dizzy) #. We also increased your mirtazapine to 30mg at nighttime #. DECREASE your aspirin to 81 mg daily Followup Instructions: PCP: [Name10 (NameIs) ] have been set up to see a Nurse Practitioner, as well as your primary care physician in the next week: Provider: [Name10 (NameIs) ] FERN, RNC Phone:[Telephone/Fax (1) 250] Date/Time:[2159-5-18] 9:00 . Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 7212], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2159-5-25] 10:30 . Cardiology: Please follow-up with Dr. [Last Name (STitle) ] Date/Time: [6-15] at 2pm Phone: [Telephone/Fax (1) 62] . Other Appointments: ORTHO XRAY (SCC 2) Phone:[Telephone/Fax (1) 1228] Date/Time:[2159-6-14] 10:40 . DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] (ortho spine) Phone:[Telephone/Fax (1) 3736] Date/Time:[2159-6-14] 11:00 . PULMONARY FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2159-6-15] 11:10 . DR. [Last Name (STitle) ] Phone: [Telephone/Fax (1) 612] Date/Time:[2159-6-15] 11:30 [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 2073]	[ "518.81", "482.9", "327.23", "V45.82", "511.9", "518.89", "428.33", "599.70", "473.9", "600.00", "564.00", "V58.61", "401.9", "272.4", "427.31", "276.0", "737.30", "V45.81", "780.52", "E942.9", "V45.76", "414.00", "428.0", "427.89", "311", "285.9", "276.3" ]	icd9cm	[ [ [] ] ]	[ "93.90", "34.91" ]	icd9pcs	[ [ [] ] ]	20538, 20596	13258, 18566	463, 470	20814, 20814	5290, 10602	22607, 23708	4420, 4644		19154, 20515		20617, 20793		18593, 19131		11100, 12979	20965, 22584				12995, 13235							4659, 5271																								276, 425													498, 3577										20829, 20941						3599, 4109	4125, 4404
47,013	190,286	41185	Discharge summary	report	Admission Date: [2108-2-6] Discharge Date: [2108-3-19] Date of Birth: [2052-9-3] Sex: F Service: NEUROSURGERY Allergies: Aspirin / Sulfa (Sulfonamide Antibiotics) / Latex / Acetaminophen / Dulcolax Attending:[First Name3 (LF) 1835] Chief Complaint: Hypothermia Major Surgical or Invasive Procedure: [2108-2-17]: Left Craniotomy and mass resection History of Present Illness: This is a 58 year old female with unknwon past medical history who was transferred to [Hospital1 18] for evaluation of unresponsiveness and hypothermia in the setting of a 5X6cm left frontal mass. She initially presented to an OSH after being found unresponsive in an abandoned car. She was taken to Southern [Hospital 3844] Hospital where she was initially agitated, moving all extremities. She had a witnessed tonic/clonic seizure with a GCS score of 3 and intubated for airway protection and found to have a temperature of 84F. Her pupils were reported to be fixed. Head CT was performed and demonstrated a large left frontal mass and patient was medflighted to [Hospital1 18] for further neurosurgical evaluation. Unable to obtain history from patient due to intubated status. In the ED, initial vital signs were 32.3 C, HR: 116, 174/82, RR: 12, 100% on assist control with TV of 500 X 14 with an FiO2 of 100% with an ABG of 7.3, 24, 586. Pupils were round to be reactive to light and patient was moving all extremities and following simple commands. Labs were notable for a sodium of 153, potassium of 2.6, bicarb of 10, anion gap of 42, white count of 16, lactate of 2.6, CK of 1237. U/a was positive for glucosuria and ketones with blood but no rbcs. Blood cultures were taken. ECG demonstrated no ischemic changes. Chest radiograph demonstrated no acute process. CT head without contrast demonstrated large left frontal extraxial mass, with associated mass effect. Patient was given 1L NS, vancomycin 1g IV X 1, zosyn 4.5mg IV X 1, decadron 2mg IV X 1. Continued on propofol gtt. Neurosurgical service was consulted who did not recommend immediate intervention. Patient is intubated upon arrival to MICU. Past Medical History: On admission: - T2DM On [2108-2-10], record based on [Location (un) 8117] Primary Care - arthritis - anemia - hypertension - DM type 2 - HLD - viral illness Social History: On admission: Unclear. [Name2 (NI) ] is homeless. Family History: On admission: Unable to obtain on admission Physical Exam: VS: Temp: 96.1, BP: 104/75, HR: 126, RR: 14, O2sat 100% on AC. GEN: intubated HEENT: pupils 3mm, reactive to light bilaterally RESP: anterior chest wall clear CV: RR, with S1 and S2 wnl, no m/r/g ABD: cooling pads in place, soft, NT, ND, +BS EXT: no pedal edema SKIN: no rashes/no jaundice/no splinters NEURO: patient is spontaneously moving hands, squeezing hands and opening eyes to commands Physical Exam on Transfer to Medicine Floor: VS- Temp 99.3 F, BP 127/45, HR 64 , R 16 , O2-sat 98 % RA, LOS fluid balance 3460 cc, I/O: 1764/2220 General- African American female in NAD HEENT: NC, skin on the cheeks appear dry and peeling, sclera anicteric, PERRLA, EOMI, mucous membrane slightly dry, OP clear Neck: supple, no thyromegaly, no JVD appreciated, no LAD LUNGS: CTAB posteriorly, occasional expiratory wheeze anteriorly, no crackles or rhonchi CV: regular, tachycardic, no m/r/g Abd: soft, non-tender, mildly obese, no rebound or guarding Extremities: warm, dry, no cyanosis or edema, 2+ DP pulses bilaterally, very long toe nails. SKIN: multiple bullae on the dorsum surface of the fingers bilaterally, bullae contained serous fluid, presence of eschar on the left knee, large skin break down in the posterior thighs bilaterally draining serous fluid, skin also appears to be peeling off in the posterior thighs. Back is without skin lesions. Neuro: awake, alert, oriented to self/time ([2108-1-21]), CN II-XII grossly intake, muscle strength 5/5, 2+ DTR throughout but diminished on the right biceps/brachioradialis, withdraws from pain with Physical Exam on [2108-2-17] prior to surgery VS: Tc. 98 (Tm 100), BP 152/70 (98-160/57-84), HR 92 (87-102), RR 18, O2Sat 99% RA, BS 115 - Blood sugar yesterday 138 (10 Nvolin, 5 Novolog)-> 143 (5 Novolog)-> 241 (15 Novolin, 6 Novolog)-> 325 (12 Novolog) - BP higher in the early AM. General: NAD HEENT: wound on the cheeks healing, sclera anicteric, PERRLA, EOMI, MMM, OP clear Neck: supple, no thyromegaly, no JVD, no LAD LUNGS: CTAB, no wheeze, crackles or rhonchi CV: regular, borderline tachycardic, no m/r/g Abd: soft, non-tender, mildly obese, no rebound or guarding Extremities: warm, dry, no pitting edema, 2+ DP pulses bilaterally, very long toe nails. SKIN: bullae on the dorsum of the fingers dried up and skin is firmer. There is an eschar on the left knee. Large skin burn in the posterior thighs, buttocks, and right posterolateral leg with serous drainage on the pad, area appear without purulent exudate, new epithelium growing Neuro: awake, alert, oriented to [Location (un) 86], [2108-2-18], president. CN II-XII intact, DTR 2+ throughout, no Babinski sign (withdraws from pain), able to move both feet/leg/thighs [4-24] and upper extremities [4-24] Physical Exam Upon Discharge: awake alert and oriented x 3, ambulatory short distances without assistance, utilizing walker to ambulate long distances, strength full, no pronator drift, no facial droop, pupils 4mm/3mm, EOMs full Pertinent Results: Labs: [2108-2-6] - CHEM 10: GLUCOSE-517* UREA N-19 CREAT-0.8 SODIUM-141 POTASSIUM-3.9 CHLORIDE-111* TOTAL CO2-14* CALCIUM-7.2* PHOSPHATE-3.9 MAGNESIUM-1.8 - Osmolal-333* - CBC with differential: WBC-12.8* RBC-4.12* HGB-11.2* HCT-34.5* MCV-84 MCH-27.3 MCHC-32.6 RDW-13.6 NEUTS-87* BANDS-1 LYMPHS-8* MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 Plt 217 - Blood smear: HYPOCHROM-OCCASIONAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL - VBG: PO2-51* PCO2-36 PH-7.19* TOTAL CO2-14* BASE XS--13 - ABG: pO2-586* pCO2-24* pH-7.30* calTCO2-12- LACTATE 1- 1.8 - LACTATE 2- 2.6 - CK(CPK)-1237* - @ 07:05PM cTropnT-<0.01 - Coagulations 1: PT-13.0 PTT-20.5* INR(PT)-1.1 - Coagulations 2: PT-23.7* PTT-26.5 INR(PT)-2.3* - Urine tox screen: bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG - Serum tox screen: ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG - Urine HCG: NEGATIVE - UA: COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.012 BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG RBC-0 WBC-0 BACTERIA-RARE YEAST-NONE EPI-0-2 [2108-2-7] - @0539 CK 1580; CKMB 16; cTropn < 0.01 - CK @1312: 2109* - Albumin-2.8* - Osmolal-315* - Phenyto-7.9* [2108-2-8] - @0351 CK 1713; CKMB 13, cTropn < 0.91 - Iron studies: calTIBC-208* Ferritn-99 TRF-160* - B12- 445 - Folate 4.2 - Hgb A1C 13.6* - Osmolal-302 - TSH-2.2 - Phenyto-7.9* [2108-2-9] - @0720 CK 674; CKMB 4 [2108-2-10] - @0620 CK: 215 [2108-2-11] - @0748 CK: 111 [2108-2-12] - UA: Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.022 Blood-NEG Nitrite-NEG Protein-NEG Glucose-250 Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2108-2-15] - Phenytoin- 6.6* [2108-2-17] - CHEM 10: Glucose-97 UreaN-9 Creat-0.5 Na-143 K-4.0 Cl-107 HCO3- 26 Calcium-8.8 Phos-3.4 Mg-2.0 - Phenytoin 11.1 - Lactate 1.1 Microbiology: [2108-2-6] - Blood culture x2: negative - MRSA screen: negative [2108-2-10] - Ucx: Yeast - Blood culture x2: negative [2108-2-12] - Ucx: Yeast - Blood culture x2: NGTD Imaging: [2108-2-6] - Chest radiograph: SEMI-UPRIGHT AP VIEW OF THE CHEST: An endotracheal tube tip terminates approximately 3.8 cm from the carina. Coiled catheter appears to be seen within the region of the hypopharynx. The cardiac, mediastinal and hilar contours are normal. There are low inspiratory lung volumes, but the lungs remain clear. No pleural effusion or pneumothorax is seen. The pulmonary vascularity is normal. IMPRESSION: Endotracheal tube in standard position, terminating 3.8 cm from the carina. A coiled catheter is noted within the hypopharynx, and likely reflects a coiled NG or OG tube for which clinical correlation is advised. - Outside Hospital CT Head without contrast [2107-2-6]: Prelim read: Large left frontal extraxial mass, with associated mass effect, and djacent white matter edema. - CT head without contrast: There is a 5.6 x 6.5 cm extra-axial mass which is relatively homogeneously hyperdense without calcifications centered in the left frontal convexity and exerting mass effect on the adjacent frontal lobes bilaterally with a small amount of surrounding edema. This mass displaces the midline structures approximately 2.3 cm to the right. The frontal horns of both lateral ventricles are compressed due to the mass effect exerted upon them. No hydrocephalus is present. There is local sulcal effacement related to the mass, but the remainder of the sulci are normal in appearance. [Doctor Last Name ] matter/white matter differentiation is preserved. No intracranial hemorrhage is seen. The visualized orbits appear normal. The mastoid air cells and visualized paranasal sinuses are clear. The calvarium is intact. Layering fluid is seen in the posterior nasopharynx and the patient's nasogastric tube is coiled in the nasopharynx. IMPRESSION: 1. Large extra-axial mass centered in the left frontal convexity, most likely represents a meningioma. MRI with contrast is recommended for further evaluation. 2. NG tube is coiled within the nasopharynx. [2108-2-8] - CTA Head: NON-CONTRAST HEAD CT: Redemonstrated is a large extra-axial left frontal mass measuring 7.1 x 6.5 x 6.0 cm (CC x AP x transverse). A 3-cm region of low density within the inferior, posterior aspect of the mass is better demonstrated today. Mass effect upon and hypodense change within the adjacent brain is unchanged with posterior and lateral displacement of the corpus callosum and left greater than right frontal lobes. There are multiple calcifications within the lesion. There is no evidence of hemorrhage or interval cortical infarct. CTA HEAD: There is mild calcific arteriosclerosis of the carotid siphons. The cavernous and more distal segments of the intracranial left internal carotid artery are moderately, diffusely small in caliber. The left A1 segment is not definitively identified. The anterior communicating artery is patent and the right A1 segment provides dominant supply. The A2 and distal ACA branches are displaced laterally and posteriorly by the mass. The left MCA is patent with normal branching pattern. The left M1 segment is slightly larger in caliber than the more proximal left ICA. The dural venous sinuses are patent. There is no evidence of aneurysm. The mass densely enhances with portions of persistent low density particularly in the inferior/posterior aspect. Enlarged draining veins are draped around the mass. Enlarged vessels also course through the center of the lesion. The falx is displaced to the right. The mass abuts the left frontal bone along the anterior vertex in the left aspect of the falx. IMPRESSION: Large extra-axial left frontal mass with dense but heterogeneous enhancement, abutting and displacing the falx and abutting the anterior left frontal bone. This most likely represents a meningioma, perhaps arising from the left anterior falx, the arachnoid along the medial convexity, or both. The regions of low intensity within the mass are better seen today compared to the prior examination and likely represent regions of cystic degeneration. The mass appears hypervascular. Vessels are displaced by the mass as described. The somewhat small in caliber distal left internal carotid artery may represent a combination of hypoplasia and underlying atherosclerosis disease. [2108-2-12] - CXR (portable): As compared to the previous radiograph, the patient has been extubated. The lungs show normal transparency and structure. No evidence of pneumonia. No pleural effusions. No focal parenchymal opacities. Borderline size of the cardiac silhouette. [2108-2-17] - Abdominal series **** - MR [Name13 (STitle) 430] * Other Studies: [2108-2-6] - EKG: Sinus tachycardia. Possible [Doctor Last Name ] waves. Other T wave abnormalities. Clinical correlation is suggested. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 111 164 94 360/449 67 32 29 [2108-2-17] - Pathology** [2108-2-17] Brain CT: IMPRESSION: 1. Small amount of post operative acute intracranial hemorrhage. 2. Postoperative changes status post resection of large left frontal extra-axial mass with loss of [Doctor Last Name 352]-white differentiation anterior left frontal lobe. [2108-2-18] Brain MRI: IMPRESSION: Postoperative changes with hemorrhage in the operative bed precluding evaluation for residual neoplasm.Small foci of restricted diffusion in the left frontal lobe which could represent postoperative cytotoxic edema or ischemia. Brief Hospital Course: 55 year old female with T2DM initially with unknown history was transferred for hypothermia, witnessed seizure, hyperglycemia, newly found left frontal mass intubated from OSH on [2108-2-6] and discharged on [2108-3-19] #. Altered mental status. Multifactorial and Delirium. Inital etiology is unknown as she was found down by the abandoned car without witness. By reconstructing her recent history, patient could have had a seizure and in post-ictal state [2-22] left frontal mass or altered personality/behavior [2-22] left frontal mass leading to her social situation (homeless) and inability to care for herself with ultimate DKA/HHS/HONC. It is impossible to know the exact cause that led to patient's initial presentation with altered mental status requiring intubation for airway protection. However, during her stay in the MICU as well as on the Medicine Floor ([2108-2-6]), she exhibited evidence of delirium with wax and [Doctor Last Name 688] mental status and fluctuating attention span. She was oriented daily with regard to her medical condition, such as the left frontal mass, frostbites, uncontrolled diabetes, seizure, etc. No pharmacological agents were necessary because she did not show signs of agitation. It is unclear what patient's baseline is as she has not had contact with her family in [Name (NI) 311] for 5 months. However, while on the medicine service, patient also showed signs of inhibited personality and pathy, which could be result of the the left frontal mass. By [2108-2-17], patient was able to answer questions with [Hospital1 2824] content rather than single word answers but continued with evidence of delirium. . #. Meningioma. This was diagnosed radiographically and by tissue. This created radiographical evidence of midline shift as well as edema. Patient was started on 300 mg of Dilantin daily on presentation. Her serum osm was followed closely on initial presentation given her critical condition. Her level was measured on a regular basis and dosed after adjusting for low albumin (2.8) for goal of [11-8].. CTA showed obvious necrosis and complex vascularization of the tumor. As patient's DKA/HHS/HONC resolved, she was started with 2 mg dexamethasone every 6 hours. However, the dose was increased to 4 mg dexamethasone every 8 hours when she developed transient nausea. Repeat CT head on [2108-2-13] did not show increased edema or changes compared to prior. Neurosurgery was closely involved with patient's care and recommended tumor resection given medical urgency. Family was finally reached and formal consent was obtained on [2108-2-16]. Patient underwent craniostomy and tumor resection on [2108-2-17] after a WAND study. A post op MRI showed post op changes and resection of tumor. She will need to have outpatient mammography done to screen for breast cancer given association with meningioma. #. Diabetic ketoacidosis/HHS/HONC and Type 2 DM. Patient presented with high blood sugar, ketosis, severe anion metabolic acidosis. Her mental status could be partly due to HONC. She was treated with aggressive hydration with normal saline. She was rehydrated with bolus IVF as well as a D5 1/2NS drip when sugars trended below 200. Initially she was maintained on an insulin gtt and then transitioned to ISS when her anion gap closed. In the MICU, patient reported taking metformin as an outpatient. Her oral medication was held given acute illness. After she transitioned to Medicine Floor, patient was switched to [Hospital1 ] NPH/Novolin and ISS. As her oral intake improved, she was transitioned and titrated to [Hospital1 ] Novolin N 15 units with meal time Novolog 5 unit and an aggressive ISS given patient was on dexamethasone prior to surgery. #. Frostbites. This is due to prolonged supine position on the ground and hypothermia. The extend of her frostbites include 2 degree with large bullae and skin loss and spread from bilaterally buttocks to entire posterior thighs as well as right sided lateroposterior leg (~17-20% loss). Wound care and plastics surgery were consulted. Plastics debrided the dead tissue. While on the Medicine Floor, care was given per pressure ulcer guideline. Support surface was the First Step Select MRS [Last Name (STitle) ] low air loss and moisture management. She was turned and repositioned every 1-2 hours and as needed. Her heels were kept off bed surfaces with Waffle Boots. She was limited to only 1 hour at a time to sit on a pressure relie cushion/ROHO cushion. Legs were elevated. Her legs were moisturized with Aloe Vesta. She had her wound cared for twice a day with wound cleansers. Initially both Silverdene, Xeroform, and large sofsorb sponges were used per Plastic recommendations. She was [Last Name (un) ] on ciprofloxacin for a total of 6 days for wound prophylaxis. She was kept on IVF almost continuously given the amount of insensible fluid loss. Her I/O were monitored closely. By the time she went to surgery on [2108-2-17], there is a lot of signs for re-epithelialization. Follow up wound care recommended....... Podiatry was consulted for multiple toe nail problems they recommended..... #. Leukocytosis. Noted on [2108-2-16]. There was no new focal finding on exam and recent CXR was negative. Foley catheter was changed on [2108-2-15] because of yeast presence on urine, likely from colonization in the Foley. This could be from the increased dexamethasone dose. On discharge her wbc.... #. Borderline fever. While on the Medicine floor, patient had borderline fever often in the low 100.0-100.7. However, there was no focal findings on exam. Her CXR was negative. UA was negative and Ucx showed yeast, likely [2-22] colonization given Foley catheter. Foley catheter was changed. (Foley catheter was kept to prevent her wounds from getting irritated by the urine or causing infection to her wounds.) Blood cultures were no growth to date. There was no GI symptoms. Her wounds were also without signs of infection. She was on ciprofloxacin for prophylaxis given significant wounds for a total of about 6 days. ABG showed mild respiratory alkalosis but PaO2 > 80% is less suggestive of PE. Tachycardia is also stable and slightly improved with fluid resuscitation from 110s to 100s. This will need to be monitored closely #. Sinus tachycardia. Stable. Initially thought to be hypovolemia, insensible loss from significant skin break down, and the stress. MI was ruled out given negative cardiac enzymes and EKG. She was without respiratory symptoms and ABG results not suggestive of PE. She was on heparin for prophylaxis. TSH was within normal limits. Patient continued to get IVF while on the Medicine Floor. She was started on metoprolol and titrated to 50 mg TID by the time of her surgery for risk reduction. This should be monitored closely. Metoprolol could continue to be titrated. #. Hypertension. Patient was noted to be more hypertensive in the early morning. This was noted after dexamethasone dose was increased. Metoprolol was started as a way to control her heart rate for risk reduction and to also lower her BP. This should be monitored and treated accordingly post-op. #. Iron deficiency anemia. Stable. No baseline Hct available. MCV 82, borderline low. Iron studies shows Fe/TIBC ratio to be 5%, Fe is low, MCV/RBC ratio ~ 20, and ferritin is unexpectedly low. This suggests predominance of iron deficiency anemia. B12 and folate within normal. She should start iron supplements. She should also have age appropriate screening tests, such as a colonoscopy, in outpatient setting. #. Hypothermia. Patient was found on the ground in an alley way in [Location (un) 8117], NH with initial temperature of 84. She was transferred to [Hospital1 18] and rewarmed using standard procedure. Her initial EKG showed elevated J points in V2-V4 and small [Doctor Last Name ] waves. Her Hgb was also elevated as expected with her initial temperature. Her temperature returned to goal at the end of [2108-2-6]. - Overnight on [2-21] the patient was found to be unresponsive. Her temperature was noted to be 94.4. This was confirmed rectally. A bear hugger was initiated and her temperature returned to 99. The medicine service was re-consulted in the AM for assistance working this up. #. Rhabdomyolysis/Myoglobinuria. Patient initially presented with elevated CK, blood in the urine but no RBCs seen in urine. This is likely due to muscle breakdown in the setting of being down for unknown period of time. Her troponin remained flat. Her CK level peaked at 2109 on [2108-2-7] at which time Crt also peaked to 0.8. She was given IVF to maintain urine output of 200-300 ml/hr. Her CK trended down to normal by [2108-2-11]. #. Acute renal failure. On initial presentation, her Crt was 0.6. It is unclear what her baseline was. However, her Crt peaked to 0.9 on [2108-2-7]. It is suspected that the inital lower creatinine (0.6) occurred in the setting of hypothermia, but as the body rewarmed, the true renal function begins to show. She was treated with IVF with urine output goal of 200-300 ml/hr, and her creatinine was 0.5 on the day of her surgery. #. Hypernatremia. Patient's initial sodium level was elevated, even in the setting of hyperglycemia. It is likely from hypovolemia and the seizure. It resolved after she was fluid resuscitated and placed on phenytoin while in the MICU and Medicine Floor. #. Leukopenia. Patient was briefly leukopenic on [2108-2-11] and [2108-2-12]. There was an initial concern for phenytoin to be the cause, but this resolved spontaneously, possibly confounded by being on dexamethasone as well. This should be monitored closely #. Respiratory status. Patient was intubated for airway protection in the field in the setting of unresponsiveness. She was able to be weaned off the ventilator after re-warming and was extubated on [2108-2-7] without event. #. Code: Presumed full given patient's delirium and initial inability to reach patient's family. #. Social Situation/Formal Consent. Patient is homeless. Per report, she was evicted from her home 2 weeks prior to presentation, then was at a shelter for about a week prior to leaving. She was then found on the ground by the [Doctor Last Name 23432] nurses at [Hospital 1725] Hospital in [Location (un) 8117], NH. Per the [Doctor Last Name 23432] nurses, patient was found on [2-6] on the ground next to a car by one of the doors that was open, "wedged" between the opened car door and the wall of the [Location (un) 1725] building. It was unclear how long she was down, because she was in the alley way where the garbage dumpster was located, so people might have thought that she parked there to throw trash out. However, the car was noted to be there in the morning from 7AM to 1PM. Patient was unreponsive when found, but was noted to move his fingers as the [Doctor Last Name 23432] nurses prayed. They thought that patient was laying on what looked like a sleeping bag and covered by a coat. They brought her blankets and called EMS. When EMS came to pull the patient out of the alley way, they noted patient's bare legs/thighs were in direct contact with the snow. They weren't sure what type of clothing patient had on. She was sent to the OSH then transferred to [Hospital1 18]. The local police also assisted in finding about patient's background to assist the medical team with finding her family. Driver's license: [Known firstname ] [Known lastname 49949], [Street Address(2) 89702], [Location (un) 8117] [Numeric Identifier 30090]. Patient later was able to tell the name of her primary care physician. [Name10 (NameIs) ], basic information was obtained from Dr.[Name (NI) 89703] office, phone ([Telephone/Fax (1) 89704], fax number [Telephone/Fax (1) 89705]. It was noted that patient's full last name was Nyambura-[Known lastname 49949] and that she has not been seen/refilled her prescription since [2106]. At the same time, one of patient's acquaintance from the Kenyan women's group assisted in tracking down the patient's family. This acquaintance was in communication with another of patient's acquaintance who knew patient from childhood. The second acquaintance then informed the family of patient's situation and the medical team's contact information. Patient's daughter, [Name (NI) 714] (spelling?) called and informed that she was very happy to hear about her mother, because she has not been able to get a hold of the patient for 5 months. The last time they spoke, her mother was still working in a nursing facility as a nurse or a nurse's aid. At that time, patient told the daughter that she was going to be very busy and working overtime. The daughter was informed of the necessity for the surgical resection of the left frontal mass. Formal consent was obtained from the daughter because she is the next of kins given patient's delirium at the time. # Communication. Family was found to be in [Location (un) 311]. Country-Code for phone number starts with 011-44-. When dialing for them, do not need to dial the initial 0 in the number listed. - Daughter: [First Name5 (NamePattern1) 714] [Last Name (NamePattern1) 89706]-[Last Name (NamePattern1) 89707] mobile [Numeric Identifier 89708], home 0[Telephone/Fax (1) 89709], e-mail [Company 89710] - Son: [Name (NI) 89711] [Name (NI) 89707], in [Name (NI) 16465] - Brother: [Name (NI) 89712] (silent N) [Telephone/Fax (5) 89713] (?) & [Telephone/Fax (5) 89714], [E-mail address 89715] - Acquaintance: [Doctor Last Name ] #1 [Telephone/Fax (1) 89716] (home), [Telephone/Fax (1) 89717] (cell) - Acquaintance: [Doctor Last Name ] #2 [Telephone/Fax (1) 89718] (cell) - [Hospital 6514] Home Health: [Telephone/Fax (1) 89719] - Emergency Contact: [Name (NI) 89720] [Name (NI) ] [Telephone/Fax (1) 89718] (unclear relationship) - [Name (NI) ] Shelter: [Telephone/Fax (1) 89721] Operative course: On [2-17] Patient was taken to the OR for left sided craniotomy for resection of left frontal mass. She tolerated the procedure well and went directly to the ICU for Q1 hour neuro checks and strict BP control to <140. She was transferred to the surgical floor on post operative day 1. She underwent an MRI which showed resection of the mass. Her neurological status improved on a daily basis. Wound nursing was re-consulted due to left leg wound from hypothermia. They commented that the wounds were showing drastic signs of improvement. - Overnight [2-21] the patient was found to be unresponsive. Her blood sugar was checked and found to be 29. She was given 1 Amp of D50. She quickly responded with a blood sugar of 230 and was back to baseline neurologically. The medicine service was re-consulted in the AM for assistance working this up. They made minor adjustments to her PM novolog and Novolin doses. The remainder of her blood sugar checks on [2-22] were in the normal range. -Social work continued to work on placement for the patient at [Doctor Last Name 89722]Rehab. Her neurological exam remained intact, and she remained on Dilantin for seizure prophylaxis. -On [2-23] [Last Name (un) ] was consulted for assistance in managing her blood glucose leveles which have been fluctating as well as for assistance in long term management as her HgbA1C was 13 upon admission. She was accepted by St [Hospital ] Rehab in [Location (un) ] but must first determine somewhere for her to go once she is done with rehab as she is homeless currently. [Date range (1) 89723] She remained neurologically stable without changes in current plan of care. on [3-1] she developed some nausea and had 2 episodes of emesis. She continued to have daily bowel movements. A KUB was ordered, which demonstrated no acute abnormality. Her nausea was treated with zofran and reglan with good effect. Given her inability to obtain a rehab bed, [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] from Physiatry was contact[Name (NI) ] to aid in her in house rehabilitation on [3-5]. She remained stable over the next few days ambulating in the [Doctor Last Name ] with a walker. She worked intensively with occupational therapy on her cognitive issues as well. On 2.25 she was offered a placment at place of promise in [Hospital1 189] and on [3-19] she was discharged with instructions for follow-up Medications on Admission: Medication based on [Location (un) 8117] Primary Care (faxed on [2108-2-10], but not been fiilled since [2106]) - metformin 1000 mg [Hospital1 *] - actos 45 mg daily - cozaar 50 mg daily Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 30 days. Disp:60 Tablet(s)* Refills:0 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation for 30 days. Disp:60 Capsule(s) Refills:0 3. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily) for 30 days. Disp:30 Tablet(s) Refills:0 4. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 30 days. Disp:120 Tablet(s) Refills:0 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for 30 days. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:0 6. phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO Q 8H (Every 8 Hours) for 30 days. Disp:180 Tablet, Chewable(s) Refills:0 7. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)) for 30 days. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: - Left frontal mass- meningioma - Diabetic ketoacidosis- Hyperosmolar non-ketotic coma Secondary diagnoses - Hypothermic burns 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/Information ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? You have been 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]. ?????? 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. Followup Instructions: * Primary care physician * Neurosurgery- You have an appointment in the Brain [Hospital 341] Clinic on [2108-4-2] @ 11AM. 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. * Plastics ** [Last Name (un) ] diabetes care / FOLLOW UP IN 2 weeks post-discharge. Please call [Telephone/Fax (1) 2378] to make appointment / Dr. [Last Name (STitle) 15279] MD Completed by:[2108-3-19**]	[ "584.9", "276.8", "401.9", "703.8", "250.32", "V60.0", "E901.0", "345.90", "791.3", "991.3", "348.31", "225.2", "276.0", "348.5", "280.9", "728.88", "991.1", "991.6" ]	icd9cm	[ [ [] ] ]	[ "96.71", "86.27", "01.59" ]	icd9pcs	[ [ [] ] ]	31193, 31199	13178, 29925	351, 405	31390, 31390	5514, 9702	32665, 33331	2455, 2455		30178, 31170		31220, 31369		29951, 30155			31573, 32642											2515, 5265																								300, 313									5295, 5495				433, 2176				9711, 13155				2469, 2500		31405, 31549						2198, 2198	2382, 2382
8,597	107,318	45165	Discharge summary	report	Admission Date: [2186-8-3] Discharge Date: [2186-8-15] Service: [Doctor First Name 147] Allergies: Heparin Agents / Fish Product Derivatives Attending:[First Name3 (LF) 1556] Chief Complaint: Bowel obstruction Major Surgical or Invasive Procedure: Exploratory laparotomy, biopsy of omental mass suspicious for metastases, mobilization of hepatic flexure of the colon, and decompressing loop transverse colostomy. History of Present Illness: Mr. [Known lastname 96536] is an 83-year-old gentleman who presented with a bowel obstruction. Workup with a CAT scan demonstrated a mass in the pancreatic body and tail extending to the splenic flexure and involving the splenic artery with apparent thrombosis of the splenic vein. The patient was admitted and treated with nonoperative management initially. However, he failed to improve. He was additionally placed on total parenteral nutrition. Because he was not improving, the decision was made to proceed with exploratory laparotomy and bowel diversion. Past Medical History: HTN DVT & PE ([2178]) s/p IVC [Location (un) 260]) filter HIT Several benign colon polyps Physical Exam: VITAL SIGNS: His temperature is 99.7, pulse is 60, blood pressure 197/91, respirations are 24, and his room air saturation is 93%. GENERAL: He is alert and oriented, in no acute distress. HEENT: Pupils are equal, round, and reactive to light. Sclerae are anicteric. NECK: Supple without jugular venous distention, bruits, or lymphadenopathy. LYMPHATICS: There are no supraclavicular nodes or axillary nodes. HEART: Regular without murmurs, rubs, or gallops. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft, distended, with normal active bowel sounds. It is somewhat tympanitic in the right and left upper quadrants. There is no tenderness or appreciable masses. RECTAL: Exam demonstrates no mass. It is guaiac negative. There are no prostatic nodules apparent. EXTREMITIES: Without clubbing, cyanosis, or edema. NEUROLOGIC: Nonfocal. Pertinent Results: LABORATORY DATA: Sodium of 131, potassium of 4.2, creatinine of 1.4, bicarbonate of 22, BUN of 26, and glucose 265. His complete blood cell count is within normal limits. His INR is 3.4 currently. Amylase is 35. Alkaline phosphatase and liver function tests are within normal limits as is bilirubin. Lipase is 68. His CEA is 35, which is elevated (reference 0-4). A CAT scan performed on [2186-8-3], demonstrates omental thickening, which is concerning for metastatic disease. He similarly has a fullness of the pancreatic body, which extends to the splenic flexure concerning for pancreatic mass or cancer. The splenic vein is not visualized, which is concerning for thrombosis. The splenic artery is encased by the mass measuring 4.3 cm. There is a small amount of perihepatic fluid. He does have what appears to be a transition point at the splenic flexure with dilated proximal colon and small intestine. The chest portion of the CT demonstrates several subcentimeter nodules in the right middle lobe as well as the right lower lobe and in the lingula. Brief Hospital Course: Pt. was admitted to [Hospital1 69] on [2186-8-3] following complaints of crampy abdominal pain. After confirmatory studies, patient was found to have a mass within the body/tail of the pancreas extending to the splenic flexure with partial obstruction of the colon at the splenic flexure, occlusion of the splenic vein and severe narrowing of the SMV. These findings were consistent with pancreatic cancer. Furthermore, soft tissue deposits within the omentum are consistent with peritoneal carcinomatosis. The patient then underwent an exploratory laparotomy, biopsy of omental mass which was suspicious for metastases, mobilization of the hepatic flexure of the colon and decompressing loop transverse colostomy on [2186-8-5]. During the operation, however, the patient was at times hypotensive into the 80s, requiring fluid resuscitation and intermittent pressures. The decision was made for the Anesthesiologist to place a Swan-Ganz catheter and to have the patient admitted to the Intensive Care Unit with continued endotracheal ventilation. On post-operative day (POD) 1, the patient was in continued need of fluid support but did not require pressors. He was also noted to be in chronic A-fib which resolvd with an amiodarone drip. He was also restarted on TPN. Patient was extubated on POD 2 and moved out of the Intensive Care Unit on POD 3. TPN was stopped on POD 4 and was moved to a clear liquid diet. On POD 5, the patient was tolerating clear liquids and was advanced to [First Name8 (NamePattern2) ] [Doctor First Name ] diet and placed back on all of his oral medications. At this time, the pathology report stated the specimen was well-differentiated metastatic adenocarcinoma and the patient was then placed on coumadin for prophylaxis against cancer-induced clotting diathesis especially given his history of DVT. The patient also had his sliding scale of insulin increased for more rigorous control. On POD 6, Oncology was consulted and recommended that he follow-up with Dr. [Last Name (STitle) 150] in [1-10] weeks for palliative chemotherapy most likely with gemcitabine. On POD 9 the patient's INR was 2.4. At that time, the patient started complaining of erythematous spots over his abdomen and upper extremities. He was given benadryl with good result. He was then discharged to [Hospital 2079] Rehab and Skilled Nursing Center on POD 10 with a Hct of 30.9 and an INR of 3.0; ambulating well with assistance, tolerating regular [Doctor First Name ] diet and continuing on a sliding scale of insulin. He was asked to follow-up with Dr. [Last Name (STitle) ] in General Surgery Clinic in [6-17] days. Medications on Admission: Coumadin 2.5mg QD Glipizide 5mg [Hospital1 ] Metformin 500mg [Hospital1 ] Lopressor 25mg [Hospital1 ] Discharge Medications: 1. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:30 Tablet(s) Refills:2 2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:30 Tablet(s) Refills:1 3. 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 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 5. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO QD (once a day). Disp:60 Tablet(s) Refills:2 6. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 7. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed. Disp:15 Capsule(s) Refills:0 9. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED) as needed. Disp:qs 1 Refills:4 Discharge Disposition: Extended Care Facility: [Hospital3 ] Rehab Center in [Location (un) 10022] Discharge Diagnosis: Metastatic adenocarcinoma, well differentiated . Discharge Condition: Good; tolerating oral diet; ambulating with assistance Discharge Instructions: 1. Call surgery clinic if you notice increased pain, bleeding, discharge, redness, or temperature > 101.5 2. You may shower, but avoid soaking wound - cover with dressing during shower Followup Instructions: 1. Follow up in [6-17] days in surgery clinic for wound check	[ "E879.8", "560.89", "197.6", "250.00", "458.29", "999.8", "V12.51", "157.8", "427.31" ]	icd9cm	[ [ [] ] ]	[ "99.07", "46.82", "54.23", "46.03", "38.93", "99.15" ]	icd9pcs	[ [ [] ] ]	7136, 7221	3163, 5850	285, 451	7313, 7369	2063, 3140	7605, 7675			6014, 7113		7242, 7292		5876, 5991			7393, 7582											1186, 2044																								228, 247													479, 1049																1071, 1171
54,190	188,571	55	Discharge summary	report	Admission Date: [2158-2-14] Discharge Date: [2158-3-6] Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 618] Chief Complaint: transferred for seizures Major Surgical or Invasive Procedure: intubation History of Present Illness: 86y M with PMH significant for HTN, CAD s/p CABG, afib (now on warfarin), stroke 2y ago, and a seizure disorder on Keppra (previously seen in clinic by Dr. [Last Name (STitle) 619]. atrial fibrillation on Coumadin. who presents with left ear pain. He presented to the OSH ED ([Hospital1 ]-[Location (un) 620]) 1wk PTA with CC: ear pain. He was sent home with Dx of cerumen in external canal. His ear pain continued and this past Friday his PCP prescribed [Name9 (PRE) 621] gtt for presumed otitis externa. Per his son, he developed progressive confusion and imbalance. He became unable to walk, and became more somnolent. He returned to the ED at [Hospital1 ]-[Location (un) 620] in the evening of [2158-2-13] (1d prior to transfer here), where his VS were notable for fever to 102.2F (after arriving afebrile) and tachycardia (normalized with 1.5 L IVF), and exam was notable for somnolence. His WBC was elevated at 14.9. INR was 3.3. Dig 0.84. Troponin negative. UA "negative" and CBC/BMP/LFTs reportedly unremarkable/wnl. A NCHCT showed Left mastoiditis. He was given a dose of IV Zosyn. ENT was consulted, and recommended admission for surgical Tx the following morning and switching to CTX (2gm IV) for mastoiditis Tx. He was given his evening dose of warfarin after clearance from ENT, with a plan for ENT surgery and ID consultation in the morning. However, around 6:00am the morning after admission ([2157-2-14]), the patient had a GTC seizure requiring 12mg IV lorazepam to stop. He was loaded with 1gm of IV phenytoin and his levetiracitam was increased to 1500mg [Hospital1 ] (from his home dose of 750mg [Hospital1 ]). He was intubated and maintained on a propofol gtt on and off. His post-ictal exam was notable for spontaneous movements of all four extremities, but lack of eye opening/arousability. A Neurologist there saw the patient, but his notes are not immediately available to me. His HCT was repeated after the seizure, and a very tiny focus of hemorrhage (hyperintensity) was seen at the posterior end of the Left lateral ventricle (~trigone). There was also also a call of hyperintensity in the interpeduncular fossa (which would, if true, suggest subarachnoid blood, but on reviewing the images I think this is an overcall). Finally, there was a large hypodensity in the Right temporal lobe, which looks old, and could be the "old stroke" seen on MRI in [2156] on OSH workup in [State 622] for his only previous GTC seizure (see PMH, below). The OSH physicians thought he may have hemorrhagic conversion of an acute stroke in the Right temporal lobe (despite a lack of any evidence for this on the NCHCT), and held his warfarin, which was a good idea anyway because he had a supratherapeutic INR at the time of 3.7. After discussing the case with a Neurologist here at [Hospital1 18], they decided to hold off on reversing his coagulopathy with vitamin K or FFP. They continued his statin. Regarding his infectious and other general medical workup/treatment, he had [4-17] BCx bottles return positive for GPC in pairs. The cultures were repeated post-antibiotics. A TTE was obtained out of concern for septic cerebral embolus, and it did not show valvular vegitations, but did show several thickened/diseased valves. TEE was considered, but not done. He was given a couple liters of IVF for decreased urine output (and urine was dark on arrival here). He was continued on his digoxin (level y/d was 0.86), and his home BB and CCB were held. He was doing just find on MV/CMV with ABG of 7.39/35/174 and an unremarkable CXR. They did not start tube feeds. Past Medical History: 1. Hypertension, on CCB/BB 2. Hyperlipidemia, on statin 3. Atrial fibrillation, lonstanding, now on warfarin (started [2157-12-6], see OMR Cardiology note) 4. h/o stroke seen on MRI at OSH (in [State 622], on presentation for stroke, see below) > or = 2y ago, details unknown to me at this point other than an OSH MRI from [2156] showed an "old stroke," which seems like the most likely culprit for his subsequent memory deficits and the seizure in [2-/2156] (and now) and the old Right-temporal abnormality seen on HCT at the OSH. 5. Seizure disorder -- first seen by a Neurologist in clinic by Dr. [Last Name (STitle) 623] here @[Hospital1 18] in early [2156], seen two subsequent times through 9/[2156]. Initially presented to OSH in [State 622] with first-ever seizure [2156-3-1] ([Hospital 624] hospital in [Location (un) 625], VA; had been visiting his son) -- a GTC x 30-45min and post-ictal [First Name4 (NamePattern1) 555] [Last Name (NamePattern1) 167]-hemiparesis, which resolved; reportedly negative MRI, echo, and EEG at the OSH, and a normal EEG here at [Hospital1 18]. See OMR for details. Although he was on 750mg [Hospital1 ] of Keppra as of the last clinic note from Dr. [Last Name (STitle) ]. in [2156], the transfer admission from [Hospital1 ]-[Location (un) 620] [2-13] today says that he was only taking a very small dose of this AED at home, 250mg [Hospital1 ]. 6. "memory issues" since the stroke/seizure in [2156]. 7. CAD s/p 3v CABG [2143] 8. h/o SBO after knee surgery, details unknown to me at this point 9. h/o "knee surgeries" (R-knee replacement) 10. "hay fever", on daily diphenhydramine at home for qAM rhinorrhea (per PCP [Name Initial (PRE) 626] [2158-2-13]) 11. h/o Depression, details unknown at this time (of note, wife died in [2156] after stroke, cancer). 12. h/o partial bowel resection (?no cancer found), temporary colostomy, reconnected; details unknown to me at this time, now c/b chronic diarrhea 2-3x per day. 13. h/o prostate cancer s/p XRT, details unknown to me at this time 14. unsteady gait, walked with cane at home Social History: Former Navy engineer, retired >20y ago, [2139]. Lives alone, accompanied at OSH by son (also retired USN). Wife of 65yrs died in [2156] (stroke, cancer); subsequent depression per son. Functionally limited by depression and memory difficulties since stroke/seizure in early [2156]. Former smoker, quit in the [2107]. Alcohol: One drink daily, Scotch. Family History: per [2156] epilepsy note, the patients' parents both died of cardiac disease. At that time, he had one healthy brother and one healthy son. Physical Exam: General Physical Examination (coma exam) on Admission Vital signs on transfer/arrival to [Hospital1 18]-ICU: afeb, [Age over 90 ]F 70-75 115/60 RR 15 and SaO2 98% on CMV FiO2=40% / PEEP=5 (f-set at 15; Vt of 570-580 on setting of 550) Eyes closed, moves all four extremities spontaneously 2x wrist restraints. Intubated, on propofol gtt. HEENT: Normocephalic and atraumatic. No scleral icterus. Mucous membranes are moist. Neck: Supple, with full range of motion. No carotid bruits appreciated. No lymphadenopathy was appreciated. Pulmonary: Lungs CTA bilaterally, equal BS. Non-labored breathing with ventilator; when I changed vent from CMV to CPAP, the patient breathed regularly and appropriately in the [11-28]/min range with good tidal volumes (400-600mL) on [5-18] and 10/5 CPAP. Cardiac: Distant HS, irregular, 70s. Abdomen: Soft, non-tender, and non-distended, + minimal bowel sounds. No masses or organomegaly were appreciated. Extremities: Warm and well-perfused, no clubbing, cyanosis, or edema. 1+ radial, 1+ DP pulses bilaterally. Skin: no rashes or lesions noted. *************** Neurologic examination (off propofol x 5-10min at ~1am): Mental Status: Eyes closed, and do not open to loud voice or to sternal rub. Does not follow commands. Grimaces to pain and moves all four extremities spontaneously. -Cranial Nerves: I: Olfaction not tested. II: PERRL, 3 to 2mm, brisk. Visual fields are full. No papilledema, exudates, or hemorrhages on fundoscopic examination. III, IV, VI: Eyes are mid-position, conjugate. Normal horizontal VOR (+doll's-eyes response). Vm: Normal +/++ jaw-jerk reflex. VII: Face appears symmetric at rest and with grimaces. Minimal resistance to eye-opening. VIII: +horizontal VOR (doll's eyes responses) IX, X: +gag, cough with suction-stimulation of oropharynx [Doctor First Name 81], XII: not tested. -Motor: No tremor or fasciculations were observed. Muscle bulk and tone are grossly normal, without any hypertonicity or spasticity that I can appreciate in UEs/LEs. -Sensory: Minimal withdrawal to noxious stimuli (pinch, nailbed pressure) in all four extremities. Does not localize. -Reflex examination (left; right): no asymmetry detected. Biceps (++;++) brisk Triceps (++;++) Brachioradialis (++;++) Quadriceps / patellar (++;++) brisk Gastroc-soleus / achilles (+;+) Plantar response was indeterminate bilaterally. No clonus. Pertinent Results: Current Labs: WBC 6.2 Hb 11.4 HCT 34.6 Plt 161 Na 139 K 4.8 Cl 109 CO2 22 BUN 23 Cr 0.6 Glu 108 INR 1.4 EEG ([2-15]): This is an abnormal routine EEG due to the presence of a poorly maintained 6.5 Hz background which appeared only briefly and due to generalized delta slowing which predominated the record. This represents a mild to moderate encephalopathy. It is also abnormal due to the presence of right temporal slowing and lower voltage activitiy which indicate focal subcortical dysfunction. Occasionally, left fronto-temporal broad-based sharp waves were seen although they were not clear spikes, but may indicate a propensity to focal cortical irritability. If the clinical suspicion for seizures is high, prolonged bedside EEG monitoring may helpful for further diagnosis MR head: No acute infarction; Redemonstration of susceptibility and fluid-fluid layering within the bilateral occipital [Doctor Last Name 534] consistent with a scant amount of intraventricular hemorrhage; Opacification of the left mastoid which given the central diffusion abnormality may represent acute mastoiditis as there is no evidence that this is chronic, recommend clinical correlation. CT abd ([2-20]): Multiple dilated loops of small bowel with no discrete transition point and an uncomplicated small bowel-containing left inguinal hernia, most likely represent ileus or enteritis CT head ([3-3]): No acute abnormality is seen. Old right temporal lobe infarction Brief Hospital Course: [Known firstname ] [Known lastname 627] is an 86-year-old man with a complicated past medical history that includes hypertension, hyperlipidemia, coronary artery disease status post CABG in [2143], atrial fibrillation on Coumadin with a prior stroke and right temporoparietal encephalomalacia, history of small-bowel obstruction with a partial colectomy, temporary colostomy, and subsequent reanastomosis, who was initially admitted to [Hospital3 ] [Hospital3 628] for a complaint of jaw pain and subsequent mastoiditis. There, he was started on antibiotics and ultimately sustained a prolonged seizure requiring intubation. He was then subsequently transferred to [Hospital1 69] and spent the first several days of his admission in the trauma ICU. Seizures: He has had known seizure disorder since [2156] and was treated by Dr. [Last Name (STitle) 629] on Keppra 750 [Hospital1 ]. At the OSH he had another GTC in the setting of lowering his AED to 250 [Hospital1 ] and a fever (unknown origin). He was at the time complaining of ear pain, and ENT had planned a procedure at the outside hospital, but he ended up seizing and requiring 12 mg Ativan which necessitated intubation and transfer to [Hospital1 18]. He had been loaded with Dilantin and Keppra was increased to 1000 mg [Hospital1 ]. He had a routine EEG performed on arrival that showed him to be encephalopathic. At that point he was taken off of the dilantin and continued on Keppra. He had MR imaging of his head to make sure there was no new process contributing to his change in status; MR imaging (including MRI/A/V) was normal. He remains on Keppra and has been seizure free while on the floor. Ear Pain: ENT was consulted regarding his MRI finding of opacification in the left mastoid. He had Strep pneumoniae otitis media and mastoiditis complicated by bacteremia. ENT felt the opacification was a chronic inflammation and that no surgery was indicated at this time. Fevers: Mr. [Name13 (STitle) 630] had 2 culture bottles from OSH that grew Streptococcus. He had no LP performed as it was felt that the risk of reversing his anticoagulation was greater than the risk of empirically treating him for a meningitis. ID consult was obtained and they suggested a TEE which was performed that showed no cardiac vegetations. He had urine cultures, blood cultures, and sputum cultures that were all negative. A BAL culture grew only Commensal Respiratory Flora. He was started on Vancomycin, Cefepime and Flagyl for his strep bacteremia and fevers and continued on this therapy until [2-24]. This was then changed to Ceftriaxone 2gm Q24h for 4 more days to complete a 2 week course of abx for Strep pneumo bacteremia. He has currently completed all of his antibiotics and has remained afebrile. Ileus: During hosptialization, he developed loose stools and abdominal distention. C. diff negative. Seen by surgery service. KUB and CT scan suggestive of an ileus. No transition point on CT scan to suggest SBO. He had NG placed to wall suction for decompression. This is now improved and his diet has been advanced. Atrial Fibrillation: Mr. [Name13 (STitle) 630] was on coumadin for his Afib. It was held on day 1 of his hospitalization as it was supratherapeutic at 3.3 and there was concern of a small area of intraventricular hemorrhage. He was restarted on anticoagulation with one day of heparin bridging when he was unable to take PO medications. HTN: Amlodipine changed to 10mg daily. Wound Care: He was found to have sacral coccyx tissue breakdown as was seen by wound care. Determined to be severe fungal rash related fecal incontinence, no pressure related breakdown. He has been on Miconazole powder. New wound care recs will sent with discharge paperwork. Medications on Admission: Transfer Medications 1. Ceftriaxone 2 grams IV bid. 2. Vancomycin 1 gram IV b.i.d. 3. Zocor 40 mg daily. (home statin was pravastatin 20mg) 4. Keppra 1500 mg IV b.i.d. (patient had been taking 250mg [Hospital1 ] at home, PTA) 5. Nexium 40 mg IV daily. (home med was omeprazole 20mg) 6. patient was given 1 gram of IV Dilantin. 7. Digoxin 0.250 mg daily (home med) 8. NS at 125cc/hr. Please note that the following home medications were held at OSH and on transfer to our hospital: -WARFARIN (dose unknown to me at this time) -ATENOLOL 50mg daily -AMLODIPINE 2.5mg daily -DIPHENHYDRAMINE 25mg daily Discharge Medications: 1. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for fungal rash. 3. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 6. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTHUR (every Thursday). Discharge Disposition: Extended Care Facility: Highgate Manor Discharge Diagnosis: seizure d/o mastoiditis a.fib Strep bacteremia Ileus Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You presented to a hospital with a generalized tonic clonic seziure in the setting of a lowered AED dose and a fever. You received 12 mg Ativan to stop the seizure and required intubation for airway protection; you were then transfered to [Hospital1 18] ICU for further management. You were loaded with Dilantin and your Keppra was increased to 1000 mg [Hospital1 ]. Your current dose of Keppra remains at 1000 mg [Hospital1 ] You were seen by ENT service regarding your opacification in the left mastoid noted on MRI. They felt that this was chronic inflammation and no current intervention was reccommended at this time. For your fevers, cultures from the outside hospital grew streptococcus. Antibiotics were started for strep bacteremia and you completed a 2 week course. Repeat cultures here were negative. During hospitalization, you were having abdominal pain and distention; there was concern for a small bowel obstruction so you were seen by the surgery service. No surgical intervention was necessary, but you did receive a NG tube for decompression. This was likely an ileus and did improve. You are now able to tolerate an oral diet. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) 631] within 3-4 weeks of discharge Please follow-up with your PCP [Name Initial (PRE) 176] 1-2 weeks of discharge [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632] Completed by:[2158-3-6]	[ "383.00", "995.92", "518.81", "486", "V43.65", "414.00", "V45.81", "038.2", "382.9", "185", "345.90", "348.30", "560.1", "401.9", "427.31", "V58.61" ]	icd9cm	[ [ [] ] ]	[ "88.72", "96.04", "96.6", "99.15", "96.71", "38.93", "33.24" ]	icd9pcs	[ [ [] ] ]	15810, 15851	10698, 14222	275, 289	15948, 15948	9194, 10675	17328, 17619	6604, 6750		15164, 15787		15872, 15927		14527, 15141			16137, 17305								8127, 9175			6765, 7943																								211, 237										14234, 14501			317, 3960										15963, 16111						3984, 6203	6219, 6588
2,336	130,928	12481	Discharge summary	report	Admission Date: [2106-2-2] Discharge Date: [2106-2-24] Date of Birth: [2033-5-15] Sex: F Service: OB/GYN CHIEF COMPLAINT: Transferred from [Hospital 1474] Hospital with small bowel obstruction. HISTORY OF PRESENT ILLNESS: This is a 72 year old female with a history of papillary serous ovarian carcinoma diagnosed in [2105-11-30], status post exploratory laparotomy and drainage of ascites on [2105-12-11], who presented to an outside hospital with small bowel obstruction. On initial surgery, unable to debulk secondary to extensive carcinomatosis. The patient is status post two cycles of Carboplatin treatment, most recently [2106-1-7]. She was admitted to [Hospital 1474] Hospital with a three day history of nausea and vomiting, and inability to tolerate any p.o. Nasogastric tube was placed and since then the patient denies any nausea and vomiting. She does report occasional crampy pain. No chest pain or shortness of breath. The patient is voiding well spontaneously. No dysuria or hematuria or hematochezia. The patient reports small bowel movements for two to three days. She also fell in the outside hospital, resulting in ecchymosis of the right hip, right knee and left arm. The patient states that she did have a CT scan twice and a KUB which was compatible with small bowel obstruction. Gastrogram enema revealed two obstructing lesions in the sigmoid. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease. 2. Peptic ulcer disease/gastroesophageal reflux disease. 3. Hiatal hernia. 4. Hypothyroidism, status post partial thyroidectomy for multinodular goiter. 5. Anemia. 6. Depression. 7. Ovarian carcinoma as per history of present illness. 8. History of small bowel obstruction in [2097]. 9. Osteoarthritis. PAST SURGICAL HISTORY: 1. Bilateral hip replacement. 2. Breast biopsy. 3. Partial thyroidectomy. 4 Exploratory laparotomy for small bowel obstruction in [2097]. SOCIAL HISTORY: History of tobacco use times fifty years. She quit in [2103-7-1]. The patient was widowed since [2085]. She is a retired R.N. MEDICATIONS ON ADMISSION: 1. Bupropion 75 mg p.o. twice a day. 2. Epogen 40,000 units q.week. 3. Zofran intravenous q6hours p.r.n. 4. Advair 250/50 one puff twice a day. 5. Dulcolax suppositories PR twice a day p.r.n. 6. Neupogen 300 mcg subcutaneously. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: Vital signs revealed temperature of 99.2, blood pressure 112/66, heart rate 109, respiratory rate 20, oxygen saturation 94% on two liters of oxygen. In general, the patient is in no acute distress, alert and oriented times three. Chest is with decreased breath sounds and occasional expiratory wheezes. Cardiovascular - tachycardic, no murmurs, rubs or gallops. The abdomen is soft, markedly distended, minimal diffuse tenderness to palpation, tympanitic areas, high pitched bowel sounds. Extremities are without edema, notable for ecchymosis in the upper arm and right hip and right knee. Neurologic examination is grossly intact throughout. Nasogastric tube is draining thick brownish discharge. LABORATORY DATA: White blood cell count 16.0, hematocrit 28.9. Sodium 129, potassium 3.9, blood urea nitrogen 12, creatinine 0.5. HOSPITAL COURSE: The patient was admitted to the OB/GYN service, and her bowel obstruction was managed conservatively. She was followed by gastroenterology and surgery services. A colonoscopy revealed a tight 3.5 centimeter stricture in the midsigmoid colon. The sharp and abrupt angulation of the stricture prevented the deployment of a metal stent. The patient was managed conservatively and was started on clear liquids on [2106-2-16]. Her hospital course was complicated by septic right knee joint for which she was started on Vancomycin. On [2106-2-10], the patient complained of difficulty breathing and was evaluated for a pulmonary embolus with a CT angiogram which showed no evidence of pulmonary embolus. The patient also had an episode of mild chest pain with tachypnea on [2106-2-14], and she ruled out for myocardial infarction at that time. Given her persistent recurrent episodes of tachypnea and tachycardia, the patient was started on Advair, for possible chronic obstructive pulmonary disease flare worsened by gastroesophageal reflux disease. Following another episode of shortness of breath with tachypnea to the mid 30s, the patient was transferred to the Medical Intensive Care Unit and started on intravenous Solu-Medrol. She was diuresed with intravenous Lasix with substantial symptomatic improvement. She received CPAP and nebulizers. She was finally transferred to the floor where she was continued on p.o. Lasix. Her respiratory function improved and the patient was considered ready for transfer to rehabilitation. On [2106-2-23], the patient received a dose of Carboplatin (725 mg). DISCHARGE STATUS: To rehabilitation. CONDITION ON DISCHARGE: Stable. DISCHARGE INSTRUCTIONS: The patient should follow-up with her primary care physician and her oncologist. She should follow a low residue diet. She should have her TSH rechecked in three weeks, to readjust her Synthroid dose (TSH found to be elevated during this hospitalization). She should have her complete blood count checked every day for three days after discharge and her potassium checked every other day for four days. It may be necessary to adjust her Potassium Chloride dose. PRECAUTIONS: Methicillin resistant Staphylococcus aureus. MEDICATIONS ON DISCHARGE: 1. Vancomycin one gram q12hours for eighteen days. 2. Levothyroxine Sodium 25 mcg p.o. once daily (the patient should have TSH rechecked in three weeks and the dose may have to be readjusted). 3. Menthol-Cetylpyridinium 2 mg lozenges one lozenge p.r.n. 4. Tylenol Elixir 325 to 650 mg p.o. q4-6hours p.r.n. 5. Maalox 15 to 30ml p.o. four times a day. 6. Fluticasone-Salmeterol one disk one puff twice a day. 7. Lorazepam 0.5 mg p.o. twice a day. 8. Famotidine 20 mg p.o. twice a day. 9. Chlorhexidine 50ml twice a day. 10. Bupropion 150 mg p.o. twice a day. 11. Paxil 20 mg p.o. once daily. 12. Lasix 40 mg p.o. twice a day. 13. Albuterol-Ipratropium one to two puffs q6hours p.r.n. 14. Iron Sulfate 325 mg p.o. once daily. 15. Heparin subcutaneous 5000 units subcutaneous injection q12hours. 16. Potassium Chloride 40 mEq p.o. twice a day for two days (potassium level should be checked every other day). 17. Prochlorperazine 10 mg p.o. q6hours p.r.n. 18. Epogen 10,000 units three times per week. 19. Prednisone taper; 40 mg once daily for two days, 30 mg once daily for two days, 20 mg once daily for the next two days and 10 mg once daily for the next two days. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 23207] Dictated By:[Last Name (NamePattern1) 5233] MEDQUIST36 D: [2106-5-8] 16:54 T: [2106-5-9] 08:55 JOB#: [Job Number 38736]	[ "560.89", "518.81", "682.6", "197.6", "711.06", "349.82", "491.21", "790.7", "428.0" ]	icd9cm	[ [ [] ] ]	[ "81.91", "99.25", "93.90", "86.04", "99.15", "45.24" ]	icd9pcs	[ [ [] ] ]												5592, 7039	2163, 2436	3315, 4980		5039, 5566									1836, 1984															2459, 3297											152, 229													258, 1432																1454, 1813	2001, 2137	5005, 5014
46,449	110,075	38957+58248	Discharge summary	report+addendum	Admission Date: [2174-5-27] Discharge Date: [2174-6-7] Date of Birth: [2100-2-13] Sex: M Service: CARDIOTHORACIC Allergies: lisinopril Attending:[First Name3 (LF) 165] Chief Complaint: chest pain and shortness of breath Major Surgical or Invasive Procedure: . Urgent coronary artery bypass graft x4; left internal mammary artery to left anterior descending artery, saphenous vein graft to posterior left ventricular branch and saphenous vein sequential graft to obtuse marginal 1 and 2 on [2174-6-1] History of Present Illness: Mr. [Known lastname 53743] is a 74 yo M with ILD, COPD, CAD, dCHF, DMII and CKD who presented with intermittent chest pain over the course of the last 3 days associated with shortness of breath. Pain is non-radiating. It is made worse with swallowing. Patient eventually decided to come in after talking to a friend with a cardiac history. In the ED, Initial VS were 98.3 73 116/67 16 98% RA. Troponin was noted to be elevated at 0.18. EKG showed PRWP and <1mm ST depressions in V4,V5. He received Aspirin and was admitted to the cardiology service for further management. Cardiac cath was done and Cardiac surgery was consulted for coronary revascularization. Past Medical History: MEDICAL & SURGICAL HISTORY: # Interstitial Lung disease # CAD # CKD, baseline creat 1.7 # Diabetes Mellitus Type 2 with ophthalmic complications # Hypercholesterolemia # Hypertension # Esophageal Reflux # Osteoarthritis # Spinal Stenosis s/p Laminectomy # Thyroid Nodule # Colonic Polyp # BPH # Cataracts # Glaucoma # Hiatal hernia # Obesity # Erectile dysfunction # Cataract # Retinal vascular occlusion # Hearing loss # Glaucoma, primary open angle # Osteoarthritis # BPH # Anemia, iron deficiency Social History: # Home: Able to climb stairs at home. Ambulates with a walker. # Work: Retired since [2160]. Has worked as karate instructor in the past. # Tobacco: hx tobacco use, 20 pack-years (quit in [2145]) # Alcohol: Rare # Drugs: Denies Family History: Denies family history of early malignancy or SCD. Physical Exam: INITIAL:PHYSICAL EXAMINATION: VS- 98.0 136/83 62 20 100% RA GENERAL- WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT- NCAT. Sclera anicteric. PERRL, EOMI. MMM NECK- Supple without JVD. CARDIAC- PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS- No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN- Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES- No c/c/e. No femoral bruits. SKIN- No stasis dermatitis or ulcers PULSES- Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [2174-6-7] 05:26AM BLOOD WBC-12.7* RBC-2.68* Hgb-7.0* Hct-21.7* MCV-81* MCH-26.0* MCHC-32.2 RDW-17.3* Plt Ct-330 [2174-5-27] 12:15PM BLOOD WBC-8.2 RBC-4.87 Hgb-12.1* Hct-38.8* MCV-80* MCH-24.8* MCHC-31.1 RDW-15.8* Plt Ct-242 [2174-6-7] 06:24AM BLOOD Hct-22.7* [2174-6-7] 05:26AM BLOOD UreaN-12 Creat-1.4* Na-134 K-4.0 Cl-98 HCO3-32 AnGap-8 [2174-5-27] 12:15PM BLOOD Glucose-346* UreaN-21* Creat-1.9* Na-135 K-3.8 Cl-92* HCO3-35* AnGap-12 [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname ] [Hospital1 18] [Numeric Identifier 86412] (Complete) Done [2174-6-1] at 3:30:18 PM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) ] Division of Cardiothoracic [Doctor First Name ] [First Name (Titles) ] [Last Name (Titles) ] [Hospital Unit Name 4081] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2100-2-13] Age (years): 74 M Hgt (in): 76 BP (mm Hg): 120/70 Wgt (lb): 244 HR (bpm): 70 BSA (m2): 2.41 m2 Indication: Coronary artery disease; hypertensive heart disease ICD-9 Codes: 402.90, 786.51 Test Information Date/Time: [2174-6-1] at 15:30 Interpret MD: [Name6 (MD) 3892] [Name8 (MD) 3893], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 3893], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2012AW02-: Machine: u/S6 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 1.4 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.4 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.6 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 45% >= 55% Aorta - Ascending: 3.2 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.8 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 13 mm Hg < 20 mm Hg Aortic Valve - LVOT diam: 2.3 cm Aortic Valve - Valve Area: 1.6 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild regional LV systolic dysfunction. Mildly depressed LVEF. 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. Simple atheroma in ascending aorta. Normal aortic arch diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve leaflets. Mild AS (area 1.2-1.9cm2). No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Written informed consent was obtained from the patient. The patient appears to be in sinus rhythm. Results were Conclusions for post-bypass data REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-BYPASS: 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. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with focalities in the mid and apical inferior. inferoseptal and inferolateral walls.. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. The left coronary cusp is non mobile. A 0.3 x 0.3 cm calcium deposit seenon the right coronary cusp. There is mild aortic valve stenosis (valve area 1.6cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [First Name (STitle) ] was notified in person of the results before surgical incision. POST-BYPASS: Intact thoracic aorta. LVEF 50%. There is a mild improvement of wall motions in the inferior, inferoseptal and inferolateral segments. No new valvular findings. Aortic valve findings remains the same as prebypass. 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) ] [2174-6-1] 16:49 ?????? [2164] CareGroup IS. All rights reserved. Brief Hospital Course: On [2174-6-1] Mr. [Known lastname 53743] was taken to the operating room and underwent Urgent coronary artery bypass graft x4; left internal mammary artery to left anterior descending artery, saphenous vein graft to posterior left ventricular branch and saphenous vein sequential graft to obtuse marginal 1 and 2 with Dr.[First Name (STitle) ]. Please see operative note for further surgical details. Cardiopulmonary Bypass time=75 minutes. Cross clamp time =67 minutes.He tolerated the procedure well and was transferred to the CVICU intubated and sedated for invasive monitoring. He awoke neurologically intact and was extubated. He weaned off pressor support, was transiently requiring Nitroglycerine for postop hypertension and Beta-blocker/Statin/ASA and diuresis was initiated. Chest tubes and Pacing wires were discontinued per protocol. Postoperatively he went into atrial fibrillation. Amiodarone was given and he converted to normal sinus rhythm. POD#2 he transferrred to the step downunit for further monitoring. Physical Therapy was consulted for strength and mobility. He was transfused packed blood cells for chronic anemia which was worsened by volume resucitation postop. Postop hypoglycemia resolved with decrease in lantus dosing. He slowly progressed and was cleared by Dr.[First Name (STitle) ] for discharge to [Hospital ] rehabilitation on POD# 6. All follow up appointments were advised. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from AtriuswebOMR. 1. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES [Hospital1 ] 2. Gabapentin 100 mg PO BID 3. Meclizine 25 mg PO DAILY 4. Clonazepam 0.25 mg PO DAILY 5. Atenolol 50 mg PO DAILY hold for SBP <90 6. Verapamil SR 240 mg PO BID 7. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES [Hospital1 ] 8. Simvastatin 20 mg PO QHS 9. insulin aspart NF* 100 unit/mL Subcutaneous QACHS per sliding scale 10. insulin glargine NF 100 unit/mL Subcutaneous [Hospital1 ] 38u AM 38u PM 11. Torsemide 100 mg PO DAILY 12. Isosorbide Mononitrate (Extended Release) 30 mg PO TID 13. Oxycodone SR (OxyconTIN) 20 mg PO Q8H hold for sedation or RR < 12 14. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 15. Omeprazole 40 mg PO BID 16. Aspirin 81 mg PO DAILY 17. Fluoxetine 30 mg PO DAILY 18. Metolazone 1.25 mg PO 1X/WEEK (MO) 19. Calcitriol 0.25 mcg PO 4X/WEEK ([Doctor First Name ],MO,WE,FR) 20. Vitamin D 50,000 UNIT PO QMONTH Discharge Medications: 1. Aspirin 81 mg PO DAILY RX Ecotrin Low Strength 81 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES [Hospital1 ] RX brimonidine 0.15 % 1 drop [Hospital1 ] twice a day Disp #1 Vial Refills:0 3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES [Hospital1 ] RX dorzolamide-timolol 2 %-0.5 % 1 drop [Hospital1 ] twice a day Disp #1 Vial Refills:0 4. Fluoxetine 30 mg PO DAILY RX fluoxetine 20 mg 1.5 tablet(s) by mouth daily Disp #30 Tablet Refills:0 5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS RX latanoprost 0.005 % 1 drop opth HS Disp #1 Vial Refills:0 6. Metolazone 1.25 mg PO 1X/WEEK (MO) RX metolazone 2.5 mg 0.5 (One half) tablet(s) by mouth once weekly Disp #20 Tablet Refills:0 7. Oxycodone SR (OxyconTIN) 20 mg PO Q8H hold for sedation or RR < 12 RX OxyContin 20 mg 1 tablet(s) by mouth q 8h Disp #60 Tablet Refills:0 8. Simvastatin 20 mg PO QHS RX simvastatin 20 mg 1 tablet(s) by mouth daily Disp #60 Tablet Refills:0 9. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #60 Tablet Refills:0 10. Furosemide 80 mg IV BID RX furosemide 10 mg/mL 80 mg Iv twice daily twice a day Disp #1 Vial Refills:0 11. Glargine 30 Units Breakfast Glargine 30 Units Bedtime Insulin SC Sliding Scale using REG Insulin RX Lantus 100 unit/mL as directed 30 Units before BKFT; 30 Units before BED; Disp #1 Vial Refills:0 RX Humulin R 100 unit/mL Up to 8 Units per sliding scale ACHS Disp #1 Vial Refills:0 12. Lactulose 30 mL PO DAILY RX lactulose 10 gram/15 mL (15 mL) 3 ml by mouth daily Disp #1 Tablet Refills:0 13. Metoprolol Tartrate 75 mg PO TID Hold for HR < 55 or SBP < 90 and call medical provider. [Last Name (NamePattern4) 9641] metoprolol tartrate 50 mg 1.5 tablet(s) by mouth three times a day Disp #60 Tablet Refills:0 14. Pantoprazole 40 mg PO Q24H RX pantoprazole 40 mg 1 tablet(s) by mouth q @4h Disp #30 Tablet Refills:0 15. Potassium Chloride 20 mEq PO Q12H Hold for K+ > 4.5 RX potassium chloride 20 mEq 1 tab by mouth q 12H Disp #60 Tablet Refills:0 16. Gabapentin 100 mg PO BID RX gabapentin 100 mg 1 capsule(s) by mouth twice a day Disp #60 Tablet Refills:0 17. Meclizine 25 mg PO DAILY RX meclizine 25 mg 1 tablet(s) by mouth daily prn Disp #30 Tablet Refills:0 Discharge Disposition: Extended Care Facility: [Hospital1 685] @ [Location (un) ]// [Hospital 1263] hospital Discharge Diagnosis: -coronary artery disease -s/p Urgent coronary artery bypass graft x4; left internal mammary artery to left anterior descending artery, saphenous vein graft to posterior left ventricular branch and saphenous vein sequential graft to obtuse marginal 1 and 2. Secondary: Past Medical History: ?Interstitial Lung disease CAD Diastolic CHF CKD, baseline creat 1.8-2 Diabetes Mellitus Type 2 with ophthalmic complications Hypercholesterolemia Hypertension Esophageal Reflux Osteoarthritis Spinal Stenosis Thyroid Nodule Colonic Polyp BPH Cataracts Glaucoma Hiatal hernia Obesity Erectile dysfunction Retinal vascular occlusion Hearing loss Anemia, iron deficiency Past Surgical History: s/p Laminectomy bialteral cataract surgery Left ear tumor removed 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 Right/Left - healing well, no erythema or drainage. Edema 1+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr.[First Name (STitle) ] #[Telephone/Fax (1) 170] on Cardiologist: Please call to schedule appointments with your Primary Care Dr.[First Name (STitle) ],[First Name3 (LF) ] L. [Telephone/Fax (1) 11962] in [11-22] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2174-6-7] Name: [Known lastname 13679],[Known firstname ] Unit No: [Numeric Identifier 13680] Admission Date: [2174-5-27] Discharge Date: [2174-6-7] Date of Birth: [2100-2-13] Sex: M Service: CARDIOTHORACIC Allergies: lisinopril Attending:[First Name3 (LF) 265] Addendum: IV Lasix was DCd prior to discharge. Oral dosing Lasix 80 mg po TID ordered. Discharge Disposition: Extended Care Facility: [Hospital1 ] @ [Location (un) ]// [Hospital 1699] hospital [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 266] Completed by:[2174-6-7]	[ "600.00", "410.71", "V58.67", "585.9", "362.01", "250.80", "427.31", "428.0", "458.29", "414.01", "338.29", "278.00", "428.32", "515", "280.9", "272.0", "530.81", "496", "250.50", "403.90" ]	icd9cm	[ [ [] ] ]	[ "39.61", "36.15", "36.13", "88.56" ]	icd9pcs	[ [ [] ] ]	16049, 16265	8035, 9467	311, 571	13856, 14086	2909, 6143	15010, 16026	2060, 2112		10553, 12926		13070, 13354		9493, 10530			14110, 14987									13767, 13835	6192, 8012	2127, 2135													2157, 2890											236, 273													599, 1266																13376, 13744	1806, 2044
49,578	149,890	54785	Discharge summary	report	Admission Date: [2109-8-11] Discharge Date: [2109-8-13] Date of Birth: [2046-7-25] Sex: F Service: MEDICINE Allergies: latex Attending:[First Name3 (LF) 2145] Chief Complaint: Pulmonary Embolus Major Surgical or Invasive Procedure: IVC filter placement History of Present Illness: The patient was a 63 year old female with metastatic breast cancer with metastases to the brain and lungs who underwent resection of brain mets and RLL biopsy 1 week prior to admission. On day of admission, patient complained of SOB. SHe presented to an OSH and was found to have two PEs in left posterior basal and middle arterial branches. She was deemed not to be a good candidate for anticoagulation due to her recent surgery. She was sent to [Hospital1 18] for further evaluation, management, and placement of IVC filter. In the ED, initial VS were T 97.6 HR 68 BP 125/76 RR 18 95% RA. Patient was transferred to IR where successful placement of an IVC filter was accomplished. She was then transferred to the MICU for further management of her PE given the contraindication for anticoagulation. Past Medical History: 1. L breast cancer s/p radiation and resection [2101] with metastasis to lung and brain in [2108] 2. Arthritis of hips, knees 3. COPD Social History: Social History: - Tobacco: 100 pack year (quit 3 weeks ago) - Alcohol: denies - Illicits: denies Family History: Father with pancreatic cancer, thyroid disease, skin cancer (still living) Physical Exam: Physical exam on admission: Vitals: 98.1 122/71 83 17 96 RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, gait deferred Physical exam on discharge: VS: 98.6 108/65 59 18 96% Gen: well-appearing female of NAD HEENT: coronal incision c/d/i, MMM, EOMI Neck: Supple without LAD Pulm: L-sided rhonchi/coarse breath sounds, scattered wheeze on R Cor: RRR (+)S1/S2 without m/r/g Abd: Soft, non-distended, non-tender abdomen with NABS Extrem: No LE edema with 2+ distal pulses Neuro: CNII-XII grossly intact, moving all extrem Pertinent Results: ADMISSION LABS [2109-8-11] 05:09PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [2109-8-11] 05:09PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]->1.050* [2109-8-11] 05:09PM PT-10.7 PTT-22.9* INR(PT)-1.0 [2109-8-11] 05:09PM PLT COUNT-336 [2109-8-11] 05:09PM NEUTS-72.1* LYMPHS-22.0 MONOS-4.5 EOS-1.1 BASOS-0.2 [2109-8-11] 05:09PM WBC-9.1 RBC-5.06 HGB-14.5 HCT-43.8 MCV-87 MCH-28.6 MCHC-33.1 RDW-15.3 [2109-8-11] 05:09PM URINE UHOLD-HOLD [2109-8-11] 05:09PM URINE HOURS-RANDOM [2109-8-11] 05:09PM proBNP-51 [2109-8-11] 05:09PM cTropnT-<0.01 [2109-8-11] 05:09PM estGFR-Using this [2109-8-11] 05:09PM GLUCOSE-89 UREA N-28* CREAT-1.2* SODIUM-138 POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-28 ANION GAP-15 Discharge Labs [2109-8-13] 07:40AM BLOOD WBC-7.1 RBC-4.25 Hgb-12.1 Hct-36.9 MCV-87 MCH-28.6 MCHC-32.9 RDW-15.3 Plt Ct-251 [2109-8-13] 07:40AM BLOOD Plt Ct-251 [2109-8-13] 07:40AM BLOOD Glucose-139* UreaN-17 Creat-0.9 Na-138 K-4.0 Cl-107 HCO3-23 AnGap-12 [2109-8-13] 07:40AM BLOOD Calcium-8.3* Phos-2.9 Mg-1.8 Brief Hospital Course: The patinet is a 63 year old female with hx of ER+, Pr+, Her2/Neu+ L breast cancer s/p resection and XRT with metastatic lesions to brain and lung presents s/p partial resection of brain lesion and lung biopsy 1 week prior presenting with acute dyspnea [1-24] pulmonary embolus, s/p IVC filter placement, hemodynamically stable. . ACUTE ISSUES #Pulmonary Embolus: diagnosis based on read from OSH. Lesion located in L posterior basal branches as well as middle basal branches. Patient is contraindicated for anti-coagulation given recent neurosurgery. Hemodynamically stable at this time with negative trop, nl BNP, no new O2 requirement. Patient was given IVC filter via IR. Has been hemodynamically stable throughout hospitalization. LENI was negative bilaterally. . #Metastatic Breast Cancer with mets to lung/brain: s/p partial resection of brain lesion (multiple lesions present) at [Hospital ] as well as lung biopsy showing ER+, PR+, Her2/neu+ cells, bronchoscopy c/w neoplastic cells. IP evaluated patient and felt there was no impending airway collapse. She will need follow up treatment for her metastatic cancer, as there is high risk for worsening of her respiratory status with tumor growth. . #[Last Name (un) ]: Cr elevated to 1.2, had recent CTA chest for PE which may have caused renal insufficiency. No PMHx suggestive of renal disease. Her Cr improved with conservative fluid resuscitation. . CHRONIC ISSUES #Osteoarthritis: chronic issue, located in hips, knees, uses ASA at home. told to hold ASA in setting of recent surgery and instead use acetaminophen for pain. #COPD: 100 pack year smoking. Started on albuterol MDI and ipratropium nebs with no respiratory distress throughout hospitalization. TRANSITIONAL ISSUES: -Patient needs to establish new PCP, [Name10 (NameIs) 648] made with Dr. [Last Name (STitle) ] in [Month (only) ] -Patient was scheduled for oncology follow-up with her primary oncologist -Patient had schedule follow-up with her neurosurgeon during week of discharge -Patient was reminded that her IVC filter was not a permanent device and would require removal as soon as possible Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. LeVETiracetam 500 mg PO BID 2. Aspirin 500 mg PO DAILY Discharge Medications: 1. LeVETiracetam 500 mg PO BID RX levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 2. Albuterol Inhaler [12-24] PUFF IH Q6H:PRN wheezing RX albuterol sulfate 90 mcg 1-2 puffs IH every six (6) hours Disp #1 Inhaler Refills:0 Discharge Disposition: Home Discharge Diagnosis: Pulmonary Embolus Metastatic Breast cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname 111978], You were treated at [Hospital1 18] for a pulmonary embolus. Since you recently had surgery, you were unable to receive blood thinners. Instead, you were given a filter in one of your veins to prevent clots to your lungs. You should follow up with your neurosurgeron tomorrow, and your PCP and [Name Initial (PRE) ] new oncologist in the next week. Information is below. You have been given an albuterol inhaler for your COPD. Directions: 1-2 puffs every 6 hours as needed for wheezing. If you're having serious difficulty breathing, please intead go the ER -- do not rely on the inhaler. Followup Instructions: You have a follow-up [Name Initial (PRE) 648] with Dr. [Last Name (STitle) 111979], Neurosurgery, on [2109-8-15] at noon (confirmed on [8-13]). Name: [Last Name (LF) ],[First Name3 (LF) 111980]-[Doctor Last Name ] Specialty:Primary Care When: Wednesday [9-18] at 11am Location: [Location (un) ] FAMILY PRACTICE Address: [Street Address(2) 75551], [Apartment Address(1) 87446], [Location (un) ],[Numeric Identifier 87435] Phone: [Telephone/Fax (1) 44915] We are working on a follow up appt with an Oncologist Dr. [First Name8 (NamePattern2) 7422] [Last Name (NamePattern1) ] in approximately one week. You will be called at home with the [Last Name (NamePattern1) 648]. If you have not heard or have questions, please call [Telephone/Fax (1) 80105]. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2158]	[ "415.11", "V15.82", "197.0", "496", "V15.3", "584.9", "V10.3", "715.35", "198.3", "715.36" ]	icd9cm	[ [ [] ] ]	[ "38.7" ]	icd9pcs	[ [ [] ] ]	6399, 6405	3740, 5481	284, 307	6492, 6492	2551, 3717	7306, 8227	1437, 1513		6109, 6376		6426, 6471		5923, 6086			6643, 7283											1528, 1542															2155, 2532			5502, 5897						227, 246													335, 1142								1556, 2127		6507, 6619						1164, 1307	1339, 1421
54,090	180,342	41613	Discharge summary	report	Admission Date: [2149-10-6] Discharge Date: [2149-10-9] Date of Birth: [2086-11-1] Sex: M Service: NEUROLOGY Allergies: Penicillins Attending:[First Name3 (LF) 5018] Chief Complaint: Transferred from OSH, intubated following seizures x 2 Major Surgical or Invasive Procedure: Endotracheal intubation History of Present Illness: History is obtained from patient, patient's family and prior notes in longitudinal medical record. HPI: 62 yo right handed man with history of chronic back pain and ?syncopal events presents with first time seizure today witnessed at home by his wife and daughter. Earlier today at 10:30am he reported to his wife that he reached down for something, stood up suddenly and hist his forehead on the edge of cabinets suffering a small laceration. There was no loss of consciousness. He reported to his family that he was feeling very flushed this morning. At 12:20pm, his wife and daughter left the room where he was sitting in a recliner chair. They returned because they heard banging and found him having a generalized seizure with tonic stiffening. His eyes remained closed. There was no cyanosis. He was making gurggling sounds and had urinary incontinence. They called an ambulance and the seizure selfresolved before their arrival estimated to be less than 5 minutes. He was post-ictally not responsive and would not make eye contact or respond. As the ambulance was leaving the house within 10minutes of the last seizure, he had a second generalized seizure which resolved prior to arrival at [Hospital6 ]. He was considered in status because of no return to his baseline in between the seizures or after the seizure and was givn Ativan 2mg. He appeared to not be protecting his airway and was intubated after Etomidate, Succylycholine, and fentanyl. After he was intubated he was give 1 gram of fosphenytoin. He required several small boluses of proprofol. On arrival he had a low bicarbonate of 7. His initial gas showed a pH of 7.23 pCo2 40, p02 104 HCo3 16.8 amd Base excess of -10.2. He did not have significant white count and his urine and chest xray did not show signs of infection. He was transferred to [Hospital1 18] for further neurological care. ROS: Unfortunately, [Known firstname 12395] is unable to answer questions for a review of symptoms. Today, he did not report to his family and concerns for infection with fever, UTI symptoms, cough, rhinnorhea. He did not tell them he had a headache. He had been having significant back pain over the last two days which he thought was due to the change in weather and also the fact he had been working on the generator preparing for the hurricane which could have aggrevated his back pain. His wife thinks that he may have taken many Tramadol pills today. In the past, he has never complained of SOB, CP, palpitations but he is known by his family as some one who doesn't complain or report medical complaints. His grandson was [Name2 (NI) ] with strep throat who he had contact with this weekend but [Name (NI) 12395] himself was not complaining of a sorethroat or fever. Past Medical History: 1) Chronic Back pain- Patient has been mostly followed by a worker's compensation physician for this problem. 2 years ago he feel while at work on the docks and fell down 14 feet injuring his back. His family wasn't sure the total of extent of his injury but think he had L4/L5 vertebral disc protrusion and stenosis of the canal. His images are at [Hospital6 ]. He had been prescribed many medications as detailed below but his family thinks that he does not follow them as prescribed and that he has been known to take many extra pills. 2) Heel Fracture- sustained during above mentioned fall 3) ?Syncope- He has two known syncopal events. One was 1.5 years ago where he reported feeling lightheaded and fell forward and hit his head suffereing a laceration of his forehead. The second was 1 year ago where he fainted while in the bathroom. His wife reports that this weekend he told her that he had having nearsyncopal events about once a month but didn't tell her more detail regarding that. He has not followed with a primary care doctor and has nto had any investigations regarding this. 4) Hemmorhoids- He has been followed by a surgeon who has recommended surgical intervention for which [Known firstname 12395] is planning on holding off on. Social History: heavy smoker- [2-9] ppd > 30 years. He drinks only occasional alcohol on special occasions. No history of illicit drug use. He is retired from being a boat mechanic since his fall 2 years ago where he injured his back. Family History: FH: He was one of 6 brother and several of them have prostate cancer. Both of his parents lived to their nineties. His mother had a stroke in her 90s. There is no family history of seizure. Physical Exam: Physical Examination on Admission: HEENT: Sclera anicteric. Oropharynx benign. Mucous membranes moist. There is a small scabbed head lac- 1cm long Cor: RRR, nl S1, S2. No m/r/g appreciated. Chest: Clear, breath sounds equal bilaterally. Abdomen: Soft, NTND. Ext: Warm, no edema. Skin: mild erythema on chest. Neuro: intubated, off propofol for 15 minutes, off paralyzing agents for several hours. Patient was able to respond to vigorous stimuli, He can open his eyes and keep them open but is not tracking. Pupils equal 2mm pinpoint and minimally reactive bilaterally. Does not blink to threat bilaterally. Face appears symmetric. He does not follow commands. He is moving all his extremities spontaneously but left upper extremity is not as vigorous. He is able to flex knees. Reflexes were 2+ throughout. Could not test babinski because of withdrawal. He is localizing to pain in his lower extremitites but not reliably in upper extremities. Pertinent Results: Labs on Admission [2149-10-6] 06:25PM BLOOD WBC-18.4* RBC-4.34* Hgb-13.9* Hct-37.8* MCV-87 MCH-32.0 MCHC-36.7* RDW-13.0 Plt Ct-361 [2149-10-6] 06:25PM BLOOD PT-11.7 PTT-24.9 INR(PT)-1.0 [2149-10-6] 06:25PM BLOOD Fibrino-375 [2149-10-6] 06:25PM BLOOD Glucose-114* UreaN-20 Creat-1.3* Na-128* K-4.5 Cl-98 HCO3-20* AnGap-15 [2149-10-6] 06:25PM BLOOD ALT-30 AST-42* AlkPhos-74 TotBili-0.5 [2149-10-7] 02:12AM BLOOD Albumin-3.4* Calcium-7.8* Phos-3.9 Mg-2.1 Iron-22* [2149-10-7] 02:12AM BLOOD TSH-0.86 [2149-10-8] 02:36AM BLOOD Phenyto-10.1 [2149-10-6] 06:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2149-10-6] 06:21PM BLOOD Type-ART Rates-/10 Tidal V-919 PEEP-5 FiO2-100 pO2-471* pCO2-35 pH-7.37 calTCO2-21 Base XS--3 AADO2-208 REQ O2-43 Intubat- [2149-10-6] 06:25PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [2149-10-7] 08:58AM URINE Eos-NEGATIVE [2149-10-7] 08:58AM URINE Hours-RANDOM Creat-52 Na-54 K-23 Cl-60 [2149-10-6] 06:25PM URINE bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG Urine, Blood Cultures: negative Reports: EEG (While intubated and sedated) BACKGROUND: Brief periods of low to moderate voltage [Hospital1 ]-occipital 10 Hz rhythms were seen representing full wakefulness with lower voltage anterior beta and theta with at times excessive amounts of precentral beta. The anterior-posterior voltage gradient was preserved. No focal, lateralized or discharging abnormalities were noted. HYPERVENTILATION: Not performed. INTERMITTENT PHOTIC STIMULATION: Not performed. SLEEP: The patient transitioned on multiple occasions to a drowsy state and on rare occasions with symmetrical spindling to stage II sleep. In fact, much of the record represented drowsiness, with brief periods of wakefulness and rapid returns to stage I sleep. CARDIAC MONITOR: No arrythmias noted. IMPRESSION: Abnormal EEG, because of the patient's inability to maintain full wakefulness. While the brief waking rhythms were seen to be normal for age, the state instability would suggest a mild early diffuse encephalopathy. No evidence for a discharging abnormality or clear focality was seen. MRI: Unremarkable MRI examination of the brain. Renal U/s: Normal renal ultrasound. No evidence of mass lesion, hydronephrosis, or cortical thinning. Brief Hospital Course: Mr. [Known lastname 7739] was transferred to the [Hospital1 18] from an OSH intubated and s/p fosphenytoin load for two generalized convulsions noted by his family and EMS personnel. He was intubated for airway protection, and had already received some IV benzodiazepine. Per report from the family, he had been experiencing increased back pain lately and had likely been taking more than his daily allotted amount of tramadol. His admission physical examination was limited by sedation, but his cranial nerve examination was unremarkable and he was noted to be moving all four extremities. He remained intubated over the first night he was in our ICU and continued to receive IV dilantin at a rate of 100mg TID. He was switched over to CPAP spontaneous breathing, and after having passed his SBT, he was successfully extubated to room air. Following his extubation, he was initially confused, sleepy and partially disoriented. This all later improved, and prior to discharge, his neurological examination was positive for some stable old right sided ptosis (without miosis), normal gait and coordination and full strength and sensation throughout. He was independent and ambulatory without support. PROBLEMS Seizures: [Name2 (NI) ] he was initially started on dilantin for his two seizures, he had an extensive work up to rule out secondary causes of symptomatic seizures. His EEG showed no epileptiform activity, and his MRI was normal. He also had an extensive metabolic work up (see below) which revealed no obvious source of infection, metabolic abnormality or electrolyte derangements. His tox screens were also unremarkable. Ultimately, on obtaining a further history from the patient and his family, he reported that he had been taking his tramadol inappropriately over the past few months. His monthly prescription of tramadol would routinely run out of pills prior to the end of the month. At times, when he would run out of his 300mg ultram ER daily, he would instead take 6 pills of 50mg tramadol (short acting). This may or may not have occurred on the day of the seizure, the patient's family cannot confirm this. I spoke with his physiatrist directly, and conveyed our thoughts about tramadol being a cause for lowered seizure threshold. He is to be seen by his physiatrist in one week (see below) where they will together come up with an alternative pain regimen. He was instructed to continue his other home medications of flexeril and lyrica. Renal Failure: On admission, his admission creatinine of 1.3 rose to 1.5 and then subsequently to 1.8 in spite of continuous IV fluids. Urine electrolytes revealed a prerenal impairment (FeNA of 1.1%) and his renal ultrasound was unremarkable. His Cr came back down to 1.6, and then subsequently came back down to 1.1 on discharge. Throughout his stay, he was never oliguric and his UAs were all unremarkable. Anemia: At the OSH, his Hb was 15, and was measured to be ~13 on admission. This worsened to 11 following IV rehydration (dilutional) and remained at ~11g/dL. Iron studies revealed evidence for iron deficiency. A digital rectal examination was performed, and stool was grossly guaiac negative. He reported a negative colonoscopy two years prior. Please consider iron supplementation as an outpatient. The etiology may be related to indolent hemorrhoidal bleeding, although the patient does not report overt bleeding in his stools. Leukocytosis: As high as 18K on admission, likely [3-12] seizure. This improved down to 11K on discharge. He was without signs of infection or fever throughout his stay. On discharge, the patient and his family was educated about findings related to his MRI, EEG and iron studies. They were instructed to follow up in our own neurology clinic at the [Hospital1 18] (see below). They verbalized understanding and all of their questions were answered. Medications on Admission: Ultram ER 300mg QD Lyrica 50mg QD Tramadol 50mg [Hospital1 ] PRN Flexeril (unknown dose) QHS Vitamin E multivitamin herbal supplement Circuleg (PRN hemorrhoid?) Discharge Medications: 1. Lyrica 50 mg Capsule Sig: One (1) Capsule PO once a day. Capsule(s) 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for back pain/discomfort. 3. hydrocodone-acetaminophen 5-500 mg Capsule Sig: One (1) Capsule PO every six (6) hours as needed for pain for 6 days. Disp:10 Capsule(s) Refills:0 4. Flexeril Oral 5. multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Seizures Chronic Lower Back Pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were hospitalized at the Neurology ICU and Wards of the [Hospital1 1535] for two generalized convulsions or seizures. You briefly received sedation following your seizures while you were intubated (with a breathing tube). We believe that your seizures were likely caused as a side effect of tramadol use, which can lower the threshold for seizures. During your hospitalization, we noticed that your kidney function had worsened slightly, but this improved with IV hydration. - DO NOT TAKE tramadol in the future. - Our decision was to NOT continue any antiepileptic medications at this time. Should you or your family notice another seizure, please contact our clinic below to set up a quicker follow up appointment. - For your pain, I have prescribed a few pills of hydrocodone/acetaminophen. Use them only on days when your pain is significantly worse than usual. - While you are not taking tramadol, consider taking one tylenol tablet every 8 hours while awake. Do not consume more than 4g of tylenol daily. - Continue to take your flexeril (as needed) and lyrica daily as augmenting pain agents. - It is important that you follow up with your appointments as listed below, including follow up with us in the Neurology Department of the [Hospital3 ] Hospital. - We noticed that your iron levels are low. This may be as a consequence of sources of bleeding from your gastrointestinal tract such as polyps, hemorrhoids or a tumor. It is important that your PCP set up an appointment for a colonoscopy as an outpatient. Followup Instructions: [Hospital 3390] Hospital Follow Up Wednesday [2149-10-15] at 1:30PM Dr. [Last Name (STitle) ] [Name (STitle) 90462] Ph: [Telephone/Fax (1) 90463] Physical Medicine and Rehabilitation Follow Up (Physiatrist) Wednesday [10-15] at 8:00AM Dr. [Last Name (STitle) 90464] Ph: [Telephone/Fax (1) 90465] Neurology Follow Up Wednesday [2149-12-10] at 4:00PM Dr. [Last Name (STitle) ] and Dr. [Last Name (STitle) 2442] [Name (STitle) 23] Building, [Location (un) 830], [Location (un) ] MA Ph: [Telephone/Fax (1) 41108] [Name6 (MD) 4267] [Last Name (NamePattern4) 4268] MD, [MD Number(3) 5023] Completed by:[2149-10-9]	[ "584.9", "280.9", "288.60", "724.2", "780.39", "305.1", "276.1", "338.29" ]	icd9cm	[ [ [] ] ]	[ "96.71" ]	icd9pcs	[ [ [] ] ]	12876, 12882	8343, 12221	328, 354	12959, 12959	5905, 8320	14666, 15383	4721, 4916		12436, 12853		12903, 12938		12247, 12413			13110, 14643											4931, 4952																								234, 290													382, 3168								4966, 5886		12974, 13086						3190, 4462	4478, 4705
6,116	141,655	10004+56087	Discharge summary	report+addendum	Admission Date: [2112-9-22] Discharge Date: [2112-10-3] Date of Birth: [2030-9-30] Sex: M Service: MEDICINE Allergies: Salsalate / Ace Inhibitors Attending:[First Name3 (LF) 689] Chief Complaint: Mental status changes, respiratory distress Major Surgical or Invasive Procedure: none History of Present Illness: 81M with h/o AFib, CVA and PE, massive GIB, dilated CMP, and chronic/recurrent left sided pleural effusion who was admitted on [2112-9-22] with mental status changes possibly from exacerbation of hypercarbia. Pt had recent hospital admission for the same complain. On his recent admission He has a history of pleural effusion and pulmonary edema of unclear etiology. No fever or cough. No chest pain. No sick contacts. Past Medical History: 1. Paroxysmal atrial fibrillation 2. Dementia: hallucinates at night 3. Dilated cardiomyopathy with EF 55% 4. Hypertension 5. Ventricular fibrillation w/ AICD 6. Psoriasis 7. Diabetes, diet controlled 8. Macular degeneration 9. Basal cell carcinoma 10. Valvular heart disease (severe MR [First Name (Titles) ] [Last Name (Titles) ]) 11. Osteoarthritis w/ decreased mobility from pain 12. Varicose vein 13. PE - [12-7] RLL segmental 14. Recent UGIB [2-5] gastritis 15. Recurrent pleural effusion- unclear etiology, cytology negative in the past. 16. Asbestosis exposure. Social History: Denies tobacco, EtOH, illicits. Recently at [Hospital3 ], but previously living with wife on [Name (NI) 3146] [Name (NI) ]. Retired teacher and coach. Family History: Notable for a father who had macular degeneration. His mother lived to be 90 and was reported to be healthy. He has one younger sister who died from cancer. There is no family history of any memory disorders. Physical Exam: EXAM on discharge: GENERAL: chronically ill appearing male in no distress. Breathing comfortably. VITALS: 98.5 97.3 98/65 (90-104/50-57) HR 97 (80-97) RR 21 O2 95%2L I/O ([Telephone/Fax (1) 33464]) -660 (net ICU stay -532) . GEN: NAD HEENT: EOMI, PERRL, NECK: no JVP elevation CHEST: bilateral crackles L>R HEART: Irregular, [2-9] holosystolic murmur over most of precordium. ABDOMEN: NABS, Soft, No organomegaly GENITAL: No scrotal swelling. EXT: No edema. Mental Status: oriented to person, place, year Pertinent Results: [2112-9-22] 10:22PM TYPE-ART TIDAL VOL-400 PO2-109* PCO2-74* PH-7.30* TOTAL CO2-38* BASE XS-6 INTUBATED-NOT INTUBA COMMENTS-CPAP LACTATE-0.8 . URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.011 BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG . GLUCOSE-165* UREA N-33* CREAT-1.5* SODIUM-147* POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-36* ANION GAP-10 CK(CPK)-23* cTropnT-0.02* CK-MB-NotDone proBNP-1335* CALCIUM-9.6 PHOSPHATE-3.4 MAGNESIUM-2.2 WBC-3.5* RBC-3.95* HGB-10.5* HCT-33.3* MCV-84 MCH-26.7* MCHC-31.7 RDW-16.9* NEUTS-68.3 LYMPHS-23.8 MONOS-6.2 EOS-1.1 BASOS-0.7 PLT COUNT-130* . RADIOLOGY Final Report CHEST (PA & LAT) [2112-9-28] 3:43 PM CHEST (PA & LAT) Reason: Please eval for infiltrate/interval change [Hospital 93] MEDICAL CONDITION: 80 year old man with bilateral pleural effusions with new oxygen requirement. REASON FOR THIS EXAMINATION: Please eval for infiltrate/interval change REASON FOR EXAMINATION: Evaluation for interval change in a patient with bilateral pleural effusions. Portable radiograph was reviewed and compared to [9-24] and [2112-9-22]. Overall gradual increase of bilateral pleural effusions . The cardiac silhouette is markedly increased due to known right atrial enlargement and pericardial effusion. The distal portion of pacemaker lead terminates in the right ventricle. . PATIENT/TEST INFORMATION: Indication: Left ventricular function. Height: (in) 68 Weight (lb): 192 BSA (m2): 2.01 m2 BP (mm Hg): 97/57 HR (bpm): 89 Status: Inpatient Date/Time: [2112-9-23] at 11:14 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007W041-0:23 Test Location: West CCU Technical Quality: Adequate REFERRING DOCTOR: DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] MEASUREMENTS: Left Atrium - Long Axis Dimension: 6.4 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 9.3 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 10.0 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.3 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.5 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.6 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 60% (nl >=55%) Aorta - Valve Level: 3.1 cm (nl <= 3.6 cm) Aorta - Arch: 3.8 cm (nl <= 3.0 cm) Aortic Valve - Peak Velocity: 2.7 m/sec (nl <= 2.0 m/sec) Aortic Valve - Peak Gradient: 29 mm Hg Aortic Valve - Mean Gradient: 17 mm Hg Aortic Valve - Valve Area: 1.6 cm2 (nl >= 3.0 cm2) Mitral Valve - E Wave: 1.3 m/sec Mitral Valve - A Wave: 0.3 m/sec Mitral Valve - E/A Ratio: 4.33 Mitral Valve - E Wave Deceleration Time: 249 msec TR Gradient (+ RA = PASP): 34 to 47 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: LEFT ATRIUM: Marked LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. A catheter or pacing wire is seen in the RA and extending into the RV. Dilated IVC (>2.5cm) with no change with respiration (estimated RAP >20 mmHg). Dilated coronary sinus (diameter >15mm). LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF (>55%). No resting LVOT gradient. No VSD. RIGHT VENTRICLE: RV hypertrophy. Markedly dilated RV cavity. RV function depressed. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Focal calcifications in ascending aorta. Mildly dilated aortic arch. Focal calcifications in aortic arch. AORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve leaflets. Mild AS (AoVA 1.2-1.9cm2). MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral annular calcification. Mild thickening of mitral valve chordae. Calcified tips of papillary muscles. No MS. Mild (1+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Thickened/fibrotic tricuspid valve supporting structures. No TS. Severe [4+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. Normal main PA. No Doppler evidence for PDA PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: Left pleural effusion. Ascites. Conclusions: The left atrium is markedly dilated. The right atrium is markedly dilated. The estimated right atrial pressure is >20 mmHg. The coronary sinus is dilated (diameter >15mm). There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 60%). There is no ventricular septal defect. The right ventricular free wall is hypertrophied. The right ventricular cavity is markedly dilated. Right ventricular systolic function appears depressed. The aortic arch is mildly dilated. There are focal calcifications in the aortic arch. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The supporting structures of the tricuspid valve are thickened/fibrotic. Severe [4+] tricuspid regurgitation is seen. There is a trivial/physiologic pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2112-6-15], both atria are even more dilated (massive biatrial enlargement is present) and th tricuspid regurgitation is now frankly severe. . RADIOLOGY Final Report CTA CHEST W&W/O C&RECONS, NON-CORONARY [2112-9-22] 5:53 PM CTA CHEST W&W/O C&RECONS, NON- Reason: assess for PE, CHF [Hospital 93] MEDICAL CONDITION: 81 year old man with h/o of PE, CHF, dementia (no longer anticoagualted [2-5] to GIB), presents w/ dyspnea, hypoxia, delerium REASON FOR THIS EXAMINATION: assess for PE, CHF CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 81-year-old man with a history PE. Pleural effusions, CHF, and dementia. No longer anticoagulated because of GI bleeding. Now with dyspnea, hypoxia, and delirium. COMPARISON: Chest radiograph from the same day. CT of the torso from [2112-6-16] and CT from [2111-9-26]. TECHNIQUE: Multidetector CT scanning of the chest was performed before and after intravenous contrast. Multiplanar reformations were obtained. CTA OF THE CHEST: There are no central or segmental pulmonary emboli. The pulmonary arteries are slightly enlarged. Severe cardiomegaly with severely dilated right atrium is again noted. A left-sided pacemaker is seen with leads in standard position. There is a small pericardial effusion. Coronary artery calcifications are noted in the right coronary as well as the left anterior descending coronary artery. Within the lungs, there is a large right-sided pleural effusion, similar in size to the prior study. Patchy opacities in the right upper lobe, however, have resolved in the interim. Atelectasis is noted in the right middle lobe adjacent to the major fissure. There is a moderate pleural effusion on the left with likely atelectasis of the lingula, and poor aeration of the remaining lung, thought marginally improved from prior. The left pleural enhancement is unchanged since [2111-9-26]. The chest tube has been removed. The caliber of the thoracic aorta is within normal limits. In the visualized upper abdomen, no definite abnormalities are detected. Inferior vena cava is markedly dilated. OSSEOUS STRUCTURES: No concerning lytic or sclerotic lesions are noted. IMPRESSION: 1. Severe cardiomegaly unchanged. 2. Large right and moderate left pleural effusions which appear similar in comparison to the prior study, with stable left pleural enhancement. Small pericardial effusion. 3. No evidence of central or segmental pulmonary embolism. Brief Hospital Course: 81 y/o male with resolving altered mental status and hypercarbic respiratory insufficiency most likely [2-5] CHF exacerbation and pleural effusion and renal failure with multiple admissions to the MICU for hypoxia, now resolved and called out. Transferred to MICU for hypercarbia and hypoxia (mild worsening of CHF on CXR) placed on BiPAP and diuresed, and following morning more alert. Considered PE, however, with quick improvement did not believe it was high likely and CTA was not considered. Given 20 IV Lasix with goal of negative 1 liter. Restarted Bumex 1 mg daily. # UTI: ecoli UTI resistant to various antibiotics. Will need to finish a full course of ceftriaxone for 7 days. 3 more days remaining after discharge. . # Acute Renal Failure: Improved. Needs to follow renal function. . # HTN: BP well controlled on metoprolol 12.5 [Hospital1 ] . # Diabetes Mellitus Type 2: Diet controlled at home. On insulin sliding scale with minimal need for coverage. Good glycemic control. . # Cardiomyopathy: mostly valvular disease. Currently no surgical intervention planned. Has pacemaker but Defibrillator turned off. Continued with ASA, metoprolol. No ACE or [Last Name (un) ] as mostly right sided dilated CMP. . # Paroxysmal AFib: Well rate controlled with metoprolol. No anticoagulation because of severe GI bleed history. # Pleural effusion: Significant left loculated and right apparently free flowing. No thoracentesis at this time. Would probably benefit from VATS/Decortication, but family has refused in the past. . # H/O PE: Not anticoagulating because of GI bleed history. . # Psychiatric: Started OP medication, Seroquel 25 mg QHS with good response and less agitation. . 12. Anemia: PO iron supplement: 325 mg Fe FEN: Monitor Electrolytes given arrhythmia history, Cardiac/Diabetic Diet Proph: SC heparin(DVT), Protonix for GERD(GI) Code: DNR, but intubation is acceptable per prior discussion s with family. Comm: Wife is health care proxy. [Name (NI) ] contact is Daughter [Name (NI) 2048] cell - [Telephone/Fax (1) 33345], [Doctor First Name ]-[Telephone/Fax (1) 33465] Medications on Admission: Aspirin 81 mg daily Lopressor 25 mg [Hospital1 ] Bumex 1 mg daily Protonix 40 mg daily Seroquel 25-50 mg po qhs Aricept 5 mg daily Iron sulfate 325 mg daily KCl 20 mEq daily Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000 units Injection TID (3 times a day). 7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) NEB Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) NEB Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 12. Bumetanide 0.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Ceftriaxone-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One (1) gram Intravenous Q24H (every 24 hours) for 3 days. Discharge Disposition: Extended Care Facility: [Hospital ] Medical Center - [Hospital1 3597] Discharge Diagnosis: Primary: Hypercarbic respiratory failure Secondary: hypertension Diabetes Mellitus Type 2, diet controlled Dilated cardiomyopathy with EF 55% (echo [6-9]) Valvular heart disease (severe MR [First Name (Titles) ] [Last Name (Titles) ])-last echo [6-9] Paroxysmal atrial fibrillation--off coumadin after massive GIB Ventricular fibrillation w/AICD (defibrillator now off) H/O L superior cerebellar stoke PE - [12-7] RLL segmental. Off coumadin after massive GIB Recurrent pleural effusion/[Name (NI) 33466] unclear etiology, cytology negative. Therapy by repeat thoracenteses. Has been offered pleurodesis in the past but he/wife has refused. Recent UGIB [2-5] gastritis. Capsule endoscopy [6-9] did not localize site of bleeding Anemia Dementia: hallucinates at night, on increasing doses of Seroquel with improvement. Osteoarthritis w/ decreased mobility from pain Basal cell carcinoma Psoriasis Macular degeneration Varicose vein Asbestosis exposure Discharge Condition: Good. Not short of breath. on 2L oxygen Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1500 You were admitted to the hospital with shortness of breath and had an extended hospital stay. Please return to the hospital if you have any shortness of breath, chest pain, fevers, chills or any other concerning symptoms. Followup Instructions: Please follow up with your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ] [Telephone/Fax (1) 1144] in [1-5] weeks. Name: [Known lastname 5830],[Known firstname 63] W Unit No: [Numeric Identifier 5831] Admission Date: [2112-9-22] Discharge Date: [2112-10-3] Date of Birth: [2030-9-30] Sex: M Service: MEDICINE Allergies: Salsalate / Ace Inhibitors Attending:[First Name3 (LF) 161] Addendum: Following point belongs to the problem list of the patient and care giver have to be aware of: Patients platelet count dropped from 130 to 93. There is some concern of heparin induced thrombocytopenia. Laboratory tests with this regard are pending upon discharge. Please call [Numeric Identifier 5834] to follow up on this results Discharge Disposition: Extended Care Facility: [Hospital ] Medical Center - [Hospital1 2314] [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 165] MD [MD Number(1) 166] Completed by:[2112-10-3*]	[ "428.33", "V12.51", "250.00", "041.4", "427.31", "518.84", "403.90", "585.9", "V45.02", "427.1", "397.0", "584.9", "428.0", "511.9", "284.1", "294.8", "425.4", "599.0" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	16232, 16467	10236, 12361	330, 336	14936, 14978	2355, 3151	15374, 16209	1596, 1806		12590, 13805	8092, 8222	13929, 14915		12387, 12567			15002, 15351							3789, 8055				1821, 1821																								247, 292	8251, 10213												364, 789	1840, 2287									2302, 2336						811, 1399	1415, 1580
73,811	117,795	8411	Discharge summary	report	Admission Date: [2180-5-16] Discharge Date: [2180-5-18] Date of Birth: [2101-7-29] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern4) 290] Chief Complaint: dyspnea and hypotension Major Surgical or Invasive Procedure: none History of Present Illness: 77 year old man with metastatic melanoma (to lungs, spleen and adrenals), severe aortic stenosis (valve area 0.8 cm2) with recent valvuloplasty [4-/2180], CAD, systolic CHF with EF 30-35%, who presents with dyspnea. He was diagnosed with melanoma in [2180-3-2] after an enlarging right axillary lesion was noted on pre-op workup for valvuloplasty. Biopsy showed BRAF V600E mutated melanoma. He has been admitted several times in the preceeding months ([3-/2180], [4-/2180], and most recently [2180-5-4] - [2180-5-12]) to the cardiology service for dyspnea thought to be due to pulmonary edema and CHF exacerbations secondary to his worsening aortic stenosis. He had valvuloplasty [4-/2180] with improvmement in valve area 0.6 -> 0.8cm2. His most recent admission for dyspnea was thought to be due to pulmonary edeam, but also pulmonary metastatic disease. He was diuresed and discharged on home lasix with follow up in heme/onc clinic to discuss treatment options for his metastatic melanoma. Upon follow up in heme/onc clinic today to evaluate candidacy for systemic chemotherapy, he appeared ill with dyspnea 94% on 3L and hypotension BP: 76/52. His left arm appeared intervally larger. PIV was placed and he was transferred to the ED. In the ED, initial VS were: 97.7 84 98/67 20 91% 4L. SBP subsequently dropped to 60s, given 2L NS with rapid improvement in SBP to 90-100s. CVL placed. Labs notable for WBC 64 (near recent baseline), K 2.7, BUN 50, Cr 0.9, BNP 9469, trop 0.01, INR 3.7, lactate 5.4 -> 4.5 after fluids. UA without RBCs or WBCs. CXR showed innumberable metastases in bilateral lungs. CT-A chest confirmed diffuse and significant burden of metastases without clear evidence of consolidation, edema or effusion, NO PE. He was placed on Bipap for increased work of breathing and tachypnea. Most recent vital signs afib HR 95 102/58 99% 24-28 on BiPap. . On arrival to the MICU, he is on Bipap 10/5 which has improved his SOB, sats 94% on 50% FIO2. He has not been feeling well lately because of poor appetite (has not been able to eat anything for days due to anorexia). He has had increased dyspnea and cough. Continues to take his medications which include lasix. Denied fever, chills, headache. No abdominal pain, diarrhea, dysuria. He has ongoing right axillary arm pain at the area of his mass. Past Medical History: Past Oncologic History: Metastatic melanoma BRAF V600E mutated - [2-/2180] Scheduled to undergo AVR but was delayed for unexplained leukocytosis. During his pre-op workup, he noted pain and a "bump" in his right shoulder/axilla. ID consult and follow up felt this was not infectious - [2180-3-21] Noted increasing size of R axillary lesion. Initial concern for a pseudoaneurysm. CTA Chest/R arm with runoff showed 6.2 x 5.8 mass in the right axillary region with mild enhancement and mild surr fat stranding. Unchanged in size from non-con CT scan on [2180-3-8] (Hounsfield units 25 on prior non-con scan) - [2180-3-23] Biopsy of the R axillary mass and a pigmented R deltoid lesion revealed melanoma, BRAF V600E mutated - [4-/2180] Multiple admission for symptomatic CHF due to AS, underwent valvuloplasty. Not yet started on systemic chemotherapy (vemurafanib could be considered in future should his cardiac disease stablize and he is hemodynamically stable). . Past Medical History: - CAD with RCA artherectomy in [2167], BMS to LAD in [2177] - Coronary artery disease s/p myocardial infarction in [2169], [2177] - Aortic stenosis s/p valvuloplasty in [2180-4-2] - Hypertension - Systolic and diastolic congestive heart failure - Benign prostatic hypertrophy - Prostate cancer- s/p cryotherapy - Bladder cancer- s/p chemoteherapy - Atrial Fibrillation - Hyperlipidemia - GERD . Past Surgical History: -s/p Back surgery -s/p Appendectomy Social History: Married for 57 years, retired firefighter after 35 years. Lives at home in [Location (un) 3320] with wife. 4 children, 5 grandkids. Denies smoking, ETOH, drug use. Family History: +Premature coronary artery disease. Father died of an MI at age 51. Physical Exam: Admission Exam Vitals: 97F, 86, 109/62 on norepi, 21, 99% on Bipap 10/5 50% Fio2 General: Alert, oriented, no acute distress, using accessory muscle of respiration HEENT: Sclera anicteric, oral mucus membranes moist, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Pertinent Results: Labs: [2180-5-16] 04:30PM BLOOD WBC-64.6* RBC-3.88* Hgb-11.0* Hct-36.6* MCV-94 MCH-28.3 MCHC-30.0* RDW-16.3* Plt Ct-213 [2180-5-16] 04:30PM BLOOD Neuts-97.1* Lymphs-1.6* Monos-1.2* Eos-0 Baso-0.1 [2180-5-16] 04:30PM BLOOD PT-38.0* PTT-34.7 INR(PT)-3.7* [2180-5-16] 04:30PM BLOOD Glucose-111* UreaN-50* Creat-0.9 Na-147* K-2.7* Cl-101 HCO3-27 AnGap-22* [2180-5-16] 04:30PM BLOOD proBNP-9469* [2180-5-16] 04:30PM BLOOD cTropnT-0.01 [2180-5-17] 05:27AM BLOOD cTropnT-0.03* [2180-5-17] 12:55PM BLOOD CK-MB-2 cTropnT-0.02* [2180-5-16] 10:39PM BLOOD Calcium-7.2* Phos-3.9 Mg-1.9 [2180-5-17] 12:55PM BLOOD Cortsol-35.2* [2180-5-16] 11:18PM BLOOD Type-ART pO2-71* pCO2-38 pH-7.45 calTCO2-27 Base XS-2 [2180-5-17] 01:03PM BLOOD Type-ART pO2-42* pCO2-44 pH-7.38 calTCO2-27 Base XS-0 [2180-5-16] 04:47PM BLOOD Lactate-5.2* [2180-5-16] 10:45PM BLOOD Lactate-4.5* [2180-5-17] 05:43AM BLOOD Lactate-4.6* [2180-5-17] 01:03PM BLOOD Lactate-5.5* [2180-5-16] 11:18PM BLOOD O2 Sat-95 [2180-5-17] 01:07AM BLOOD O2 Sat-72 [2180-5-17] 09:44AM BLOOD O2 Sat-67 Imaging: [2180-5-16] CXR: IMPRESSION: Extensive bilateral nodular opacities in lungs suspicious for progression of metastatic disease. No definite pulmonary edema or new confluent consolidation, although subtle changes may be missed due to extensive burden of metastatic disease. [2180-5-16] CT chest: IMPRESSION: 1. No evidence of pulmonary embolism. 2. Significant increase in innumerable pulmonary metastases. 3. Large right necrotic axillary metastasis and increasing intrathoracic lymphadenopathy. 4. Enlarging T10 and T11 vertebral metastases, with cortical breakthrough. 5. Right adrenal metastasis. 6. Resolving perisplenic hematoma/seroma. ECHO [2180-5-17]: IMPRESSION: Severe aortic valve stenosis. Mild symmetric left ventricular hypertrophy with regional systolic dysfunction c/w multivessel CAD. Compared with the prior study (images) reviewed ([2180-4-11]), the severity of aortic stenosis has progressed and regional left ventricular systolic dysfunction is more apparent. Brief Hospital Course: 77 year old man with metastatic melanoma (to lungs, spleen and adrenals), severe aortic stenosis (valve area 0.8 cm2) with recent valvuloplasty [4-/2180], CAD, systolic CHF with EF 30-35%, who presented with dyspnea and hypotension. Henodynamic shock was likely hypovolemic in etiology given poor oral intake while taking lasix, low CVP and normal SvO2. Fluid resuscitation was complicated by pulmonary edema secondary to his systolic dysfunction and aortic stenosis. Imaging (CXR and CT chest) showed rapid progression of melanoma with extensive pulmonary involvement. Echocardiogram showed increased severity of aortic stenosis and worsening left ventricular systolic function. Oncology was consulted and recommended initiation of vemurafinib. He intermitttently required Bipap for respiratory support. The patient together with his family expressed desire to transition care to comfort measures only. He was started on morphine drip, his pressor was slowly discontinued and he died with his family at the bedside. Autopsy was declined. Medications on Admission: 1. aspirin 81 mg daily 2. oxycodone 5-10 mg PO Q8H PRN 3. omeprazole 40 mg daily 4. digoxin 125 mcg daily 5. Lasix 40 mg [Hospital1 ] Discharge Medications: deceased Discharge Disposition: Expired Discharge Diagnosis: Metastatic melanoma Severe aortic stenosis Systolic congestive heart failure Respiratory failure Hypovolemic shock Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] Completed by:[2180-5-18]	[ "530.81", "198.7", "V10.46", "584.9", "V49.86", "197.0", "401.9", "518.81", "276.0", "414.01", "276.2", "172.6", "427.31", "428.22", "412", "424.1", "785.59", "428.0", "V45.82", "272.4", "197.8" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	8725, 8734	7450, 8503	336, 342	8892, 8902	5295, 7427	8959, 9134	4452, 4522		8692, 8702		8755, 8871		8529, 8669			8926, 8936									4211, 4249		4537, 5276																								272, 298													370, 2741																3773, 4188	4265, 4436
76,676	174,280	15344	Discharge summary	report	Admission Date: [2171-12-23] Discharge Date: [2171-12-24] Date of Birth: [2121-6-9] Sex: F Service: MEDICINE Allergies: Penicillins / Morphine / Codeine / Aspirin / Guaifenesin Attending:[First Name3 (LF) 594] Chief Complaint: headache/nausea/somnolence this morning Major Surgical or Invasive Procedure: none History of Present Illness: 50 year old female with breast cancer s/p chemotherapy and nonhealing right lower extremity ulcer who was doing well until two days ago. She was noted to have cough and rhinorrhea for past two days thought to be due to viral URI. She was treated with mucinex. She was noted to have headache/somnolence/nausea this morning and noted to be cyanotic. She was transferred to [Hospital 18654] hospital where her initial pulse ox was 80% on NRB. She was noted to have chocolate brown blood and metHgb level of 56.7. She was given methylene blue 150mg (2mg/kg) and had significant improvement of cyanosis and pulse ox to 100%. . She was transferred to [Hospital1 18] for further evaluation and management. In the ED, her initial vitals were 98.3 92 114/84 22 97% 4LNC. VBG showed MetHgb level decreased to 3. She was admitted to MICU for further observation. . On arrival to the MICU, she reports no other complaints. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: -Breast cancer -Reflex muscular dystrophy -RLE tibial fracture c/b nonunion, compartment syndrome and reported osteomyelitis s/p rotational flap approximately 25 years ago. . Past Surgical History: Bilateral mastectomies TAH-BSO multiple surgeries to her leg debridement and skin graft on her left hand following tissue damage from Adriamycin Social History: The patient is married and lives with her husband. She has 4 children. She denies any alcohol, tobacco, or illicit substance use. Family History: non-contributory Physical Exam: ADMISSION EXAM: General: Pale appearing female in mild distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses. Right shin with dressing Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact DISCHARGE EXAM: General: Pale appearing female, NAD HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: warm, well perfused, 2+ pulses. Right shin with dressing Pertinent Results: ADMISSION LABS: [2171-12-23] 05:45PM BLOOD WBC-8.3# RBC-4.23 Hgb-10.9* Hct-32.7* MCV-77# MCH-25.7 MCHC-33.3 RDW-16.3* Plt Ct-403# [2171-12-23] 05:45PM BLOOD Neuts-81.3* Lymphs-17.0* Monos-1.6* Eos-0 Baso-0.1 [2171-12-23] 05:45PM BLOOD PT-12.0 PTT-28.9 INR(PT)-1.1 [2171-12-24] 03:40AM BLOOD Ret Aut-2.1 [2171-12-23] 05:45PM BLOOD Glucose-133* UreaN-14 Creat-0.8 Na-143 K-2.8* Cl-113* HCO3-23 AnGap-10 [2171-12-24] 03:40AM BLOOD LD(LDH)-121 [2171-12-24] 03:40AM BLOOD Calcium-8.6 Phos-2.5* Mg-1.9 Iron-33 [2171-12-24] 03:40AM BLOOD calTIBC-293 Ferritn-16 TRF-225 [2171-12-23] 05:56PM BLOOD Type-[Last Name (un) ] pO2-53* pCO2-42 pH-7.35 calTCO2-24 Base XS--2 Comment-GREEN-TOP [2171-12-23] 05:56PM BLOOD O2 Sat-81 MetHgb-3* DISCHARGE LABS: [2171-12-24] 04:20AM BLOOD Hgb-10.0* calcHCT-30 O2 Sat-97 MetHgb-1 [2171-12-24] 03:40AM BLOOD WBC-7.5 RBC-3.88* Hgb-9.6* Hct-29.7* MCV-77* MCH-24.9* MCHC-32.4 RDW-16.6* Plt Ct-353 [2171-12-24] 03:40AM BLOOD Neuts-58.0 Lymphs-37.7 Monos-3.7 Eos-0.3 Baso-0.3 [2171-12-24] 03:40AM BLOOD Glucose-96 UreaN-10 Creat-0.7 Na-144 K-3.0* Cl-113* HCO3-24 AnGap-10 Brief Hospital Course: 50 year old female with breast cancer s/p chemotherapy and nonhealing right lower extremity ulcer admitted with methhemoglobenemia. 1. Methemoglobenemia: Unsure of the precipitant though suspect new medication guaifenesin, which was started two days prior to admission. There are case reports of this in the literature as well. She had reponded well to methylene blue at the OSH prior to admission, so on transfer to [Hospital1 18] her MetHb was only 3. She did well clinically overnight and did not receive further methylene blue at [Hospital1 18]. Repeat MetHg the morning after admission was 1. She was stable so she was discharged back to rehab. 2. Anxiety/Depression: Held home buproprion, trazodone and citalopram as methylene blue is a potent reversible MAO inhibitor and might precipitate serotonin syndrome. She can plan to restart these on [12-25] to ensure time for methylene blue to be metabolized from system. 3. RSD: Continued Oxycontin 60 mg CR QID which was her rehab medication; Held off on oxycodone 8 mg po q3 prn because pt was not asking for it. Continued gabapentin 300 mg po qhs. 4. GERD: Continued omeprazole 40 mg po BID 5. Anemia: Microcyctic with MCV of 77. Checked iron, TIBC, ferritin (all normal), retic count (normal), LDH (normal) and hemoglobin electropheresis (pending at the time of discharge) to evaluate. Unlikely to be G6PD deficient unless she has hemolysis after methylene blue to hold off on G6PD especially in acute setting. Transitional Issues: 1. follow up hemoglobin electropheresis to evaluate microcytic anemia in setting of normal iron studies. 2. restart psychiatric medications on [2171-12-25] to avoid serotonin syndrome in setting of recent administration of methylene blue. Medications on Admission: Buproprion 100 mg SR po BID Citalopram 40 mg po qdaily MVA with minerals po qdaily Omeprazole 40 mg po BID Trazodone 50 mg po qhs Oxycontin 60 mg CR po QID Valium 10 mg po BID Dilaudid 12 mg po q3 prn pain Colace 100 mg po BID Gabapentin 300 mg po qhs Heparin 5000 units TID Mucinex 600 ER po BID Discharge Medications: 1. multivitamin Tablet Sig: One (1) Tablet PO once a day. 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 3. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia: OK to restart on [2171-12-25]. 4. oxycodone 20 mg Tablet Extended Release 12 hr Sig: Three (3) Tablet Extended Release 12 hr PO QID (4 times a day). 5. diazepam 10 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed for anxiety. 6. Dilaudid 4 mg Tablet Sig: Three (3) Tablet PO q3h as needed for pain. 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 9. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 10. bupropion HCl 100 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO twice a day: OK to restart on [2171-12-25]. 11. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day: OK to restart on [2171-12-25]. Discharge Disposition: Extended Care Facility: [Location (un) 582] at [Location (un) 620] Discharge Diagnosis: Methemoglobinemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Thank you for letting us take part in your care at [Hospital1 771]. You were transferred to our hospital for further evaluation after being treated for methemoglobinemia (a cause of low oxygen levels) in your blood. This condition can occur as a result of the way your body processes certain medications. Essentially, the hemoglobin which normally carries oxygen through your blood was blocked by other molecules instead. This is treated by giving you a medication (methylene blue) that knocks those molecules off your hemoglobin and allows it to carry oxygen again. We think the cause of this was mucinex (guaifenesin), and you should avoid this medication in the future. Some of your medications were held while you were here because they can interact with methylene blue. It will be safe to restart them tomorrow. No changes were made to your medications. You can restart citalopram, bupropion, and trazodone tomorrow on [2171-12-25]. Do not these medications today, as they interact with the methylene blue that you received for treatment of methhemoglobinemia. Do not take guaifenesin (mucinex) or any medications that contain it again. Followup Instructions: Please follow up with your PCP in one week.	[ "V45.71", "V10.3", "311", "530.81", "300.00", "289.7", "337.20", "V88.01", "707.13" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	7716, 7793	4521, 6012	357, 363	7855, 7855	3341, 3341	9189, 9236	2286, 2304		6625, 7693		7814, 7834		6303, 6602			8006, 9166				4127, 4498					1973, 2120		2319, 2927						2943, 3322												6033, 6277			1331, 1753			278, 319													391, 1312						3357, 4111				7870, 7982						1775, 1950	2136, 2270
60,408	147,038	35543	Discharge summary	report	Admission Date: [2184-4-13] Discharge Date: [2184-4-21] Date of Birth: [2106-9-15] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 2641] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: PICC placed History of Present Illness: 77 year old male with history of atrial fibrillation on coumadin, diabetes mellitus, HTN who initially presented with altered mental status, delerium and fever. He was intuabed at an outside hospital for airway protection and transferred to [Hospital1 18] for management. . On initial presentation, patient presented from home with altered mental status for one day. Per patient's wife he had been alert and oriented and fully functional at baseline. He was at his baseline the night prior to admission and had no complaints. When he woke up the next morning he was confused and talking to people who weren't there and unable to follow commands. He was naked and combative. He has no history of recent travel. No recent sick contacts. [Name (NI) ] was generally otherwise healthy. . He was initially taken to [Hospital3 1443] hospital where he was intubated for airway protection for his delerium. He had a negative toxicology screen. UA showed significant glucose, protein and blood but negative WBCs, negative nitrite and esterase. Chemistries were notable for a normal sodium, creatinine of 1.3 and calcium. WBC count was elevated at 16.7 with 91.5 % neutrophils. INR was elevated at 2.4. He received lidocaine, etomoddate, vecuronium and succinylcholine for intubation. He received propofol for sedation. He had a CT head without contrast which was negative for acute hemorrhage. He had a CXR which showed a concern for a left lower lobe pneumonia and he received vancomycin 1 gram x 1 and moxifloxacin 400 mg IV x1. He was transferred to the [Hospital1 18] emergency room for further management. Past Medical History: Atrial Fibrillation Hypertension Skin Cancer Diabetes Mellitus Social History: No smoking, alcohol or illicit drug use. Lives with his wife. Performs all his ADLS independently. No recent travel or sick contacts. Family History: Non contributory. Physical Exam: 97.7 112/63 77 18 100%/RA NAD CV: Irregular rhythm, no m/r/g CTAB Abd: soft, NT, ND, no rebound, no guarding Ext: no c/c/e Neuro exam: A&O x3, no focal motor or sensory deficits, able to say the days of the week backward but not the months of the year Pertinent Results: [2184-4-21] 06:09AM BLOOD WBC-8.6 RBC-3.44* Hgb-10.3* Hct-30.8* MCV-90 MCH-30.0 MCHC-33.5 RDW-13.7 Plt Ct-252 [2184-4-20] 06:23AM BLOOD WBC-8.1 RBC-3.46* Hgb-10.4* Hct-31.5* MCV-91 MCH-30.2 MCHC-33.1 RDW-13.4 Plt Ct-238 [2184-4-18] 04:37AM BLOOD WBC-8.7 RBC-3.64* Hgb-11.2* Hct-32.3* MCV-89 MCH-30.8 MCHC-34.7 RDW-13.6 Plt Ct-192 [2184-4-17] 03:38AM BLOOD WBC-8.3 RBC-3.56* Hgb-10.5* Hct-32.6* MCV-92 MCH-29.6 MCHC-32.3 RDW-13.6 Plt Ct-207 [2184-4-16] 05:02AM BLOOD WBC-6.5 RBC-3.41* Hgb-10.2* Hct-30.8* MCV-90 MCH-29.9 MCHC-33.1 RDW-13.4 Plt Ct-173 [2184-4-14] 09:54AM BLOOD WBC-8.1 RBC-3.31* Hgb-10.1* Hct-29.2* MCV-88 MCH-30.5 MCHC-34.5 RDW-13.5 Plt Ct-154 [2184-4-14] 04:22AM BLOOD WBC-7.8 RBC-2.77# Hgb-8.4# Hct-24.6# MCV-89 MCH-30.2 MCHC-34.0 RDW-13.4 Plt Ct-157 [2184-4-15] 02:00AM BLOOD Neuts-78.3 Lymphs-13.8* Monos-4.4 Eos-3.4 Baso-0.2 [2184-4-14] 04:22AM BLOOD Neuts-79.1* Lymphs-14.1* Monos-4.9 Eos-1.5 Baso-0.3 [2184-4-21] 06:09AM BLOOD PT-17.4* PTT-35.5* INR(PT)-1.6* [2184-4-20] 07:09AM BLOOD PT-15.4* PTT-32.6 INR(PT)-1.4* [2184-4-19] 04:40AM BLOOD PT-14.2* PTT-33.4 INR(PT)-1.2* [2184-4-15] 09:43AM BLOOD PT-15.7* PTT-28.8 INR(PT)-1.4* [2184-4-15] 02:00AM BLOOD PT-17.8* PTT-33.1 INR(PT)-1.6* [2184-4-14] 01:49PM BLOOD PT-19.4* PTT-29.6 INR(PT)-1.8* [2184-4-13] 02:10PM BLOOD PT-34.9* PTT-37.7* INR(PT)-3.7* [2184-4-14] 12:23AM BLOOD ESR-59* [2184-4-21] 06:09AM BLOOD Ret Aut-0.6* [2184-4-21] 06:09AM BLOOD Glucose-64* UreaN-25* Creat-1.2 Na-144 K-3.3 Cl-107 HCO3-28 AnGap-12 [2184-4-20] 06:23AM BLOOD Glucose-67* UreaN-26* Creat-1.2 Na-142 K-3.4 Cl-104 HCO3-30 AnGap-11 [2184-4-19] 07:27AM BLOOD Glucose-141* UreaN-27* Creat-1.2 Na-141 K-3.9 Cl-103 HCO3-28 AnGap-14 [2184-4-19] 04:40AM BLOOD Glucose-154* UreaN-26* Creat-1.2 Na-141 K-6.1* Cl-103 HCO3-28 AnGap-16 [2184-4-18] 04:37AM BLOOD Glucose-138* UreaN-25* Creat-1.3* Na-144 K-3.5 Cl-105 HCO3-28 AnGap-15 [2184-4-17] 04:22PM BLOOD Glucose-173* UreaN-20 Creat-1.4* Na-145 K-4.1 Cl-105 HCO3-26 AnGap-18 [2184-4-17] 03:38AM BLOOD Glucose-109* UreaN-18 Creat-1.4* Na-145 K-3.9 Cl-108 HCO3-28 AnGap-13 [2184-4-16] 03:19PM BLOOD Glucose-141* UreaN-17 Creat-1.3* Na-144 K-4.4 Cl-110* HCO3-28 AnGap-10 [2184-4-16] 05:02AM BLOOD Glucose-95 UreaN-16 Creat-1.2 Na-145 K-3.6 Cl-109* HCO3-28 AnGap-12 [2184-4-15] 02:00AM BLOOD Glucose-170* UreaN-20 Creat-1.2 Na-142 K-3.9 Cl-109* HCO3-25 AnGap-12 [2184-4-14] 04:22AM BLOOD Glucose-232* UreaN-25* Creat-1.4* Na-147* K-3.4 Cl-102 HCO3-24 AnGap-24* [2184-4-13] 08:48PM BLOOD K-4.7 [2184-4-13] 01:55PM BLOOD Glucose-457* UreaN-27* Creat-1.4* Na-136 K-5.1 Cl-100 HCO3-25 AnGap-16 [2184-4-16] 05:02AM BLOOD ALT-19 AST-34 LD(LDH)-209 CK(CPK)-272* AlkPhos-76 TotBili-0.2 [2184-4-15] 02:00AM BLOOD ALT-19 AST-40 LD(LDH)-210 CK(CPK)-766* AlkPhos-63 TotBili-0.2 [2184-4-14] 09:54AM BLOOD ALT-14 AST-41* LD(LDH)-322* CK(CPK)-1244* AlkPhos-65 TotBili-0.4 [2184-4-13] 08:48PM BLOOD CK(CPK)-598* [2184-4-13] 01:55PM BLOOD ALT-13 AST-19 CK(CPK)-155 AlkPhos-90 Amylase-35 TotBili-0.5 [2184-4-16] 05:02AM BLOOD CK-MB-4 cTropnT-0.05* [2184-4-15] 02:00AM BLOOD CK-MB-7 [2184-4-14] 09:54AM BLOOD CK-MB-9 cTropnT-0.08* [2184-4-13] 08:48PM BLOOD CK-MB-6 cTropnT-0.18* [2184-4-21] 06:09AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.3 Iron-51 [2184-4-20] 06:23AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.2 [2184-4-19] 07:27AM BLOOD Albumin-3.3* Calcium-8.7 Phos-3.3 Mg-2.1 Cholest-215* [2184-4-19] 04:40AM BLOOD Calcium-4.7* Phos-3.3 Mg-1.1* [2184-4-18] 05:00PM BLOOD Mg-2.0 [2184-4-18] 04:37AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.0 [2184-4-15] 04:09PM BLOOD Mg-2.3 [2184-4-14] 09:54AM BLOOD Albumin-3.0* Calcium-7.6* Phos-2.4# Mg-2.4 [2184-4-14] 04:22AM BLOOD Albumin-3.1 Calcium-7.6* Phos-4.1 Mg-2.4 [2184-4-13] 01:55PM BLOOD Albumin-3.7 Calcium-9.0 Phos-3.2 Mg-1.9 [2184-4-21] 06:09AM BLOOD calTIBC-260 VitB12-559 Folate-12.2 Ferritn-282 TRF-200 [2184-4-13] 01:55PM BLOOD %HbA1c-12.7* [2184-4-19] 07:27AM BLOOD Triglyc-191* HDL-26 CHOL/HD-8.3 LDLcalc-151* [2184-4-14] 09:54AM BLOOD Osmolal-297 [2184-4-21] 06:09AM BLOOD Vanco-15.3 [2184-4-20] 06:23AM BLOOD Vanco-28.4* [2184-4-16] 08:03AM BLOOD Vanco-11.7 [2184-4-13] 08:48PM BLOOD Digoxin-1.5 [2184-4-13] 01:55PM BLOOD GreenHd-HOLD [2184-4-16] 05:18AM BLOOD Type-ART Temp-36.6 Rates-/26 Tidal V-513 PEEP-5 FiO2-40 pO2-144* pCO2-46* pH-7.44 calTCO2-32* Base XS-6 Intubat-INTUBATED Vent-SPONTANEOU [2184-4-15] 02:03AM BLOOD Lactate-1.0 [2184-4-14] 04:32AM BLOOD Lactate-1.7 [2184-4-13] 07:08PM BLOOD Lactate-1.6 [2184-4-13] 02:18PM BLOOD Lactate-3.4* Brief Hospital Course: The patient was transferred from outside hospital to [Hospital1 18] emergency department. In the emergency room his initial vitals were T: 102 BP: 149/58 HR: 87 RR: 16 O2: 100% on ventilator. He received ceftriaxone 2 grams, ampicillin 2 grams, acyclovir 900 mg, one liter normal saline and tylenol. He had a CT torso which did not show pneumonia and he had a non-contrast CT head which was negative. LP was not performed because of elevated INR. He was admitted to the MICU for further management. . In the ICU, patient received 6 units of FFP for reversal of INR before LP could be safely obtained by IR on hospital day 3. LP notable for protein of 178, WBC 3, RBC 12, glucose 116. Patient was continued on vancomycin, cetriaxone, ampicillin, and acyclovir pending the results of CSF cultures. MRI of the head showed no evidence of any infection. Patient was mildly hypotensive but never required pressors. Anti-hypertensives were restarted on hospital day 4 after SBP > 200, and patient was successfully extubated on hospital day 5. He was now called out of the ICU for further management. . Vital signs at the time of transfer to the floor were: T97.8, HR 89 (in fib/flutter), BP 139/60 by NIBP (168/61 by A-line), RR 22 O2 93% 2L NC. LOS fluid balance of +3.2L, net out 550cc for the day, with 2.9L of UOP over the day. On the floor, patient was continued on broad spectrum antibiotics and acyclovir as culture data was difficult to inerpret as patient was on empiric antibiotics for about 48 hours prior to LP. Mental status steadily improved. With regard to his hypertension, patient's blood pressure continued to remain elevated despite treatment with amlodipine 5mg, lisinopril 40mg, and metoprolol 75mg TID. It is likely that the patient's blood pressure was not optimally controlled as an outpatient. His amlodopine was increased to 10mg QD. His blood pressures were reasonable on this regimen. On [4-20], his HSV PCR came back as negative and his acyclovir was discontinued. Pt was continued on vancomycin, ceftriaxone, and ampicillin to cover for possible bacterial meningitis for full two week course (last day of treatment will be [2184-4-30]). It is unclear it patient had a known diagnosis of diabetes prior to his hospital admission but he was found to have a HgbA1C of 13 at presentation consistent with longstanding diabetes. Pt was strated on Glargine and insulin sliding scale. Blood sugars were reasonable on this regimen. On presentation, pt's EKG demosntrated deep ST wave depressions and T wave inversions in the inferior and lateral leads. He denies any history of chest pain. He had been on digoxin on presentation but his digoxin level was found to be 1.5 and he initially had bradycardia so his digoxin was held. Cardiac enzymes were elevated on presentation but trended downward with clinical picture more consistant with demand ischemia rather than true ACS. Pt was treated with aspirin 325mg QD, metorpolol. A lipid panel was checked to determine need for statin therapy. Patient LDL was found to be 151 and triglycerides were 191. He was started on lipitor. Patient did not have any episodes of chest pain throughout his hospital course. Pt has a history of atrial fibrillation which was rate controlled on metoprolol. As his INR was reversed with FFP in the unit, pt was tritrated back to therapeutic INR with lovenox bridge. Patient's digoxin was held during this admission due to mild bradycardia. His heartrate remained in a good range without the digoxin, therefore the medication was not continued in patient's discharge medication. Of note, patient had mild episode of acute kidney injury with elevated creatinine in the ICU. This returned to baseline with improvement of mental status and IV hydration. Pt was also found to have a small right heal ulcer on presentation which he had not been aware of prior to admission. Pt consistently had good pedal pulses. The ulcer was treated with daily wet to dry dressing changes performed by the wound care team. Medications on Admission: ASA 81 QD Coumadin 5mg QD Metoprolol SR 100 QD Lisinopril 40mg QD Digoxin 250 mcg QD Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:270 Tablet(s) Refills:1 4. Enoxaparin 100 mg/mL Syringe Sig: One (1) 90 Subcutaneous Q12 HOURS (). Disp:10 1 Refills:2 5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:30 Tablet(s) Refills:2 6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 7. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig: One (1) Intravenous twice a day for 6 days. Disp:24 g Refills:0 8. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours) for 6 days. Disp:6 grams Refills:0 9. Ampicillin Sodium 2 gram Piggyback Sig: One (1) Intravenous every six (6) hours for 6 days. Disp:48 g Refills:0 10. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: [Hospital 3137] Care Center Discharge Diagnosis: Meningitis Discharge Condition: stable Discharge Instructions: You were admitted with altered mental status and fevers secondary to meningitis/encephalitis. Initially you had difficulty breathing and stayed in the intensive care unit while you were intubated. You were treated with broad spectrum antibiotics and acyclovir. You lab work demonstrated no HSV infection therefore you are leaving only with antibiotics and no longer on the acyclovir. . We had to reverse your coumadin in order preform a lumbar puncture and obtain a CSF sample. You are currently being bridged back to your therapeutic coumadin level with lovenox. You were also noticed to have some EKG changes on arrival consistent with NSTEMI with mild elevation of your cardiac enzymes. You should call you primary care doctor as an outpatient to schedule a cardiac stress test. . You were also noted to have elevated blood sugars and started on an insulin sliding scale and glargine. You should work with your primary care doctor as an outpatient to determine the best regimen to control you blood glucose levels . You blood pressures were also elevated during your hospital admission so we started you on a new blood pressure medication - amlodipine 10mg by mouth once per day. . We also found a small ulcer on your right heel and left fore arm that we are treating with daily wet-to-dry dressing changes Medication changes include: * We started amlodipine, glargine, antibiotics (ampicillin, vancomycin, ceftriaxone), lovenox until you are therapeutic on your coumadin, and lipitor * We increased your Aspirin to 325mg per day * We changed your Metoprolol to 75 PO three times per day * Your heart rate was slightly low when you were admitted therefore we did not give you your digoxin. You can talk with your primary care provider about when to restart this. Followup Instructions: Please follow up with your primary care provider [Last Name (NamePattern4) ] 2 weeks Please follow up with Dr. [Last Name (STitle) ] of Neurology in [4-12] weeks, call ([Telephone/Fax (1) 5088] to make this appointment	[ "584.9", "401.9", "707.07", "427.31", "V58.61", "276.0", "518.81", "410.71", "250.12", "320.9", "707.22", "441.4" ]	icd9cm	[ [ [] ] ]	[ "03.31", "38.91", "96.71", "96.6" ]	icd9pcs	[ [ [] ] ]	12529, 12587	7272, 11311	294, 308	12642, 12651	2521, 7249	14472, 14710	2209, 2228		11446, 12506		12608, 12621		11337, 11423			12675, 14449											2243, 2502																								233, 256													336, 1955																1977, 2041	2057, 2193
2,999	108,247	25778	Discharge summary	report	Admission Date: [2102-8-14] Discharge Date: [2102-8-16] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1145] Chief Complaint: In for elective coronary catheterization and PCTA Major Surgical or Invasive Procedure: Right Heart Catheterization Coronary Angiography Percutaneous Transluminal Coronary Angiioplasty with Cypher Stenting of Left Main, Left Anterior Descending, and Right Coronary Artery History of Present Illness: 86 y/o male with PVD and history of abnormal ETT (pMIBI [2102-7-19]) who presents for elective cardiac cath. He has significant LE clauidication for 3-4 years with discomfort at 10-25 feet of walking. He was referred for peripheral noninvasive testing. Had right ABI 0.76 which went to 0.52 with exercise and left ABI 1.01 which went to 0.74 with exercise. Past Medical History: Peripheral Vascular Disease with Claudication Hiatal Hernia Hypercholesterolemia Degenaerative Joint Disease Social History: Former Smoker Family History: No known history of Heart Disease Physical Exam: No significant findings on exam. Pertinent Results: Admission Labs: [2102-8-14] 08:00AM BLOOD UreaN-11 Creat-0.9 K-4.3 [2102-8-14] 12:30PM BLOOD CK(CPK)-42 [2102-8-14] 09:33PM BLOOD CK(CPK)-92 [2102-8-15] 04:46AM BLOOD CK(CPK)-73 [2102-8-15] 05:10PM BLOOD CK(CPK)-71 [2102-8-14] 12:30PM BLOOD CK-MB-NotDone cTropnT-<0.01 [2102-8-15] 04:46AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.7 [2102-8-14] 09:33PM BLOOD Plt Ct-108* [2102-8-14] 08:00AM BLOOD Hct-39.6* Cardiac Cath [2102-8-14] 1. Selective coronary angiography of this right dominant system demonstrated left main and two vessel coronary artery disease in the left coronary system. The LMCA had a proximal 80% lesion. The LAD had a midvessel 70% lesion. And the LCx had a 90% midvessel lesion. 2. Limited resting hemodynamics revealed normal central blood pressures of 129/62 mmHg. Post-procedure the mean PCWP was 10 mmHg. Cardiac index was 4.5 L/min/m2 by Fick. 3. Successful placement of 3.0 x 8 mm Cypher drug-eluting stent (DES) in the LMCA postdilated with a 3.25 mm balloon. Final angiography demonstrated no residual stenosis, no angiographically apparent dissection, and normal flow (See PTCA Comments). 4. Successful placement of four overlapping Cypher DES in the LAD (from proximal to distal a 3.0 x 13 mm, a 3.0 x 8 mm, a 2.5 x 23 mm, and a 2.5.x 8 mm). The first two stents were placed initially. The last two stents were placed after development of slow flow and concern for a dissection after the LCx stent was placed. Final angiography demonstrated no residual stenosis, no angiographically apparent dissection, and normal flow (See PTCA Comments). 5. Successful placement of 2.5 x 18 mm Vision stent in the mid-LCx with a 3.0 x 8 mm Cypher [Name Prefix (Prefixes) ] [Last Name (Prefixes) 64218] and more proximally in the proximal LCx. Final angiography demonstrated no residual stenosis, no angiographically apparent dissection, and normal flow (See PTCA Comments). FINAL DIAGNOSIS: 1. Multivessel coronary artery disease. 2. Normal central blood pressure. 3. Normal cardiac index. 4. Successful treatment of LMCA with drug-eluting stent. 5. Successful treatment of LAD with drug-eluting stents. 6. Successful treatment of LCx with stents. Cardiac Cath [2102-8-15] 1. Coronary angiography of this right dominant system demonstrated multivessel coronary artery disease. The LMCA had no angiographically apparent, flow-limiting disease and a widely patent stent. The LAD had a proximal 30% mild lesion with the remainder of the newly stented vessel free of angiographically apparent, flow-limiting disease. The LCx had no angiographically apparent, flow-limiting disease with the newly placed stents. The RCA had a tubular 40% midvessel lesion as well as a distal, tortuous 50% lesion. The r-PDA had a 90% focal lesion. 2. Limited resting hemodynamics revealed a normal central blood pressure of 129/59 mmHg. 3. Successful placement of a 2.5 x 8 mm Cypher drug-eluting stent in the r-PDA. Final angiography demonstrated no residual stenosis, no angiographically apparent dissection, and normal flow (See PTCA Comments). FINAL DIAGNOSIS: 1. Multivessel coronary artery disease. 2. Planned, staged intervention of r-PDA. 3. Normal central blood pressure. 4. Successful placement of drug-eluting stent in r-PDA. Brief Hospital Course: 86 y/o Male with severe 3VD (including 80% LMCA, 99% RPL, 60% pLAD, 80% mLCX) presented for elective cath. . 1. CAD: Severe 3VD. Not a surgical candidate for Peripheral surgery so he underwent two phases of staged percutaneous intervention. First had 1 LMCA stent, 3 LAD stents (with LAD dissection), and 2 LCx stents. Second stage included Cypher drug-eluting stent in the r-PDA. First cath complicated by LAD disection with TIMI 1 flow. LAD Restented. Other complications included bradycardia and hypotension after haveing femoral sheaths removed. He received atropine and IV fluid with good resolution of hemodynamics. Treated with asa/plavix/statin/BB. Monitored on Telemetry throughout stay. Recovered excellently after procedures. . 2. PVD: Will have percutaneous intervention of Lower extremtiy in the future. R ABI 0.7 --> 0.52 c exercise. L ABI 1.01 --> 0.74 c exercise. . 3. Thrombocytopenia: Chronic. Not worked up during stay. Needs follow up. Medications on Admission: Lipitor 40 mg QD Plavix 75 mg QD Atenolol 25 mg QD 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. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:15 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Coronary Artery Disease (3 Vessel Disease) Discharge Condition: Good, without chest pain. Discharge Instructions: Please call your doctor or come to the emergency room if you have any chest pain or concerning symptomes. Please follow up with Dr. [First Name (STitle) ] in the next two weeks. Please call him at [Telephone/Fax (1) 920] to make an appointment. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3184], M.D. Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 920] Date/Time:[2102-12-19] 4:00 Completed by:[2102-8-19]	[ "553.3", "427.89", "287.5", "458.29", "997.1", "440.21", "414.01", "272.0" ]	icd9cm	[ [ [] ] ]	[ "36.01", "88.56", "36.07", "37.22", "37.23", "36.05" ]	icd9pcs	[ [ [] ] ]	6012, 6018	4472, 5431	312, 498	6105, 6133	1170, 1170	6435, 6663	1067, 1102		5532, 5989		6039, 6084		5457, 5509		4275, 4449	6157, 6412											1117, 1151																								223, 274													526, 888						1186, 3100										910, 1020	1036, 1051
17,938	140,217	19548	Discharge summary	report	Admission Date: [2178-4-2] Discharge Date: [2178-4-9] Date of Birth: [2107-5-24] Sex: F Service: GOLD [Doctor First Name 147] HISTORY OF PRESENT ILLNESS: This is a 70 year old female with a past medical history of non-insulin dependent diabetes mellitus and biliary surgery status post open cholecystectomy and CBD exploration times two who developed epigastric pain and right upper extremity pain leading to an endoscopic retrogram cholangiopancreatography revealing a distal common bile duct structure and CT scan revealed a mass at head of pancreas. The patient was stented for relief of jaundice and interventions revealing 2.5 cm mass of pancreatic head. FNA was suspicious for carcinoma. The patient is pleasant and normal appearing. Abdomen is soft, nontender, nondistended. It was decided that the patient would be taken to the Operating Room for an exploratory laparotomy and a Whipple resection. HOSPITAL COURSE: The patient underwent the procedure without any complications. The patient was transferred to the SICU secondary to significant intravenous load during the case. The patient received over ten liters in the Operating Room; otherwise the patient was doing well without any complaints or issues. The patient was kept intubated and sedated overnight due to the 12 hour surgery and greater than ten liter fluid requirement. The patient was extubated the following day and brought to the floor where she was placed in Whipple protocol. The patient actually had no real acute events as she progressed through the Whipple protocol except on postoperative day five / six, she began to complain of some gout pain in her right foot. It was decided that the Indocin which treats her should be held until discharge on postoperative day seven due to the fresh anastomosis and risks involved thereof. However, the patient was able to tolerate a regular diet and on postoperative day seven, it was decided that the patient could be discharged home on the following: DISCHARGE MEDICATIONS: 1. Reglan four times a day. 2. Percocet. 3. Colace. DISCHARGE INSTRUCTIONS: 1. The patient was to follow-up with Dr. [Last Name (STitle) ] in two weeks time. 2. The patient was clipped and stripped and her [Location (un) 1661]-[Location (un) 1662] was discontinued after her amylase came back at around 6.0. 3. She was also instructed to follow-up with her primary care physician in regards to her usual at home medications and for adequate diabetes mellitus and sugar, insulin control. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 8275] Dictated By:[Name8 (MD) ] MEDQUIST36 D: [2178-4-9] 16:01 T: [2178-4-9] 16:40 JOB#: [Job Number 53027]	[ "577.1", "285.9", "568.0", "401.9", "196.2", "250.00", "157.0" ]	icd9cm	[ [ [] ] ]	[ "52.7", "89.61", "54.59", "54.21", "96.04", "99.04", "38.93", "50.12", "96.71" ]	icd9pcs	[ [ [] ] ]									2047, 2103					968, 2024		2127, 2809																																																192, 950
14,110	143,516	18442	Discharge summary	report	Admission Date: [2152-10-23] Discharge Date: [2152-10-27] Service: CCU HISTORY OF PRESENT ILLNESS: Ms. [Known lastname 50738] is an 82-year-old Russian only speaking female who presents with a chief complaint of chest pain. The patient states that at approximately 6:00 am on the morning of admission she developed crushing chest pain which radiated to her back. She identified no ameliorating or exacerbating factors. She attempted to relieve the pain by taking a Russian over-the-counter medication which usually relieves her baseline anginal pain, however, this had no effect. The patient was taken by ambulance to [Hospital 47] Hospital where she was noted to have an anterior MI by EKG, and elevated cardiac enzymes. She was started on Integrilin, aspirin, Nitro drip and morphine. Beta blocker at that time was held secondary to bradycardia. On this regimen, the patient was still with significant complaint of chest pain. She was then transferred to [Hospital1 18] for further evaluation. At baseline, the patient can walk approximately [1-6] miles without difficulty. She can climb 2 flights of stairs without shortness of breath. The patient denies paroxysmal nocturnal dyspnea, dyspnea on exertion, shortness of breath, fever, chills, nausea, vomiting, and she denies diaphoresis. The patient does report a history of mild, intermittent chest pain which could come at rest, or with activity. For this pain, the patient has been taking an over-the-counter Russian medication which she does not know the name of. This medication usually resolves her chest pain. PAST MEDICAL HISTORY: 1. Diet controlled diabetes. 2. Hypothyroidism. 3. Hypertension. ALLERGIES: No known drug allergies. MEDICATION: 1. Nitropatch. 2. Trazodone. 3. Levoxyl 100 mcg qd. 4. Over-the-counter anginal medication. SOCIAL HISTORY: The patient lives alone. She is Russian only speaking. No smoking or alcohol use. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: Temperature 96.1, heart rate 71, blood pressure 102/76, respiratory rate 15, satting 100% on 2 liters via nasal cannula. HEENT: EOMI, PERRL, moist mucous membranes. NECK: Supple, JVD 8 cm, no thyromegaly appreciated on exam. PULMONARY: No wheezes, mild crackles bilaterally, otherwise clear to auscultation bilaterally. CARDIAC: Normal S1 and S2. No murmurs, rubs or gallops. ABDOMEN: Normal bowel sounds, soft, nontender, nondistended. EXTREMITIES: No pitting edema noted. DP and PT pulses were 1+ bilaterally. The patient had a right groin hematoma. NEURO: The patient was alert and oriented x 3. Cranial nerves II through XII were intact. No focal deficits were noted on exam. LABS: CBC was notable for a hematocrit of 36.3 down from 40.1. The patient's INR was 1.6. Chem-7 was notable for a potassium of 3.3. Troponin was elevated at 2.25. HOSPITAL COURSE: The patient was seen at the [Hospital1 18] and was taken to the Cardiac Cath Laboratory where she was noted to have an LAD lesion described as a 90% complex stenosis just after the origin of D1, and an LCX 60% stenosis. The patient underwent a LAD stent with PTCA of the D1. Her cardiac output and cardiac index were measured at 3.15 and 1.87, respectively. Her pulmonary artery pressures were measured at 42 and 24. Her pulmonary capillary wedge pressure was measured at 25. Her right atrial pressure was measured at 11. She was admitted to the Cardiac Critical Care Unit after her catheterization. In the CCU, the patient was continued on Levoxyl 100 mg qd. She was started on a statin and beta blocker, metoprolol and captopril. In addition, she was continued on her postcath medications including Integrilin, aspirin and Plavix. On presentation to the CCU, the patient was noted to have a right groin hematoma at the site of her cardiac catheterization. Initially, it was felt that this hematoma was stable. However, within 4 hours of presentation, the hematoma was noted to be enlarging. At this time, the patient's beta blocker, ACE inhibitor and Integrilin were all held. Direct pressure was applied above the cardiac catheterization site. The patient was bolused with IV normal saline and 2 units of blood were ordered from the blood bank. The patient received 1 unit of blood, and her hematocrit bumped appropriately. It was felt that the bleeding stopped with direct pressure to the site. The patient was then monitored with q 6 h hematocrit checks. Cardiac enzymes were again cycled. The following day, the patient was noted to have a stable hematocrit, status post blood transfusion. Her cardiac enzymes were trended down. Her chem-7 was unremarkable. The patient was on aspirin, Atorvastatin, metoprolol, captopril. A cardiac echo was obtained which revealed that the left atrium was moderately dilated. No atrioseptal defect was seen. The left ventricular wall thickness was normal. The left ventricular cavity was also normal. However, overall left ventricular systolic function was severely depressed with an ejection fraction of 20-30% secondary to akinesis of the entire intraventricular septum, anterior free wall and apex. The right ventricular chamber size and free wall were within normal limits. In total, these findings were consistent with an extensive anteroseptal infarct with severe left ventricular contractile dysfunction. With the echo findings, the patient was then started on heparin and Coumadin with a goal INR of 2 to 2.5. The patient was seen by physical therapy on the floor who felt that she was deconditioned and would benefit from a stay in a rehabilitation hospital. The patient was thus screened. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To extended care facility. DISCHARGE DIAGNOSES: 1. Status post myocardial infarction. 2. Status post stent placement to the left anterior descending coronary artery. 3. Hypothyroidism. 4. Hypertension. 5. Hypercholesterolemia. DISCHARGE MEDICATIONS: 1. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 4786] Dictated By:[MD Number(1) 50739] MEDQUIST36 D: [2152-10-26] 14:42 T: [2152-10-26] 14:43 JOB#: [Job Number 50740]	[ "414.01", "458.29", "998.12", "244.9", "410.11", "V58.61", "401.9", "250.80", "E879.0" ]	icd9cm	[ [ [] ] ]	[ "36.01", "36.06", "99.11", "88.56", "37.23" ]	icd9pcs	[ [ [] ] ]							1970, 1988	5769, 5949	5972, 6273					2891, 5667																										2011, 2873																								120, 1620																1642, 1851	1868, 1953	5692, 5748
22,162	136,537	19540+57059	Discharge summary	report+addendum	Unit No: [Numeric Identifier 53006] Admission Date: [2184-9-4] Discharge Date: [2184-9-21] Sex: F Service: [Last Name (un) ] HISTORY OF PRESENT ILLNESS: This is an 83-year-old female with type 2 diabetes, peripheral vascular disease status post bilateral femoral distal bypass in [2183] and [2184] with a history of atrial fibrillation who presents to the emergency room complaining of abdominal pain. She states that she had some dyspepsia for several weeks, but on the Friday prior to admission, she developed severe abdominal pain. The pain she described as non-radiating, constant, but feels better when she rocks to and fro. The patient also states she had some nausea and one episode of bilious emesis. The patient denies fevers or chills or bright red blood per rectum or melena. She denies discolored stools or dark urine. PAST MEDICAL HISTORY: As above. MEDICATIONS AT HOME: Amiodarone, Coumadin, Lipitor, Mavik and Avandia. ALLERGIES: None. PHYSICAL EXAMINATION: Temperature is 96.5, heart rate 97, blood pressure 128/77, respiratory rate 16, saturating 97% on room air. General - elderly lady in no acute distress. HEENT - anicteric. Cardiovascular - 2/4 systolic murmur noted, irregular heart rate. Pulmonary exam - clear to auscultation bilaterally. Abdomen was soft, nondistended, positive tenderness in the right upper quadrant and epigastrium with [Doctor Last Name 515] sign positive, positive periumbilical hernia with reducible hernial sac. Extremities - bilateral lower extremity edema with 2+ pedal pulses bilaterally. Rectal - guaiac negative. LABORATORY: CBC - white blood cells 8, hematocrit 33.2, platelets 172 with 85% neutrophils. Chem-7 - 132, 4.5, 106, 23, 25, 0.9 and glucose of 210. LFTs - 118, 209, 159, 1.4, alkaline phosphatase 36. Ultrasound shows a thickened gallbladder wall with the common bile duct 4 mm in diameter, no stones seen. PROCEDURES PERFORMED: Laparoscopic cholecystectomy and periumbilical hernia repair. CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted on hospital day 1 for IV hydration and preop preparations. She was started on IV fluids and Levo-Flagyl. The following morning, she underwent a laparoscopic cholecystectomy and a repair of umbilical hernia. Her postoperative course was complicated by difficult intravascular fluid management. Her cardiac ejection fraction had previously been documented at 30% and the patient quickly became oliguric while at the same time bilateral crackles were noted in the lung fields. Her urine output was maintained with fluid boluses and her pulse oximetry was noted to be satisfactory in the upper 90s on nasal cannula oxygen. The patient's cardiovascular and urine output status continued to deteriorate until postop day 6 at which time she was transferred to the surgical intensive care unit for better hemodynamic monitoring and fluid status maintenance. At that time, her urine output had been 180 cc for the previous 24 hours despite multiple fluid boluses and IV fluid hydration. The patient's creatinine had increased to 1.7 from 0.7 preoperatively. At that time, due to fluid overload, the patient developed respiratory distress and was transferred to the SICU. Under more intensive monitoring, the patient's hemodynamic status and urine output improved and she was transferred back to the floor on postop day 9. At that time, her creatinine had lowered back down to 0.6. The patient continued to slowly improve until postop day 9 when it was noted that her umbilical hernia repair wound was draining some serous fluid. On investigation of this, it was noted that her umbilical wound repair had failed so on postop day 9, the patient was taken back to the operating room where an open repair of a complex umbilical hernia repair was performed. Postoperatively, the patient was maintained in the PACU for better hemodynamic monitoring for the 1st postop day. She was then transferred to the floor where she continued to have low urine output and was difficult to manage hemodynamically. She was able to be managed though this time by increasing her beta blockade which kept her heart in a sinus rhythm as opposed to reverting to atrial fibrillation as it had multiple times throughout her hospital stay. Throughout this hospital stay, she also complained of multiple episodes of chest pain for which she was ruled out for MI multiple times. Her EKG varied between atrial fibrillation with moderate to fast ventricular response to normal sinus rhythm. The tendency to enter atrial fibrillation was secondary most probably to either electrolyte imbalance which was corrected daily or to fluid overload. On postoperative day 9, the patient was also noted at the time of her periumbilical wound investigation and re- repair to have some erythema surrounding the wound. For this, she was placed on vancomycin which was continued for the 5 postop days after the 2nd surgery in the hospital and will be continued with linezolid x7 more days in rehab. The patient was discharged to rehab on postop day 5 and 16, stable. DISCHARGE DIAGNOSES: 1. Acute acalculous cholecystitis. 2. Periumbilical hernia with subsequent re-repair of complex periumbilical hernia. 3. Peripheral vascular disease. 4. Type 2 diabetes. 5. Atrial fibrillation. 6. Congestive heart failure with an ejection fraction of 30%. 7. Peri-wound cellulitis. DISCHARGE MEDICATIONS: 1. Amiodarone 200 mg tablets - take 1 p.o. daily. 2. Albuterol inhaler metered dose MDI - 1-2 puffs p.o. q.6 p.r.n. 3. Guaiphenesin 100 mg/5ml syrup - please take [5-18] ml p.o. q.6 p.r.n. 4. Atrovent metered dose inhaler - take 1-2 puffs q.6 p.r.n. 5. Rosiglitazone 2 mg tablets - take 1 p.o. daily. 6. Atorvastatin 40 mg - take 1 p.o. daily. 7. Trandolapril 4 mg 1 p.o. daily. 8. Pantoprazole 40 mg p.o. daily. 9. Lopressor 25 mg 1 p.o. t.i.d. 10. Miconazole 2% powder - apply topically to perineal area b.i.d. p.r.n. 11. Hydromorphone 2 mg tablets [1-11] p.o. q.[4-14] p.r.n. 12. Warfarin 1 mg 1 p.o. q.h.s. 13. Linezolid for 7 days at a dose of 500 mg p.o. q.12. FOLLOW-UP PLANS: The patient is to follow up with Dr. [Last Name (STitle) ] in 2 weeks' time. The patient will be given the phone number of Dr. [Last Name (STitle) ] which is [Telephone/Fax (1) 6439]. The patient also has pre- existing appointments with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in the far building on [10-28] at 9:40 in the morning and she has an appointment for an echocardiogram at [Hospital Ward Name 23] Center on [2185-1-18] at 10:00 a.m. She also has an appointment with [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] at the [Hospital Ward Name 23] Building on [2185-1-18] at 11:00 a.m. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [MD Number(2) 16263] Dictated By:[Last Name (NamePattern1) 5032] MEDQUIST36 D: [2184-9-21] 09:32:10 T: [2184-9-21] 10:31:43 Job#: [Job Number 53007] cc:[Hospital3 53008] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Name: [Known lastname 9848],[Known firstname ] F Unit No: [Numeric Identifier 9849] Admission Date: [2184-9-4] Discharge Date: [2184-9-21] Date of Birth: [2101-2-20] Sex: F Service: [Last Name (un) ] ADDENDUM: DISCHARGE MEDICATIONS: The patient should also be on insulin sliding scale with fingerstick's four times a day. The patient should receive 2 units of regular insulin subcutaneously for a fasting blood sugar of 121 to 160. 4 units for 161-200, 6 units for 201-240, 8 units for 241 to 280. 10 units for 281-320, 12 units for 321-360 and 14 units for 361 to 400. For metoprolol, there is a holding parameter for systolic blood pressure of less than 100 or a heart rate of under 60. FOLLOW UP: She should also follow-up with her primary care doctor sometime in the next two weeks to reassess her glycemic control. [Last Name (LF) ],[First Name3 (LF) 801] 02-AAK Dictated By:[Last Name (NamePattern1) 9850] MEDQUIST36 D: [2184-9-21] 09:42:47 T: [2184-9-21] 09:54:20 Job#: [Job Number 9851] cc:[CC Contact Info 9852]	[ "427.31", "574.10", "250.00", "428.0", "997.5", "443.9", "272.0", "998.59", "553.1", "998.32" ]	icd9cm	[ [ [] ] ]	[ "51.23", "54.3", "53.49" ]	icd9pcs	[ [ [] ] ]								5098, 5396	7483, 7940													918, 988														7952, 8336	2040, 5077			1011, 2011						6138, 7459																		175, 862																885, 896
15,527	121,207	14177	Discharge summary	report	Admission Date: [2122-5-19] Discharge Date: [2122-5-24] Date of Birth: [2063-10-4] Sex: F Service: Urology DISPOSITION: Home. DISCHARGE CONDITION: Stable. HISTORY: This is a 58 year-old female who was found to have a slightly enhancing left renal mass. A preoperative abdominal CT scan showed no evidence of metastatic disease. Preoperative chest CT scan also showed no evidence of metastatic disease. The patient was counseled for surgical therapy. PAST MEDICAL HISTORY: 1. Status post motor vehicle accident in [2122-1-23]. 2. Lichen planus. 3. Anxiety. 4. She is status post D&C in [2097]. MEDICATIONS: 1. Celexa. 2. Ativan. ALLERGIES: She has no known drug allergies. SOCIAL HISTORY: She does not smoke and does not drink alcohol. PHYSICAL EXAMINATION: Shows a slightly obese, middle aged woman in no acute distress. She is very nervous. Her heart rate is 71. Her blood pressure is 192/100. Her head and neck exams are benign. Her lungs are clear to auscultation. Her heart is regular rate and rhythm with no murmurs. Her abdomen is soft, nontender. There is no costovertebral angle tenderness. Her lower extremities showed no pedal edema. HOSPITAL COURSE: The patient was admitted on [2122-5-19] status post a left radical nephrectomy performed by Dr. [Last Name (STitle) 9125]. Intraoperatively an inferior mesenteric vein and splenic vein tear were repaired. The patient was volume resuscitated and postoperatively was transferred to the Intensive Care Unit for monitoring. Due to a positive air leak with intubation the decision was made to postpone extubation. Postoperatively the patient remained hemodynamically stable. Her respiratory status remained stable. She was extubated on postoperative day two and was subsequently transferred to the surgical floor. Her nasogastric tube was removed on postoperative day three and with the passage of flatus her diet was advanced as tolerated. Her postoperative hematocrit remained stable at 25, 25 and 27. Her creatinine peaked at 1.1. She advanced her diet without difficulty. She moved her bowels. On examination on discharge she remained afebrile with stable vital signs. Her incision was clean, dry and intact. Her epidural had been removed and she was tolerating pain control with Percocet. She was voiding without difficulty. On postoperative day five she was discharged to home to follow up with Dr. [Last Name (STitle) 9125] in the office for staple removal and pathology review. DISCHARGE MEDICATIONS: 1. Percocet one to two tablets po q four hours prn pain. 2. Colace 100 mg po bid. 3. Niferex 150 mg po bid. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern1) ], MD [MD Number(1) 13269] Dictated By:[Last Name (NamePattern1) 18686] MEDQUIST36 D: [2122-5-24] 08:57 T: [2122-5-25] 13:44 JOB#: [Job Number 42186]	[ "300.00", "998.2", "189.0" ]	icd9cm	[ [ [] ] ]	[ "39.32", "55.51" ]	icd9pcs	[ [ [] ] ]				179, 484					2536, 2952					1216, 2513																										811, 1199																																								506, 723	740, 788
30,015	149,414	48780	Discharge summary	report	Admission Date: [2154-1-5] Discharge Date: [2154-1-16] Date of Birth: [2079-1-1] Sex: F Service: MEDICINE Allergies: Latex / Amoxicillin / Percocet / Propoxyphene Attending:[First Name3 (LF) 4232] Chief Complaint: Fall with multiple fractures Major Surgical or Invasive Procedure: [1-5]: I&D/VAC L leg, Ex Fix LLE, splint R leg ([Doctor Last Name 7376] Sat [1-5]) [1-8]: I&D, closure, ex-fix adjustment LLE; ORIF R distal tibia NO further [Month/Year (2) ] surgery other than removal of ex fix Fixation of tibia and fibula History of Present Illness: Ms. [Known lastname ] is a 75 year old spanish speaking F with a history of OSA, Asthma/COPD, CAD, CHF (unkown EF), HTN, DM on insulin, and CKD (Cr 1.6-2.0, recently 3.0) who 'fell out of bed' and found at [Last Name (un) 2299] house with an open left tib/fib fracture. . In the ER multiple films were done which showed negative ct head/c-spine/torso. Xrays showed open tib-fib comminuted fracture, calcaneal fracture. She had a suspected right sided fracture as well. Seen by [Last Name (un) ] in the ED and planned for surgery this morning. Labs in ED were notable for elevated K (6.7) and acute on chronic renal failure (Cr 3.2). She received kayexalate x1, 10U insulin, 1amp D50. For pain she was given 2mg dilaudid. She also received 1gram Ancef. Vital signs were T99, HR 71, BP 142/88, RR 16, 91% RA, 99% 2L. She was taken directly from ED to OR pre-op area. . She was admitted and evaluated by the [Doctor Last Name ] Firm in the Pre-Op Area where a repeat K was 7.0 and not following commands. She was given another round of insulin and D50, one amp of bicarb, and 1000mg calcium gluconate in the operating room. The case was discussed with the orthopedic team and anesthesia. Given that the washout and ex-fix for an open fracture was necessary within 8 hours after injury, she was taken to the OR. She remained hemodynamically stable with 100cc EBL. She remained intubated in the PACU given her mental status prior to surgery, and her thick secretions. Her c-spine films were normal, but clearance was deferred as the patient's mental status was altered. . She was transferred to the MICU due to difficulties extubating. It was felt to be due to increased secretions. Her VS were T96.0, BP 160/40, RR 15 and HR 63, 100% on AC. An ABG was 7.29/52/110 on AC 500x14, FiO2 50%, PEEP of 5, at time of evaluation in the PACU. A CXR did not show any new changes compared to pre-OP CXR. An EKG did not show any peaked T waves or new changes. Sputum cultures were sent. Past Medical History: Renal insufficiency (baseline Cr 1.8-2 b/[Initials (NamePattern4) ] [February 2153] & [December 2153]) Diabetes mellitus, type 2 CHF CAD Gout Depression (h/o hallucinations) OSA Asthma/COPD Hypercholesterolemia h/o angina GERD Vaginal bleeding Osteoarthritis Right tib/fib fx ('[52]) Social History: Lives in nursing home. Denies smoking or alcohol. No illicit drug use. Patient is Spanish speaking only, from [Name (NI) 5976], husband passed away after their move to the United States. Family History: Non-contributory. Physical Exam: Physical Exam on Admission: VS: T96.0, BP 160/40, RR 15 and HR 63, 100% on AC 500x14, FiO2 50%, PEEP of 5 Gen: Comfortable, sedated/intubated woman in NAD HEENT: C-Spine Collar in place CV: Regular, nl S1, S2, No S3 apparent, no m/r/g Chest: Expiratory wheezes, coarse BS b/l anteriorly Abd: obese, pos BS, soft, nt/nd Ext: left leg splinted; R ankle cast, 1+ edema on RLE Neuro: sedated, unresponsive to verbal commands; anisocoria (s/p cataract/lens implant). Appears to be moving all extremities. No e/o facial asymmetry. Pertinent Results: EKG: Pre-OP: Sinus bradycardia; no ST segment changes or q waves. Early R wave progression. Post-OP: NSR, no peaked T waves, no acute ST changes. --------------- Studies: [2154-1-5] Knee Xray: AP AND LATERAL LEFT KNEE: Overlying casting material obscures bony detail. Fracture is identified involving the proximal fibula. No joint effusion is detected. IMPRESSION: Non-displaced fracture of the proximal fibula. [2154-1-5] CT Chest: CT OF THE CHEST WITHOUT INTRAVENOUS CONTRAST: The lungs show mild dependent atelectasis. No pneumothorax, pleural or pericardial effusion is identified. The heart is enlarged and demonstrates coronary artery calcification. The thoracic aorta maintains a normal contour. Note is made of enlargement of left lobe of the thyroid, which may represent a goiter, however, confirmation with physical exam and thyroid function tests is recommended. ---------------- CT OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST: The liver, spleen, adrenal glands, and pancreas are within normal limits. The kidneys are atrophic. No intra-abdominal free air, free fluid, or lymphadenopathy is identified. Intra-abdominal loops of large and small bowel maintain normal caliber without evidence of obstruction. The abdominal aorta demonstrates calcified atherosclerotic plaques, however, maintains a normal caliber throughout. CT OF THE PELVIS WITHOUT INTRAVENOUS CONTRAST: The rectum, sigmoid colon, bladder, uterus, and intrapelvic loops of small bowel are within normal limits. No free fluid or lymphadenopathy. BONE WINDOWS: No suspicious sclerotic or lytic lesion is identified. Note is made of diffuse osteopenia. IMPRESSION: No evidence of intra-abdominal parenchymal organ injury. [2154-1-5] Tib/Fib: AP AND LATERAL VIEWS OF THE TIBIA AND FIBULA: Overlying splint obscures fine detail. There is a comminuted fracture of the distal tibia and fibula. The distal fracture fragment is externaly rotated. Additional fractures are identified involving the plantar surface of the calcaneus as well as the proximal fibula. [2154-1-5] CXR: IMPRESSION: Apparent widening of the mediastinum, which may be related to technical factors, however, CT or repeat chest radiograph with PA and lateral technique should be employed for further evaluation. [2154-1-5] CXR: Comparison is made to prior radiographs from [2154-1-5]. There is an endotracheal tube with distal tip is at the level of the clavicles, 4.5 cm above the carina. The feeding tube is appropriately sited. There is persistent cardiomegaly and mediastinal prominence which is unchanged since the previous study. There is no focal consolidation or signs of overt pulmonary edema. There is widening of the left AC joint suggestive of prior surgery or trauma. [2154-1-5] CT Head: IMPRESSION: 1. Exam is somewhat limited by motion, however, no evidence of intracranial hemorrhage. 2. A 3-mm rounded sclerotic focus is seen within the left mandibular condyle, which may represent a bone island, however, correlation with history of malignancy is recommended. [1-15] RIGHT ANKLE: There is a large medial fracture plate in the distal tibia fixating a fracture through the distal tibia. There is also a compound complex fracture of the distal fibula. The alignment is grossly anatomic. The tibiotalar joint is slightly widened medially. There is generalized osteopenia. There is soft tissue swelling. LEFT ANKLE: External fixation hardware is seen within the tibial shaft and in the calcaneus. There is a complex fracture involving the tibial metaphysis with multiple fracture fragments within the central portion of the bone. There is also a complex fracture of the distal fibular shaft at the same level. The ankle mortise is preserved. TTE [1-7] Conclusions The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild to moderate regional left ventricular systolic dysfunction with focal hypokinesis of the distal half of the septum and, basal and distal inferior wall, and mid anterior wall. The remaining segments contract normally (LVEF = 40%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([2-13]+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is top normal. There is an anterior space which most likely represents a fat pad. IMPRESSION: Mild regional left ventricular systolic dysfunction c/w CAD (multivessel CAD or other diffuse process). Mild- moderate mitral regurgitation. CLINICAL IMPLICATIONS: Based on [2153] 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. Hematocrit at discharge was 26 Brief Hospital Course: A/P [1-8]: 75F h/o CAD, DM2, CKD, presented to ED s/p fall at nursing home with open L tib/fib fracture, s/p external fixation left, right comminuted closed tib/fib difficulty extubating post-OP [3-16] increased secretions, transferred to ICU for monitoring on ventilator. . # LEFT OPEN TIB/FIB FRACTURE / RIGHT CLOSED ANKLE FRACTURE Sustained after falling out of bed at rehab. [1-5]: Incision and Dressing/vac dressing to left leg, external fixation of left lower extremity, splint to right leg by Dr. [Last Name (STitle) 7376]. [1-8]: I&D, closure, ex-fix adjustment LLE; ORIF R distal tibia. Follow up appointment scheduled with Orthopedics on [2154-1-29] for stitches to be removed and determination of further orthopedic intervention. . # Respiratory failure Transferred to Medical ICU post-operatively for failure to wean from ventilator. Thick, yellow tracheal secretions prior intubation noted. Chest x-ray revealed left retrocardiac opacity and a left-sided pleural effusion. Sputum gram stain with gram positive cocci but culture negative. Given concern for infection, pt was started on levofloxacin and metronidazole IV, and was continued on cefazolin for prophylaxis s/p external fixation. Metronidazole was discontinued. Levofloxacin was administered for likely pneumonia for an 8 day course. She also has a history of CHF (EF 40% on [1-7]). She was diuresed with furosemide to relieve pulmonary vascular congestion with good effect. She was extubated [1-10] and subsequently maintained oxygenation/ ventilation on supplemental oxygen. She was weaned off oxygen and placed back on her furosemide dose. # Enterococcus UTI Urine culture on [2154-1-5] grew enterococcus for, she completed 7 days of treatment with vancomycin, the culture was pan sesnitive. . # Delirium Mrs. [Known lastname ] was extubated on [1-10] after which she time she experienced agitation and delirium which was thought to be due to a combination of post-injury/ post-operative pain, multiple tubes and lines/drains as well as underlying medical issues. Lines were discontinued and restraints limited. The chronic pain service was involved and their recommendations were implemented in an effort to control pain and minimize delirium. Upon transfer to the floor medications were stopped such as Haldol, restraints and NGT were removed. Patient's mental status returned back to her baseline within a few days. . # Chronic Kidney Disease Ms. [Known lastname 102520] baseline is 1.8-2.1 bur on admission was 3.2 on admission. She was followed by nephrology and their recommendations implemented. Her creatinine gradually improved throughout her hospital [Last Name (un) 10128] and returned to her baseline. She was scheduled outpatient follow up with nephrology for continued following of her renal function. Creatinine at discharge was 1.7, furosemide and lisinopril were restarted. . # Diabtes Hgb A1c 7.8 this admission. She was started on an insulin drip in the perioperative period and was transitioned to glargine and a siding scale. Upon discharge she was on glargine 55 units and a regular sliding scale, titrate up as needed. # DEPRESSION - on Celexa . # OSTEOPENIA - Likely secondary to CKD; alk phos nml; pth pending. Will check 25-vit D. Pt will need outpt bone mineral density study. . # COMMUNICATION: HCP [Name (NI) 1894] [Name (NI) ] [Telephone/Fax (1) 102521]. Friend of pt. No family. . # Full code. Confirmed with HCP. Medications on Admission: Lantus 90U hs Novolin sliding scale Lasix 30mg PO daily Celexa 30mg daily Isosorbide Mononitrate 120mg daily Lisinopril 20mg daily Oxybutynin 5mg daily Ferrous Sulfate 325mg daily Senna 2 tabs daily Colace 100mg [Hospital1 ] Flovent 220mcg 1puff [Hospital1 ] Gabapentin 300mg [Hospital1 ] Lopressor 50mg TID Tramadol 50mg hs Famotidine 20mg hs Simvastatin 40mg hs Trazodone 50mg hs Allopurinol 100mg daily Folate 1mg daily Megace 200mg [Hospital1 ] Oxycodone 5mg q6H (start on [1-3]) APAP Recently completed course of Bactrim x 10 days. Discharge Medications: 1. Lantus 100 unit/mL Cartridge Sig: Fifty Five (55) units Subcutaneous at bedtime. 2. Novolin R 100 unit/mL Cartridge Sig: as directed Injection four times a day: sliding scale as directed. 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Imdur 120 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO once a day. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO once a day. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a day. 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 15. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 17. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 18. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 19. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 20. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 21. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 22. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 23. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day. 24. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 25. Heparin (Porcine) 5,000 unit/mL Syringe Sig: One (1) Injection three times a day: while immobilized. 26. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 27. Hydromorphone 2 mg/mL Syringe Sig: One (1) Injection Q4H (every 4 hours) as needed: as needed for breakthrough pain. Discharge Disposition: Extended Care Facility: [Hospital3 1186] - [Location (un) 538] Discharge Diagnosis: Left tibia and fibula fracture Right ankle fracture Left ankle fracture Delirium Enterococcus UTI Discharge Condition: Alert and oriented times 3 Stable Discharge Instructions: You were admitted with left leg and bilateral ankle fractures. After your surgery you developed a urine infection and delirium which resolved. You were discharged back to the [First Name4 (NamePattern1) 2299] [Last Name (NamePattern1) ]. You have follow up appointments with Orthopedics in a few weeks to have your stitches removed and to determinte course of action. You also have appointments to follow up with your primary care doctor and with Nephrology to ensure follow up of your kidney disease. Return to the ER if any further worrisome symptoms, otherwise all yur appointments have been set up for you. Followup Instructions: Provider: [Name Initial (NameIs) 394]/[Name8 (MD) ] MD Phone:[Telephone/Fax (1) 253] Date/Time:[2154-1-22] 11:00 Provider: [Name10 (NameIs) ] XRAY (SCC 2) Phone:[Telephone/Fax (1) 1228] Date/Time:[2154-1-29] 11:00 Provider: [First Name11 (Name Pattern1) 2191] [Last Name (NamePattern4) 2192], [MD Number(3) 1240]:[Telephone/Fax (1) 1228] Date/Time:[2154-1-29] 11:20 [2154-3-18] 01:30p INTERPRETER,SPANISH INTERPRETERS [2154-3-18] 01:30p [Last Name (LF) ],[First Name3 (LF) ] [Hospital6 29], [Location (un) ] RENAL DIV-CC7 (SB) [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(1) 4236]	[ "428.0", "272.0", "428.23", "518.5", "584.9", "293.9", "250.00", "823.82", "599.0", "585.9", "041.04", "823.92", "493.20", "E888.9" ]	icd9cm	[ [ [] ] ]	[ "79.36", "79.66", "38.93", "96.6", "93.54", "78.17" ]	icd9pcs	[ [ [] ] ]	15240, 15313	8746, 12257	333, 600	15455, 15491	3743, 6505	16159, 16860	3163, 3182		12864, 15217		15334, 15434		12283, 12841			15515, 16136											3197, 3212							8454, 8723																	265, 295													628, 2616		6514, 8431						3226, 3724								2638, 2939	2955, 3147
75,772	185,195	9685	Discharge summary	report	Admission Date: [2105-11-3] Discharge Date: [2105-11-17] Date of Birth: [2021-10-31] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 602] Chief Complaint: Wound infection Major Surgical or Invasive Procedure: Surgical debridement of left leg eschar History of Present Illness: 84 year old with a pmh significant for a-fib, HTN, renal artery stenosis s/p stenting, HLD, COPD, and multiple abdominal surgeries with a recent MVC with several injuries including several fractures and pneumothorax presenting for wound eval. She was evaluated by her rehab physician today and there was concern over her left lower leg incision which had developed eschar. She has not had fevers or chills, or purulent drainage. . She also notes that her edema has been improving greatly since being at rehab. Except for her left arm which remains very swollen. She denies any pain (except soreness from fractured ribs), SOB, wheeze, congestion, cough, N/V/D, abd pain, myalgias. . In the ED, initial VS: 97.6 103 121/74 18 90% RA. Surgery evaluated the wound, not overly concerned, perhaps overlying cellulitis. Recommended 3 days of antibiotics. A LUE ultrasound showed thrombus of brachial vein and partial thrombus of basilic vein. She was given Cefazolin 1g, heparin gtt was started. CXR showed small bilateral pleural effusions and fluid in the fissures. Transfer vitals: 98.7 104 126/72 16 98% 3l. . Currently, resting comfortably, mildly short of breath. Otherwise without complaint. . REVIEW OF SYSTEMS: Per HPI, otherwise negative. Past Medical History: A-fib renal artery stenosis s/p L renal a stent placement [2097] HTN dyslipidemia COPD (per [2097] d/c summary, pt denies), PSH: AAA repair and ABI [2093] b/l TKA L3/L4 laminectomy remote appendectomy remote ovarian cystectomy R THR [2101] mult bowel obstructions s/p ex-lap (details unclear) c/b mesh infections TRAUMA HX: MVC c/b; L rib fx [2-15], R rib fx [3-21], forehead/LUE/LLE lacs, sternal fracture, R distal fibula fx, L PTX Social History: Recently moved to [Location (un) 3493]. Living on her own prior to MVC. Loves cribbage. Tobacco: former EtOH: 2 glasses of wine daily Drugs: Denies Family History: Non-contributory Physical Exam: On admission: VS - Temp 96.6F, BP 122/60, HR 103, R 21, O2-sat 96% 2L (90% on RA) GENERAL - Chronically ill appearing woman in NAD, mildly tachypneic, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM NECK - supple, no thyromegaly, JVD ~12 LUNGS - fine crackles throughout with wheeze, good air movement, resp unlabored, no accessory muscle use, mildly tachypneic HEART - tachycardic, irregular ABDOMEN - NABS, soft/NT, distended EXTREMITIES - [2-13]+ anasarca edema, left arm significantly more swollen than right, no c/c/e, left knee with laceration with mild erythema, eschar, serosanguinous discharge SKIN - ecchymoses no rashes or lesions LYMPH - no cervical LAD NEURO - awake, A&Ox3, CNs II-XII moving all extremities On discharge: SpO2 92-94% on RA, L knee without erythema, no drainage from lateral L shin laceration. [1-15]+ anasarca edema symmetric. Otherwise unchanged. Pertinent Results: Notable Labs: [2105-11-3] 10:05PM BLOOD WBC-12.7# RBC-3.36 Hgb-9.9* Hct-31.1* MCV-92 MCH-29.4 MCHC-31.8 RDW-16.5* Plt Ct-453* [2105-11-8] 04:34AM BLOOD WBC-7.0 RBC-2.78* Hgb-8.6* Hct-26.2* MCV-94 MCH-31.0 MCHC-32.9 RDW-16.7* Plt Ct-201 [2105-11-17] 05:57AM BLOOD WBC-14.4* RBC-3.32* Hgb-9.9* Hct-31.8* MCV-96 MCH-29.8 MCHC-31.1 RDW-17.6* Plt Ct-582* [2105-11-11] 02:27AM BLOOD Neuts-92.3* Lymphs-6.6* Monos-0.8* Eos-0.1 Baso-0.3 [2105-11-17] 05:57AM BLOOD PT-24.5* PTT-42.4* INR(PT)-2.3* [2105-11-16] 05:36AM BLOOD PT-18.1* INR(PT)-1.7* [2105-11-15] 05:14AM BLOOD PT-14.5* PTT-28.0 INR(PT)-1.4* [2105-11-14] 11:53AM BLOOD PT-19.2* PTT-30.9 INR(PT)-1.8* [2105-11-11] 02:27AM BLOOD PT-57.9* PTT-58.4* INR(PT)-5.8* [2105-11-8] 04:34AM BLOOD PT-42.0* INR(PT)-4.3* [2105-11-7] 06:27AM BLOOD PT-81.7* INR(PT)-9.4* [2105-11-6] 08:55PM BLOOD PT-138.4* INR(PT)-17.5* [2105-11-6] 05:58AM BLOOD PT-96.5* PTT-67.0* INR(PT)-11.5* [2105-11-14] 11:53AM BLOOD Glucose-141* UreaN-27* Creat-0.8 Na-144 K-4.4 Cl-109* HCO3-32 AnGap-7* [2105-11-13] 06:20PM BLOOD Glucose-239* UreaN-29* Creat-0.9 Na-146* K-4.4 Cl-110* HCO3-31 AnGap-9 [2105-11-17] 05:57AM BLOOD Glucose-74 UreaN-23* Creat-0.8 Na-138 K-3.8 Cl-100 HCO3-34* AnGap-8 [2105-11-3] 10:05PM BLOOD Glucose-88 UreaN-31* Creat-1.3* Na-144 K-3.4 Cl-109* HCO3-25 AnGap-13 [2105-11-14] 11:53AM BLOOD ALT-100* AST-80* LD(LDH)-215 AlkPhos-80 TotBili-0.3 [2105-11-13] 04:47AM BLOOD Type-[Last Name (un) ] pO2-37* pCO2-54* pH-7.42 calTCO2-36* Base XS-8 Notable studies: Sputum Cx: SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S ---- CXR on admission: IMPRESSION: Bibasilar atelectasis, tiny pleural effusions. No PICC line seen. ---- RUE US: Occlusive thrombus within one of two left brachial veins as well as nonocclusive thrombus within the left basilic vein. ---- RLE US: No evidence of deep venous thrombosis in the right lower extremity. ---- L Knee film: IMPRESSION: Stable-appearing left total knee arthroplasty ---- Head CT: IMPRESSION: Stable head CT without evidence for acute process. Studies pending on Discharge: none Brief Hospital Course: 84 yo F with atrial fibrillation, hypertension, chronic obstructive pulmonary disease, and left leg eschar admitted for left leg cellulitis. Hospital course was notable for discovery left upper extremity deep venous thrombosis, MRSA [Last Name (un) 1064] requiring transfer to the medical intensive care unit, and acute diastolic heart failure. #Left leg Cellulitis/Eschar: Patient was admitted with left leg cellulitis. She was treated with cefazolin then cephalexin and was evaluated Plastic surgery. She had an eschar debrided on [11-5] and [11-9] and will follow up with Plastic surgery as an outpatient. She was maintained on [Hospital1 ] wet to dry dressings. #Upper extremity deep venous thrombosis: Patient was noted to have left arm swelling on admission and was found to have a deep venous thrombosis in the cephalic and basilic veins. Given that she had had a PICC line in that arm previously, it was felt that this was PICC related. patient was started on anticoagulation to be continued for at least 4 weeks, but decision was made that patient would benefit from life long anticoagulation for atrial fibrillation (see below). Patient was treated with enoxaparin bridge to Coumadin. #Hypoxia/Chronic obstructive pulmonary disease/Methicillin resistant staph aureus [Hospital1 1064]: Patient had hypoxia and somnolence on the medical floor and was transferred to the Medical Intensive Care Unit. Patient grew MRSA from sputum culture and imaging was consistent with bilateral [Hospital1 1064] and patient was treated with an 8 day course of antibiotics for MRSA [Hospital1 1064]. Patient was also started on steroid pulse for treatment of possible concurrent COPD exacerbation. Her hypoxia slowly improved and she was transferred back to the floor for continuation of antibiotics and steroids which were completed prior to discharge. Tiotropium was started on discharge. # Hypotension: Patient developed hypotension in the setting of [Hospital1 1064] and diuresis, but improved with gentle fluid boluses and withholding of antihypertensive agents which were restarted prior to discharge. #Atrial fibrillation: Patient was admitted in persistent atrial fibrillation wth tachycardia. She was rate controlled with diltiazem as tolerated by her blood pressure and was started on Coumadin. Given her elevated CHADS2 score with evidence of hypertension, diastolic heart failure, and age >70, it was felt that the patient would benefit from lifelong anticoagulation for her atrial fibrillation in addition to anticoagulation for her upper extremity thrombus. INR level and Coumadin dosing should be followed and adjusted by rehab facility and then by PCP. #Hypertension: See above. Patient had BP regimen adjusted in house but was discharged home on her previous anti-hypertensive regimen. #Chronic kidney disease: Renal function was stable during hospitalization. #Acute Diastolic Heart failure: Patient had acute diastolic heart failure in the setting of infection. She was diuresed with IV diuretics with improvement in her edema and oxygen saturation. Patient was felt to still be slightly volume overloaded on day of discharge and was discharged to acute rehab to continue 2 more days of IV diuresis with transition to oral diuretics to maintain euvolemia thereafter. #Encephalopathy: Patient had encephalopathy felt to be related to her [Hospital1 1064] and hypoxia which improved with treatment of [Hospital1 1064] and improvement in respiratory status. #Disposition: Patient was discharged to acute rehab to have PCP and Plastic surgery follow up thereafter. #Transitions of care: - Please pull PICC once patient completes course of IV lasix. - consider rechecking LFTs in [1-15] weeks and increasing dose of simvastatin depending on future LFTs - please monitor volume status clinically - please check INR on [2105-11-19] and adjust warfarin dosing accordingly Medications on Admission: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID prn Constipation. 2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Nebs: 1 Inh Q6H prn SOB 3. heparin (porcine) 5,000 unit/mL: 1 Injection [Hospital1 ] (2 times a day). 4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H 5. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS 6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY 7. furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY 8. labetalol 200 mg Tablet Sig: One (1) Tablet PO QHS 9. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY 10. tiotropium bromide 18 mcg Capsule: 1 Cap Inhalation DAILY 11. terazosin 5 mg Capsule Sig: One (1) Capsule PO Q 24H 12. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. diltiazem HCl 180 mg Capsule: 1 Cap PO Q 24H 14. pantoprazole 40 mg Tab: One(1) Tablet PO Q24H 15. bisacodyl 10 mg Suppository: 1 PR HS prn constipation. 16. oxycodone 5 mg Tablet: 0.5 Tab PO Q4H prn for pain. 17. tramadol 50 mg Tablet: 0.5 Tab PO Q6H as needed for pain. 18. docusate sodium 50 mg/5 mL: One (1) PO BID prn constipation. 19. ipratropium bromide 0.02%: One (1) nib Inh Q6H prn wheezing. 20. calcium carbonate 200 mg calcium (500 mg): 1 Tab PO TID Discharge Medications: 1. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 6. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for pain. 8. guaifenesin 100 mg/5 mL Syrup Sig: Fifteen (15) ML PO Q6H (every 6 hours). 9. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 10. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: 0.63 mg Inhalation q6hPRN () as needed for wheezing. 11. diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 12. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 13. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 15. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 16. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 17. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 18. collagenase clostridium hist. 250 unit/g Ointment Sig: One (1) Appl Topical TID (3 times a day). 19. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 20. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath. 21. furosemide 10 mg/mL Solution Sig: Forty (40) mg Injection DAILY (Daily) for 1 days: give for 1 day (on [2105-11-18]), reasses volume status and re-dose as necessary, follow up chemistry panel on [2105-11-19]. 22. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day. 23. potassium chloride 20 mEq Packet Sig: One (1) PO once a day for 2 days: continue for 2 days, then titrate according to chemistry panel. 24. Heparin Flush (10 units/ml) 2 mL IV PRN line flush Mid-line, heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above, daily and PRN per lumen. 25. 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. 26. Outpatient Lab Work Please obtain Chem 7 and PT/INR on [2105-11-19]. Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: Hospital-acquired [Location (un) 1064] Upper Extremity Deep Venous Thrombosis Acute on Chronic diastolic CHF Chronic Obstructive Pulmonary Disease Atrial Fibrillation 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: Dear Ms. [Known lastname 32734], It was a pleasure taking care of you in the hospital. You were admitted with infection of your skin overlying the left knee and a clot in the left leg. The infection is called cellulitis. You were treated with antibiotics and blood thinners. You got very sick with low blood pressures while you were in the hospital. You were transferred to the ICU for a short time period. We increased the antibiotics because we think that maybe you had a stronger infection in your skin and possibly a [Known lastname 1064]. The following changes were made to your medications: - Decrease Simvastatin to 10mg (this was decreased to help improve your liver function, your primary doctor may want to increase in future) - START guaifenasin for cough - START levalbuterol (like albuterol but will decrease rapid heart rate) - INCREASE Diltiazem to 60mg Every 6 Hours - START Metoprolol to control your heart rate - START Vitamin C - START Collagenase (santyl) applied to your left leg lesion until you are seen by Dr. [First Name (STitle) 1022]. - START Warfarin 1mg daily (your dose will need to be changed in 2 days by the doctors at rehab, this drug will help prevent strokes) - START Potassium 20mg daily for 2 days (for use while you are on high dose lasix) - START Lasix at 40mg IV daily for 1 day on [2105-11-18] (the doctors at rehab [Name5 (PTitle) ] determine your dose going forward) Followup Instructions: Please be sure to set up an appointment with your primary care physician 1 week after discharge from Rehab. Department: SURGICAL SPECIALTIES/PLASTIC SURGERY When: MONDAY [2105-11-30] at 1:30 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2477], MD [Telephone/Fax (1) 31444] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: ORTHOPEDICS When: TUESDAY [2105-12-22] at 2:45 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2235], MD [Telephone/Fax (1) 1228] Building: [Hospital6 29] [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "996.74", "276.0", "272.4", "428.0", "427.31", "707.19", "491.21", "453.81", "E878.1", "482.42", "403.90", "453.82", "V43.65", "276.3", "518.81", "585.9", "682.6", "348.30", "428.33" ]	icd9cm	[ [ [] ] ]	[ "86.22" ]	icd9pcs	[ [ [] ] ]	13731, 13828	5884, 9507	321, 363	14042, 14042	3275, 5363	15681, 16432	2305, 2323		11073, 13708		13849, 14021		9844, 11050			14219, 15658											2338, 2338																	5855, 5861				1605, 1636			266, 283													391, 1586				5761, 5841				5377, 5752		14057, 14195		9528, 9818				1658, 2119	2135, 2289
27,684	176,939	31366	Discharge summary	report	Admission Date: [2140-6-29] Discharge Date: [2140-7-4] Date of Birth: [2104-7-3] 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: [2140-6-30] Off-Pump Coronary Artery Bypass Graft x 2 (LIMA to LAD, L radial to diag) History of Present Illness: Mr. [Known lastname ] is a 35 y/o male with h/o CAD s/p multiple stents this year c/b restensosis. He continued to have recurrent angina and underwent cardiac cath at OSH which revealed progression of LAD disease. Coronary disease was not amenable to PCI and was transferred to [Hospital1 18] for surgical revascularization. Past Medical History: Coronary Artery Disease s/p stent to prox and mid LAD c/b subacute stent thrombosis s/p thrombectomy of LAD and stent [2140-4-7], s/p DES to prox LAD [2140-6-3], h/o retroperitoneal/extraperitoneal bleed, Hypertension Social History: Biochemist. Denies tobacco and ETOH use. Family History: Father with stents at age 65. Physical Exam: VS: 66 20 176/98 5'9" 195# Gen: WDWN male in NAD HEENT: EOMI, PERRL, NC/AT Neck: Supple, FROM, -JVD, -bruit Chest: CTAB -w/r/r Heart: RRR -c/r/m/g Abd: Soft, NT/ND, +BS Ext: Warm, well-perfused, -edema, -varicosities Neuro: A&O x 3, MAE, non-focal Pertinent Results: [6-30] Echo: The left atrium is normal in size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No spontaneous echo contrast or thrombus is seen in the body of the right atrium or the right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). There is mild symmetric left ventricular hypertrophy. 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. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Post off pump: Preserved biventricular systolic function. Overall LVEF 55%. Aortic contour is intact [7-4] CXR: The patient is status post recent median sternotomy and coronary bypass surgery. Cardiomediastinal contours are stable in the post-operative period. Minor basilar atelectasis and small pleural effusions are present. No pneumothorax is evident. [2140-6-29] 12:45PM BLOOD WBC-6.6 RBC-4.77 Hgb-13.7* Hct-37.8* MCV-79* MCH-28.8 MCHC-36.4* RDW-13.9 Plt Ct-311 [2140-7-4] 09:15AM BLOOD WBC-10.0 RBC-3.28* Hgb-9.3* Hct-26.7* MCV-82 MCH-28.4 MCHC-34.8 RDW-14.4 Plt Ct-371# [2140-6-29] 12:45PM BLOOD PT-11.7 PTT-23.2 INR(PT)-1.0 [2140-7-2] 01:24AM BLOOD PT-13.0 INR(PT)-1.1 [2140-6-29] 12:45PM BLOOD Glucose-109* UreaN-12 Creat-1.0 Na-140 K-4.4 Cl-103 HCO3-29 AnGap-12 [2140-7-3] 05:20AM BLOOD Glucose-126* UreaN-12 Creat-1.0 Na-142 K-4.0 Cl-105 HCO3-28 AnGap-13 [2140-7-2] 01:24AM BLOOD Phos-3.4 Mg-1.9 Brief Hospital Course: As mentioned in the HPI, Mr. [Known lastname ] was transferred from OSH for surgical revascularization of his coronary disease. He underwent usual pre-operative testing and was brought to the operating room on [6-30] where he had a off-pump coronary artery bypass x 2. Please see operative report for details. Following surgery he was transferred to the CSRU 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 beta blocker and diuretics were started and he was gently diuresed towards his pre-op weight. On post-op day two his chest tubes were removed and he was then transferred to the SDU for further care. Epicardial pacing wires were removed the following day. Physical therapy worked with pt. during post-op period for strength and mobility. He continued to improve and was ready for discharge home with services on post operative day 4. Medications on Admission: At transfer: Plavix 75mg qd, Aspirin 325mg qd, Zocor 40mg qd, Lisinopril 5mg qd, Toprol XL 100mg qd, Heparin gtt. 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. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 7. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 9. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily) for 3 months. Disp:30 Capsule, Sustained Release(s) Refills:2 10. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Five (5) ML Mucous membrane [Hospital1 ] (2 times a day) for 1 weeks. Disp:70 ML(s) Refills:0 11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day for 1 months. Disp:30 Tablet(s) Refills:0 12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:10 Tablet(s) Refills:0 13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day for 10 days. Disp:20 Capsule, Sustained Release(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 ] Discharge Diagnosis: Coronary Artery Disease s/p Off-Pump Coronary Artery Bypass Graft x 2 PMH: s/p stent to prox and mid LAD c/b subacute stent thrombosis s/p thrombectomy of LAD and stent [2140-4-7], s/p DES to prox LAD [2140-6-3], h/o retroperitoneal/extraperitoneal bleed, Hypertension Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Please call to schedule all appointments Dr. [First Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] Dr. [Last Name (STitle) 5874] in [12-26] weeks Dr. [Last Name (STitle) 43672] in [11-24] weeks [Telephone/Fax (1) 6256] Wound check [Hospital Ward Name ] 2 please schedule with RN [Telephone/Fax (1) 3633] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2140-7-4]	[ "401.9", "V45.82", "414.01", "413.9" ]	icd9cm	[ [ [] ] ]	[ "36.15", "36.11" ]	icd9pcs	[ [ [] ] ]	6110, 6157	3313, 4266	329, 420	6477, 6483	1419, 3290	6994, 7460	1105, 1136		4430, 6087		6178, 6456		4292, 4407			6507, 6971											1151, 1400																								279, 291													448, 782																804, 1031	1047, 1089
16,320	125,935	49537	Discharge summary	report	Admission Date: [2133-3-12] Discharge Date: [2133-3-14] Date of Birth: [2084-9-5] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 30] Chief Complaint: Overdose Major Surgical or Invasive Procedure: NG tube History of Present Illness: Mr. [Known lastname ] is a 48 year old man with a history of hepatitis C, bipolar disorder with suicide attempts in the past, recent psych admit earlier in [3-3] who was found alert approximately one hour after taking an unspecified number of pills. Per report, there were empty bottles of Inderal and Klonopin found at bedside, as well as [11-30] full bottles of geodon, gabapentin, Lescol and paroxitine. The patient was reportedly alert at scene, and then became unresponsive in route to the hospital. In the ED, the patient was intubated and given activated charcoal. His initial BP was 60/P with a pulse in the 60s. He was given 4 amps of calcium gluconate, and started on a Calcium gtt. He was also given 5mg of glucagon and started on a glucagon drip with good response. His urine and serum tox screens were notable only for benzos, otherwise negative. He was seen by cardiology, and toxicology was consulted via telephone. . He was admitted to the MICU, intubated for airway protection and started on both a calcium and glucagon drip. There was evidence of possible aspiration pneumonia on CXR, though he was extubated without incident on the AM of transfer to the medicine floor. Psych was made aware, and they are actively involved in his care. Past Medical History: Hep C Bipolar D/O with one suicide attempt by overdose several years ago Agoraphobia Panic disorder Narcissism No history of head trauma or seizure disorder Social History: Denies alcohol use. Has a history of cocaine abuse - in remission for 6 years , with one relapse 2.5 years ago. Has a history of qualude use since high school, also in remission. Denies use of AA/NA. Smokes 1ppd. Patient lives at home with his mother, father and brother. Reports that he has suffered from anxiety since childhood and needed to drop out of college. Unemployed and on disability. Waiting for a subsidized apartment. No current relationship. Family History: Denies. Physical Exam: Vitals: 99.3 67 (60-70) 99/53 (90-100s) 96% on RA 3.7L + LOS Gen: caucasian man lying in bed, NAD HEENT: NCAT, PERRL, EOMI, no icterus, OP clear, MMM, no tongue fasciculations Neck: supple, no LAD, no JVD CV: RRR, nl s1 s2, no m/g/r Lungs: ? decreased BS over left middle lung, otherwise CTA Abd: normal size, nd, no scars, nl bs, soft, nt, palp liver Ext: no c/c/e, no edema Neuro: no asterixis, CN II-XII intact, 5/5 strength throughout, sensation to LT intact throughout, gait deferred Psych: A+Ox3, mood "great," affect approp, speech stuttering, linear TP, no SI or HI Pertinent Results: Labs on admit: [2133-3-12] 09:55PM BLOOD WBC-8.9 RBC-4.94 Hgb-15.8 Hct-45.3 MCV-92 MCH-31.9 MCHC-34.8 RDW-12.4 Plt Ct-175 [2133-3-12] 09:55PM BLOOD Neuts-49.9* Lymphs-42.4* Monos-5.5 Eos-1.6 Baso-0.6 [2133-3-12] 09:55PM BLOOD Plt Ct-175 [2133-3-12] 09:55PM BLOOD PT-12.8 PTT-25.7 INR(PT)-1.0 [2133-3-12] 09:55PM BLOOD Glucose-108* UreaN-13 Creat-0.7 Na-146* K-3.7 Cl-109* HCO3-30* AnGap-11 [2133-3-12] 09:55PM BLOOD Albumin-3.9 Calcium-8.5 Phos-4.2 Mg-2.0 [2133-3-12] 09:55PM BLOOD ALT-44* AST-31 AlkPhos-36* TotBili-0.2 [2133-3-12] 09:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Labs today: [2133-3-13] 09:30AM BLOOD WBC-10.1 RBC-4.35* Hgb-14.2 Hct-39.9* MCV-92 MCH-32.6* MCHC-35.6* RDW-12.4 Plt Ct-151 [2133-3-13] 09:30AM BLOOD Glucose-115* UreaN-14 Creat-0.8 Na-142 K-4.1 Cl-112* HCO3-26 AnGap-8 [2133-3-13] 09:30AM BLOOD Calcium-10.4* Phos-2.8 Mg-1.8 [2133-3-13] CXR: An endotracheal tube terminates just above the thoracic inlet approximately 6.5 cm above the carina. The nasogastric tube terminates within the stomach. Cardiac and mediastinal contours are within normal limits. There is a patchy area of increased opacity in the left retrocardiac region, which was not seen on the earlier study. Right lung is clear. Left costophrenic angle has been excluded from the study and cannot be assessed. There is no evidence of right pleural effusion or right pneumothorax. IMPRESSION: 1) Endotracheal tube is slightly proximal in location, and could be advanced approximately 1.5 cm for more optimal placement. 2) Patchy left retrocardiac opacity which may be due to patchy atelectasis, aspiration, or early pneumonia. Followup radiograph suggested Brief Hospital Course: A/P: 48yo man with h/o HCV, bipolar DO, h/o suicide attempts, a/w overdose of Inderal, Klonopin, Geodon, s/p MICU stay with intubation for airway protection, with question of L retrocardiac infiltrate, now doing well. . Overdose: -monitor on tele overnight -if HR drops, restart glucagon gtt -watch for BZD withdrawal, agitation . Bipolar disorder: -appreciate Psych consult; patient to be discharged to inpatient psych facility once stable -suicide precautions . Activity: OOB with assist . FEN: house diet . PPX: SC heparin, bowel regimen, nicotine patch . CODE: full . DISPO: transfer to inpatient psych likely tomorrow Medications on Admission: Neurontin 800mg tid Ziprasidone [Hospital1 ] Propanolol 20mg tid Klonopin 2mg tid Paxil 30mg qd Protonix 40mg qd Folate 1mg qd Lescol 40 qd Discharge Disposition: Home Discharge Diagnosis: Depression Discharge Condition: Depressed Discharge Instructions: Going to [Hospital1 ] 4. Followup Instructions: Please f/u with PCP [Last Name (NamePattern4) ] 2 weeks. Completed by:[2133-3-14]	[ "300.21", "276.8", "507.0", "E950.3", "972.0", "E950.4", "311", "969.4", "070.70", "296.80", "518.81", "977.8", "301.81" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.07", "96.71" ]	icd9pcs	[ [ [] ] ]	5510, 5516	4692, 5316	321, 330	5571, 5582	2930, 4669	5659, 5751	2304, 2313				5537, 5550		5342, 5487			5606, 5636											2328, 2911																								273, 283													358, 1634																1656, 1814	1830, 2288
30,466	154,234	54537	Discharge summary	report	Admission Date: [2148-12-9] Discharge Date: [2148-12-15] Date of Birth: [2098-5-29] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: asymptomatic Major Surgical or Invasive Procedure: [12-9] AVR (tissue)/Ascending Aortic & Hemi-Arch Repair History of Present Illness: 50 yo M with known bicuspid AV and AS. Serial echos with dilated ascaneding aorta and worsening AS. Past Medical History: Hyperlipidemia, aortic stenosis, dilated ascending aorta, varicosities of right leg, hernia repair Social History: works as college professor 1 etoh/day denies tobacco Family History: no premature CAD Physical Exam: HR 66 RR 12 BP 112/78 NAD Lungs CTAB heart RRR 4/6 SEM Abdomen benign Extrem warm, no edema right leg varicosities Pertinent Results: [2148-12-14] 06:55AM BLOOD WBC-9.6 RBC-2.93* Hgb-8.8* Hct-26.0* MCV-89 MCH-30.0 MCHC-33.8 RDW-14.2 Plt Ct-303 [2148-12-15] 05:35AM BLOOD PT-20.8* PTT-29.3 INR(PT)-2.0* [2148-12-14] 06:55AM BLOOD Glucose-95 UreaN-15 Creat-0.9 Na-137 K-4.4 Cl-103 HCO3-26 AnGap-12 CHEST (PA & LAT) [2148-12-13] 12:54 PM INDICATION: Evaluation for pleural effusions. FINDINGS: The right hemidiaphragm is well-delineated, no pleural effusion. On the left side, a small pleural effusion is seen. Its height is around 2 cm in the dorsal regions of the sinus. Consecutive hypoinflation of the left suprabasal lung. The diameter of the cardiac silhouette is in the upper range of normal. No fluid overload, no pneumothorax. IMPRESSION: Small left-sided pleural effusion, no right-sided pleural effusion, no pneumothorax. Brief Hospital Course: He was taken to the operating room on [12-9] where he underwent an AVR, ascending aorta and hemiarch replacement. He was transferred to the ICU in stable condition. He awoke and was extubated later that same day. He was transferred to the floor on POD #1. Once on the floor he went into rapid atrial fibrillation, for which he was placed on amiodarone and coumadin. His lopressor was increased as much as tolerated. Chest tubes DC on POD # 2. Pacing wires DC on POD # 3. PT consult. On Dc NSR on amiodarone / coumadin (INR 2.0) on dc. PCP to [Name9 (PRE) 86284] INR as outpt. Medications on Admission: Asa 81', MVI, Omega 3 1200mg' 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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 3. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:50 Tablet(s) Refills:0 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Outpatient Lab Work Will need an INR check on [12-16] faxed to [First Name8 (NamePattern2) 2048] [Last Name (NamePattern1) ] at the office of Dr. [Last Name (STitle) 111575] at ([Telephone/Fax (1) 111576]. Their phone is ([Telephone/Fax (1) 111577]. 7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:30 Tablet(s) Refills:0 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO twice a day: take 400 [Hospital1 ] for one week, then 400 daily for one week, then 200 daily . Disp:60 Tablet(s) Refills:0 9. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO Q 8H (Every 8 Hours). Disp:135 Tablet(s) Refills:0 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:10 Tablet(s) Refills:0 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 10 days. Disp:20 Tab Sust.Rel. Particle/Crystal(s) Refills:0 12. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO ONCE (Once) for 1 doses: Take four mg (two tablets) on the night of discharge and then continue dosing as directed by Dr.[Name (NI) 111578] office. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: community health and hospice Discharge Diagnosis: bicuspid aortic valve & aortic stenosis, dilated ascending aorta now s/p AVR/ascending aortic replacement PMH: Hyperlipidemia, varicosities of right leg, hernia repair Discharge Condition: Good. Discharge Instructions: Call with fever, redness of drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds or driving until follow up with surgeon. [Last Name (NamePattern4) 2138]p Instructions: See Dr. [Last Name (STitle) 111575] on [2148-1-4] at 3:10 See Dr. [Last Name (STitle) ] 2 weeks. Please call to make an appointment. Dr. [Last Name (Prefixes) ] 4 weeks. Please call to make an appointment. Will need an INR check on [12-16] faxed to [First Name8 (NamePattern2) 2048] [Last Name (NamePattern1) ] at the office of Dr. [Last Name (STitle) 111575] at ([Telephone/Fax (1) 111576]. Their phone is ([Telephone/Fax (1) 111577]. Spoke to [First Name8 (NamePattern2) 2048] [Last Name (NamePattern1) ] on [2148-12-13] at 11:00 to confirm this plan. Completed by:[2148-12-15]	[ "424.1", "997.1", "427.31", "441.2", "746.4", "272.4", "454.9", "E878.1" ]	icd9cm	[ [ [] ] ]	[ "88.72", "35.21", "38.45", "39.61" ]	icd9pcs	[ [ [] ] ]	4271, 4330	1748, 2337	335, 397	4542, 4550	902, 1725		734, 752		2417, 4248		4351, 4521		2363, 2394			4574, 4826					4877, 5518						767, 883																								283, 297													425, 526																548, 648	664, 718
12,733	163,392	6447	Discharge summary	report	Admission Date: [2193-5-26] Discharge Date: [2193-6-15] Date of Birth: [2128-7-16] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 1253] Chief Complaint: left hand pain Major Surgical or Invasive Procedure: Transesophageal Echocardiogram Mechanical Intubation and Ventilation L wrist incision and drainage with pulse lavage washout and wick placement History of Present Illness: 65 yo M with PMH of ESRD on HD (MWF), CAD, PVD s/p R toe amputations and left BKA, DM, HTN here with left hand cellulitis. On Friday developed pain and swelling in his left hand in the morning. He placed a heating pad on his hand without improvement. Symptoms worsened with more significant pain. He began taking percocets that he had at home. He denied any fevers/chills but did develop blisters on 5th finger that he attributed to heating pad being too hot. He has significant neuropathy of both hands and feet. Given no improvement in symptoms, he presented to the ED. In the ED, VS: 98.7 80 128/62 18 96. Labs notable for WBC 13.6, lactate 1.6. Received dilaudid 2mg IV x 1. Evaluated by hand recommended splint and 1g Vanco.Blood cx sent and patient received 1g vancomycin. No acute surgical intervention. Tapped carpal joint for fluid but unable to aspirate any. Plastics felt joint unlikely to be infected. Did have fever in ED of 101.4 though he was asymptomatic. He received tylenol 1gram PO x 1. . On the floor, he is resting comfortable with adequate pain control. Past Medical History: * Cardiac - CAD s/p CABG [2171] (LIMA --> LAD, SVG --> OM). - NSTEMI in [6-26] s/p left main stent, PTCA x 2. - Nuclear stress test in [4-27] with reversible defects in the LAD and PDA territories. - stress [2190]: fixed defects in ant, lateral, inferior walls * CHF - H/o systolic and diastolic HR. Echo [12-29] showed EF 30-40% * PVD - s/p R transmetatarsal amputation in [2181] - right BKA - ischemic right foot s/p right iliofemoral endarterectomy with Dacron patch, right common iliac artery stent graft, right external iliac artery stent graft and a right SFA angioplasty x2 in [12-29] * DM. * HTN. * Hypercholestemia * ESRD on HD since [2188], [2-25] to DM2. [2-27] placement of L brachiocephalic fistula. * GIB [2-25] plavix * [Doctor Last Name 10834] 4 melanoma, s/p right shoulder resection in [2188-9-24], no recurrence Social History: Lives with alone in [Location (un) 4628]. 20 py smoking history but quit in [2187]. No EtOH. No IVDU. Dialysis M/W/F at [Location (un) ] Dialysis in [Location (un) ] (phone [Telephone/Fax (1) 5972], fax [Telephone/Fax (1) 10374]) Family History: CVA, CAD Physical Exam: On admission: VS: T 99, BP 116/56, HR 91, RR 18, 96RA, FS 337 GEN: WDWN man sitting up in bed, conversant HEENT: EOMI, PERRL, anicteric NECK: supple CHEST: CTABL, no w/r/r; good air movement CV: RRR, S1S2, no audible murmurs ABD: Soft/obese/NT EXT: L BKA, R foot all 5 toes s/p amputation; edema 1+ RLE SKIN: hemorrhagic bullae on Left fifth finger; splint in place NEURO: AAO x 3, CN ii- Xii intact, no focal deficits Upon discharge: GEN: NAD, patient with difficulty sitting up on his own HEENT: PERRL, patient with difficulty with smooth pursuit during EOM testing, but has full range of EOM, anicteric NECK: supple, no [Doctor First Name ] CHEST: CTAB with good air movement CARD: RR, nl S1, nl S2, no M/R/G ABD: obese, BS+, soft, NT, slightly distended and tympanitic EXT: L BKA, R foot with toe amputations, L wrist with open wound that is packed with gauze, wound appears to have yellow granulation tissue, L wrist is without odor, large sacral tissue injury with black eschar covering SKIN: Multiple hemorrhagic bullae on bilateral upper extremity digits NEURO: Oriented to location, some confusion of date, though eventually reports "[2193-5-24]", has no recollection of presenting complaint or events of hospitalization Pertinent Results: TTE (Complete) Done [2193-5-30]: Conclusions: There is severe global left ventricular hypokinesis (LVEF = 20 %). with severe global free wall hypokinesis. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. CT PELVIS W&W/O C Study Date of [2193-6-1]: IMPRESSION: No identification of skin or subcutaneous lesions at the level of the coccyx that could suggest pilonidal cyst. LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of [2193-6-2]: IMPRESSION: 1. Grossly normal hepatic echotexture without evidence of hepatic abscess. 2. Cholelithiasis without other secondary signs to suggest cholecystitis. Portable TTE (Complete) Done [2193-6-3] at 4:44:59 PM: Conclusions There is severe global left ventricular hypokinesis (LVEF = 20 %). No thrombus is seen, but apical images are suboptimal. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. MR HEAD W/O CONTRAST Study Date of [2193-6-4]: IMPRESSION: 1. Acute infarctions of different ages with punctate infarctions in the left centrum semiovale and corona radiata of more recent occurence than larger infarction within the left posterior occipital lobe; the overall pattern is suggestive of embolic events from a central source, likely related to recent cardiac surgery. 2. No specific evidence of hypoxemic-ischemic injury related to cardiac arrest. 3. MRA significantly limited by motion artifact. Apparent globally decreased flow is demonstrated within the intracranial left carotid artery; given limitations of study, findings suggest more proximal ("inflow") stenosis in the neck, and CTA of the cervical vessels may be obtained for further evaluation, when feasible. 4. Fenestration of the proximal basilar artery. CAROTID SERIES COMPLETE Study Date of [2193-6-5]: Left ICA stenosis 80-99%. CT PELVIS W/CONTRAST Study Date of [2193-6-5]: CT PELVIS: There is no skin or subcutaneous lesion or tract identified at the level of the coccyx to suggest a pilonidal cyst. Mild edema is noted in the soft tissues, likely due to third spacing of fluid. The presacral space is normal. The rectum contains a flexi- seal rectal catheter. There is no free fluid or free air. The [Date Range 1106] stent is again seen in the right iliac artery. There is dense atherosclerotic calcification of the visualized vessels. TEE (Complete) Done [2193-6-6]: Conclusions No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is severely depressed (LVEF= 20-25 %). Right ventricular chamber size and free wall motion are normal. 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 masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. MR HEAD W/O CONTRAST Study Date of [2193-6-11]: IMPRESSION: Multiple foci of restricted diffusion identified on the left cerebral hemisphere and left occipital region which appear more onspicuous on the corresponding FLAIR sequence, indicating subacute stage. New foci of restricted diffusion identified under the right frontal lobe (202:17). There is no evidence of acute intracranial hemorrhage or hydrocephalus. AVF/DUPLEX HEMO/DIAL ACCESS Study Date of [2193-6-12]: IMPRESSION: Patent left upper extremity AV fistula for dialysis, no evidence of intraluminal thrombus. CT LUMBAR W&W/O CONTRAST Study Date of [2193-6-14]: PRELIMINARY READ No epidural spinal abscess seen. PERTINENT HEMATOLOGY: [2193-5-26] 08:50PM WBC 13.6 HCT 41.1 PLT 125 [2193-6-6] 05:20AM WBC 32.4 HCT 32.6 PLT 192 [2193-6-15] 05:18AM WBC 9.0 HCT 29.3 PLT 184 PERTINENT CHEMISTRY: [2193-6-1] 04:36AM ALT 881 AST 806 CK(CPK) 7842 AlkPhos 248 TBili 1.1 [2193-6-10] 06:20AM CRP 75.9 [2193-6-15] 05:18AM ALT 52 AST 43 LD(LDH) 269 CK(CPK) 127 AlkPhos 270 TotBili 1.0 MICROBIOLOGY: [2193-6-14] BLOOD CULTURE Blood Culture, Routine-PENDING [2193-6-11] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE-PRELIMINARY; BLOOD/AFB CULTURE-PRELIMINARY INPATIENT [2193-6-10] BLOOD CULTURE Blood Culture, Routine-PENDING [2193-6-8] BLOOD CULTURE Blood Culture, Routine-FINAL [2193-6-7] BLOOD CULTURE Blood Culture, Routine-FINAL [2193-6-7] BLOOD CULTURE Blood Culture, Routine-FINAL [2193-6-5] BLOOD CULTURE Blood Culture, Routine-FINAL [2193-6-5] BLOOD CULTURE Blood Culture, Routine-FINAL [2193-6-4] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL [2193-6-3] BLOOD CULTURE Blood Culture, Routine-FINAL [2193-6-2] BLOOD CULTURE Blood Culture, Routine-FINAL [2193-6-2] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL [2193-6-1] SWAB GRAM STAIN-FINAL; WOUND CULTURE-FINAL {STAPH AUREUS COAG +}; ANAEROBIC CULTURE-FINAL {BACTEROIDES FRAGILIS GROUP} [2193-6-1] BLOOD CULTURE Blood Culture, Routine-FINAL [2193-6-1] BLOOD CULTURE Blood Culture, Routine-FINAL [2193-5-31] BLOOD CULTURE Blood Culture, Routine-FINAL [2193-5-31] BLOOD CULTURE Blood Culture, Routine-FINAL [2193-5-30] BLOOD CULTURE Blood Culture, Routine-FINAL {[Female First Name (un) ] PARAPSILOSIS}; Aerobic Bottle Gram Stain-FINAL [2193-5-29] SWAB GRAM STAIN-FINAL; WOUND CULTURE-FINAL {PASTEURELLA MULTOCIDA}; ANAEROBIC CULTURE-FINAL [2193-5-29] BLOOD CULTURE Blood Culture, Routine-FINAL {PASTEURELLA MULTOCIDA, PASTEURELLA MULTOCIDA}; Anaerobic Bottle Gram Stain-FINAL; Aerobic Bottle Gram Stain-FINAL [2193-5-29] BLOOD CULTURE Blood Culture, Routine-FINAL {PASTEURELLA MULTOCIDA}; Aerobic Bottle Gram Stain-FINAL; Anaerobic Bottle Gram Stain-FINAL SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PASTEURELLA MULTOCIDA AMPICILLIN------------ S CEFTRIAXONE----------- S LEVOFLOXACIN---------- S TRIMETHOPRIM/SULFA---- S [2193-5-28] BLOOD CULTURE Blood Culture, Routine-FINAL [2193-5-27] MRSA SCREEN MRSA SCREEN-FINAL [2193-5-27] BLOOD CULTURE Blood Culture, Routine-FINAL [2193-5-26] BLOOD CULTURE Blood Culture, Routine-FINAL [2193-5-26] BLOOD CULTURE Blood Culture, Routine-FINAL Brief Hospital Course: # PEA arrest: In the OR for wrist wash-out on [2193-5-29], the patient became hypoxic, then bradycardic, hypotensive and went into asystole. Per anesthesia record, an attempt was made to palce an LMA. He was ultimately intubated and then 20-30 min later developed PEA. There was a question of difficultly placing the LMA. The patient received chest compressions but no defibrillation. In addition, he was given epinephrine and atrophine. His heart rate and BP improved. It was then decided, that since he had stabalized, to continue with the wash-out. Gross pus was drained from his wrist and a wick left in place. In the PACU, he then became hypoxic and bradycardic once again, code blue was called. His blood pressure and HR recovered with an epinephrine and phenylephrine drip. Per the plastics attending a quick echo in the OR, showed biventricular dysfunction. An EKG was performed post-op with ST changes that were unchanged from prior. He received dilauded in the PACU for pain. He received Midazolam, vecuronium, sevoflurane, esmolol, metoprolol, ephedrine, epinephrine, atropine, phenelephrine and propofol by anesthesia in the OR. He was transferred to the MICU following the arrest. He was closely monitored on telemetry for two weeks following the PEA arrest with no further concerning events prior to discharge. # Stroke: After transfer out of the MICU, patient was noted to have difficulty with visual acuity as well as short term memory deficit and confusion about events surrounding hospitalization. On [6-4] an MRI was obtained and showed concern for acute left occiptal lobe and left basal ganglia infarct. Neurology was consulted and followed case throughout hospital course. Carotid dopplers on [6-5] revealed a 80-99% stenosis of left ICA. [Month/Year (2) ] surgery was consulted and recommended outpatient follow-up. TEE was obtained on [6-6] and showed no concern for valvular vegetations. Repeat MRI on [6-11] showed concern for new right frontal lobe infarct. LUE ultrasound was obtained on [6-12] and was negative for AV fistula thrombus. As patient was clinically improving from standpoint of memory and subjective visual acuity, further work-up of acute stroke was deffered to outpatient setting. Patient will be maintained on aspirin and clopidogrel as he was previously taking. He has a follow-up appointment with [Month/Year (2) 1106] surgery on [2193-7-23], at this time they may choose to address the left ICA stenosis. # Lower extremity weakness: Toward end of hospitalization patient began to complain of lower extremity weakness. Neuro exam of lower extremities revealed symmetric 5/5 strength. Despite this, given his history of bacteremia, a CT lumbar spine was obtained on night of [2193-6-14] to attempt to rule out a spinal epidural abscess. At time of discharge preliminary read of CT was that there was no evidence of spinal process to explain patient's subjective LE weakness. Sense of weakness likley related to prolonged hospitalization causing deconditioning. Likely to benefit from physical therapy and occupational therapy following discharge. # CK elevation: Labs just after PEA arrest with CK 74. This rose to 385 nine hours later. Several hours later his CK then peaked at [Numeric Identifier 24799]. His troponin was also positive immediately post PEA arrest, peaking at 0.8, but MBI remained low at 0.2. It was thought that the troponin elevation was due to CPR but could also represent cardiac ischemia. The patient was intially seen by cardiology who did not think he had had a primary cardiac event. ECHO did show biventricular depressed EF, new from prior. However, his CK were disproportionately elevated relative to troponin. He was evaluated for muscular causes of elevation: No sign of compartment syndrome. No neuroleptics or SSRI's given; anesthesia did not think anesthetics would have caused this. Rhabdo for inactivity was unlikely as pt was actually agitiated and moving around frequently. There was no documented seizure activity in the OR. His CK elevation was eventually was solely attributed to hypotension in setting of PEA arrest on [2193-5-29]. His CK trended down to 127 on [2193-6-15], the morning of discharge. # Septic arthritis: Hand surgery saw the pt in the ED but was unable to aspirate any fluid on a tap. He was placed on Vancomycin. Originally, plastics felt that the joint was unlikely to be infected; however, as his pain escalated, he was taken to the OR for a wash-out on [2193-5-29]. In the OR, he had PEA arrest during anesthesia induction (see above). Intra-op wound culture returned as pasteurella (levofloxacin sensitive). Later, blood culture from [5-29] returned as containing pasteurella (also levofloxacin sensitive). Due to patient's penicillin allergy, he was initially on aztreonam for the gram negative bacteremia; however, when final sensitivities revealed levofloxacin sensitivity, the patient was switched to levofloxacin. He had a leukocytosis up to WBC count of 32K; however, this trended down several days after initiation of levofloxacin therapy. Patient's final recommended antibiotic course is to receive Vancomycin IV as well as Moxifloxacin IV until follow-up in [Hospital ] clinic on [2193-7-11]. Further decision about total antibiotic course will be made at this ID follow-up appointment. Patient should receive ongoing betadine soaks of left wrist as well as wet to dry gauze [Year (4 digits) ] to left wrist three times daily until further recommendations to be made in follow-up with plastic surgery had clinic within 2-4 weeks following discharge from the hospital. # Yeast bacteremia: Grew 1/2 bottles yeast through a-line on [2193-5-30] that later speciated as [Female First Name (un) ] parapsilosis. He was initially started on Micafungin upon receiving positive culture result; however, was switched to fluconazole upon learning that the yeast was [Female First Name (un) ] parapsilosis. Transthoracic ECHO (TTE) a day after PEA arrest showed no vegetations. TTE was repeated on [2193-6-3] with note of globally reduced LV systolic function with depressed EF to 20%. Again, no vegetations were noted. After new stroke was noted on MRI imaging on [6-4], concern was again raised for [Female First Name (un) ] endocarditis and a transesophageal ECHO was performed on [6-6] and noted no vegetations on aortic or mitral valve. LVEF was still depressed to ~20% at that time. Thoughout hospitalization, surveillance blood cultures were drawn and following the [2193-5-30] culture positive for [Female First Name (un) ], there were 14 negative blood cultures drawn up until time of discharge. Patient is scheduled to complete course of fluconazole (200 mg IV Q48H) on [2193-6-22]. # Visual changes: Patient complained of some blurry vision and poor visual acuity following transfer out of the MICU. Patient had ophthalmologic evaluation to rule out candidal endophthalmitis and was found to have no concern for endophthalmitis; however, poor visual acutity and diabetic proliferative changes were noted. MRI on [6-4] noted a left occiptal lobe stroke. Was recommended that he follow-up in ophthalmology clinic following discharge for visual field testing s/p occipital lobe stroke as well managment of diabetic retinopathy. # Sacral hematoma: In the MICU, the patient c/o exquisite pain to sacrum and was unable to lie on his back. General surgery was consulted. Given hx pilonidal cysts and concern for surrounding erythema, it was thought initially that he had a pilonidal cyst with cellultis. In addition, there was a concern for abcess or fasciitis with elevate CK and pain out of proportion to exam. The patient was restarted on Vanc (hx MRSA) and Flagyl (anearobic coverage). CT pelvis with contrast on [6-1] showed no concern for abscess. The attending surgeon unroofed the "cyst" and determined that is was a hematoma overlying a sacral decubitous ulcer. As the patient's sacral wound continued to look worse through the hospitalization and as WBC count conttinued to rise, a repeat CT pevlis was obtained on [6-5] and again there was no concern for abscess or sinus tract associated with sacral deep tissue injury. Wound care nursing consult as well as plastic surgery team were involved in care for the sacral wound. No debridement of sacral wound was needed through hospitalization. On [2193-6-14] (day prior to discharge) plastic surgery came by for final evaluation and reported that the wound had "a large stable eschar overlying it that is dry without drainage." Recommendation was for patient to be OOB as tolerated with aggressive decubitus pressure relief as well as ongoing wound care with daily "Critic Aid Clear Moisture Barrier Ointment to perianal tissue" as well as follow-up in outpatient plastic surgery clinic in [7-1] weeks following discharge from hospital. # Diabetes Mellitus: Patient was maintained with reasonable glycemic control, most values in mid-100s on modification and adjustment of home [Hospital1 ] NPH dosing. At discharge patient was receiving 22 units NPH at breakfast and 12 units NPH at dinner as well as humalog sliding scale insulin. Medications on Admission: Plavix 75 mg PO daily Zemplar 1 mc cap given at HD Protonix 40 mg PO daily Humulin 70/30 40U [Hospital1 ] Sensipar 30 mg PO daily ASA 81 PO daily Renal camp 1 mg PO daily Fosrenol 200 mg PO daily Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Lanthanum 500 mg Tablet, Chewable Sig: Three (3) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 13. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 14. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous HD PROTOCOL (HD Protochol): Please continue until ID outpatient appointment on [2193-7-11]. 15. Fluconazole in Saline(Iso-osm) 200 mg/100 mL Piggyback Sig: One (1) Intravenous Q48H (every 48 hours): Please dose after HD on HD days. Last dose on [2193-6-22]. Duration - [Date range (1) 24800] . 16. Moxifloxacin in Saline 400 mg/250 mL Piggyback Sig: One (1) Intravenous once a day: Please continue until ID outpatient appointment on [2193-7-11]. 17. Outpatient Lab Work Please check weekly: CBC/diff, chem 7, LFTs, ESR/CRP, vancomycin trough. All laboratory results should be faxed to Infectious disease R.Ns. at ([Telephone/Fax (1) 6313] 18. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 19. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 20. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 21. Sodium Chloride 0.9 % 0.9 % Syringe Sig: Three (3) ML Injection Q8H (every 8 hours) as needed for line flush. 22. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty Two (22) units Subcutaneous QAM. 23. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twelve (12) Units Subcutaneous QPM. 24. Insulin Lispro 100 unit/mL Solution Sig: One (1) Unit Subcutaneous four times a day: Per sliding scale. See attached. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Primary: 1. Pasteurella multocida left wrist septic arthritis 2. Pasteurella multocida septicemia 3. [Female First Name (un) 564] parapsilosis fungemia 4. Sacral decubitus ulcer 5. Cerebrovascular accident 6. PEA cardiac arrest Discharge Condition: Stable, afebrile, vital signs stable Discharge Instructions: You were admitted with a infection of your left wrist. You underwent a surgical drainage of your wrist to treat the infection. During the procedure you suffered a cardiac arrest and briefly required intbuation and blood pressure support. You are continuing on a course of antibiotics to treat your wrist and bloodstream infection. You will remain on Vancomycin and Moxifloxacin until you are seen in Infectious disease clinic on [7-11]. You will need to follow up with plastic surgery and continue your daily wound care as directed. . You also developed a fungal infection in your blood and are being treated with fluconazole to complete a 2 week course on [2193-6-22]. . As a complication of your low blood pressure related to your arrest, you developed a large pressure ulcer on your sacrum. You will remain on antibiotics as listed above. Also, you will require continued wound care of this area. . Also related to your infection and low blood pressure you have suffered a stroke. You were evaluated by neurology and recommended to continue aspirin and plavix for life. . Your heart has a decreased pumping ability after your cardiac arrest. You will need to weight yourself daily and call a physician if you gain for than 3 pounds as this may be a sign of worsening heart failure. You should continue your metoprolol and lisinopril. You should continue your hemodialysis as scheduled. . Please return or call your physician if you notice a worsening of your wrist and decubitous ulcer. You should also return if you develop fever, chest pain or shortness of breath. Followup Instructions: Please follow up in Infectious Disease Clinic as listed: Provider: [First Name4 (NamePattern1) 8495] [Last Name (NamePattern1) 8496], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2193-7-11] 10:00. All questions regarding your outpatient antibiotics should be directed to the infectious is closed. You will need weekly safety labs sent to the [Hospital ] clinic as listed in your discharge plan. You will need ophthalmology follow-up at the retina clinic within 2 weeks of discharge for visual field testing as well as evaluation of diabetic retinopathy. Please call [Telephone/Fax (1) 253] to schedule an appointment. Please follow up with Plastic Surgery in Hand Clinic in [4-29] weeks. Please call [Telephone/Fax (1) 4652] to schedule an appointment. Please follow-up with plastic surgery clinic in [7-1] weeks for interval evaluation of sacral wounds. Please call [Telephone/Fax (1) 4652] to arrange appointment. [Telephone/Fax (1) ] surgery: [Last Name (LF) ],[First Name3 (LF) ] D. Phone:[Telephone/Fax (1) 1237] Date/Time: [2193-7-23] 10:15 for studies prior to appointment Location: LM [Hospital Unit Name ], [Location (un) ] [Location (un) ] SURGERY (SB) Completed by:[2193-6-15]	[ "433.10", "443.9", "V49.75", "V10.82", "997.69", "682.2", "250.80", "250.50", "412", "V58.67", "707.23", "362.01", "570", "285.21", "428.42", "707.03", "E924.8", "682.4", "434.91", "112.5", "428.0", "944.21", "585.6", "997.02", "V45.81", "711.03", "027.2", "996.62", "427.5" ]	icd9cm	[ [ [] ] ]	[ "88.72", "39.95", "80.13", "99.60", "38.91", "38.93", "86.28" ]	icd9pcs	[ [ [] ] ]	22701, 22780	10558, 19804	287, 433	23056, 23095	4021, 10535	24721, 25991	2735, 2746		20055, 22678		22801, 23035		19830, 20032			23119, 24698											2761, 2761																								233, 249												3197, 4002	461, 1539								2775, 3181								1561, 2447	2463, 2719
27,131	175,093	34390	Discharge summary	report	Admission Date: [2146-8-30] Discharge Date: [2146-9-9] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2597] Chief Complaint: Ischemic ulcer of the right foot Major Surgical or Invasive Procedure: [8-30]: Rt CFA-Peroneal with NRSVG, profunda/SFA EA [9-5]: Cardiac catheterization with bare metal stent to the RCA complicated by L groin hematoma [9-5]: Ex1. Left groin exploration. 2. Repair of left iliac vein bleed and left external iliac artery bleed. 3. Evacuation of retroperitoneal hematoma. History of Present Illness: The patient is an 89-year-old gentleman has severe ischemic rest pain and nonhealing ischemic ulcers of his right foot. Arteriography showed him to be a poor candidate for endovascular treatment; his common femoral artery was heavily calcified with a high-grade calcific plaque at the origin of the profunda femoris artery and essential total occlusion of all vessels down to the level of the mid peroneal artery which was his best runoff vessel distally. For these reasons he was admitted to [Hospital1 18] with planned bypass graft in the right leg. Past Medical History: PVD with non-healing ulcers of R foot HTN Colon CA s/p colectomy Carotid stenosis-chronic 100% occlusion L carotid AFib CRI with baseline creatinine 2.0 Chronic macrocytic anemia [Male First Name (un) 4746] disease by CT PSH: TURBT, s/p R CEA Social History: Lives alone, his wife died a few years ago. Served in WWII. Has family nearby. Family History: N/C Physical Exam: Upon discharge A and O NAD VSS PERRL, moist mucus membranes, no JVD RRR + systolic murmur nl S1 S2 CTAB soft slight TTP at L inguinal region extensive ecchymoses at R and L flanks abdominal staples along LLQ; incision c/d/i R groin incision c/d/i R LE + pitting edema, + incision c/d/i; open staples at proximal thigh L LE no c/c/e Pulses: L DP neither palpable nor dopplerable, L PT dopplerable; R DP and PT dopplerable Pertinent Results: [2146-9-8] 05:10PM BLOOD Hct-32.0* [2146-9-7] 10:49AM BLOOD WBC-11.4* RBC-3.16* Hgb-10.1* Hct-28.2* MCV-89 MCH-32.0 MCHC-35.9* RDW-14.6 Plt Ct-224 [2146-9-1] 06:00AM BLOOD WBC-13.5* RBC-2.61* Hgb-8.6* Hct-25.4* MCV-97 MCH-33.1* MCHC-34.0 RDW-13.4 Plt Ct-296 [2146-8-30] 02:05PM BLOOD WBC-12.4* RBC-2.69* Hgb-8.7* Hct-25.7* MCV-96 MCH-32.5* MCHC-34.1 RDW-13.1 Plt Ct-323 [2146-9-7] 10:49AM BLOOD Glucose-124* UreaN-25* Creat-1.2 Na-141 K-3.9 Cl-109* HCO3-27 AnGap-9 [2146-8-30] 02:05PM BLOOD Glucose-127* UreaN-26* Creat-1.5* Na-143 K-5.1 Cl-114* HCO3-21* AnGap-13 [2146-9-7] 10:49AM BLOOD Calcium-7.4* Phos-2.4* Mg-2.0 Brief Hospital Course: The patient is an 89 yo male who was admitted for scheduled angiography and intervention. The patient was admitted to Vascular surgery/Dr. [Last Name (STitle) ] on [2146-8-30], taken to angio suite and inderwent successful Rt CFA-Peroneal with NRSVG, profunda/SFA EA. The patient recovered in PACU then transferred to [Hospital Ward Name 121] 5 for further observation. On routine post-op check patient was noted to have cold L lower extremity(non-intervention leg) and no DP pulse, but no complaints of pain. POD1 [2146-8-31] No acute events, L foot is now warm with [Last Name (un) ] DP pulse. Routine nursing care, lines discontinued. LENI- showed significant L iliac, SFA and tibial disease. POD2 [2146-9-1] Patient complained of chest pain, EKG was done that showed ST depression throughout the precordium. Cardiac enzymes were cycled, initial Troponin .04; repeat 0.15. His hct was noted to be 25.4, down from 28.2 on admission. The patient most likely suffered demand ischemia in setting of postoperative acute blood loss anemia, with his symptoms, ECG changes, and enzyme changes consistent with NSTEMI. Transfused with 2 units PRBC's with Lasix in between. Cardiology consulted. POD3 [2146-9-2]: cardiac Echo: Efx 55%, elongated LA, dilated RA, mild regional systolic LV dysfunction, mild-moderate MR, thickened Ao, Mitral, TC valve leaflets. Cards plan for cardiac cath on Monday [2146-9-5], to give Mucomyst night prior to procedure. POD4 [2146-9-3] Transfused with 1 unit PRBC. POD5 [2146-9-4] Pre-oped for cardiac cath. POD6 [2146-9-5] Cardiac catheterization: The patient successfully underwent cardiac catheterization, which revealed 90% occlusion in RCA s/p bare metal stent, 70% occlusion in distal left main, no intervention done. Left groin hematoma s/p exploration, evacuation, left external iliac arteriotomy and L iliac venotomy: Unfortunately the patient became hypotensive to SBP 60s and a large groin hematoma was noted while the groin sheath was being pulled by cardiology in the catherization area. The patient was intermittently placed on dopamine, then vascular surgery was called, and the patient was given IVF, and 2 units of packed RBC with pressure held to the groin with his SBP returning to the 150s. His blood pressure began to drop again, however, to the 70s systolic, and so he was taken emergently to the operating room on [9-5] under general anesthesia for L groin exploration that revealed a bleeding L external iliac artery, L iliac vein, both of which were sutured. The hematoma was evacuated. A JP drain was left in place and the patient was extubated and returned to the CCU, and then to the floor. He did receive 2 units of blood intraoperatively and then 1 unit following the surgery, but his hematocrit remained stable at 28-29. He remained hemodynamically stable postoperatively and thereafter. A Foley catheter was placed on [9-5] when the patient returned to the operating room. Two staples were removed in the upper thigh on the right with concern for infection but there was no drainage. The slight redness is thought to be secondary to scrotal irritation. The patient was then seen by physical therapy, who recommended short term rehab. The remainder of his stay was uneventful, and he is being discharged today in stable condition. Medications on Admission: LISINOPRIL 10', LOVASTATIN 20', METOPROLOL TARTRATE 50', NIFEDICAL XL 60', QUININE SULFATE 324', TRIAZOLAM .25', ASA 81' Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime as needed. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. 9. Triazolam 0.25 mg Tablet Sig: One (1) Tablet PO qhs () as needed. 10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 14. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO at bedtime. Discharge Disposition: Extended Care Facility: [Hospital3 7665] Discharge Diagnosis: PVD with non-healing ulcers of R foot, ischemic L leg HTN Carotid stenosis-chronic 100% occlusion L carotid AFib CRI with baseline creatinine 2.0 Chronic macrocytic anemia [Male First Name (un) 4746] disease by CT PSH: TURBT, s/p R CEA, Colon CA s/p colectomy Discharge Condition: Weak but stable Discharge Instructions: 1. The upper thigh wound may be covered with a dry sterile gauze as needed 2. The patient is being discharged with a leg bag and Foley catheter. He is s/p TURP and you may attempt to d/c the Foley again. He needs follow up with his primary care physician. Division of Vascular and Endovascular Surgery Lower Extremity Bypass Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use [2-13] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: 1. Follow up with your cardiologist, Dr. [Last Name (STitle) ]: Phone:([Telephone/Fax (1) 30479] 3:30 pm [9-21] 2. Follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Phone:[Telephone/Fax (1) 79097] This is very important because you need follow up for your prostate and difficulties urinating as well as your other medical problems. 3. Follow up with Dr [Last Name (STitle) ] on [2146-9-22] 12:50 pm and [2146-9-26] at 11:10 am; phone: [Telephone/Fax (1) 1237] for your vascular surgery. Completed by:[2146-9-9]	[ "285.1", "998.12", "998.11", "403.90", "414.01", "440.23", "V10.05", "427.31", "410.71", "707.15", "585.9" ]	icd9cm	[ [ [] ] ]	[ "88.56", "39.31", "39.29", "00.66", "38.18", "37.23", "00.45", "00.40", "54.0", "36.06" ]	icd9pcs	[ [ [] ] ]	7445, 7492	2720, 6085	293, 614	7801, 7819	2049, 2697	10923, 11515	1585, 1590		6257, 7422		7513, 7780		6112, 6234			7843, 10491	10517, 10900										1605, 2030																								221, 255													642, 1200																1222, 1472	1488, 1569
64,245	130,097	54272	Discharge summary	report	Admission Date: [2186-8-28] Discharge Date: [2186-9-3] Date of Birth: [2118-10-29] Sex: F Service: MEDICINE Allergies: Metformin Attending:[First Name3 (LF) 4760] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [Known lastname ] is a 67 year old female with multiple medical problems including COPD on 2L home O2 and diastolic CHF, CAD s/p stents, DM, HTN, PVD s/p b/l amputations and now with 4 days of increased sleepiness, SOB, and orthopnea. She notes that she has been feeling more fatigued and sleepy associated with increased swelling of stumps of LE. She denies chills, fevers, chest pain, cough, increased sputum production, sick contacts, nausea, vomiting, or diarrhea. She denies medication non-compliance, although notes her PCP recently decreased her lasix to just in am. She also reports her diet has been stable. . In the ED, initial vitals were T: 98.6 BP: 167/65 HR: RR:26 O2 sat: 100% on 2L. Patient noted to have decreased breath sounds at bases bilaterally, crackles and pitting edema of L stump. Groin - erythematous, likely candidal infection being treated with Vagisil. Given 80mg IV lasix x1 with good output 300cc, duonebs, and solumedrol 125mg IV x1. ABG was obtained 7.43/67/103 with HCO3 stable at 41. Her BNP was elevated at 1309, CEs negative x1. . Of note, patient recently admitted and discharged for GI bleed, found to GAVE s/p Argon plasm coagulation [7-21]. Hematocrit has been trending up since that discharge. . 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: Diabetes Dyslipidemia Hypertension CAD s/p Drug eluting stent to mid RCA & angioplasty to distal RCA Diastolic Heart Failure EF 60% PVD s/p b/l lower extremity amputation(R BKA & L AKA) ?CVA vs. TIA h/o depression COPD with FEV1 45%, FEV1/FVC 82%, TLC 81%, on 2L home O2 Gastric antral vascular ectasia, treated by argon plasma coagulation (APC) [7-21] Social History: No current tobacco use, quit ~5 yrs ago after 100 pack-year history. Denies ETOH. Lives with daughter who is primary care giver. Family History: diabetes, heart disease & HTN. Mother died of an MI, age unknown. Physical Exam: Vitals: T: BP:130/44 HR:92 RR:22 O2Sat: 97% on 2.5L NC GEN: obese female, mildly tachypnic, able to speak in full sentences HEENT: EOMI, PERRL, sclera anicteric, mild injection of conj b/l, no epistaxis or rhinorrhea, MMM, OP Clear NECK: unable to assess JVD [1-14] neck girth, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, HS distant, no M/G/R appreciated, normal S1 S2, radial/dorsalis pedis pulses +2 PULM: bibasilar rales, no W/rhonchi, fair air movement, no prolongation of expiratory phase ABD: Obese, Soft, NT, ND, +BS, no HSM, no masses, no hepatojugular reflux EXT: +1 right BKA edema, trace on left. No cyanosis. 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. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [2186-8-28] 03:11PM PLT COUNT-219 [2186-8-28] 03:11PM NEUTS-76.6* LYMPHS-13.5* MONOS-5.0 EOS-4.3* BASOS-0.6 [2186-8-28] 03:11PM WBC-6.2 RBC-3.60* HGB-9.1* HCT-31.5* MCV-87 MCH-25.2* MCHC-28.8* RDW-15.8* [2186-8-28] 03:11PM CK-MB-NotDone cTropnT-<0.01 proBNP-1309* [2186-8-28] 03:11PM CK(CPK)-52 [2186-8-28] 03:11PM estGFR-Using this [2186-8-28] 03:11PM GLUCOSE-84 UREA N-15 CREAT-0.6 SODIUM-141 POTASSIUM-4.5 CHLORIDE-95* TOTAL CO2-41* ANION GAP-10 [2186-8-28] 05:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [2186-8-28] 05:00PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.009 [2186-8-28] 05:00PM URINE GR HOLD-HOLD [2186-8-28] 05:00PM URINE HOURS-RANDOM [2186-8-28] 05:09PM PO2-103 PCO2-67* PH-7.43 TOTAL CO2-46* BASE XS-17 [2186-8-28] 08:48PM TYPE-[Last Name (un) ] PO2-34* PCO2-87* PH-7.33* TOTAL CO2-48* BASE XS-14 INTUBATED-NOT INTUBA [2186-8-28] CXR - IMPRESSION: Unchanged cardiomegaly, with mild interstitial edema. Post- surgical changes as previously seen. Brief Hospital Course: This is a 67 year old female with multiple medical problems including COPD on 2L home O2 and diastolic CHF, CAD s/p stents, DM, HTN, PVD s/p b/l amputations, presenting with 4 days of increased sleepiness, SOB, and orthopnea. She was initially admitted to the ICU given ABG of 7.43/67/103 (prior ABG in past had shown CO2 of 40s, but last one had been in [2181]). Initial O2 sat was 100% on 2L NC. . # CHF Exacerbation, acute on chronic diastolic EF 60%: Exacerbating factors could have been poorly controlled HTN as well as recent decrease in lasix. The patient reports compliance with taking her lasix and eating a low salt diet. The patient had 2 negative sets of cardiac enzymes and her EKG was at her baseline. Chest xray showed no acute change. Her initial SBP on admission was elevated in the 160s. She received IV lasix 80mg IV in ED with 800cc urine response, and additional 40mg IV on admission to the ICU with negative fluid balance of 1.4L. She had been satting 100% on 2L upon admission to the ICU. She was also started on CPAP at night in the ICU given concern that OSA could be worsening her heart failure. She was called out of the unit the following day. She was continued on Lasix 40 mg IV twice daily for another 2 days on the floor. She was fluid restricted to 1.2 L a day, and she was continued on her lisinopril, statin, and imdur. Her metoprolol was titrated up to 37.5 mg three times a day for improved blood pressure control. On HD 4, the pts bicarb was 41, and she felt dizzy with nausea. She was felt to be adequately, and likely over, diuresed. Her IV diuresis was discontinued, and she was restarted just on Lasix 80 mg daily oral. This however was stopped after the patient became hypotensive as per below. Her Lasix will be held until follow up with her PCP. . # Hypotension: The patient became hypotensive to the 90s with dizziness and nausea/vomiting on [8-31]. This was felt to be due to overdiuresis. There is some question as to dietary and medication compliance as the patients fingersticks also dropped on her home lantus regimen and her blood pressure dropped with her home blood pressure regimen. Alternatively, it is also very possible that her new CPAP regimen at night has been drastically improving her blood pressure and fluid status. All of her blood pressure medications and lasix were held on [9-1]. She was gently rehydrated with IVF and her SBP rose up to 130s. On the day of discharge, the pts SBP was in the 90s to low 100s (asymptomatic) and it was decided to decrease the pts lisinopril to 10 mg daily and hold her lasix until follow up with her PCP. . # COPD: No evidence of exacerbation. Patient appears at baseline HCO3, O2 requirement. Received IV solumedrol 125mg in ED, further steroids were held. She was continued on tiotropium, albuterol prn. Salmeterol was started as the pt often had mild wheezing on exam. A follow up appointment with a new pulmonary doctor was made, as her last PFTs were in [2180]. . # Groin Rash: This appeared fungal. She was treated with 3 days of oral fluconazole as she had failed topical treatments. . # Diabetes Mellitus, insulin dependent, controlled, without complications: The patients fingersticks in the ICU were in the 300s, but she had not been given her lantus. On the floor her fingersticks dropped to the 50s-70s on her home regimen of lantus 64 units QHs, humalog SS. She was seen by [Last Name (un) ] and it was recommended to decrease her lantus to 58 U at night. Her fingersticks were still low, so her final regimen was adjusted to Lantus 48 U at night with humalog sliding scale. She was given a copy of the sliding humalog scale used in house. . # Dyslipidemia: Continued atorvastatin at home regimen. . # Hypertension: Patient on ACE, BB at home. As per above, these were held when she became hypotensive and restarted at discharge (with her lisinopril cut in half). . # GAVE: Patient is s/p recent admission for GI bleeding found to have GAVE. She was treated by argon plasma coagulation (APC). Hematocrit on admission was improved from discharge. She was continued on PPI and is scheduled for repeat APC as outpt. Medications on Admission: Albuterol Sulfate neb Q6H as needed. Atorvastatin 10 mg PO DAILY Calcium Carbonate 500 mg PO TID Tiotropium Bromide 18 mcg DAILY Zolpidem 5 mg PO HS Acetaminophen-Codeine 300-30 mg 1-2 Tablets PO Q6H as needed. Ferrous Sulfate 325 mg PO BID Nitroglycerin 0.4 mg Sublingual Sublingual PRN Omeprazole 20 mg PO BID Lisinopril 20 mg PO DAILY Metoprolol Tartrate 25 mg PO BID Hydrocortisone 2.5 % Cream on Rectum twice a day prn pain Aspirin 81 mg PO DAILY Simethicone 80 mg PO QID as needed for gas. Furosemide 80mg QAm, 40mg QPM(has not been taking) Isosorbide Mononitrate 60 mg SR daily Lantus 64units Subcutaneous at bedtime. Humalog Subcutaneous at bedtime: FS 201-250 2 units; 251-300 4 units; 301-350 6 units 351-400 8 units. Humalog Brkfst, Lunch, Dinner: FS 151-200: 2 units; FS 201-250: 4 units; FS 251-300 6 units; FS 301-350 8 units; FS 351-400 10 units. Discharge Medications: 1. BIPAP Set at 15/10. Titrate 2 L of oxygen to keep sats >93%. Diagnosis: OSA. 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 4. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 7. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 13. Lantus 100 unit/mL Solution Sig: Forty Eight (48) unit Subcutaneous at bedtime. 14. Humalog 100 unit/mL Solution Sig: One (1) unit Subcutaneous as directed: per the sliding scale you were given. Disp:1 bottle Refills:2 15. Calcium Citrate-Vitamin D3 250-200 mg-unit Tablet Sig: Two (2) Tablet PO twice a day: This can be purchased over the counter. 16. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:1 inhaler Refills:0 17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): This should be purchased over the counter. 19. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: This should be purchased over the counter. 20. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation every twelve (12) hours. Disp:1 disk Refills:2 21. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 22. Lactulose 10 gram/15 mL Solution Sig: Thirty (30) ml PO three times a day as needed for constipation. Disp:300 ml Refills:0 23. Insulin Syringe-Needle U-100 0.3 mL 29 x [12-14] Syringe Sig: One (1) syringe Miscellaneous as directed. Disp:100 syringes Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary: Acute on chronic diastolic congestive heart failure Secondary: Obstructive sleep apnea coronary artery disease hypertension peripheral vascular disease Discharge Condition: stable, satting 98-100% on 2 L oxygen (nasal cannula); systolic blood pressure 106 Discharge Instructions: You were admitted with acute shortness of breath, felt to be due to heart failure. You were admitted to the intensive care unit initially and treated with IV Lasix (to help you urinate out your extra fluid). After you were transferred to the regular medicine floor you were given more IV Lasix. You were also started on CPAP at night, which is a breathing machine for sleep apnea. You had a sleep titration study while you were here. . Your Lantus was changed to 48 units at night, because your fingersticks dropped when you received your home dose of 64 units at night. You should continue on all of your other home medications except lasix (and with lisinopril at a decreased dose of 10 mg a day instead of 20 mg a day because of low blood pressure). You should not take your lasix until you follow up with Dr. [Last Name (STitle) ] this week. . You were started on a new inhaler called salmeterol to add to your COPD regimen. This will help you to breath better. . Weigh yourself every morning, call your doctor if your weight increases more than 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1200 ml . Call your doctor or return to the ER if you experience difficulty breathing, chest pain, fever, increased leg swelling, or any other concerning symptoms. Followup Instructions: 1.Please follow up with Dr. [First Name8 (NamePattern2) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 612] on [2186-9-5] at 11:00 AM in the [Hospital1 18] [Hospital Ward Name 5074] [Hospital Ward Name 23] Bulding, [Location (un) ] (sleep doctor for your obstructive sleep apnea) 2. Please go to the [Hospital1 18] [Hospital Ward Name 517] [Hospital Ward Name 121] Building [Location (un) 453] for intake at 8:00 AM on [2186-9-6]. You should not eat the night prior. This is for the EGD procedure--the stomach scope (because you had GI bleeding before). Phone:[Telephone/Fax (1) 5072] if you have questions. . 3. Dr. [First Name8 (NamePattern2) 3403] [Last Name (NamePattern1) ] on [2186-9-7] at 11:30 AM [Hospital Ward Name 23] Center [Telephone/Fax (1) 250] . 4. Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2643] in Stone Building of [Hospital Ward Name 516] [Hospital1 18] [Location (un) ] for your endoscopy (stomach scope) on [2186-9-7] at 1:00 PM. Do not eat the night prior. . 5. Please follow up with Dr. [First Name (STitle) ] and Dr. [Last Name (STitle) ] at the [Hospital1 18] [Hospital Ward Name 5074] [Hospital Ward Name 23] Building [Location (un) 436] on [2186-9-14] at 1:00 PM (do not come late) for a new lung doctor appointment with lung studies to be done on your arrival. . 6. Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3037] on [2186-11-22] at 1:00 PM (GI appointment), [Hospital Unit Name 1825] [Location (un) 453], [Hospital Ward Name 516] [Hospital1 18].	[ "401.9", "280.0", "414.01", "V49.76", "V49.75", "428.33", "110.3", "276.3", "428.0", "458.29", "496", "327.23", "V45.82", "250.80" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	12229, 12287	4630, 8782	290, 297	12493, 12578	3469, 4607	13897, 15570	2477, 2544		9695, 12206		12308, 12472		8808, 9672			12602, 13874											2559, 3450																								231, 252													325, 1933																1955, 2314	2330, 2461
68,295	145,859	41583	Discharge summary	report	Admission Date: [2175-2-2] Discharge Date: [2175-3-1] Date of Birth: [2121-4-3] Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 618] Chief Complaint: Intracerebral hemorrhage. Major Surgical or Invasive Procedure: PEG Tracheostomy External ventricular drain, placed, removed and replaced History of Present Illness: [Known firstname 10827] [Known lastname 54591] is a 53 yo woman found unresponsive this AM by a friend. [Name (NI) ] the doumentation, the patient was found sitting on a couch unresponsive, vomitus in her mouth. She was cold to touch. EMS was called and the patient was intubated in the field with minimal cough, HR was in the 30's and the patient was given 0.5mg atropine. The patient was taken to [Hospital3 ]. Vitals there were notable for SBP 190/102 pulse 95 Resp 14 Temp 96.9. 100% ventilated. Labs were notable for WBC 15, HCT 42, CPK 138, Glucose 167, BUN 10, Cr .87, trop negative. Head CT showed a large right frontal IPH with intraventricular extension. Her pupils were reported as unequal, she received decadron 10mg, mannitol 20mg and a dilantin load. She was started on a nicardipine gtt and transfered to [Hospital1 18] via [Location (un) ]. Past Medical History: - Hypertension - Strokes x 2 with residual right-sided weakness, mild - Alcohol abuse - Depression - Concaine abuse Social History: Lives alone. Heavy smoker, drinks alcohol and uses cocaine frequency, lives alone in public housing but family close by. Family History: Hypertension in several family members. Physical Exam: Discharge Exam: Afebrile for > 48 hours on antibiotics. Remaining vital signs normal including blood pressures typically 110s - 120s. Regular heart rate in 70s. She continues to produce some secretions from her trach. Transmitted upper airway sounds. Regular heart, no murmurs. Soft abdomen. Opens eyes to voice at times, or touch. When drowsy in early a.m. may take a while to awaken and sometimes has disconjugate gaze if on the verge of sleep. Comprehension limited at best, occasionally following simple commands with left hand in Spanish, although this is infrequent. No attempts to speak or mouth words. Tone normal throughout. Right arm is paretic. Localizes pain on right leg (with left foot), but does not move spontaneously. Spontaneous antigravity movements of left arm and leg. Reflexes symmetric. Upgoing right great toe. Exam on admission: T 96 BP 190/100 HR 130 RR 21 100% General: intubated Head and Neck: mmm. no carotid bruits appreciated. Pulmonary: Lungs clear to auscultation anteriorly Cardiac: regular rate, No murmurs appreciated. Abdomen: soft, normoactive bowel sounds Extremities: well perfused Skin: no rashes or lesions noted. Neurologic: Intubated, propofol off. Does not respond to commands, does not open eyes. Pupils minimally reactive, + corneals, more brisk on left. Eyes slightly dysconjugate with right eye deviated out. + Cough to deep suctioning. Right arm and leg with brisk reflexes and right toe upgoing. Withdraws to noxious stimulation in the legs. Has extensor posturing of the left arm, turns into stimulus on right arm. Left sided reflexes are less compared to right. left toe mute. Pertinent Results: CT Head [2-14]: IMPRESSION: 1. No significant interval change in the right frontal parenchymal hemorrhage and intraventricular extension of bleed. 2. Stable ventricular size, with interval placement of left transfrontal ventriculostomy catheter in satisfactory position. 3. Evolving extensive left cerebral hemispheric infarcts, without evidence of hemorrhagic conversion. CXR [2-14]: IMPRESSION: Slightly increased vascular engorgement and cardiomegaly with improved right lower lung aeration. Cerebral angio [2-6]: IMPRESSION: 1. 70-79% stenosis of the right internal carotid artery. 2. Occlusion of the left internal carotid artery. Cultures and Microbiology: [2175-2-13] 2:43 pm CSF;SPINAL FLUID Source: Shunt NO GROWTH [2175-2-12] 3:35 pm CATHETER TIP-IV L RADIAL ARTERIAL LINE.: No growth CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2175-2-12]): Negative [2175-2-10] 4:44 am URINE: Negative [2175-2-10] 4:44 am BLOOD CULTURE Source: Line-L CVL: Negative [2175-2-8] 2:51 pm BRONCHIAL WASHINGS: No growth [2175-2-6] 8:40 pm SPUTUM Source: Endotracheal ACINETOBACTER BAUMANNII COMPLEX \| AMPICILLIN/SULBACTAM-- <=2 S CEFEPIME-------------- 8 S CEFTAZIDIME----------- 16 I CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN----------<=0.12 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- 2 S Further blood, including mycolytic, and CSF cultures were negative. CT Head [2175-2-25] A large right frontal parenchymal hematoma is again noted, measuring approximately 42 x 23 mm (2, 9) similar in size compared to [2175-2-23], previously 23 x 43 mm. A small amount of blood continues to layer in the occipital [Doctor Last Name 534] of the left lateral ventricle, but appears slightly decreased compared to the most recent prior examination. The ventricles remain mildly dilated, but unchanged compared to [2175-2-23]. An 8-mm leftward shift of normally midline structures with subfalcine herniation is mildly decreased compared to [2175-2-23], previously 10 mm leftward shift. Hypodensities in the left frontal, parietal and occipital lobes are again noted, relatively stable. Partial opacification of mastoid air cells is once again noted. IMPRESSION: No significant change in ventricle size compared to the most recent prior examination. Otherwise, layering blood within the left occipital [Doctor Last Name 534] is slightly decreased compared to the most recent prior examination. Otherwise, no significant interval change since [2175-2-23]. [2175-2-27] 05:19AM BLOOD WBC-6.8 RBC-2.97* Hgb-10.3* Hct-30.2* MCV-102* MCH-34.5* MCHC-33.9 RDW-15.4 Plt Ct-449* [2175-2-23] 05:04AM BLOOD Neuts-68.6 Lymphs-23.1 Monos-4.2 Eos-3.2 Baso-0.9 [2175-2-27] 05:19AM BLOOD Plt Ct-449* [2175-2-3] 03:51AM BLOOD PT-12.9 PTT-26.0 INR(PT)-1.1 [2175-2-2] 12:41PM BLOOD Fibrino-306 [2175-2-27] 05:19AM BLOOD Glucose-92 UreaN-12 Creat-0.5 Na-134 K-4.7 Cl-99 HCO3-30 AnGap-10 [2175-2-19] 08:05AM BLOOD CK(CPK)-19* [2175-2-3] 03:51AM BLOOD ALT-16 AST-10 LD(LDH)-147 CK(CPK)-73 AlkPhos-76 TotBili-0.3 [2175-2-23] 05:04AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.2 [2175-2-2] 03:18PM BLOOD %HbA1c-5.6 eAG-114 [2175-2-3] 03:51AM BLOOD Triglyc-181* HDL-49 CHOL/HD-4.4 LDLcalc-131* [2175-2-26] 04:28AM BLOOD Vanco-17.9 [2175-2-2] 12:41PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2175-2-22] 11:22AM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.015 [2175-2-22] 11:22AM URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-NEG [2175-2-22] 11:22AM URINE RBC-46* WBC-4 Bacteri-FEW Yeast-NONE Epi-<1 TransE-1 [2175-2-22] 11:22AM URINE Hours-RANDOM Creat-57 [2175-2-2] 12:41PM URINE bnzodzp-POS barbitr-NEG opiates-NEG cocaine-POS amphetm-NEG mthdone-NEG Brief Hospital Course: Intraparenchymal Hemorrhage, Ischemic Stroke and Obstructive Hydrocephalus: Patient [Name (NI) 54591] was admitted to the ICU as a transfer from [Hospital3 ] after being found down at her home unresponsive, intubated on the field and found to have on subsequent CT a large right frontal intraparenchymal hemorrhage with intraventricular extension. She had an EVD placed in the ED and was taken to the ICU for further care. Over the course of her ICU stay she was intubated and started on Keppra prophylactically with IV agents for blood pressure control as her pressures were difficult to control (goal was less then 160) - for her final regimen see medications below. Before her arrival she was a known cocaine abuser and beta blockers were avoided. She had a CT with vessel imaging that demonstrated significant stenosis in the left ICA. This was confirmed on subsequent cerebral angiogram which failed to show evidence for vessel abnormalities known to cause such hemorrhages. It was noted that there was significant vasculature disease throughout that was consistent with poor medical adherence. EVD was necessary given obstructive hydrocephalus that developed in the context of blood in the third and fourth ventricles. She had her EVD clamped at one moment after drainage on an open valve of 15 showed less then 200 cc over a 24 hour period. After 24 hours of clam the patients EVD was pulled and she subsequently developed an acute hypertensive emergency. A CT scan of the head demonstrated new intraventricular blood with serial CT scans demonstrating increase ventricular size. The EVD was replaced and shunting planning. Repeat head CT on [2-11] for presurgical planning revealed new left hemispheric infarcts, likely related to severe left carotid stenosis which had progressed to closure. Shunt was then deferred to managed hydrocephalus with EVD. Starting on [2-20] her drain was progressively raised from 10 cm to 15 cm then 20 cm over three days, without increased ventricular size (that could not be accounted for by reducing edema after infarcts). She tolerated drain clamping and removal without worsening hydrocephalus on imaging. On the final day of drain clamping, she was febrile and a CSF pleocytosis was noted. This can sometimes occur with ventriculitis in the context of drain and blood in CSF, but infection could not be excluded, so meropenem coverage (see Pneumonia below) was broadened to include vancomycin. Her fevers resolved on vancomycin, but CSF grew no organisms. Pneumonia and Fever: She was initially febrile and after multiple attempts to isolate an organism was found to grow pan sensitive Acinetobacter on sputum culture. It was believed that her fever was of central cause. Her antibiotics were pared down to nafcillin then switched to meropenem to better cover acinetobacter given some respiratory distress on [2-19]. Vancomycin was added on [2-22]. The course of vancomycin and meropenem can end on [2175-3-5]. General Care: During her ICU course she also received a PEG and a Trach and she subsequently tolerated trach collar. The trach. size is too large for Passy-Muir, but was maintained given secretions. There were no issues surrounding her endocrine, kidney, heme, GI, GU systems. Goals of Care: Her daughter wanted her to be full code and everything to be done for her care. Medications on Admission: Enalapril 20mg daily Diclofenac 75mg daily Discharge Medications: 1. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 2. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a day). 3. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 4. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. ferrous sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig: One (1) PO DAILY (Daily). 6. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 11. 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. 12. Meropenem [2163] mg IV Q8H Duration: 14 Days CSF infection. Please give in normal saline, not D5, if possible. 13. Vancomycin 750 mg IV Q 8H Please supply in normal saline if possible, not D5. 14. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for fever > 100 F. Discharge Disposition: Extended Care Facility: [Hospital6 979] - [Location (un) 246] Discharge Diagnosis: Right Frontal Intraparanchymal bleed with intraventricular extension Left MCA Infarct Obstructive Hydrocephulus, resolved Pneumonia Ventriculitis Discharge Condition: Alert during the day, typically. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted to the hospital after bleeding in your brain. Blood compressed your brain and spilled into the fluid filled spaces within your brain, necessitating drain placement. During the hospitalization you had further stroke, in the context of severe vascular disease, developed pneumonia (now resolving and being treated). The drain was eventually removed without worsening. You are now medically stable to move to hospital level care outside of the hospital. Followup Instructions: Please follow-up in clinic with Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 7394]: [Hospital Ward Name 23] Building, Level 8, [Hospital Ward Name 516], [Hospital1 18], [Location (un) 86] [Name6 (MD) ] [Name8 (MD) ], M.D. Phone:[Telephone/Fax (1) 2574] Date/Time:[2175-5-9] 1:00 You will need to complete registration before you can attend this appointment, choose a PCP and update insurance information so that there can be a insurance referral. Please call registration as soon as possible on ([Telephone/Fax (1) 22161] (this should be done by her daughter). [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632]	[ "348.4", "331.4", "401.9", "305.60", "322.9", "431", "482.41", "348.5", "434.91" ]	icd9cm	[ [ [] ] ]	[ "96.6", "02.39", "03.31", "88.41", "43.11", "38.91", "38.93", "33.24", "31.1", "96.71", "99.10" ]	icd9pcs	[ [ [] ] ]	12097, 12169	7335, 10705	327, 402	12358, 12469	3331, 7312	12986, 13688	1612, 1653		10799, 12074		12190, 12337		10731, 10776			12493, 12963											1668, 1668						1685, 2510																		262, 289													430, 1317								2525, 3312								1339, 1457	1473, 1596
68,780	193,820	53536	Discharge summary	report	Admission Date: [2170-2-15] Discharge Date: [2170-2-21] Date of Birth: [2087-11-6] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 425] Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac catheterization with bare metal stent to proximal LAD History of Present Illness: 82 F admitted [2-12] for L total hip replacement. EBL 500cc during surgery. On the morning of [2170-2-14], the patient was noted to be more hypoxic and lethargic. She was given more IV fluids for concern of dehydration. Later during the day sats were dropping to 80%. She was placed on a non-rebreather face mask. She was denying any chest pain. She had a mild cough, poorly productive. She had no nausea, no vomiting, no clear documentation of aspiration. She appeared pale. She was sleepy, but easily arousable and cooperative. She appeared initially in no acute distress. Rapid response was called and the patient was transferred to the ICU for initial concern of congestive heart failure. On [2-14] had CXR with perihilar lower lobe opacities and LUL opacity with concern of HF vs. multifocal PNA. Patient's respiratory status decompensated and repeat CXR showed LUL, LLL, RML, RLL opacities more suggestive of aspiration PNA, subsequently patient was intubated that night. Patient was started on norepinephrine. Patient was started on ASA, heparin held given drop in HCT. 2 units PRBC being given. On Vanco and Zosyn. Scheduled for RP u/s to r/o bleed. . On arrival to the floor she was intubated and found to be hemodynamically stable. Floor EKGs showed ST depression in lateral leads and slow R wave progression. At 9pm was hypotensive with MAPS to 46 about 1 hour after getting metoprolol 12.5. EKG unchanged, started on levophed, backed off sedation. . Past Medical History: Past Medical History: 1)Type 2 Diabetes 2)Peripheral vascular disease: s/p left common femoral to below-knee popliteal artery bypass with in situ saphenous vein and an open transluminal angioplasty of the anterior tibial and below knee popliteal arteries in [5-14]. 3)Hypertension 4)Hyperlipidemia 5)Hx of R breast ca s/p lumpectomy 6)Depression . Home medications: Metformin 1000mg PO BID Lipitor 20mg PO daily Prozac 20mg PO daily Triamterene 25mg PO daily Neurontin 300mg PO TID Actonel 35mg PO weekly ASA 81mg daily . Medications on Transfer lisinopril 5mg daily lopressor 12.5 mg [Hospital1 ] trazadone 50 qhs depakote 125mg daily remeron 15mg bedtime zocor 40mg daily lasix 40mg IV q12-hours PRN aricept 5mg daily prozac 20mg daily neosynephrine drip IV heparin low dose plavix 300mg x 1 ASA 325 . Social History: Lives alone. Has 2 sisters who live in the area. Denies alcohol or IVDA. 50 pack year history of tobacco use. Continues to smoke 3 ciggarettes/day. . Family History: Mother with history of CAD . Social History: SOCIAL HISTORY: She lives at home and runs a day care with two assistants at home. She is pretty independent in her ADL, IADL's and very functional. Denies any history of smoking, alcohol or drug abuse. Family History: FAMILY HISTORY: Noncontributory. Physical Exam: PHYSICAL EXAMINATION: Vs: Tc: HR:71 BP:91/51 RR:25 SP02: 93% Alert and oriented to person and place, disoriented to time. No JVP HR: II/VI SEM heard best at the apex. Resp: CTA-B, no wheeze, no rales, ext: cool bilateral lower extremities, no edema no femoral bruit bilaterally. -dopplerable pulses bilaterally. . LABS/STUDIES Overall EKGs show dynamic T wave changes EKG: [2170-2-15] 4:41 am : nl axis, nl intervals TWI in II, III, aVF, V5, V6.TWI in AVF and precordial leads are new. <0.05 STD in lead II, V3-V5. [2170-2-14] at 21:18 STD in lead II,V2-V5,? TWI in III. [2170-2-14] 19:03: TWI II, III, avF, V1, V5-V6, STD in lead II, V2-V5. OSH labs: Cr 1.8 from 1.3 on admission to [Hospital1 ]. WBC 15.3 on [2170-2-15] from 7.0 on [2170-2-14] . HCT stable at 32.9 , INR 1.04 BNP: 265 . 2D-ECHOCARDIOGRAM: [2170-2-15]. The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is mild regional left ventricular systolic dysfunction with akinesis of the inferior and inferolateral walls. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size and free wall motion are normal. 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. Moderate to severe (3+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Inferior and inferolateral akinesis consistent with prior infarction. The posterior leaflet of the mitral valve is tethered with consequent assymetric coaptation of the mitral leaflets and at least moderate-to-severe mitral regurgitation, directed posteriorly. Moderate pulmonary artery systolic hypertension. . Echo [2165]: LV systolic function is intact with an estimated LVEF of 60%. Chamber sizes are normal. There is mild MR and trace TR noted. PA pressures are normal. There is no pericardial effusion. . ETT: [2165]. For HTN and syncope. [Doctor First Name ] with myoview. In summary this study is inconclusive for myocardial ischemia by ST criteria since patient did not achieve 85% of predicted maximum heart rate. Adjunctive myocardial perfusion imaging at the workload achieved will be reported separately by [Doctor First Name ]. . ASSESSMENT AND PLAN: 80 y/o woman with hx alzheimers transfered with dynamic EKG changes/mild troponin leak equivocal for NSTEMI with decision for medical management. . # CORONARIES: Acute CHF at OSH in setting of CP/troponin leak. Echo showed tethered MV, overall more consistent with chronic MR. [Name14 (STitle) 16720] troponin leak. serial CE. -medical management with aspirin, atorvastatin. Hold home BB/Ace given hypotension . # PUMP: Tethered mitral valve, may be chronic MR. Ideal to have diuresed for afterload reduction but hypotensive requiring pressors. No evidence endocarditis, afebrile, small white count. Volume overloaded but intravascularly dry. Small fluid boluses PRN. -Continue pressor support for goal MAPS >60. Repeat CXR in am. . # RHYTHM: Sinus Continue telemetry . ## Renal Failure: Baseline Cr 1.3. Increased to 1.9. Unclear if ATN vs [1-9] poor forward flow. -check urine lytes. . #Leukocytosis: Afebrile, no evidence infection ? stress response -check UA/blood cx. . #Dementia: continue aricept. . #Diabetes: hold metformin in setting renal failure RISS/GFS . FEN: # Low sodium, . ACCESS: PIV's . PROPHYLAXIS: -DVT ppx with * -Pain management with -Bowel regimen with . CODE: DNR/DNI . COMM: HCP [Name (NI) 122] [Name (NI) 40019]: [Telephone/Fax (1) 110038] . DISPO: CCU for now Pertinent Results: [2170-2-15*] 11:15PM TYPE-ART PO2-147 PCO2-34* PH-7.43 TOTAL CO2-23 BASE XS-0 [2170-2-15] 11:00PM POTASSIUM-4.8 [2170-2-15] 11:00PM CK(CPK)-998* [2170-2-15] 11:00PM CK-MB-36* MB INDX-3.6 cTropnT-4.84* [2170-2-15] 11:00PM MAGNESIUM-3.2* [2170-2-15] 11:00PM HCT-31.0* [2170-2-15] 09:28PM LACTATE-1.4 [2170-2-15] 09:28PM LACTATE-1.4 [2170-2-15] 03:20PM LACTATE-1.1 [2170-2-15] 03:20PM O2 SAT-93 [2170-2-15] 02:49PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.018 [2170-2-15] 02:49PM URINE BLOOD-SM NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2170-2-15] 02:49PM URINE RBC-0-2 WBC-3 BACTERIA-OCC YEAST-NONE EPI-2 [2170-2-15] 02:49PM URINE GRANULAR-<1 HYALINE-0-2 [2170-2-15] 02:48PM GLUCOSE-126* UREA N-23* CREAT-0.9 SODIUM-134 POTASSIUM-3.1* CHLORIDE-102 TOTAL CO2-22 ANION GAP-13 [2170-2-15] 02:48PM ALT(SGPT)-51* AST(SGOT)-262* CK(CPK)-1414* ALK PHOS-51 TOT BILI-0.8 [2170-2-15] 02:48PM CK-MB-66* MB INDX-4.7 cTropnT-4.99* [2170-2-15] 02:48PM CALCIUM-7.3* PHOSPHATE-2.9 MAGNESIUM-1.6 [2170-2-15] 02:48PM WBC-12.6# RBC-3.78 HGB-11.4* HCT-32.2* MCV-85# MCH-30.2 MCHC-35.4* RDW-14.2 [2170-2-15] 02:48PM NEUTS-79.7* LYMPHS-15.0* MONOS-4.5 EOS-0.6 BASOS-0.2 [2170-2-15] 02:48PM PLT COUNT-188 [2170-2-15] 02:48PM PT-19.9* PTT-33.7 INR(PT)-1.8* . [2170-2-15]-CXR Improving pulmonary edema. Continued follow up recommended to exclude left upper lobe pneumonia. Given the history of recent orthopedic procedure, pulmonary fat embolism should be considered. The study and the report were reviewed by the staff radiologist. . The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with severe hypokinesis of the distal halves of the anterior septum, anterior and inferior walls as well as apex. The remaining segments contract normally (LVEF = 30-35 %). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] No masses or thrombi are seen in the left ventricle. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Echo [2170-2-19] IMPRESSION: Normal left ventricular cavity size with extensive regional systolic dysfunction c/w multivessel CAD (mid-LAD and PDA distributions). Increased PCWP. Moderate mitral regurgitation. Pulmonary artery systolic hypertension. CLINICAL IMPLICATIONS: The left ventricular ejection fraction is <40%, a threshold for which the patient may benefit from a beta blocker and an ACE inhibotor or [Last Name (un) ]. Based on [2166] 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. Cardiac Catheterization: [2170-2-19] 1. Coronary angiography of this right dominant system demonstrated 2 vessel coronary artery disease. The LMCA had a 40% distal stenosis. The LAD had a 90% proximal stenosis and a 30% mid-vessel stenosis. The LCX had a 40% proximal stenosis. The RCA was occluded proximally. There was left to right collaterals filling the distal RCA. 2. Resting hemodynamics revealed elevated right and left sided filling pressures with a RVEDP of 11 mmHg and a mean PCWP of 25 mmHg. There was mild pulmonary arterial hypertension with a PA pressure of 41/25 mmHg. Central aortic pressure was 125/55 mmHg. The cardiac index was normal at 3.4 L/min/m2. 3. Successful PTCA and placement of a 2.75x15mm Vision bare-metal stent were performed in the proximal LAD. The stent was postdilated using a 3.0mm diameter balloon. Final angiography showed normal flow, no apparent dissection, and a 5% residual stenosis. (See PTCA comments.) FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Biventricular diastolic dysfunction. 3. Mild pulmonary arterial hypertension. 4. Placement of a bare-metal stent in the proximal LAD. . [2170-2-19] [2170-2-19] Echo The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with severe hypokinesis of the distal halves of the anterior septum, anterior and inferior walls as well as apex. The remaining segments contract normally (LVEF = 30-35 %). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] No masses or thrombi are seen in the left ventricle. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size with extensive regional systolic dysfunction c/w multivessel CAD (mid-LAD and PDA distributions). Increased PCWP. Moderate mitral regurgitation. Pulmonary artery systolic hypertension. CLINICAL IMPLICATIONS: The left ventricular ejection fraction is <40%, a threshold for which the patient may benefit from a beta blocker and an ACE inhibotor or [Last Name (un) ]. Based on [2166] 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. Brief Hospital Course: ASSESSMENT AND PLAN: 82 y/o woman s/p hip replacement now intubated for respiratory distress with ? PNA, noted on echo to have acutely worsened MR. Respiratory Distress: The patient was intubated and sedated on arrival from the outside hospital. Her respiratory distress was initially thought secondary to PNA due to a LL opacity, however blood cultures were negative and antibiotics were stopped. It became evident that her respiratory distress was secondary to heart failure that had developed secondary to mitral regurgitation which was secondary to ischemia. Had echo prior to arrival showing new antero apical wall motion abnormality which would suggest plaque in LAD. Had poor R wave progression and LAFSB which would be consistent with anterior ischemia but her ST depressions are in V5-V6 more consistent with ischemia involving Lcx.Her cardiac cath revealed LAD disease and a bare metal stent was placed. She will require plavix and high dose aspirin for a month. On Echocardiogram, she had apical akinesis. We therefore are recommending that she remain anticoagulated for the next 6 months with coumadin. PTT/INR should be checked daily. She should follow up with the coumadin clinic following discharge from rehab. . # HCT drop: HCT 32.2 on admission following 2U PRBC at [Location (un) 620]. Concern at OSH was for RP bleed however no evidence of this clinically and HCT trended down slowly from 32 on admit and has been stable currently. An active type and screen was maintained,she was guaic negative. . #s/p Hip replacement: She had a left hip replacement at an outside hospital. Communication with performing surgeon related that she was full weight bearing and she was evaluated by PT with a recommnedation for rehab. She felt as though her knee would buckle thus plain films of the left leg were taken and showed changes consistent with osteoarthritis. Her wound from her hip surgery should be kept covered at all times. She is on lovenox bridge to coumadin currently and She will follow up with her orthopedic surgeon as scheduled within two weeks of the procedure. Medications on Admission: Simvastatin 40 mg p.o. daily, atenolol 50 mg p.o. daily, hydrochlorothiazide 50 mg p.o. daily, Lido patch, lisinopril 40 mg p.o. Benicar hydrochlorothiazide 50/12.5, Detrol LA 1 mg twice a day, Tramadol 50 mg p.o. t.i.d multivitamin. Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 3. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. Disp:30 Tablet(s) Refills:0 4. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day: Hols SBP < 100. 8. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) syringe Subcutaneous [Hospital1 ] (2 times a day): Give until INR > 2.0, then d/c. 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever, pain. 10. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: 2.5 Tablet Sustained Release 24 hrs PO once a day: Hold HR < 55, SBP < 100. Discharge Disposition: Extended Care Facility: [Hospital3 2732] & Retirement Home - [Location (un) 55] Discharge Diagnosis: Primary NSTEMI Systolic Congestive Heart Failure Secondary Mitral Regurgitation s/p hip replacement [2170-2-12] Discharge Condition: Alert and oriented to person, place and time, mobilizes with assistance s/p hip replacement. Discharge Instructions: You were admitted to the hospital because you had a heart attack. You had a stent placed in one of your coronary blood vessels. You will need to continue taking aspirin and plavix for one month, lovenox for six months and coumadin indefinitely. You had a hip replacement. Please keep the wound covered. You will need physical therapy to recover from the hip replacement. . Medication changes: 1. Stop taking Benicar 2. Stop taking Hydrochlorothiazide 3. Stop taking Tramadol 4. Decrease your Lisinopril to 20 mg daily 5. Change your Atenolol to Metoprolol XL 125mg daily 6. Start taking clopidogrel (Plavix) every day for at least one month. Do not stop taking Plavix or miss [First Name (Titles) 691] [Last Name (Titles) 4319] unless Dr. [Last Name (STitle) ] tells you to. 8. Start Aspirin 325 mg daily, do not stop taking or miss [First Name (Titles) 691] [Last Name (Titles) 11014] unless Dr. [Last Name (STitle) ] tells you to. 9. Increase Simvastatin to 80 mg daily 10. Start Ranitidine to prevent stomach bleeding with the blood thinners. . Please weigh yourself every day and call Dr. [Last Name (STitle) ] if your weight increases more than 3 pounds in 1 day or 6 pounds in 3 days. Followup Instructions: Dr [Last Name (STitle) 44955]: Tuesday [2170-2-27] at 11:00am [Street Address(2) 110039], [Location (un) 620] Telephone: [Telephone/Fax (1) 110040] . Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 6475], MD, MPH[MD Number(3) 708]:[Telephone/Fax (1) 3070] Date/Time:[2170-3-5] 11:20 Provider: [Name10 (NameIs) 706] Phone:[Telephone/Fax (1) 327] Date/Time:[2170-7-23] 1:25 Provider: [Name10 (NameIs) 706] Phone:[Telephone/Fax (1) 327] Date/Time:[2170-7-23] 1:40 . Cardiology: [Last Name (LF) ], [First Name3 (LF) 122] Phone: [Telephone/Fax (1) 4105] Date/time: [3-14] at 4pm.	[ "250.00", "443.9", "518.0", "396.2", "518.81", "E878.1", "428.21", "997.1", "311", "780.52", "263.9", "414.01", "275.41", "E849.7", "272.4", "V10.3", "401.9", "410.71", "428.0", "285.1", "458.9" ]	icd9cm	[ [ [] ] ]	[ "36.06", "96.71", "00.45", "37.23", "88.56", "00.66", "00.40" ]	icd9pcs	[ [ [] ] ]	16829, 16919	13475, 15569	325, 389	17080, 17175	7350, 10252	18442, 19120	3203, 3221		15854, 16806		16940, 17059		15595, 15831		11651, 13031	17199, 17572											3236, 3236			2294, 2736				13054, 13452						3258, 7331										17592, 18419	275, 287													417, 1901																1945, 2276	2983, 3171
83,361	192,111	49501	Discharge summary	report	Admission Date: [2177-8-20] Discharge Date: [2177-9-5] Date of Birth: [2106-3-12] Sex: F Service: MEDICINE Allergies: Codeine / Bactrim / Erythromycin Base / Penicillins / Prochlorperazine / Nalbuphine / Iodine / Phenothiazines / Aspirin Attending:[First Name3 (LF) 31685] Chief Complaint: Respiratory Distress Major Surgical or Invasive Procedure: flexible bronchoscopy History of Present Illness: The patient 71 year old female with a hx of breast cancer, recent dx of esophageal cancer (SCCa) approx 1 month prior, TE fistula s/p esophageal and Bronchus Y stent placement two weeks ago, who is followed by Dr. [First Name (STitle) ] [Name (STitle) ] at [Hospital3 ]. Please see admission note for full details. Briefly, she had a recent diagnosis of esophageal cancer. She presented to an OSH on [7-17] w/ acute onset wheezing and underwent endoscopy that reavealed large esophafeal mass and TE fistula. A esophageal and left main stent were placed on [7-26] and she was stent was placed on [7-26] and was intubated on [2177-8-5] for respiratory distress and left main stem obstruction. It was thought she had an aspiration pna and dislodgement of her bronchus stent. She was then transferred to [Hospital1 18] on [2177-8-6]. On [2177-8-7] she underwent Rigid bronchoscopy, flexible bronchoscopy, tumor destruction with mechanical forceps,tumor destruction with cryotherapy, and Y-stent placement. She was discharged home on tube feeds on [2177-8-11] following stent placement. She presented to clinic on [8-19] with severe nausea/ vomiting, treated with anti-emetics, dexamethasone and IV fluids without significant effect, and transferred to [Hospital1 18] for pallitative treatment. . Overnight she was having severe "retching" and was increasingly agitated. At baseline she is oriented x3, but per nursing she was confused, only oriented x1, and pulling and difficult to settle. She remained tachycardic in the 130's, with HR as high as 160's. She was given a total of ativan 0.25mg x2 and morphine 1mg this morning. She then triggered this AM for respiratory distress with O2 sats as low as 75%. She remained tachy in the 130's and BP 160/100. The patient had was refusing secreations and increasing agitated. The patient was spitting up clear secreations and complaining of not getting enough air. She was transferred to the [Hospital Unit Name 153] for emergent bronch to assess her airway. . On arrive to the [Hospital Unit Name 153] she was 100% on RA, tachypneic with RR 30's, tachy to the 130's. She was initially calm, but escalated with episodes of stridous breathing, increasing secreations and agitation. She refused suction due to pain. She also states that she "just want's to go home." . Spoke with the patient's husbnad over the phone and discuss her situation at length. He said she had similar episodes in the past when she is agitated and delerious that she will refuse treatment. However, he emphasized that when she is mentating clearly that she wanted everything performed including intubation and other invasic procedures. Past Medical History: Stage II T2N0M0), left breast CA in [2162], s/p left mastectomy and 4 cycles of chemo with adriamycin/cytoxan limited due to Gi toxicity, and tamoxifen 20 mg for 5 years until [2170]. -Esophageal Cancer: dx [2177-7-17]. An endoscopy ([7-21]) and a CT scan were performed and showed a large esophageal ulcerating mass with TE fistula. Pathology revealed squamous cell carcinoma. . Depression. Chronic back pain with opioid addiction (per prior notes) GERD Hypertension Migraines Hiatal hernia with severe reflux status post pyloroplasty. palpitations Status post hysterectomy, status post cholecystectomy and status post left mastectomy. Social History: Married, lives in [Location ], MA. Husband extremely supportive and is primary caregiver. [First Name (Titles) 1817] [Last Name (Titles) 1818], quit [2148]. Family History: non-contributory Physical Exam: Vitals - T:97.9 BP:145/92 HR:124 RR:18 02 sat: 100%RA GENERAL: extremely agitated and short shallow breathes. Episodes of stridrous breath sounds and expectoring clear secreations. Pt saying "I want to go home," thin frail appearing SKIN: warm and well perfused, no rashes visible HEENT: anicteric sclera, pink conjunctiva, patent nares, MMM CARDIAC: tachycardic, regular rate, S1/S2, no mrg LUNG: coarse rhonchi, episodes of stridorous upper airway sounds ABDOMEN: nondistended, +BS, diffusely tender, no rebound/guarding, midline staples and j tube in place. M/S: no cyanosis, clubbing or edema, no obvious deformities PULSES: 2+ DP pulses bilaterally NEURO: pupils equal round and reactive, patient unable to cooperated with neuro exam. Moving all ext spontaneously. No obvious focal deficits. Pertinent Results: [2177-8-22] 03:57AM BLOOD WBC-17.0* RBC-4.21 Hgb-11.7* Hct-36.1 MCV-86 MCH-27.8 MCHC-32.5 RDW-14.7 Plt Ct-587* [2177-8-21] 12:41AM BLOOD WBC-14.2* RBC-3.85* Hgb-10.8* Hct-33.1* MCV-86 MCH-28.0 MCHC-32.6 RDW-14.7 Plt Ct-553* [2177-8-20] 07:30PM BLOOD WBC-15.7* RBC-4.06* Hgb-11.2* Hct-34.9* MCV-86 MCH-27.5 MCHC-32.1 RDW-14.3 Plt Ct-570* [2177-8-22] 03:57AM BLOOD Neuts-84.0* Lymphs-10.1* Monos-5.4 Eos-0.3 Baso-0.2 [2177-8-20] 07:30PM BLOOD Neuts-78.2* Lymphs-14.0* Monos-6.8 Eos-0.8 Baso-0.2 [2177-8-22] 03:57AM BLOOD PT-13.4 PTT-52.5* INR(PT)-1.1 [2177-8-22] 03:57AM BLOOD Glucose-162* UreaN-4* Creat-0.4 Na-140 K-2.8* Cl-99 HCO3-29 AnGap-15 [2177-8-21] 12:41AM BLOOD Glucose-113* UreaN-7 Creat-0.5 Na-141 K-3.1* Cl-101 HCO3-32 AnGap-11 [2177-8-20] 07:30PM BLOOD Glucose-100 UreaN-7 Creat-0.5 Na-141 K-3.2* Cl-102 HCO3-31 AnGap-11 [2177-8-20] 07:30PM BLOOD ALT-13 AST-18 AlkPhos-83 TotBili-0.2 [2177-8-22] 03:57AM BLOOD Calcium-10.0 Phos-2.4* Mg-1.7 [2177-8-21] 12:41AM BLOOD Calcium-9.6 Phos-2.6* Mg-1.9 [2177-8-20] 07:30PM BLOOD Albumin-3.2* Calcium-10.0 Phos-2.5* Mg-2.0 [2177-8-21] 02:40PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.007 [2177-8-21] 02:40PM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG [2177-8-21] 02:40PM URINE RBC-15* WBC-1 Bacteri-NONE Yeast-NONE Epi-0 [2177-8-21] 02:40PM URINE Mucous-RARE . . Cx Pending: neg to date [2177-8-22] BLOOD CULTURE Blood Culture, No growth [2177-8-21] BLOOD CULTURE Blood Culture, No growth [2177-8-21] URINE URINE CULTURE, No growth . . CT CT Chest/Abdomen/Pelvis [8-25]: 1. Mediastinal mass with locules of air suggesting erosion outside the esophageal stent. Also noted compression of the subglottic trachea just above the tracheobronchial Y stent. . 2. Subpleural nodularity, pleural thickening and irregularity, part of which could reflect rounded atelectasis; however, in the setting of malignancy, Metastatic involvement cannot be excluded and attention on followup is recommended. Alternatively may relate to radiation sequelae, correlation with history is recommended. 3. Loculated right oblique fissure fluid. 4. Incidental note of aberrant right subclavian artery. . Bone scan [8-29]: No findings of bony metastatic disease. Brief Hospital Course: Brief Hospital Course: The patient is a 71-year-old female with a remote history of breast cancer, recent diagnosis of esophageal CA s/p esophageal and bronchial Y stent in [2177-6-30], who was admitted to OSH with persistent nausea and vomiting. She was transferred to [Hospital1 18] for chemotherapy and radiation, but soon after admission was sent to the [Hospital Unit Name 153] for an urgent brochoscopy because of respiratory distress and difficulty clearing secretions. The bronchoscopy showed that the patient's Y stent was patent, and thick secretions were suctioned. She was then transferred back to the floor and received daily chemotherapy with 5FU and Cisplatin. She was initiated on XRT on [2176-9-5]. She tolerated the procedure well and was discharged to her outpatient appointment with Dr. [Last Name (STitle) ]. . #. Respiratory Distress: The patient had a patent Y stent on bronchoscopy, but intermittent evidence of upper airway obstruction on physical examination, concerning for mucous plugging. She was treated with albuterol, atrovent and acetylcisteine neubulizers and mucinex. She also completed a 14 day course of moxifloxacin on [2177-8-25]. . #Agitation/Anxiety: The patient had intermittent agitation, responsive to haldol. She was also treated with Remeron at night. During her admission, benzos were avoided because of a history of paradoxical reaction to ativan in the past (per husband). . # Esophageal Ca: The patient was treated with daily chemotherapy while an inpatient, initiated XRT, with a plan to XRT and chemotherapy as an outpatient. She tolerated chemotherapy well, with moderated nausea and vomiting responsive to zofran and compazine. . # pain management: The patient has a long history of chronic pain and opioid use. While inpatient she was continued on her home dose of methadone 20mg TID, but her fentanyl patch was decreased from 120 mcg to 75 mcg q72 hrs. . #HTN: Nifedipine was changed to amlodipine for administration through j tube. . #Hypothyroidism: Continued on home dose of synthroid . #FEN/GI: The patient had a recent swallow study showing moderate oropharyngeal dysphagia and aspiration of thin liquids. Consequently, she was placed on strict aspiration precautions with head of bed at 45 degrees at all times and tube feeds were only administered while sitting up. Medications on Admission: 1. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for agitation or anxiety. Disp:30 Tablet(s) Refills:0 2. Mucinex 1,200 mg Tab, Multiphasic Release 12 hr Sig: One (1) Tab, Multiphasic Release 12 hr PO twice a day for 2 weeks. Disp:28 Tab, Multiphasic Release 12 hr(s) Refills:0 3. Tessalon Perles 100 mg Capsule Sig: One (1) Capsule PO three times a day as needed for cough for 2 weeks. Disp:60 Capsule(s) Refills:0 4. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Transdermal Q72H (every 72 hours). 5. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Transdermal once a day: total 125 mcg/hr . 6. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for wheezes or SOB. 7. Methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble PO TID (3 times a day). 8. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for Esophageal fistula for 2 weeks. Disp:12 Tablet(s) Refills:0 10. Senna 8.8 mg/5 mL Syrup Sig: 1-2 Tablets PO BID (2 times a day). 11. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 12. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 13. Acetylcysteine 10 % (100 mg/mL) Solution Sig: Three (3) mL Miscellaneous twice a day: for Y stent patency Mix w/albuterol to prevent bronchospasm. Disp:180 mL Refills:2 14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) mL Inhalation twice a day: mix w/mucomyst. 15. Procardia 10 mg [Hospital1 ] Discharge Medications: 1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Three (3) ML Miscellaneous TID (3 times a day). Disp:270 ML(s) Refills:2 3. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:10 Patch 72 hr(s) Refills:2 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: 2.5 mg Inhalation Q6H (every 6 hours) as needed for shortness of breath. mg 6. Guaifenesin 100 mg/5 mL Syrup Sig: Fifteen (15) ML PO Q6H (every 6 hours). 7. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) teaspoons PO twice a day. 8. Senna 8.8 mg/5 mL Syrup Sig: One (1) teaspoon PO BID (2 times a day) as needed for constipation. 9. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for agitation. Disp:60 Tablet(s) Refills:0 10. Methadone 10 mg/5 mL Solution Sig: Ten (10) cc PO TID (3 times a day). Disp:1 bottle (100cc) Refills:0 11. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:2 12. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day. Disp:60 Tab Sust.Rel. Particle/Crystal(s) Refills:2 14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:2 0 Refills:0 15. Mirtazapine 7.5 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:30 Tablet(s) Refills:2 16. Prilosec 10 mg Susp,Delayed Release for Recon Sig: Twenty (20) mg PO once a day. Disp:1 bottle (300cc) Refills:2 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: primary: esophageal cancer secondary: hypertension, depression, anxiety Discharge Condition: stable, afebrile. Right side catheter with access in place. Discharge Instructions: You were admitted to [Hospital1 18] on [2177-8-20] for nausea and vomiting. We treated you for your esophageal cancer with chemo and radiation therapy. You developed an episode of severe shortness of breath and an emergent bronchoscopy was performed in the ICU and the stent that you have in place in your lungs was suctioned to clear secretions. You returned to the oncology floor for daily chemotherapy. Radiation therapy was initiated while inpatient and will continue as outpatient. A number of your medications have changed during your hospital Please see attached sheet for new medication regimen. Please return to the emergency room if you experience any shortness of breath, chest pain, severe headaches, severe nausea and vomiting. Followup Instructions: Please follow up with Dr. [Last Name (STitle) ] at 12:30pm on Friday [2177-9-6]. Your next treatment with radiation oncology is scheduled for Monday. Please call [Telephone/Fax (1) 9710] for date and time. Completed by:[2177-9-7]	[ "244.9", "E935.8", "300.4", "150.8", "530.81", "478.31", "401.9", "V10.3", "304.01", "292.81", "507.0", "V44.4", "530.84", "276.3", "934.1", "518.81" ]	icd9cm	[ [ [] ] ]	[ "33.22", "92.29", "96.6", "99.25" ]	icd9pcs	[ [ [] ] ]	13271, 13320	7304, 9648	401, 424	13436, 13499	4903, 7258	14302, 14551	4051, 4069		11363, 13248		13341, 13415		9674, 11340			13523, 14279											4084, 4884																								341, 363													452, 3167																3189, 3845	3861, 4035
81,020	104,710	51635	Discharge summary	report	Admission Date: [2184-7-7] Discharge Date: [2184-8-12] Date of Birth: [2139-8-7] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 20640] Chief Complaint: Hematuria Major Surgical or Invasive Procedure: Cystoscopy Angiogram of the left kidney History of Present Illness: Ms. [Known lastname 59777] is a 44 year old female with a history of recently diagnosed stage IV non-small cell lung cancer metastatic to brain, adrenals, and kidneys who presents with complaints of blood when she urinates. She notes that she first noticed this two days ago. She also notes pain with urination since she noticed the blood. She ntes it has been the worst between 1 am and 5 am where she can't leave the BR due to constant need to urinate. She also urinates several times during the day. Each time is extremely painful. She notes that since the bleeding began, the pain has begun to improve but the bleeding has continued at the same frequency. She denies any vaginal bleeding, melena, hematochezia, or hematemesis. In the [Hospital1 18] ED, 98.3, 108/70, 96, 18, 100% RA. While in the ED she was noted to have frank hematuria. Pelvic exam was performed without evidence of vaginal or cervical bleeding. No obvious GI bleeding was noted. She was guiaic negative. Labs were remarkable for Hct drop from 34->20 over 1 month. Coags, WBC, and plts normal. Electrolytes showed new renal failure with BUN/Cr 46/2.3 from 14/0.6 1 month prior. K was 6.0, bicarb 17. U/A revealed >50 RBCs, 21-50 WBCs, LE and nitrite negative, and no bacteria. She received 30 grams of kayexalate, 10 mg of dexamethasone, zofran, and morphine. Prior to floor transfer, she lost her IV access. Bilateral femoral CVLs were attempted but wire could not be passed. She then had a successful R IJ CVL placement. Currently, she feels well. Episode of frank hematuria witnessed upon arrival to the floor, also notable for stringlike clot. On ROS, she denies any fevers, chills, chest pain, SOB, DOE. She does note increased fatigue and recent poor po intake. She also notes intermittent nausea when taking her medications. She denies any numbness or tingling, weakness, or confusion. Denies any muscle or joint pains which the exception of chronic R thumb pain which improved with steroids and has worsened with taper. All other ROS negative. Past Medical History: # stage IV non-small cell lung cancer metastatic to brain, adrenals, kidneys (see below) # h/o intermittent asthma # h/o tooth infection & extraction between [2184-2-15]. # History of subluxation of the metaphalangeal joint in [2178-6-17]. # Prior history of obesity. Past Oncologic history: Initially presented in [2-/2184] with complaints of weight loss, nausea and vomiting. It seems that her symptoms were initially mild. She did not have shortness of breath, cough or other complaints at that time. By [3-/2184], she continued to lose weight and was found to have a potential right-sided dental abscess. She was treated for that empirically with antibiotics and continued to have weight loss, diarrhea. It seems that in the end of [Month (only) 958] and beginning of [5-/2184], the patient represented to medical attention with mild shortness of breath with exertion and chest discomfort. She also had noted at that point subjective low-grade temperatures and some cough productive of brown sputum. In [5-/2184], she already had a 20-pound weight loss. During the initial presentation, she also complained of one episode of hemoptysis with production of more than one teaspoon of blood. Due to the above-mentioned symptoms, the patient underwent a computer tomography of the chest on [2184-5-14] that disclosed a 2.6 cm cavitary lesion in the posterior right upper lobe with additional smaller right-sided pulmonary nodules and extensive right hilar lymphadenopathy with marked narrowing of the hilar airways and vessels. At that point, further staging imaging was obtained with a computer tomography of the torso on [2184-5-29] that disclosed the chest findings as detailed above. There was also right upper lobe pulmonary interstitial thickening, which was worrisome for lymphangitic spread. There was a subtle sclerosis of the T4 vertebral body. There was no evidence of extrathoracic disease. The adrenals had 2 cm masses. There were multiple enlarged retroperitoneal lymph nodes measuring up to 1.3 cm. An MRI of head was performed on [2184-5-29] and showed multiple areas of enhancement identifying with surrounding edema in both cerebral hemispheres as well as in the posterior fossa. The largest lesion measured 1.5 cm in the left frontal lobe. The patient had had some intermittent headaches that were thought to be migraines at that point. However, she had no problems with motor strength up to the time of initial MRI when she developed some gait instability and required a cane. She also complained of intermittent blurry vision. She was diagnosed the etiology of the brain lesions. A brain biopsy was performed on [2184-5-30]. Multiple fragments were obtained. All showed small nests of large cell undifferentiated carcinoma throughout brain lesions. D cells were positive for CK7 and TTF1. Due to the presence of nonsmall cell lung cancer with brain metastasis and edema, the patient was referred to neurooncology and radiation oncology. Whole brain radiation was started on [2184-6-5]. The patient received 3000 cGy to the brain. She was also started on dexamethasone. Her last day of radiation was [2184-6-15]. She has most recently been on a steroid taper. She is currently in the planning stages of palliative chemotherapy. Social History: Lives in [Location 1411] with fiance and three children. The patient started smoking cigarettes at age 13. ~45-pack-year history. No history of alcohol use. She has a remote history of prior intravenous drug use and cocaine use. Originally from Sicily. Moved to USA in [2135]. She worked as a domestic cleaner and had some exposure to areas affected by asbestos and heavy chemicals. She currently is out of work and living with family members. Family History: Mother, grandfather, and grandmother with DM. Father passed away at 76 due to "natural causes". Mother is 76. [Name2 (NI) ] maternal grandfather had a diagnosis of stomach cancer. Her paternal grandfather had a diagnosis of prostate cancer. Physical Exam: T: 97.6 BP: 138/70, HR: 103, RR: 20 O2 98% RA Gen: Pleasant, chronically ill appearing female, NAD HEENT: +Alopecia. MMM. OP clear. NECK: Supple. JVP low. R IJ CDI CV: RRR. nl S1, S2. No murmurs, rubs or [Last Name (un) 549] LUNGS: CTAB ABD: NABS. Soft, NT, ND. No HSM EXT: WWP, NO CCE. Full distal pulses SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Moving all extremities. Normal gait. Pertinent Results: [2184-7-7] 08:28PM GLUCOSE-111* UREA N-46* CREAT-2.3# SODIUM-132 POTASSIUM-6.0* CHLORIDE-99 TOTAL CO2-17* ANION GAP-22* [2184-7-7] 08:28PM ALT(SGPT)-29 AST(SGOT)-17 LD(LDH)-350* CK(CPK)-24* ALK PHOS-58 TOT BILI-0.2 DIR BILI-0.1 INDIR BIL-0.1 [2184-7-7] 08:28PM ALBUMIN-3.4 [2184-7-7] 08:28PM OSMOLAL-290 [2184-7-7] 08:28PM WBC-9.5 RBC-2.29# HGB-6.9# HCT-20.0# MCV-87 MCH-30.2 MCHC-34.5 RDW-17.3 [2184-7-7] 08:28PM NEUTS-82.0* LYMPHS-14.6* MONOS-1.5* EOS-1.7 BASOS-0.3 [2184-7-7] 08:28PM PLT COUNT-215 [2184-7-7] 08:28PM PT-12.4 PTT-23.1 INR(PT)-1.1 [2184-7-7] 08:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2184-7-7] 08:30PM URINE RBC->50 WBC-21-50* BACTERIA-NONE YEAST-NONE EPI-0 Imaging: ======== CXR ([7-10]): IMPRESSION: Development of focal area of increased density in the right mid lung consistent with atelectasis or consolidation. PA and lateral views may be helpful for further evaluation. Renal US [7-9]: 1. Multiple bilateral hypoechoic renal masses, consistent with known metastases. 2. Doppler ultrasound demonstrates rapid systolic upstrokes, with impaired diastolic flow, and elevated resistive indices. The main renal veins are patent. These findings most likely reflect increased vascular resistance secondary to mass effect of multiple metastatic lesions. There is no evidence for renal vein thrombosis. CXR [7-8]: Tip of the new right internal jugular line projects over the low SVC. Mediastinal widening and right hilar enlargement due to adenopathy are stable. No pneumothorax or pleural effusion. Lungs are grossly clear. Heart size normal. ECG [7-7]: NSR @ 83. Nl axis and intervals. Isolated < 1 mm STE in aVF. Compared to prior [2184-5-30], no sig change. renal u/s [7-7]: Both kidneys enlarged and heterogeneous. Both contain multiple masses with indistinct borders, some appear hypervascular. No hydronephrosis. Echogenic lesion in bladder likely representing blood clot. Pelvic US [7-7]: CT torso [6-30]: 1. Slight decrease in the size of right upper lobe lung nodules. There has been no substantial change in the appearance of the hilar and mediastinal lymphadenopathy. 2. Slight increase in the size of the bilateral adrenal lesions. 3. Increase in confluence and increase in size of some of the bilateral renal lesions. Retroperitoneal and mesenteric lymphadenopathy as before. [6-30] bone scan: No evidence of osseous metastatic disease. Abnormal uptake in the kidneys bilaterally. Recommend correlation with additional anatomic imaging, such as ultrasound, as clinically indicated. Brief Hospital Course: 44F with metastatic NSCLC (brain, bilat adrenals, bilat kidneys) p/w frank hematuria, anemia, renal failure. The bleeding was from renal mets and was localized to the L kidney based on blood seen coming from the L ureter at cystoscopy. The renal failure was believed to be due to a combination of ATN, mets, and contrast. Ultimately she was started on HD. The L kidney was embolized to prevent further bleeding. She is now HD dependent. Her hospitalization has been further complicated by pneumonia and adrenal insufficiency. Ultimately, after a trial of dialysis, the pt opted to be CMO. However, when she did not pass over a weekend, she considered this a sign that she could live longer and possbily survive cancer. A family meeting was convened and an accommodation was achieved wherein we would restart abx and try to relieve her of her anasarca using either diuretics or ultrafiltration. That said, after failing diuretics and prolonged difficulties with the dialysis catheter, another meeting was convened. Antibiotics were stopped again and the patient was returned to [Location 3225] with ultrafiltration. During an ultrafiltration treatment, she went into respiratory failure and passed. Medications on Admission: albuterol prn dexamethasone 1 mg four times daily (decreased [7-5], due to drop to 2 mg daily [7-12]) keppra 1000 mg [Hospital1 ] lisinopril 10 mg daily lorazepam 1 mg qhs prn nystatin swish and spit protonix 40 mg daily ranitidine 150 mg [Hospital1 ] tylenol prn Discharge Medications: none Discharge Disposition: Home with Service Discharge Diagnosis: Primary - Hematuria likely from a bleeding kidney metastasis Metastatic non-small cell lung carcinoma Acute renal failure requiring initiation of dialysis Acute blood loss anemia Hyperkalemia Hyponatremia Discharge Condition: deceased Discharge Instructions: You were admitted to the hospital due to hematuria and low blood counts. You were given multiple blood transfusions and eventually your hematuria stopped. You were found to have acute renal failure and eventually needed to be placed on dialysis. You developed pneumonia and received antibiotics for that. Finally, you received your first cycle of chemotherapy. Please take your medications as ordered. Call your primary doctor, or go to the emergency room if you experience fevers, chills, shortness of breath, chest pain, recurrent hematuria, dizziness, blood in your stool, dark black stool, or other concerning symptoms. Followup Instructions: n/a Completed by:[2184-8-12]	[ "584.5", "285.21", "198.0", "458.9", "275.3", "162.3", "198.7", "112.0", "427.31", "E879.8", "401.9", "996.73", "255.41", "276.6", "276.7", "287.5", "E947.8", "511.9", "285.1", "276.1", "276.2", "693.0", "348.5", "486", "493.90", "198.3", "599.70", "278.00", "E930.8", "E930.0", "V66.7" ]	icd9cm	[ [ [] ] ]	[ "96.48", "57.32", "99.05", "57.94", "99.25", "38.95", "39.95", "99.04", "38.93", "88.45", "99.07", "99.29" ]	icd9pcs	[ [ [] ] ]	11278, 11297	9715, 10919	324, 365	11546, 11556	6996, 9692	12232, 12267	6276, 6523		11249, 11255		11318, 11525		10945, 11226			11580, 12209											6538, 6977																								275, 286													393, 2438																2460, 5787	5803, 6260
23,242	151,897	7577+55847+55849	Discharge summary	report+addendum+addendum	Admission Date: [2161-1-31] Discharge Date: [2161-2-12] Date of Birth: [2085-3-28] Sex: M Service: MEDICINE Allergies: Beta-Adrenergic Blocking Agents Attending:[First Name3 (LF) 5755] Chief Complaint: Tx from [Hospital3 ] with SOB, increased sputum Major Surgical or Invasive Procedure: Interventional pulmonology procedure for trach upsizing History of Present Illness: 75 yo M with h/o COPD, OSA s/p trach, on home oxygen 10-15L via NC/trach, CHF, pulm hypertension, afib on coumadin, who presented to [Hospital3 ] hospital with 3 days of SOB, thick green sputum production. He also complains of substernal chest pain, worse with inspiration. He denies orthopnea, has intermittent swelling of the lower extremities, denies fever, chills, sick contacts. ON arrival to CCH ER he was satting 93% on 15L, BP 128/78, P 84, RR 22. He was transferred to [Hospital1 18] presumably because his pulmonary records are here. On arrival to [Hospital1 18] ER, his vitals were T 97, P 86, BP 100/57, 94% NRB. He was given lasix, azitromycin, ceftriaxone, solumedrol and nebs. He was transferred to the [Hospital Unit Name 153] given his high o2 requirement. On arrival to [Hospital Unit Name 153] he looked well but was satting mid to low 90s on NRB. We placed a trach mask on him to provide some humidified air. His ABG was 7.27/69/56. His trach was changed so we could place him on the ventilator for his hypercarbia and concern for impending hypercarbic resp failure. Past Medical History: 1. Severe COPD. FEV1 1.45 (53% predicted). Followed by Dr. [Last Name (STitle) 575] in [Hospital ] Clinic. On home oxygen via high flow NC during the day (10-15L) and trach mask at night. Home O2 sat reportedly in 87-90% range. 2. OSA, s/p tracheostomy 3. CHF, EF 40-50% [2159-6-20], repeat echo [3-24] with EF 50% 4. severe pulmonary hypertension PAP 50-55 mmHg ([6-23]), repeat echo in [3-24] shows pulmonary artery pressure to be higher but was likely underestimated in prior study 5. Chronic renal insufficiency, baseline creat ~1.2-1.3 6. Atrial fibrillation / flutter on coumadin 7. Morbid obesity 8. H/O supraventricular tachycardia; also h/o episodes of bradycardia 9. Chronic RBBB 10. History of atrial myxoma s/p resection [2148] 11. Gastroesophageal reflux disease 12. PTSD 13. S/P appendectomy 14. S/P cholecystectomy Social History: Quit TOB >15 yrs ago (smoked 1.5 ppd x ~40 yrs). Some EtOH with dinner few times per wk. Lives w/wife. Family History: NC Physical Exam: T 97.8, HR 80-90, BP 100-124/60-80, RR 20's, 85-90% NRB Gen: pleasant male, comfortable, not appearing in resp distress HEENT: JVP difficult to assess, OP clear, trach in place CV: irregular, heart sounds partially obscured by oxygen flow Resp: Crackles at bases bilaterally, decreased air movement diffusely Abd: obese, soft, nt, nd, +bs Ext: 2+ edema in lower legs Neuro: A&Ox3 Pertinent Results: [2161-1-31] CXR OSH: Moderately enlarged heart and slightly increased when compared to previous exams. Patchy densities bibasilar c/w edema vs. infiltrate. B/L small effusions. . [2161-2-2] Echocardiogram: Moderate global left ventricular systolic dysfunction (LVEF 35-40%). Dilated right ventricle with severe right ventricular systolic dysfunction. Mild aortic regurgitation. Mild mitral regurgitation. Severe tricuspid regurgitation. Pulmonary hypertension. Markedly dilated aortic root. Compared with the prior study (images reviewed) of [2160-6-3], tricuspid regurgitation severity has increased. The other findings, including left ventricular systolic function and aortic root dimensions, are similar. . [2161-2-3] Echocardiogram w/ bubble study: Agitated saline was administered, but image quality was suboptimal and no opacification was identified in the venous [Doctor Last Name 1754]. If the clinical suspicion for a paradoxical embolism is high, a TEE with agitated saline is suggested. . [2161-1-31] 07:10PM CK-MB-NotDone cTropnT-0.04* proBNP-1385* [2161-1-31] 07:10PM CK(CPK)-52 [2161-2-1] 07:22AM BLOOD CK-MB-4 cTropnT-0.04* [2161-2-1] 07:22AM BLOOD CK(CPK)-58 [2161-1-31] 07:10PM BLOOD Glucose-96 UreaN-32* Creat-1.2 Na-138 K-4.4 Cl-97 HCO3-33* AnGap-12 [2161-2-3] 03:00AM BLOOD Glucose-123* UreaN-73* Creat-3.0* Na-134 K-5.3* Cl-93* HCO3-29 AnGap-17 [2161-2-6] 05:19PM BLOOD Glucose-117* UreaN-96* Creat-2.0* Na-139 K-4.9 Cl-97 HCO3-31 AnGap-16 [2161-1-31] 07:10PM BLOOD PT-20.4* PTT-37.9* INR(PT)-2.0* [2161-2-3] 03:00AM BLOOD PT-34.9* PTT-41.4* INR(PT)-3.8* [2161-2-6] 05:19PM BLOOD PT-16.5* PTT-50.6* INR(PT)-1.5* [2161-1-31] 07:10PM BLOOD WBC-9.3 RBC-4.75 Hgb-14.2 Hct-45.2 MCV-95 MCH-29.9 MCHC-31.4 RDW-16.1* Plt Ct-197 [2161-1-31] 07:10PM BLOOD Neuts-74.3* Lymphs-18.2 Monos-5.4 Eos-1.0 Baso-1.2 Brief Hospital Course: 75 y/o M with COPD, OSA with trach, CHF with EF 50%, pulmonary hypertension who presents with worsening dyspnea, increased O2 requirement, and increased sputum production. . # SOB: Given his increased sputum production in the setting of increased oxygen requirement, precipitator of his increased SOB and hypoxemia appeared to be likley COPD flare [2-20] to tracheobronchitis. There was no clear evidence of infiltrate on CXR to suggest underlying pneumonia. He was started on azithromycin and completed a 5 day course. Sputum cultures grew pseudomonas and he was started on cefepime, on which he will remain for a 14 day course. He was originally started on IV steroids on admission, and oral taper was then initiated. His last day of steroids is [2161-2-12]. CHF seemed a less likely contributor as he had minimal bibasilar crackles on exam, borderline BNP, although CXR did show evidence of small bilateral pleural effusions and edema vs. chronic parenchymal changes. He was transiently placed on ventilator support as he was persistently hypoxemic below his baseline (nml sats at home are 87-90% on 10-15L O2 via NC) and pCO2 was also elevated beyond his baseline of 50-55. His trach, however, had persisent leak thought [2-20] to tracheomalacia. Interventional pulmonology was consulted and replaced his trach so that there was no leak around the balloon cuff. He tolerated brief AC and then PS and then was weaned to trach collar with 15L O2 via and 5L via NC with ABGs revealing baseline pCO2 and pO2. His O2 saturations have been at his baseline as well, largely 87-90% but on increased O2 support (90% via T piece) + 6 L NC. Plan to change out patient's trach for his original cuffless trach prior to discharge from rehab. . # Atrial fibrillation: He was admitted with therapeutic INR and was well rate controlled in A. fib and he is not currently on a nodal [Doctor Last Name 360] (no beta blocker given severity of COPD). Coumadin was held in the setting of the above IP procedure. He did receive vit. K at request of IP x1 and FFP periprocedure. He was restarted on home dose of coumadin (6mg) following IP procedure and is now again therapeutic. His coags will need to be followed and he should continue at current dose. . # CHF: He may have mild CHF on top of COPD flare given mild bibasilar rales. He has been restarted on his home 120mg PO lasix daily. Please follow daily weight and increase lasix prn for weight gain > 3 lbs. . # CAD: EKG on admisison was not ischemic. He has baseline troponin of 0.03-0.05 likely secondary to his CRI and was 0.04 on this admission. CKs were flat. . # Acute on chronic RF: Recent baseline over the past year appears to be approx. 1.4-1.8. Creat bumped directly following admission and UA c/w ATN. Creatinine peaked at 3.0 and has since trended downwards and he is now back at his baseline creatinine (1.1 on day of discharge). . # Metabolic alkalosis: Suspect contraction alkalosis from diuresis. Patient restarted on his standing diamox to treat. Please follow chem 7 two times weekly to monitor. . # PTSD: He is followed at the VA for his PTSD. During this hospital stay, he did have more nightmares and anxiety. He was started on seroquel qhs in addition to his prn ativan and he responded very well to this, with fewer nightmares and less anxiety. . # FEN: Evaluated by speech and swallow and tolerates regular diet even with trach with cuff up in place. Medications on Admission: 1. Coumadin 6mg qhs 2. Oxycodone prn 3. Captopril 4. Lasix 120mg QD 5. Potassium 6. Phenergan 7. Mag Oxide Discharge Medications: 1. Cefepime 1 g Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours) for 7 days. 2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [4-24] Puffs Inhalation Q4H (every 4 hours). 3. Acetazolamide 250 mg Tablet Sig: 0.5 Tablet PO Q24H (every 24 hours). 4. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 5. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day): hold for sbp < 100. 6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 7. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Warfarin 2 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain: hold for rr < 8 or oversedation. 13. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 days. 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 15. Fluticasone 110 mcg/Actuation Aerosol Sig: Eight (8) Puff Inhalation [Hospital1 ] (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital ] Hospital of [Location (un) ] & Islands - [Location (un) 6251] Discharge Diagnosis: primary: pseudomonal pneumonia acute on chronic renal failure metabolic alkalosis secondary: atrial fibrillation severe COPD cor pulmonale posttraumatic stress disorder severe obstructive sleep apnea s/p tracheostomy Discharge Condition: fair: stable on 90% Tpiece and 6 L NC, afebrile Discharge Instructions: Please monitor for increased somnolence, temperature > 101, increased sputum, shortness of breath, or other concerning symptoms. Followup Instructions: Please call to schedule follow-up with Dr. [Last Name (STitle) 575] within [3-22] weeks following discharge from rehab. Phone: ([Telephone/Fax (1) 513] Name: [Known lastname 4785],[Known firstname ] [Initial (NamePattern1) ] [Last Name (NamePattern1) 201] Unit [Name2 (NI) ]: [Numeric Identifier 4786] Admission Date: [2161-1-31] Discharge Date: [2161-2-12] Date of Birth: [2085-3-28] Sex: M Service: MEDICINE Allergies: Beta-Adrenergic Blocking Agents Attending:[First Name3 (LF) 4787] Addendum: Discussed case with patient's primary pulmonologist who reviewed the CXR and sputum culture. He would recommend not continuing vancomycin. Please do aggressive pulmonary toilet, including chest PT to aid with mucous clearance to decrease risk of recurrent mucous plugging. Discharge Disposition: Extended Care Facility: [Hospital ] Hospital of [Location (un) 776] & Islands - [Location (un) 777] [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 4788] MD [MD Number(2) 4789] Completed by:[2161-2-12] Name: [Known lastname 4785],[Known firstname ] [Initial (NamePattern1) ] [Last Name (NamePattern1) 201] Unit [Name2 (NI) ]: [Numeric Identifier 4786] Admission Date: [2161-1-31] Discharge Date: [2161-2-12] Date of Birth: [2085-3-28] Sex: M Service: MEDICINE Allergies: Beta-Adrenergic Blocking Agents Attending:[First Name3 (LF) 4787] Addendum: On day of anticipated discharge, patient had acute desaturation to 69%. Oxygen saturation improved back to baseline with suctioning by respiratory. I suspect this was mucous plugging. CXR post event shows no evidence of collapse but was concerning for new right lower lobe atelectasis versus infiltrate. However, given patient report of chest congestion, vancomycin was added to his medication regimen, but no gram positive cocci seen on repeat sputum culture (just 1+ budding yeast). Plan to treat with the vancomycin for 10 days. Patient had another desaturation this morning after accidental disconnection from supplemental O2 via T piece. His oxygen saturation returned to baseline after reconnection. Otherwise, his sats have been stable at 90% on 90% T piece and 6 L NC. Of note, patient's PICC line placement has been confirmed by CXR. Discharge Disposition: Extended Care Facility: [Hospital ] Hospital of [Location (un) 776] & Islands - [Location (un) 777] [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 4788] MD [MD Number(2) 4789] Completed by:[2161-2-12]	[ "426.4", "V15.82", "585.9", "424.2", "428.0", "428.20", "584.5", "530.81", "491.21", "276.3", "518.81", "519.01", "327.23", "482.1", "519.19", "309.81", "278.01", "416.8", "V58.61", "427.31" ]	icd9cm	[ [ [] ] ]	[ "38.91", "93.96", "96.72", "38.93", "99.07", "33.21", "97.23", "99.21" ]	icd9pcs	[ [ [] ] ]	12997, 13268	4896, 8351	344, 401	10287, 10337	2977, 4873	10515, 11394	2557, 2561		8509, 9890		10046, 10266		8377, 8486			10361, 10492											2576, 2958																								253, 306													429, 1538																1560, 2421	2437, 2541
50,579	126,977	42476	Discharge summary	report	Admission Date: [2102-1-26] Discharge Date: [2102-1-31] Service: SURGERY Allergies: Lithium Attending:[First Name3 (LF) 1390] Chief Complaint: s/p Motor vehicle crash Major Surgical or Invasive Procedure: Epidural catheter placement History of Present Illness: [Age over 90 ] year old female who is s/p motor vehicle crash as a front passenger on a highway. She was one of three people in the car when the vehicle suffered major damage. The patient was taken to [Hospital 487] Hospital, where CXR and head CT were performed. Her CXR was positive for multiple rib fractures, and head CT was negative. She apparently had free fluid in her abdomen on CT scan. She had an initial blood pressure of 80, thereafter was normotensive. No new issues on transfer via med flight to [Hospital1 18]. Past Medical History: PMH: HTN, bipolar (on ECT) PSH: port-a-cath; urethral sling Social History: Lives in independent living facility alone. Family History: Noncontributory Physical Exam: Upon presentation: HR: 85 BP: 97/48 Resp: 21 O(2)Sat: 100 Normal Constitutional: Not ill appearing, mildly uncomfortable in pain HEENT: Hematoma over left forehead and blood around mouth. No blood in mouth. Teeth intact. Cervical collar in place Chest: Lungs with diminished sounds, diminished expansion, tender bilaterally but not free-floating rib cage Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nontender, rib fractures Pelvic: Pelvis is stable Rectal: good rectal tone Extr/Back: 2+ pedal pulses bilaterally, ecchymosis to left shin, abrasion to left thigh, abrasion on left arm with ecchymosis, abrasion and ecchymosis on right hip and knee. Skin: Warm and dry Neuro: Speech fluent; GCS 13. moving all extremities. Psych: Normal mentation Pertinent Results: [2102-1-26] 03:22PM GLUCOSE-208* LACTATE-4.0* NA+-142 K+-3.6 CL--107 TCO2-24 [2102-1-26] 03:22PM WBC-20.0* RBC-3.11* HGB-9.4* HCT-28.8* MCV-93 MCH-30.1 MCHC-32.4 RDW-13.1 [2102-1-26] 03:22PM PLT COUNT-286 [2102-1-26] 03:22PM PT-10.8 PTT-26.3 INR(PT)-1.0 CT Head [1-26] - no acute intracranial processes CT C spine [1-26] - no fracture or malalignment - normal prevertebral soft tissues with degenerative changes. CT chest/abd/pelvis [1-26] - Multiple rib fractures as described above with possible splenic(and less likely hepatic) lacerations with hemoperitoneum tracking along the right colon and jejunum concerning for bowel injury MRI cervical spine IMPRESSION: 1. No acute fracture, malalignment, or ligamentous injury. There is no evidence of cord edema or epidural hematoma. 2. Multilevel degenerative changes as described above. 3. Multiloculated cystic left parotid mass could be a lymphatic malformation or pleomorphic adenoma. 4. Two thyroid nodules. Brief Hospital Course: She was admitted to the Acute Care Surgery team for her rib fractures and spleen injury. Initially she was transferred to the Trauma ICU for close monitoring. Serial exams and hematocrits were followed closely and remained stable. Once hemodynamically stable she was transferred to the floor. She was noted with some mental status changes - a chest xray and urine were sent. She was found to have a positive urinalysis and a consolidation on chest xray concerning for likely pneumonia. She was started on Levaquin for of total 5 days. Her sodium was also noted to be elevated during her stay and she was given IV fluids - on [1-31] her Na normalized at 145. The Acute Pain service was consulted for epidural catheter for her rib fractures. This remained in place for several days and was then removed. Standing Tylenol and Ultram were then started along with Lidoderm patch over the rib fracture sites. She was evaluated by Physical therapy and is being recommended for rehab after her acute hospital stay. Her home medications were restarted and she is tolerating a regular diet. Medications on Admission: HCTZ 25', Metop 50', lamictal 225', seroquel 150', alendronate weekly Discharge Medications: 1. Lamictal 150 mg Tablet Sig: 1.5 Tablets PO once a day. 2. quetiapine 150 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO HS (at bedtime). 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 4. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 5. tramadol 50 mg Tablet Sig: 0.5 Tablet PO QID (4 times a day). Disp:120 Tablet(s) Refills:0 6. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): please apply to chest wall bilat over rib fracture sites . 7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection [Hospital1 ] (2 times a day). 8. levofloxacin 250 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): stop date [2102-2-2] after last dose . 9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 10. senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day as needed for constipation. Discharge Disposition: Extended Care Facility: The Meadows - [Location 9583] Discharge Diagnosis: s/p Motor vehicle crash Injuries: Grade III splenic laceration Ribs fractures [7-22] on right & [3-22] on left Pneumonia Urinary tract infection Delirium Hypernatremia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital after a motor vehcile crash where you sustained multiple injuries including rib fractures on both sides of your chest and an injury to your spleen. You did not require any operations for these injuries. You were seen by the pain specialist an a deviec called an epidural catheter was inserted into your back where medications to help control your pain from the rib frastures were administered. You were seen by the Physical and Occupational therapists who have recommneded that you go to a rahb facility after hospital discharge. Followup Instructions: * Department: GENERAL SURGERY/[Hospital Unit Name 2193] When: TUESDAY [2102-2-14] at 3:15 PM With: ACUTE CARE CLINIC/ Dr. [Last Name (STitle) ] Phone:[Telephone/Fax (1) 600] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage *You will need a chest x-ray prior to this appointment. Please go to [Hospital1 7768], [Hospital Ward Name 517] Clinical Center, [Location (un) ] Radiology 60 minutes prior to your appointment. Please discuss with the staff at the facility the need for a follow up appointment with your PCP when you are ready for discharge. Completed by:[2102-1-31]	[ "599.0", "276.0", "958.4", "807.08", "401.9", "868.03", "338.11", "E812.1", "296.80", "920", "865.00", "486", "293.0" ]	icd9cm	[ [ [] ] ]	[ "38.91", "03.90" ]	icd9pcs	[ [ [] ] ]	5137, 5197	2870, 3959	238, 268	5417, 5417	1846, 2847	6184, 6912	996, 1013		4079, 5114		5218, 5396		3985, 4056			5595, 6161											1028, 1827																								175, 200													296, 836										5432, 5571						858, 919	935, 980
27,809	170,734	26691	Discharge summary	report	Admission Date: [2161-9-4] Discharge Date: [2161-9-10] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2145] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [Known lastname 65783] is an 84-year-old woman with a history of COPD, schizophrenia, DM, HTN, and colon cancer, and recent admission to [Hospital1 18] for gastroenteritis, who presents today from a group home with a report of altered mental status. . Pt felt good on discharge from the hospital until the morning of admission, when (as per the care givers) she slept much longer than normal, and was not "acting normal." She did not wash herself or get dressed. She also had difficulty doing her finger stick and seemed confused about how to use her glucometer. She was able to speak and walk normally. When she did not improve, her care givers called EMS. According to EMS, her FS glucose was 217 at that time. . On arrival in the ED she was febrile to 101.3, tachycardic to the 110's, hypotensive to 85/32, respiration rate of 35, and sating 84%. She was given IVF and O2. At that time it was noted that she was not responding appropriately to questions or following commands. She was also noted to be falling to the R side. A neuro consult was called and she was sent to head CT. Ultimately, head CT and neuro exam were normal. A chest x-ray taken at that time showed a left lower lobe infiltrate. Her labs were notable for a WBC of 13.3 with 92% PMN, BNP 70, and WNL ABG. She was started on azythromycin, ceftriaxone, combivent nebs, solumedrol, and tylenol and given a total of 2L NS. She was admitted to the MICU for observation given concern for respiratory failure . On admission to the MICU her temperature was 96.5, pulse 104, BP 123/52, respiration rate 22, satting 91% on 4L. On questioning she was oriented to person and time. She complained of SOB on questioning but denied that this is any different from her normal level of SOB. She reports DOE and occassional cough. She says that she has coughed up blood in the past, but not recently. She reports smoking 2.5 packs of cigarettes per day for many years, but cannot recall how many. She also says that she gets occassional chest pain, but none today. She generally gets chest pain when walking. She reports a few days of diarrhea, but cannot recall how long or how frequent. She denied bloody diarrhea. Past Medical History: - COPD - DM - HTN - Schizophrenia - Colon CA s/p resection. - Bilateral cataract surgery [66] yrs ago - Psoriasis Social History: Occupation: retired nurse . Drugs: denies . Tobacco: by report >60 pack years - pt reports long term smoking of 2.5 packs per day but not how long . Alcohol: denies . Other: Pt lives in a psychatric/dementia facility. She used to work as nurse [First Name8 (NamePattern2) ] [Last Name (Titles) 4628] Nursing Home, stopped at age 65. Family History: Noncontributory. Physical Exam: Tmax: 35.8 ??????C (96.5 ??????F) Tcurrent: 35.8 ??????C (96.5 ??????F) HR: 96 (96 - 104) bpm BP: 109/50(64) {109/45(64) - 126/52(67)} mmHg RR: 26 (22 - 28) insp/min SpO2: 94% Heart rhythm: SR (Sinus Rhythm) Height: 60 Inch . General Appearance: Well nourished, No acute distress, Overweight / Obese, smiling, inappropriate affect . Eyes / Conjunctiva: No(t) PERRL, No(t) Pupils dilated, Conjunctiva pale, pupils poorly reactive to light . Head, Ears, Nose, Throat: Normocephalic, Poor dentition, No(t) Endotracheal tube, No(t) NG tube, No(t) OG tube . Lymphatic: Cervical WNL, Supraclavicular WNL, no axillary LAD . Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t) Absent), (S2: Normal), (Murmur: No(t) Systolic, No(t) Diastolic) . Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present), carotid and temporal pulses 2+ bilat . Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical), (Percussion: Resonant : , No(t) Dullness : ), (Breath Sounds: No(t) Clear : Distant, No(t) Crackles : , No(t) Bronchial: , Wheezes : on the left, No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: ) . Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended, No(t) Tender: , Obese . Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, Clubbing . Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand, strength 5/5 throughout . Skin: Warm, No(t) Rash: , No(t) Jaundice . Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Oriented (to): person and time, Movement: Purposeful, No(t) Sedated, No(t) Paralyzed, Tone: Normal Pertinent Results: LABS ON ADMISSION ([2161-9-4]): . HEMATOLOGY: [2161-9-4] 12:30PM BLOOD WBC-13.3# RBC-4.76 Hgb-15.1 Hct-42.4 MCV-89 MCH-31.6 MCHC-35.5 RDW-13.5 Plt Ct-233 [2161-9-4] 12:30PM BLOOD Neuts-92.3* Lymphs-4.8* Monos-2.4 Eos-0.2 Baso-0.3 [2161-9-4] 12:30PM BLOOD PT-13.7* PTT-26.5 INR(PT)-1.2* . CHEMISTRY: [2161-9-4] 12:30PM BLOOD Glucose-204* UreaN-19 Creat-0.8 Na-136 K-4.5 Cl-98 HCO3-29 AnGap-14 [2161-9-4] 12:30PM BLOOD ALT-52* AST-34 LD(LDH)-192 CK(CPK)-29 AlkPhos-151* TotBili-1.8* [2161-9-4] 12:30PM BLOOD Lipase-11 [2161-9-4] 12:30PM BLOOD CK-MB-NotDone proBNP-70 [2161-9-5] 03:51AM BLOOD Albumin-3.7 Calcium-9.3 Phos-2.0* Mg-1.8 [2161-9-4] 12:26PM BLOOD Lactate-1.3 . URINE: [2161-9-4] 12:50PM URINE Color-Amber Appear-Clear Sp [Last Name (un) ]-1.008 [2161-9-4] 12:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-8* pH-6.0 Leuks-NEG . LABS ON DISCHARGE: ([9-10]) HEMATOLOGY: [2161-9-9] 07:20AM BLOOD WBC-7.0 RBC-4.24 Hgb-13.1 Hct-37.4 MCV-88 MCH-30.9 MCHC-34.9 RDW-13.5 Plt Ct-234 . CHEMISTRY: [2161-9-9] 07:20AM BLOOD Glucose-155* UreaN-12 Creat-0.6 Na-141 K-3.8 Cl-102 HCO3-32 AnGap-11 [2161-9-9] 07:20AM BLOOD Calcium-9.1 Phos-2.6* Mg-1.8 . . LIPID PANEL: [2161-9-7] 06:45AM BLOOD Triglyc-152* HDL-46 CHOL/HD-3.2 LDLcalc-73 . . . MICROBIOLOGY: Urine Cx - negative Legionella Urinary Ag (Type 1) - negative . . . CARDIOLOGY: EKG ([2161-9-4]): Sinus tachycardia. Otherwise, findings are within normal limits. . . . RADIOLOGY: CT Head w/o contrast ([2161-9-4]): IMPRESSION: No acute intracranial abnormalities. . CAROTID DOPPLER U/S: IMPRESSION: Less than 40% stenosis of the internal carotid arteries bilaterally. This is a baseline examination at the [Hospital1 18]. . CXR AP ([2161-9-4]): IMPRESSION: Added density in the left lower lobe suggestive of infection. Brief Hospital Course: In summary, Ms [Known lastname 65783] is an 84-y/o woman with COPD, DM2, HTN, SCZ, colon cancer, and recent admission to [Hospital1 18] for gastroenteritis, who originally presented from a group care home with fever, diarrhea, altered mental status, and was found to have community-acquired PNA. . # COPD exacerbation w/ PNA: Pt w baseline COPD presented with altered mental status, fever, hypoxemia (baseline SaO2 of 92% on RA, on admission 88% on 4L), and respiratory distress. Found to have leukocytosis (WBC=13) and LLL infiltrate on CXR Met SIRS criteria, so admitted to the MICU, but quickly stabilized with hydration and was then transferred to the floor. She was treated with ceftriaxone 1g IVq24hrs x 5 days for community-acquired PNA and azythromycin 250mg POq24hrs x 5 days for question Legionella given PNA and diarrhea. Urinary antigen for Legionella returned negative. She was then switched to levofloxacin 750mg PO daily for an additional 2 days, for a total of 7 days of abx treatment. On admission, she was also started on methylpred 125mg IVq8 then switched to PO 60mg prednisone because she clinically did not need IVs, which was then tapered as her condition improved. She was continued on home nebs with fluticasone, ipratropium, albuterol, and salmeterol throughout her stay. Pt afebrile, hemodynamically stable and with baseline oxygenation on discharge. . # Diarrhea: Likely secondary to acute stress from PNA/respiratory distress. Legionella antigen negative. C. diff was also considered given recent admission and the fact that she lives at a group home. Hx of diarrhea from Pt not reliable. Group home does not report diarrhea and had regular bowel movements on the floor. . # DM: Home glyburide held on admission and pt was covered with insulin sliding-scale until her condition improved. Glyburide was restarted once her condition improved. Sliding-scale insulin is to be continued until blood glucose levels normalize s/p prednisone. . # HTN: Pt continued on verapamil. Normotensive on discharge. . # Schizophrenia: Pt with h/o of SCZ on neuroleptics, continued home risperidone, no acute changes. . # Toxic encephalopathy: Pt presented with altered mental status and possible right-sided weakness. Neurology was consulted and a stroke evaluation was performed, which showed no acute neurological deficits. Head CT (no acute intracranial processes) and a carotid U/S (40% stenosis b/l). Pt neurologically stable during the admission, on aspirin 325mg QD. . # Unclear hx CHF in prior OMR summaries. Not fully documented, no echo here. Unclear if real diagnosis. Consider outpt eval. Pt with no signs CHF here. Medications on Admission: Aspirin 325mg PO daily Verapamil SR 180mg PO daily Glyburide 5mg PO QAM Risperidone 1mg PO QAM, 2mg PO QPM Ranitidine 150mg PO BID Loperamide 2mg PO BID Acetaminophen 500mg PO q8h:PRN for fever/pain Mupirocin Calcium 2% cream 1 application TP [Hospital1 ] Ammonium Lactate 12% Lotion 1 Appl TP [Hospital1 ] PRN for dry skin Betamethasone 0.05% Cream 1 Appl TP [Hospital1 ] PRN for itching Fluticasone [Flovent] 220 mcg/Actuation Aerosol 2 Puff Inh [Hospital1 ] Salmeterol 50 mcg/Dose Disk with Device 1 Inh Q12H Ipratropium-Albuterol [Combivent] 103-18 mcg/Actuation Aerosol 2 puffs PO TID:PRN for breathing Discharge Medications: 1. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation Q12H (every 12 hours). 4. Risperidone 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Risperidone 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Ammonium Lactate 12 % Lotion Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed. 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Betamethasone Dipropionate 0.05 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed. 9. Glyburide 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 10. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). 11. Loperamide 2 mg Tablet Sig: One (1) Tablet PO twice a day. 12. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO TID:PRN as needed for fever or pain. 13. Fluticasone 220 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation twice a day. 14. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation TID:PRN as needed for shortness of breath or wheezing. 15. Salmeterol 50 mcg/Dose Disk with Device Sig: Two (2) puffs Inhalation twice a day as needed for shortness of breath or wheezing. 16. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO daily () for 2 doses: [9-10] and [9-11]. 17. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO daily () for 2 doses: [9-12] and [9-13]. 18. Prednisone 20 mg Tablet Sig: One (1) Tablet PO daily () for 2 doses: [9-14] and [9-15]. 19. Prednisone 10 mg Tablet Sig: One (1) Tablet PO daily () for 2 doses: [9-16] and [9-17]. 20. Prednisone 5 mg Tablet Sig: One (1) Tablet PO daily () for 2 doses: [9-18] and [9-19]. 21. Insulin Regular Human 100 unit/mL Solution Sig: as directed Injection four times a day for 7 days: Please use a sliding-scale according to the attached. . Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 731] Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Pneumonia 2. Acute COPD Exacerbation 3. Diabetes Mellitus . SECONDARY DIAGNOSIS: HTN Psoriasis Schizophrenia Discharge Condition: Afebrile, hemodynamically stable, oxygenating at baseline Discharge Instructions: You were admitted to the hospital with shortness of breath due to pneumonia and a COPD exacerbation. We treated you with antibiotics and steroids and your breathing has improved significantly. . We have added the following medications to your regimen: - prednisone - we gave you this medication to treat COPD exacerbation, now we are tapering the doses through 9/6/8 - insulin - we have added insulin to better control your sugar while you are on prednisone. . If you have fever, shortness of breath, chest pain, diarrhea, weakness, confusion, language problems, new neurological deficits or any other symptoms that concern you, please call your physician [Name Initial (PRE) 2227]. Followup Instructions: Provider: [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) 122] [Last Name (NamePattern1) 8499], [Telephone/Fax (1) 7976]. Appointment on [9-17] @ 3:45pm, [Hospital1 ], [Location (un) 686], MA. . Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 7449], MD Phone:[Telephone/Fax (1) 1971] Date/Time:[2161-10-8] 11:15 . Provider: [Name10 (NameIs) ] IMAGING Phone:[Telephone/Fax (1) 253] Date/Time:[2161-11-19] 10:00 [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2158] Completed by:[2161-9-10]	[ "491.21", "401.9", "V10.05", "250.02", "305.1", "295.62", "787.91", "486", "349.82" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	12048, 12143	6659, 9310	283, 289	12318, 12377	4736, 5667	13112, 13730	3017, 3035		9984, 12025		12164, 12164		9336, 9961			12401, 13089											3050, 4717																								222, 245				5686, 6636									317, 2501			12267, 12297				12183, 12246									2523, 2643	2659, 3001
6,579	115,553	25951	Discharge summary	report	Admission Date: [2112-11-30] Discharge Date: [2112-12-7] Date of Birth: [2078-1-21] Sex: M Service: MEDICINE Allergies: Clindamycin Attending:[First Name3 (LF) 4654] Chief Complaint: Fall, nausea and vomiting secondary to alcohol use. Major Surgical or Invasive Procedure: Flexible bronchosopy ([2112-12-1]). History of Present Illness: 34 y/o gentleman with known alcohol abuse was found down in his bathroom with vomit and blood around him. His landlord called police after a water leak from his apartment. Patient was transfered to [Hospital3 ] and was found to have two seizure episodes en route. Patient received IVF greater than 1 L NS (unclear amount), thiamine 100 mg and 1 mg folate. Patient also received 10 mEq KCl, 40 mg IV pantoprazole and Zosyn 3.375 gm IV once. CXR there showed pneumomediastimum without pneumothorax and he was transfered to [Hospital1 18] ED. . In [Hospital1 18] ED his vitals were T 98.2 HR 92 BP 124/50 RR 16 O2 sat 98%. Patient was alert and oriented times three but was a poor historian. His family saw him and thought that he was at baseline. He has had trouble giving history and recalling events at baseline per family. Patient was given metronidazole 500 mg IV, Fluconazole 200 mg IV and vancomycin 1 gram IV. He also received 1 unit of PRBC. His urine output was greater than 700 ml in ED over approx 4 hours. Thoracics was consulted who recommended a barium swallow study. Preliminary read was some distal filling defect without any extravasation. Recommended GI consult. . On arrival to the MICU his vitals were T 95.9 HR 89 BP 156/53 RR 15 100% 4LNC. Patient denies any acute distress. He states that he was aware of EMS coming into his house. He states that he might have had a seizure this morning. He also had a seizure one week ago. He has had episodes of binge drinking. His last drink was three days ago per patient. He drank greater than 1 bottle of Vodka that night but unable to quantify. He denies any fever, chills, chest pain, shortness of breath, nausea, abdoinal pain, dysuria, diarrhea, constipation, focal numbness or weakness. He has noticed dark urine and dark colored stool in the last two days. He has depressed mood per family history after losing his job recently. Patient denies any suicidal ideation. Past Medical History: Alcohol abuse SDH in [2109] secondary to fall Known alcohol withdrawl seizures Otherwise denies any medical problems Social History: Works in construction. 20 pack/year tobacco. Drinks ETOH in binges. Family History: Noncontributory. Physical Exam: Vitals: T 95.9 HR 89 BP 156/53 RR 15 100% 4LNC Gen: Alert and oriented x 3 (not date but month/year). Poor historian. NAD HEENT: PEERL, EOM-I, Mucous membranes are dry, bruise in lower lip, JVP not elevated Lungs: Clear to auscultate bilaterally Heart: Tender to palpate in left chest wall, S1S2 RRR, no MRG Abdomen: BS present, soft NTND Ext: WWP, DP 2+ Neuro: CN II-XII grossly intact, strength 5/5, sensation is intact, normal muscle tone. Pertinent Results: Complete blood count [2112-11-30] 10:01PM BLOOD WBC-10.0 RBC-2.96# Hgb-10.2# Hct-26.0# MCV-88 MCH-34.4 MCHC-39.1* RDW-13.0 Plt Ct-145* [2112-12-1] 03:07AM BLOOD WBC-9.5 RBC-3.02* Hgb-10.2* Hct-26.1* MCV-87 MCH-33.7* MCHC-38.9* RDW-13.8 Plt Ct-155 [2112-12-2] 05:15AM BLOOD WBC-9.2 RBC-3.05* Hgb-10.1* Hct-28.0* MCV-92 MCH-33.1* MCHC-36.0* RDW-13.4 Plt Ct-200 [2112-12-3] 06:05AM BLOOD WBC-6.9 RBC-2.98* Hgb-10.0* Hct-27.3* MCV-92 MCH-33.5* MCHC-36.5* RDW-13.9 Plt Ct-199 [2112-12-4] 05:10AM BLOOD WBC-7.2 RBC-2.99* Hgb-10.3* Hct-28.1* MCV-94 MCH-34.6* MCHC-36.8* RDW-14.0 Plt Ct-267 . Liver function and coags [2112-11-30] 04:25PM BLOOD ALT-52* AST-131* CK(CPK)-8404* AlkPhos-41 TotBili-1.6* [2112-12-1] 12:44PM BLOOD ALT-54* AST-115* AlkPhos-33* TotBili-1.0 [2112-12-2] 05:15AM BLOOD ALT-56* AST-130* LD(LDH)-372* CK(CPK)-2634* AlkPhos-36* TotBili-1.0 [2112-12-4] 05:10AM BLOOD ALT-49* AST-66* CK(CPK)-615* AlkPhos-33* TotBili-0.3 [2112-11-30] 04:25PM BLOOD PT-13.5* PTT-22.2 INR(PT)-1.2* [2112-12-1] 03:07AM BLOOD PT-12.6 PTT-20.7* INR(PT)-1.1 [2112-12-2] 05:15AM BLOOD PT-12.1 PTT-22.1 INR(PT)-1.0 . Renal function and electrolytes [2112-11-30] 04:25PM BLOOD Glucose-102 UreaN-149* Creat-3.1# Na-126 K-2.6* Cl-72* HCO3-41* AnGap-16 [2112-11-30] 10:01PM BLOOD Glucose-93 UreaN-110* Creat-2.3* Na-135 K-2.8* Cl-89* HCO3-36* AnGap-13 [2112-12-1] 03:07AM BLOOD Glucose-93 UreaN-86* Creat-2.0* Na-140 K-3.0* Cl-95* HCO3-37* AnGap-11 [2112-12-1] 12:44PM BLOOD Glucose-82 UreaN-59* Creat-1.6* Na-143 K-3.0* Cl-99 HCO3-35* AnGap-12 [2112-12-1] 11:50PM BLOOD Glucose-80 UreaN-36* Creat-1.2 Na-139 K-2.7* Cl-97 HCO3-33* AnGap-12 [2112-12-2] 05:15AM BLOOD Glucose-75 UreaN-27* Creat-1.2 Na-138 K-2.9* Cl-98 HCO3-32 AnGap-11 [2112-12-2] 12:48PM BLOOD Glucose-87 UreaN-19 Creat-1.0 Na-134 K-3.4 Cl-98 HCO3-29 AnGap-10 [2112-12-3] 06:05AM BLOOD Glucose-92 UreaN-10 Creat-1.1 Na-137 K-3.0* Cl-101 HCO3-30 AnGap-9 [2112-12-4] 05:10AM BLOOD Glucose-134* UreaN-6 Creat-1.0 Na-137 K-3.9 Cl-107 HCO3-25 AnGap-9 [2112-11-30] 10:01PM BLOOD Albumin-2.8* Calcium-6.6* Phos-2.5# Mg-3.1 [2112-12-1] 03:07AM BLOOD Albumin-3.0* Calcium-7.2* Phos-1.8* Mg-3.3* [2112-12-4] 05:10AM BLOOD Calcium-7.9* Phos-1.6* Mg-1.8 . Cardiac enzymes [2112-11-30] 04:25PM BLOOD CK-MB-19* MB Indx-0.2 [2112-11-30] 04:25PM BLOOD cTropnT-0.05* [2112-11-30] 10:01PM BLOOD CK-MB-14* MB Indx-0.2 cTropnT-0.04* . Anemia studies [2112-12-1] 03:07AM BLOOD calTIBC-291 VitB12-878 Folate-12.0 Ferritn-377 TRF-224 Iron-42* . Serum toxicology [2112-11-30] 04:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . Electrocardiogram ([2112-11-30]) Sinus rhythm. Non-specific ST-T wave changes. Compared to the previous tracing ST-T wave changes are new. . Imaging Barium swallow ([2112-11-30]) IMPRESSION: 1. No extraluminal contrast appreciated. No evidence for esophageal perforation. 2. Filling defect in the distal esophagus persistent on all images and associated with a delay in clearance of the esophagus. This is concerning for food/other impacted material, and endoscopic evaluation is recommended. . Abdominal ultrasound ([2112-12-1]) IMPRESSION: No evidence of fluid or hemorrhage. . CXR pa and lateral ([2112-12-1]) IMPRESSION: Slight improvement in pneumomediastinum. Left lower lobe opacification remains the same and is most likely atelectasis versus aspiration. . CT chest with po contrast ([2112-12-2]) IMPRESSION: 1. Findings do not suggest active esophageal perforation or mediastinal infection: interval decrease in pneumomediastinum, no extravasation of oral contrast or dominant periesophageal gas collection, no mediastinal fluid collection. The presence of a small esophageal tear is better evaluated endoscopically. 2. Normal esophagus. Small hiatal hernia. 3. New bibasilar peribronchial infiltrates may represent aspiration versus atelectasis. Minimal right pleural effusion. Brief Hospital Course: A 34 year-old gentleman with alcohol abuse presents with seizure, pneumomediastinum, acute renal failure and rhabdomyolysis. . 1. Pneumomediastium / ?esophageal tear / ?mediastinitis Possibly secondary to alcohol withdrawal seizure versus esophageal tear during emesis. Distal barium filling defect on barium swallow raised concern of distal esophageal origin. . On admission to the ICU, the patient was afebrile and hemodynamically stable. Thoracic surgery was consulted in the ED and felt surgery was not indicated. Vancomycin, Zosyn and fluconazole were initiated. Interventional pulmonary performed a bronchoscopy showing normal anatomy and no evidence of tear or rupture. GI was also consulted and recommended NPO and intravenous PPI. Endoscopy was deferred in order to avoid risk of any further damage to the esophagus. A repeat CXR showed a stable pneumomediastinum. Fluconazole was discontinued after discussion with ID. . Patient spent one night in the ICU after which he underwent CT chest with po contrast showing no esophageal leak and resolving pneumomediastinum. He was then transferred to the medical floors with stable vitals. Per GI recommendations, his diet was progressed slowly to cold clears, then full clears, then solids. His antibiotics were switched to Augmentin and Flagyl for presumptive treatment of mediastinitis eventhough there was no radiographic evidence to suggest inflammation to the mediastinum. He will complete a ten day course of antibiotics. . GI has recommended that patient undergo upper endoscopy as outpatient, once stabilized, for close evaluation for esophageal tear. . 2. Rhabdomyolysis. This was felt to be secondary to his fall and seizures. He was treated with IV fluids and his CK normalized. . 3. Acute renal failure. This was felt to be secondary to dehydration and rhabdomyolysis; his admission FeNa was c/w prerenal azotemia. His creatinine normalized with IV hydration. He maintained a good urine output. . 4. Alcohol dependence and withdrawal. Per OSH report, he had seizures en route to the ED from his apartment, most likely due to alcohol withdrawl. On admission to this hospital CIWA protocol was instituted and he was monitored on telemetry. His serum toxicology was negative on admission. . Upon transfer to the floors, his CIWA scores were consistently less than 10. However, he was intermittently tachycardic and as he was 48-72 hours after his last drink, with a history of DTs and withdrawal seizures, he was started on standing Valium with a slow taper. He was monitored on telemetry and there was no seizure activity. There were no hallucinations. . He was treated with IV hydration, multivitamin, thiamine, and folate from time of admission. Social work was consulted and provided information regarding detox programs. . 5. Anemia. His hematocrit was stable in the high 20s during this admission. He was guiaic positive stool in ED and noted to have tarry stools by GI service. An abdominal ultrasound was negative for intra-abdominal bleed. His iron was 42 with a TIBC of 291 and ferritin of 277, suggestive of mild iron deficiency. B12 an folate were normal. He will need to have endoscopy and colonoscopy as outpatient to work-up GI bleed. . 6. Depression. Patient may benefit from psychiatric consult as outpatient. . 7. Dizziness. He developed dizziness after transfer to the floors from the intensive care unit. His description was consistent with BPPV, brought on with rapid head movements, position changes in bed, or shifts from supine to standing. [Last Name (un) ]-hallpike maneuver demonstrated lateral nystagmus and reproducibility of dizziness. Epley meneuver was moderatly thereapeutic, although this did not entirely cure his symptoms. We believe he may have BPPV secondary to head trauma prior to admission. As there were no other neuorologic symptoms and CT at OSH was negative, we did not feel follow-up imaging was warranted. His dizziness quickly resolves after head movement ceases, he is able to ambulate, and overall his symptoms have been improving gradually since onset about five days prior to discharge. He has been cleared by physical therapy. . He was NPO initially and his diet progressed slowly as tolerated. Electrolytes were repleted as needed. Subcutaneous heparin was used for venous thrombosis prophylaxis. His code status is full code. Medications on Admission: None Denies any OTC/herbal Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 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. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days: last day [12-17]. Disp:20 Tablet(s) Refills:0 6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 10 days: last day [12-17]. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses Alcohol withdrawal Pneumomediastinum likely secondary to small esophageal tear Rhabdomyolysis Acute renal failure . Secondary Diagnoses Alcohol dependence Discharge Condition: Vital signs stable. Afebrile. Discharge Instructions: You were hospitalized for treatment of nausea and vomiting. There was air in the space surrounding the heart, which may be due to leak from the esophagus while you were vomiting. Recent imaging shows that the air has almost entirely gone away. Furthermore, there is no leak in the esophagus seen on recent imaging. It is possible that this leak has healed. Bronchoscopy was performed while you were in the intensive care unit to look at the airways. There were no abnormalities detected. . We have started you on antibiotics to treat infection from the esophageal leak. In order to complete a ten-day course, please take clindamycin and Augmentin for 10 more days. We have also given you prescriptions for vitamins and a medicine called pantoprazole to help decrease acid secretion in the stomach. . You met with our social worker while you were in the hospital and she helped you arrange for a place to stay. You planned to go to Place of Promise on the day after leaving the hospital. . Please follow-up with your primary care provider. [Name10 (NameIs) ] should have an upper endoscopy performed as an outpatient to look at the esophagus, stomach, and first part of the small intestine. . Please call your doctor or return to the emergency room if you have any bleeding, belly pain, or any other symptoms that are concerning to you. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) ] in the next two weeks [0-0-]. You need to have upper endoscopy performed as outpatient. [First Name8 (NamePattern2) ] [Name8 (MD) 474] MD [MD Number(2) 4658] Completed by:[2112-12-7]	[ "V60.0", "303.92", "386.11", "518.1", "584.9", "728.88", "276.8", "276.9", "780.39", "311", "276.1", "285.9", "291.81", "530.7" ]	icd9cm	[ [ [] ] ]	[ "33.22" ]	icd9pcs	[ [ [] ] ]	12375, 12381	7125, 11500	325, 367	12598, 12631	3085, 7102	14026, 14313	2588, 2607		11578, 12352		12402, 12577		11526, 11555			12655, 14003											2622, 3066																								234, 287													395, 2342																2364, 2487	2503, 2572
17,393	124,071	27308	Discharge summary	report	Admission Date: [2143-3-11] Discharge Date: [2143-3-23] Date of Birth: [2068-4-26] Sex: M Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 1505] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: 74yo man with h/o CAD, DM2, A fib, HTN, hyperlipidemia, and recent episode of bronchitis presented with two days of worsening dyspnea. He initially presented to [Location (un) 620] with complaints of shortness of breath for two days. He reports that he does not have dyspnea at his baseline; normally, he can climb a flight of stairs and walks his dog daily without any chest pain or shortness of breath. . About 2.5 weeks ago, he was playing hand ball, and noticed that he got very winded and fatigued after only five minutes of activity; he rested, felt better, and then again he got instantly winded. He subsequently went on a trip to [State 4565], and reports that during the travel and for several days after he was more fatigued than normal. Two days prior to admission, he was raking leaves in his yard with his hands, and afterward he experienced continued shortness of breath at both rest and worsened with exertion, which persisted for two days. . He initially presented to [Location (un) 620] for this continued fatigue / dyspnea. At [Location (un) 620], evaluation notable for elevated d-dimer, elevated troponin at 0.153 (0.00 - 0.01), and elevated BNP at 4133. BUN/Creat of 32/1.5. He was given ASA 325mg and lopressor 25mg. . In ED at [Hospital1 18], he was given metoprolol 5mg, 150mEq of bicarbonate, and mucomyst prior to CTA of chest to r/o PE. He was continued on home medications. He spiked to 100.3, and was started on levofloxacin for presumed CAP. On [2143-3-12] he was taken to the cardiac catheterization lab, where he was found to have the following stenoses: LMCA- 20%; LAD- ostial 90%, mid 70%, dist apical 80%, large diag subtotal occluded; LCX- ramus 80%, 70% tubular stenosis, OM1 70%, OM2 severe. Right heart catheterization revealed elevated right and left sided filling pressures (RVEDP = 14 mmhg, mean PCWP 25 mmhg with prominent v waves). There was no evidence for pulmonary hypertension. Cardiac output and index were depressed at 3.4 and 1.7 L/min/m2 respectively. . ROS: No recent fevers, chills, weight loss, sick contacts. [Name (NI) ] denies chest pain, orthopnea, PND, peripheral edema, claudication. He has had a non-productive cough. He had not had any abdominal pain, constipation, diarrhea, nausea, vomiting. He denies dysuria, frequency, discharge. He has not noticed any nosebleeds, BRBPR, easy bruising, hematuria. He denies calf pain. Referred to Dr. [Last Name (STitle) ] for surgical evaluation. Past Medical History: PMH: 1. CAD - no documentation for this available; I discussed his history with his Cardiologist, Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 44655]. - last stress echo ([9-12]): . 6min, 77% pred max hr . ekg changes c/w ischemia . inferior basal ischemia on echo - this was a small area and unchanged compared to prior in '[37]. - cath records not available; by report, "only mild disease"; has never had stents or CABG done. 2. Atrial fibrillation; failed cardioversion in past 3. HTN 4. Insulin requiring DM2 5. depression 6. hyperlipidemia 7. inguinal hernias 8. kidney stones 9. s/p bronchitis about three weeks ago 10. reports h/o allergic symptoms, dyspnea, cough with previous exposure to leaves. 11. feet neuropathy Social History: Retired [Company 378] employee (19 years ago). Married, lives with wife, has 8 children. Denies ever using tobacco; occasionally uses alcohol ([12-10] glass wine daily). Family History: Father: DM2, MI at 74 Son: DM2 Physical Exam: Physical exam: vitals: 99.5, 60, 130/57, 12, 90-91% RA . gen a/o, mildly dyspneic heent dry mucous membranes neck JVP 10cm cv irregularly irregular; no m/r/g resp bibasilar crackles abd obese, soft, nt, nd extr trace bilateral edema with stasis pigmentation changes. no calf tenderness or asymmetric findings. Pertinent Results: ECG [Location (un) 620]: atrial fibrillation, 76bpm, likely old anterior wall MI with Q waves in anterior precordial leads. Non-specific ST/T wave changes in lateral precordial leads V4-6 (no old EKG for comparison) . ECG [Hospital1 18]: atrial fibrillation, 83 bpm, q waves V1, V3, V4. Nl intervals. Nl axis. Flat T waves I, II, III, aVL. Compared to tracing from [Location (un) 620] . CXR: 1. Mild congestive heart failure. 2. Ill-defined retrocardiac density. Follow up PA and lateral chest radiograph after resolution of pulmonary edema is recommended to further assess for resolution and to exclude a neoplastic nodule in this area. . CTA chest: IMPRESSION: 1) No evidence of pulmonary embolism. 2) Congestive heart failure with small bilateral pleural effusions. 3) Right hilar lymphadenopathy, which may be reactive. Follow-up is recommended after treatment of congestive heart failure. . ECHO: Conclusions: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. There is moderate regional left ventricular systolic dysfunction. Overall left ventricular systolic function is moderately depressed. Resting regional wall motion abnormalities include mid to distal anterior septal/anterior akinesis and apical akinesis dyskinesis. No definite LV thrombus identified but cannot definitively exclude. Right ventricular chamber size and free wall motion are normal. 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. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. . CATH: 1. Selective coronary angiography of this left dominant system revealed severe native three vessel coronary artery disease. The left main coronary artery has a 20% ostial stenosis. The left anterior descending is diffusely diseased. There is a 90% ostial LAD stenosis. There is a 70% mid-LAD stenosis. There is an 80% distal - apical LAD stenosis. A large diagonal branch is sub-totally occluded. There is a significant ramus branch with a 80% ostial stenosis. The left circumflex artery is the dominant vessel. There is a 70% tubular stenosis of the LCX. The OM1 has a 70% stenosis. The OM2 and LPDA are severely diseased. The right coronary artery is non-dominant and is diffusely diseased. 2. Right heart catheterization revealed elevated right and left sided filling pressures (RVEDP = 14 mmhg, mean PCWP 25 mmhg with prominent v waves). There was no evidence for pulmonary hypertension. 3. Cardiac output and index were depressed at 3.4 and 1.7 L/min/m2 respectively. 4. Left heart cathererization did not reveal evidence of systemic hypotension. . CAROTID US: . IMPRESSION: Moderate plaque with a left 40-59% carotid stenosis. On the right, there is less than 40% stenosis. . CT CHEST: FINAL REPORT INDICATION: Right sided chest pain and congestive heart failure. COMPARISON: No previous chest CT. Chest radiographs of the same day are available for correlation. TECHNIQUE: Gated axial multidetector CT images of the chest were obtained with 100 cc of intravenous Optiray. Multiplanar reformatted 2D and 3D images were obtained. CHEST CT ANGIOGRAM: There are no filling defects in the pulmonary vasculature to suggest pulmonary embolism. The heart and aorta appear unremarkable. There is no pericardial effusion. Small bilateral pleural effusions are present. There are bilateral ground glass opacities, predominantly in the lower lobes, compatible with pulmonary edema. The tracheobronchial tree is patent to the subsegmental levels. There is a 14 mm segmental lymph node in the right lower lobe and an 11 mm right interlobar lymph node. Subcentimeter paratracheal and left periaortic lymph nodes are also present. The imaged portions of the liver, spleen, pancreas, stomach, and gallbladder appear unremarkable. No suspicious lytic or sclerotic bone lesions are identified. CT RECONSTRUCTIONS: Multiplanar reformatted images were essential for delineating the pulmonary vascular anatomy. IMPRESSION: 1) No evidence of pulmonary embolism. 2) Congestive heart failure with small bilateral pleural effusions. 3) Right hilar lymphadenopathy, which may be reactive. Follow-up is recommended after treatment of congestive heart failure. THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST. DR. [First Name11 (Name Pattern1) 95] [Initial (NamePattern1) ]. [Last Name (NamePattern1) 96] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ]. [Last Name (NamePattern1) 2601] Approved: TUE [2143-3-12] 9:44 AM Procedure Date:[2143-3-11] [Known lastname ],[Known firstname ]: Laboratory Detail - CCC Record #[Numeric Identifier 66951] COMPLETE BLOOD COUNT (BLOOD) DATE WBC 4.0-11.0 K/uL RBC 4.6-6.2 m/uL Hgb 14.0-18.0 g/dL Hct 40-52 % MCV 82-98 fL MCH 27-32 pg MCHC 31-35 % RDW 10.5-15.5 % [2143-3-23] 8:18A (2) 27.7* (2) Source: Line-arterial [2143-3-23] 3:17A 26.8* CHECKED FOR NRBC 2.95* 9.4* 27.3* 92 32.0 34.6 16.2* [2143-3-23] 8:18A (66) 34BUN 2.3 creat . Brief Hospital Course: IMPRESSION/PLAN: 74yo man with h/o DM2, HTN, Hyperlipidemia, CAD admitted with fatigue and shortness of breath worsening over the past few weeks. He was found to have three vessel disease during catheterization, with evidence of increased filling pressures and decreased cardiac output / index. . NSTEMI: Patient had evidence of an non ST-elevation myocardial infarction with elevated cardiac enzymes, dynamic ECG changes, and severe three vessel disease seen at catheterization. He was kept anticoagulated, and was received from the cath lab with dobutamine and nitro drip. He was a candidate for surgery, but needed optimization of his respiratory status, renal insufficiency, and infectious issues prior to surgery. He had continued to have intermittent rises in his cardiac enzymes while awaiting surgery, presumably from demand / ongoing ischemia. He eventually required the placement of an intra-aortic balloon pump for optimization of his corornary perfusion and cardiac output while awaiting surgery. He had an episode the night prior to surgery where he became bradycardic and hypotensive, that lead to a code blue. He was emergently intubated, required dopamine briefly for BP support, and he quickly recovered. The following morning he was taken to the operating room. . CONGESTIVE HEART FAILURE: Systolic, with EF 35-40%. Exacerbatoin recently likely due to ischemia. At cath, he had poor CI/CO, and was started on dobutamine. He is lasix naive, but with allergy to sulfa. He was given lasix 80mg in cath lab, and then was aggressively diuresed in the CCU. His oxygenation did not improve drastically, and it was considered that much of his hypoxia was due to an infectious process / mulit-lobular pneumonia since it was not improving and he had a persistent leukocytosis. He was started empirically with vanc / levo / flagyl, and finished a course for HAP. It was subsequently determined that, since he did not really improve with the antibiotics, and his WBC remained elevated without any fever, that most of his hypoxia was due to ongoing ishemia and congestive failure. Prior to the code blue the morning of surgery, he was weaned to 5L nasal cannula. . ATRIAL FIRBRILLATION: Has had long standing a.fib, on amiodarone and warfarin as an outpatient. He is currently well rate-controlled. He was kept on his amiodarone dose before and after surgery, and was well rate-controlled. He remained in atrial fibrillation. Heparin gtt was used for anticoagulation. . DIABETES: On insulin as outpatient. He was continued on RSSI. . HYPERTENSION: His norvasc was held, and his bb / ace-i were intermittently when he was requiring dobutamine. . DEPRESSION: No issues. - continued elavil . FEN: diabetic, cardiac diet. NPO p MN for surgery. Replete lytes prn. . CODE: full . PPX: bowel meds, hep gtt, PPI . ACCESS: right femoral line, PIV . COMMUNICATION: . [Name (NI) ] [Name (NI) ], wife [Telephone/Fax (1) 66952] the CCU for further management. Surgery to be done when ? infectious process/leukocytosis resolved. Dobutamine weaned off. Transferred from CCU to [Hospital Ward Name 121] 6 on [3-15]. Taken back to cath lab for IABP insertion on [3-17]/ ? early cardiogenic shock/ ? sepsis/ rising creatinine/ PNA on CT chest and evaluated again by Dr. [Last Name (STitle) ]. Suffered an arrest and had CPR in the early hours of [3-21].Taken urgently to OR and underwent cabg x5 on [3-21]. Transferred to the CSRU in fair condition on milrinone, levophed, insulin, and epinephrine drips. Remained intubated and had frequent episodes of VTach despite lidocaine drip and defibrillation. Additional pressor support was required and renal was consulted for worsening renal failure.CRRT initiated. Amiodarone and levophed drips additionally for support on [3-22] as patient continued to be critically ill. Epicardial pacing wires lost capture in the early morning of [3-23]. EP following patient. IABP removed for blood in IABP tubing line. Platelets and FFP infused simultaneously for platelets 56K and elevated INR. Became metabolically acidotic, bicarb given and epinephrine started. Plans made to transport pt. to cath lab for venous pacing wire and new IABP. Pt. suffered gradual loss of HR in nodal rhythm, had VTach, and was shocked. ACLS protocols instituted for arrest. Unable to resuscitate patient and at 9:04 AM, code called by Dr. [Last Name (STitle) ] and patient expired. Family notified, and did not consent to post mortem. Medications on Admission: MEDS: coumadin 2mg qd lipitor 10mg amiodarone 200mg qD norvasc 10mg qD toprol xl 50mg qD elavil 10mg qD neurontin 100mg TID captopril 12.5 TID pentoxyfiline 400mg TID folate 1mg insulin 15N/15R am, then 8R/4N in pm Discharge Disposition: Expired Discharge Diagnosis: Asystole, CHF, Cardiogenic shock, coronary artery disease, s/p CABG x5, hypertension, diabetes, hyperlipidemia, renal failure, AFib, depression, elev. chol. Discharge Condition: Expired Discharge Instructions: None Completed by:[2143-5-10]	[ "V58.67", "424.0", "410.71", "414.01", "486", "428.0", "427.5", "585.3", "584.5", "785.51", "511.9", "287.5", "599.0", "286.9", "427.31", "272.0", "401.9", "250.00" ]	icd9cm	[ [ [] ] ]	[ "00.13", "99.60", "99.04", "88.72", "88.56", "99.07", "00.17", "99.05", "96.04", "34.91", "36.15", "39.61", "37.23", "39.64", "37.61", "36.14" ]	icd9pcs	[ [ [] ] ]	14313, 14322	9538, 14046	295, 320	14523, 14533	4195, 9515		3813, 3846				14343, 14502		14072, 14290			14557, 14592											3877, 4176																								248, 257													348, 2832																2854, 3602	3618, 3797
7,612	106,791	14557+56555	Discharge summary	report+addendum	Admission Date: [2154-8-6] Discharge Date: [2154-9-17] Date of Birth: [2081-10-8] Sex: F Service: Vascular CHIEF COMPLAINT: Mesenteric ischemia. HISTORY OF PRESENT ILLNESS: (Information was obtained from the transfer records for [Hospital ] Hospital and interview of the patient) This is a 72-year-old nondiabetic white female with a history of hypertension, hypercholesterolemia, and history of migraines headaches with complaints of postprandial epigastric pain since [Month (only) 404]. She eats a regular diet with good appetite, but pain starts about one and a half hours after eating anything and last from two to two and a half hours. She has lost 25 pounds since [Month (only) 404] and has been admitted to [Hospital ] Hospital several times. A gastrointestinal workup with an esophagogastroduodenoscopy and colonoscopy showed mild gastritis, diverticulosis, and was negative for Helicobacter pylori biopsy. An abdominal CT with ultrasound were negative. A magnetic resonance angiography was done on [2154-6-28] which showed superior mesenteric artery and internal mammary artery stenosis. The patient was treated with Plavix and nitrates without improvement. She is now transferred here for further evaluation and treatment. PAST MEDICAL HISTORY: (Illnesses include) 1. Aortic insufficiency. 2. Hypertension. 3. Gastritis. 4. History of migraines. 5. History of hypercholesterolemia. PAST SURGICAL HISTORY: Tonsillectomy. MEDICATIONS ON ADMISSION: Medications included aspirin 81 mg p.o. q.d., nitroglycerin paste one-half inch q.6h., atenolol 25 mg p.o. q.d., Pepcid 20 mg intravenously b.i.d., Senokot tablets one p.o. b.i.d., Darvocet-N 100 one p.o. q.i.d. as needed. At home, she took hydrochlorothiazide 25 mg q.48h. and Plavix 75 mg p.o. q.d. ALLERGIES: Drug allergies are PENICILLIN (which causes erythema and swelling), ERYTHROMYCIN (reaction unknown). SOCIAL HISTORY: She lives with a roommate. She is single. She is a former smoker of one pack per day. She denies alcohol. FAMILY HISTORY: There is a family history of neurologic disease, heart disease, and cancer. REVIEW OF SYSTEMS: Except for the postprandial abdominal pain, there were no other remarkable review of systems. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed temperature was 98.5, blood pressure was 170/86, pulse was 60, respiratory rate was 18, oxygen saturation was 97% on room air. General appearance revealed an alert and cooperate white female in no acute distress. Skin was warm and dry. There were no rashes. There were multiple actinic keratosis on the back. Head, eyes, ears, nose, and throat examination was unremarkable. There was no lymphadenopathy. There was no thyromegaly or carotid bruits. She had intact carotid, radial, and femoral pulses bilaterally. She had a palpable abdominal aorta without bruits. The pedal pulses were a dopplerable signal only. Neurologic examination was grossly intact. The chest was clear to auscultation. Heart had a regular rate and rhythm. A 1/6 systolic ejection murmur at the base. Abdominal examination was unremarkable. The rectal examination was deferred. Bone and joint examination were essentially warm and pink in color without ulceration. HOSPITAL COURSE: The patient was evaluated by our Cardiology Department prior to surgery for risk assessment. She felt she was at a low risk for a high-risk procedure. Their recommendations were an echocardiogram to determine the degree of aortic insufficiency and that postoperatively she should be started on an ACE inhibitor with captopril 12.5 mg t.i.d. and titrate up to a dose as blood pressure tolerates. She needed no further imaging or stress studies. Change the atenolol to metoprolol 37.5 mg p.o. b.i.d. and watch for bradycardia. Echocardiogram results revealed transesophageal echocardiogram demonstrated left ventricular wall thickness, cavity size, and systolic function were normal with an ejection fraction of greater than 55%, regional left ventricular motion was normal. There was simple atheroma in the descending aorta. The aortic valves were moderately thickened. There was mild-to-moderate aortic insufficiency. The mitral valves were mildly thickened with mild mitral regurgitation. The aorta and mesenteric bypass graft was not visualized. There was no significant change from previous echocardiogram done on [2154-7-19]. The patient was admitted to the preoperative holding area. On [2154-10-7] she underwent two bisiliac aorta to celiac artery and a superior mesenteric artery bypass with 12 X 6 bifurcated graft. She tolerated the procedure well and was transferred to the Postanesthesia Care Unit in stable condition. On immediate postoperative check, she was hemodynamically stable and afebrile. Cardiac index was 3.07, systemic vascular resistance was 1233, pulmonary artery was 38/13, central venous pressure was 6. Blood gas was 7.28/42/134/21/-6. She did well and was transferred the Medical Intensive Care Unit for continued monitoring and care. On postoperative day two, the patient developed respiratory failure and required reintubation and was transferred to Intensive Care Unit for continued respiratory support. Nutrition saw the patient. She was assessed for total parenteral nutrition. Serial creatine kinase, MB, and troponin levels were drawn. Her peak creatine kinase was 370, MB fraction was flat, and troponin levels were less than 0.3. ALT and AST were elevated at 335 and 716 with an elevated white count. Levofloxacin and Flagyl were begun. A transesophageal echocardiogram was obtained which was negative for vegetations. She required one unit of packed red blood cells for her hematocrit. Venous Doppler studies were [Female First Name (un) ] which were negative for deep venous thrombosis. She had an episode of hypotension requiring Levophed for blood pressure support. Levofloxacin and Flagyl were discontinued, and vancomycin and Bactrim were begun. Tube feeds were considered, but these were deferred. A left pleural tap was done on [8-15] for a total of 1.6 liters. The patient had a repeat tap 48 hours later. An ultrasound of her gallbladder was obtained with questionable cholecystitis. She remained intubated. On [8-27], General Surgery was consulted and a cholecystotomy tube was placed percutaneously. This was to remain in for a total of three weeks. The patient underwent studies at that time. A chest CT showed no bowel ischemia. There was a simple liver cyst. The cholecystectomy tube had decompressed the gallbladder. The superior mesenteric artery, internal mammary artery, and celiac arteries were patent. A chest x-ray showed diminished pleural effusion. Multiple sputum, urine, and blood cultures were obtained, and cultures of the pleural fluid. All of these were no growth and finalized. The patient had a peripherally inserted central catheter line placed on [8-29] for further intravenous access. Gastroenterology saw her on [9-3] because of persistent inability to eat solids or liquids. An esophagogastroduodenoscopy was done which demonstrated an esophagus with a grade 1 candidiasis. The stomach was atrophic gastritis changes, and the duodenum showed an intrinsic stenosis at the distal duodenal bulb which the scope could pass through. Fluconazole was begun at this time. She was continued on total parenteral nutrition and then converted to tube feeds, and these were discontinued, and caloric assessments were made. The patient did not meet necessary caloric requirements. Gastroenterology was consulted again on [9-17] and repeated the endoscopy which demonstrated a normal esophagus with mild gastritis. The duodenum was normal. A #20 French percutaneous endoscopic gastrostomy tube was placed in the stomach for anticipated tube feeds. Nutrition would make their appropriate recommendations regarding tube feeds, and this would be initiated 24 hours after the tube insertion. The patient also had a swallow done prior to have the percutaneous endoscopic gastrostomy tube placed, and there was no aspiration; although, she had a delayed aorticopulmonary bolus transit time with premature spillage into the funiculi with delayed swallowing, but there was no aspiration. At the time of discharge, the patient was stable. She was ambulating and working with Physical Therapy. Tube feeds will be dictated as an addendum. MEDICATIONS ON DISCHARGE: (Discharge medications included) 1. Reglan 10 mg p.o. a.c. and q.h.s. 2. Fluconazole 100 mg p.o. q.24h. (this was started on [2154-9-9] and will continue through [2154-9-23] and then be discontinued). 3. Lopressor 75 mg p.o. b.i.d. (hold for a systolic blood pressure of less than 100 and heart rate of less than 50). 4. Lasix 20 mg p.o. q.d. 5. Enteric-coated aspirin 81 mg p.o. q.d. 6. Tube feeds with Empac with fiber starting at 10 cc per hour; this will be advanced for a goal rate to be determined. Residuals should be checked q.4h., and tube feeds should be held if residual is greater than 100 cc. DISCHARGE FOLLOWUP: Follow up with Dr. [Last Name (STitle) ] in two to three weeks. DISCHARGE INSTRUCTIONS: The patient may ambulate, full weightbearing, ad lib distances. DISCHARGE DIAGNOSES: 1. Mesenteric ischemia; status post celiac superior mesenteric artery bypass graft. 2. Pleural effusion, status post thoracentesis times two. 3. Respiratory failure requiring reintubation. 4. Esophageal candidiasis; treated. 5. Gallbladder disease; status post percutaneous cholecystotomy with gallbladder decompression; this has continued anorexia and difficulty in feeding; the etiology is undetermined. Status post esophagogastroduodenoscopy times two and barium swallow which were unremarkable. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) 2604], M.D. [MD Number(1) 6223] Dictated By:[Last Name (NamePattern1) 1479] MEDQUIST36 D: [2154-9-17] 14:56 T: [2154-9-17] 15:02 JOB#: [Job Number 42959] Name: [Known lastname 7835], [Known firstname ] Unit No: [Numeric Identifier 7836] Admission Date: [2154-9-17] Discharge Date: [2154-9-20] Date of Birth: [2081-10-8] Sex: Service: ADDENDUM: The patient was discharged on [2154-9-20] in stable condition to a rehabilitation facility for continued physical therapy to increase mobility and independence. Tube feeds were adjusted to Ultracal 50 cc per hour; chest residuals q.4h.; hold if greater than or equal to 100 cc; irrigate feeding tube q.8h. 30 cc water. The wound sites were clean and intact. Additional discharge diagnosis: Status post PEG placement. This was done on [2154-9-3]. The remaining hospital course was unremarkable. The patient should follow up with Dr. [Last Name (STitle) 7837]. Please call his office to arrange for appropriate time and placement. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1548], M.D. [MD Number(1) 1549] Dictated By:[Last Name (NamePattern1) 145] MEDQUIST36 D: [2154-9-20] 12:19 T: [2154-9-20] 12:29 JOB#: [Job Number ]	[ "511.9", "112.84", "575.10", "272.0", "396.3", "518.5", "458.2", "535.40", "557.9" ]	icd9cm	[ [ [] ] ]	[ "99.15", "51.04", "45.13", "43.11", "39.26", "42.23", "38.91", "34.91", "38.93" ]	icd9pcs	[ [ [] ] ]							2093, 2170	9342, 10764			10786, 11309	8518, 9139	1532, 1950	3320, 8491		9256, 9321									1489, 1505																							2191, 3301			157, 179			9161, 9230										208, 1298																1321, 1464	1967, 2076
79,465	161,719	4284	Discharge summary	report	Admission Date: [2177-3-28] Discharge Date: [2177-4-9] Date of Birth: [2143-9-20] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3531] Chief Complaint: Fevers Major Surgical or Invasive Procedure: right forearm skin biopsy. History of Present Illness: 33F with history of multiple sclerosis and recent admission in [2177-1-27] for fevers, fatigue, and wheezing, presenting with fevers and pain, as well as progressive weakness and numbness/tingling in the arm and leg. During her last admission, she was admitted for FUO and had an extensive workup, including TTE, multiple blood cultures, autoimmune workup, and multiple imaging studies. Multiple etiologies of her (then) low-grade fevers and asthma were entertained, including Churg-[Doctor Last Name 3532], eosinophilic pneumonia, ABPA, and infectious etiologies. . She was started on high dose steroids with improvement in wheezing and fevers; she was discharged with appropriate follow up. She was seen by an OSH rheumatologist who diagnosed her with Churg [Doctor Last Name 3532] clinically; her steroids were tapered to 80mg daily, and he started her on azathioprine. She took these medications for 10 days, but on or about [3-22] was seen by a pulmonologist, who did not feel her symptoms were related to vasculitis, and apparently instructed her to discontinue her prednisone. Within a few days, she started feeling more pain, and her fevers started two days prior to admission. The day prior to admission, she noted diarrhea and dizziness. She is frustrated with the different opinions she has received from all different providers. . In the ED, triage vitals were T106F, BP 123/101, HR 165, RR 16, Sat 100%. She was given 3L normal saline, morphine for pain, Zofran for nausea, Tylenol and Motrin, at which time her fever came down. Blood and urine cultures were sent, and she was admitted to the floor for further workup. . At the time of admission, she is complaining of chills, body pain, including nerve and muscle pain in her right arm and right leg, as well as a burning pain in her left hand and left toes. She also has a pain in her upper back. She denies cough, dysuria, diarrhea, abdominal pain, sore throat, neck pain, headache, and other signs of infection. Past Medical History: # Relapsing-Remitting Multiple Sclerosis (first symptoms in [2171], diagnosed in [11-1] and initially treated with steroid followed by Tysabri, last infusion end of [11-4], no treatment for MS until 3 days prior to admission when she started Copaxone. Copaxone stopped on [2-12] by neurologist pending eval of fevers. Last on IV steroids in [5-4], and got prednisone 2.5 weeks ago for respiratory wheezing. # PCOS- on metformin # GERD # Obesity # s/p Lumbar Laminectomy # history of malaria as child Social History: Internationally known opera singer. No tob/etoh. Lives with husband. Lived in [State 18559] as child. Traveled all over south pacific with father in [Name2 (NI) 18560]. Most recent travel to [Country 4754] with international group of singers. Reports neg PPD 2.5 years ago prior to starting MS medications. No known TB exposures. No other recent travel. Family History: Mother has schizophrenia, substance abuse and liver problems Father has bipolar disorder, diabetes, HTN, stroke. Physical Exam: Vitals T 99.4F, BP 93/55, HR 101, RR 24, Sat 96%RA General: Uncomfortable obese female, no acute distress HEENT: Flushed face Neck: No lymphadenopathy Heart: Tachycardic, no m/r/g Lungs: CTA bilaterally, no wheezes appreciated Abdomen: Obese, soft, non-tender, non-distended + bowel sounds Ext: WWP, 2+ pulses bilaterally Neuro: CN II-XII intact, strength decreased in lower extremities R>L Pertinent Results: STUDIES: . Cardiology Report ECG Study Date of [2177-3-28] 8:13:34 AM Sinus tachycardia. Compared to the previous tracing of [2177-2-6] sinus tachycardia is present. Intervals Axes Rate PR QRS QT/QTc P QRS T 152 0 88 [Telephone/Fax (2) 18561] . . 4/0/10 CXR: IMPRESSION: No evidence of pneumonia. If clinical suspicion is high for intrathoracic process, PA and lateral radiographs should be considered. . . [2177-3-30] CTA CHEST: IMPRESSION: 1. No central or segmental pulmonary embolism. No acute aortic pathology. 2. Stable sub 5-mm perifissural nodules. . . [2177-3-31] EMG: IMPRESSION: Abnormal study. The reduced activation seen in most of the right lower extremity muscles tested is most likely secondary to a CNS lesion (as in multiple sclerosis), pain, or decreased patient cooperation. There is no electrophysiologic evidence for a right lumbosacral radiculopathy or for a right peroneal neuropathy. . . [2177-4-3] MRI ORBITS: 1. Stable appearance of the U-shaped focus of FLAIR-hyperintensity in the right perirolandic subcortical white matter, without discrete abnormality of the overlying grey matter, when compared with previous examinations dating back to [2174-9-11]. No new foci of abnormal signal intensity or enhancement are identified to suggest progression of demyelinating disease. . 2. No evidence of abnormal signal intensity or enhancement involving the optic nerves, tracts or chiasm. . . LABS: [2177-3-28] 08:20AM BLOOD WBC-9.0 RBC-4.70 Hgb-12.1 Hct-37.7 MCV-80* MCH-25.8* MCHC-32.1 RDW-16.8* Plt Ct-212 [2177-3-29] 07:45AM BLOOD WBC-4.9 RBC-4.13* Hgb-11.0* Hct-34.6* MCV-84 MCH-26.7* MCHC-31.8 RDW-16.6* Plt Ct-215 [2177-3-30] 04:55AM BLOOD WBC-5.4 RBC-4.34 Hgb-11.7* Hct-36.3 MCV-84 MCH-27.1 MCHC-32.4 RDW-16.9* Plt Ct-214 [2177-4-1] 07:35AM BLOOD WBC-7.2 RBC-3.59* Hgb-9.8* Hct-30.2* MCV-84 MCH-27.3 MCHC-32.4 RDW-17.2* Plt Ct-244 [2177-4-5] 06:50AM BLOOD WBC-13.7# RBC-3.92 Hgb-10.7* Hct-32.3* MCV-82 MCH-27.3 MCHC-33.2 RDW-16.9* Plt Ct-395# [2177-4-6] 07:00AM BLOOD WBC-15.2* RBC-4.06* Hgb-11.5* Hct-33.4* MCV-82 MCH-28.3 MCHC-34.4 RDW-16.9* Plt Ct-442* [2177-4-7] 07:00AM BLOOD WBC-14.6* RBC-4.35 Hgb-11.7* Hct-36.1 MCV-83 MCH-26.8* MCHC-32.4 RDW-16.7* Plt Ct-511* [2177-4-8] 07:20AM BLOOD WBC-14.5* RBC-4.36 Hgb-11.6* Hct-36.2 MCV-83 MCH-26.7* MCHC-32.1 RDW-16.8* Plt Ct-514* [2177-3-28] 08:20AM BLOOD Neuts-83.6* Lymphs-7.8* Monos-5.6 Eos-2.9 Baso-0.1 [2177-3-29] 07:45AM BLOOD Neuts-83.3* Lymphs-12.9* Monos-3.5 Eos-0.1 Baso-0.1 [2177-4-6] 07:00AM BLOOD Neuts-67.1 Lymphs-22.4 Monos-10.3 Eos-0.1 Baso-0.1 [2177-3-28] 08:20AM BLOOD Plt Ct-212 [2177-3-29] 07:45AM BLOOD PT-11.4 PTT-22.8 INR(PT)-1.0 [2177-4-5] 06:50AM BLOOD Plt Ct-395# [2177-4-7] 07:00AM BLOOD Plt Ct-511* [2177-4-8] 07:20AM BLOOD Plt Ct-514* [2177-3-28] 08:20AM BLOOD ESR-24* [2177-3-28] 08:20AM BLOOD Glucose-183* UreaN-5* Creat-0.9 Na-139 K-3.9 Cl-104 HCO3-22 AnGap-17 [2177-3-29] 07:45AM BLOOD Glucose-158* UreaN-5* Creat-0.5 Na-142 K-4.1 Cl-110* HCO3-20* AnGap-16 [2177-3-30] 04:55AM BLOOD Glucose-128* UreaN-4* Creat-0.8 Na-144 K-3.6 Cl-110* HCO3-21* AnGap-17 [2177-4-1] 07:35AM BLOOD UreaN-9 Creat-0.6 Na-140 K-3.4 Cl-106 HCO3-26 AnGap-11 [2177-4-5] 06:50AM BLOOD Glucose-122* UreaN-12 Creat-0.7 Na-138 K-4.3 Cl-101 HCO3-32 AnGap-9 [2177-4-6] 07:00AM BLOOD Glucose-124* UreaN-15 Creat-0.6 Na-140 K-4.4 Cl-102 HCO3-32 AnGap-10 [2177-4-7] 07:00AM BLOOD Glucose-119* UreaN-14 Creat-0.7 Na-138 K-4.5 Cl-101 HCO3-32 AnGap-10 [2177-4-8] 07:20AM BLOOD Glucose-159* UreaN-13 Creat-0.7 Na-138 K-4.9 Cl-103 HCO3-30 AnGap-10 [2177-3-28] 08:20AM BLOOD ALT-35 AST-24 LD(LDH)-285* AlkPhos-65 TotBili-0.4 [2177-3-29] 07:45AM BLOOD ALT-33 AST-26 LD(LDH)-281* CK(CPK)-26* AlkPhos-49 TotBili-0.3 [2177-4-1] 07:35AM BLOOD CK(CPK)-20* [2177-4-6] 07:00AM BLOOD CK(CPK)-14* [2177-3-28] 08:20AM BLOOD Lipase-30 [2177-3-29] 07:45AM BLOOD Albumin-3.6 Calcium-8.7 Phos-2.1# Mg-2.4 [2177-4-5] 06:50AM BLOOD Calcium-9.3 Phos-3.2 Mg-2.6 Iron-22 [2177-4-6] 07:00AM BLOOD Calcium-8.9 Phos-2.8 Mg-2.7* [2177-4-8] 07:20AM BLOOD Calcium-9.3 Phos-3.3 Mg-2.6 [2177-4-5] 06:50AM BLOOD calTIBC-350 Ferritn-76 TRF-269 [2177-3-29] 07:45AM BLOOD CRP-185.8* [2177-4-5] 06:50AM BLOOD CRP-9.7* [2177-3-28] 08:34AM BLOOD Lactate-2.7* [2177-3-28] 09:30AM URINE HOURS-RANDOM [2177-3-28] 09:30AM URINE UCG-NEGATIVE [2177-3-28] 09:30AM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.003 [2177-3-28] 09:30AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [2177-3-28] 09:30AM URINE RBC-0 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 . . MICRO: [2177-3-28] 8:20 am BLOOD CULTURE FINAL REPORT [2177-4-3] Blood Culture, Routine (Final [2177-4-3]): NO GROWTH. . . [2177-3-28] 9:30 am URINE Site: CLEAN CATCH FINAL REPORT [2177-3-29] URINE CULTURE (Final [2177-3-29]): <10,000 organisms/ml. . . [2177-3-29] 4:50 pm BLOOD CULTURE FINAL REPORT [2177-4-4] Blood Culture, Routine (Final [2177-4-4]): NO GROWTH. . . [2177-4-4] 7:24 pm TISSUE Source: Skin biopsy. GRAM STAIN (Final [2177-4-4]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [2177-4-7]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [2177-4-5]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): . . PATHOLOGY: [Hospital1 69] [Location (un) 86], [Telephone/Fax (1) 15701] Pathology Examination Name Birthdate Age Sex Pathology # [Hospital1 18] [Known lastname 18562],[Known firstname ] [2143-9-20] 33 Female [Numeric Identifier 18563] [Numeric Identifier 18564] Report to: DR. [Last Name (STitle) ]. LIM Gross Description by: DR. [Last Name (STitle) ] [Last Name (NamePattern4) ]/mtd SPECIMEN SUBMITTED: RUSH...PUNCH BX RT. FOREARM (1 JAR) Procedure date Tissue received Report Date Diagnosed by [2177-3-31] [2177-3-31] [2177-4-8] DR. [Last Name (STitle) ]. ZIMAROWSKI/mrr?????? Previous biopsies: [Numeric Identifier 18565] GASTRIC AND COLON BXS (2). . DIAGNOSIS: Skin, right forearm, punch biopsy: Perivascular granulomatous and neutrophilic inflammation with scattered eosinophils, focal vascular injury, and associated polarizable foreign material. . Note: The combined pathologic features are unusual. There are granulomatous areas comprised of histiocytes, neutrophils with some leukocytoclasia, and eosinophils (some within interstitium). The granulomas form palisades about polarizable foreign material and vessels involving the dermis and subcutis. Some foci show vascular injury consistent with granulomatous vasculitis. . The differential diagnosis includes infection. Special stains ([Last Name (un) 18566], AFB, PAS, GMS, and gram) are negative for organisms, however, culture is a more sensitive method to detect organisms. A recent biopsy was taken for cultures. If infection is excluded the combined findings of small palisading granulomas with neutrophils, eosinophils and focal vasculitis are suggestive of Churg-[Doctor Last Name 3532] (allergic) granulomatosis. The polarizable foreign material and history of scar / trauma at this site suggests the possibility of Churg-[Doctor Last Name 3532] granulomatosis Koebnerizing a site of prior injury. The findings are not typical of foreign body granulomas which would show more giant cells and lack neutrophils. Rarely palisading granulomas may be observed as a reaction to foreign material, but again, they usually lack neutrophils. Sarcoidosis (which may Koebnerize) is considered, however, the granulomas are not typical of "naked" granulomas of sarcoid. While neutrophils may be observed in sarcoidosis, the number of neutrophils in this specimen would be unusual. Lastly the histologic differential diagnosis for disorders that may show Churg-[Doctor Last Name 3532] type of granulomas includes Wegener's granulomatosis, systemic lupus erythematosus, and rheumatoid arthritis, however, these disorders usually lack eosinophils. Clinical-pathologic correlation is recommended. . Clinical: Punch biopsy right forearm-4 mm- patient with fever of unknown origin to 106, mild eosinophilia, arthralgias, history of asthma. Biopsy to help team determine if ? vasculitis. Clinically appears to be an erythematous scar with some soft tissue swelling. Gross: The specimen is received in a formalin-filled container, labeled with the patient's name, "[Known lastname ], [Known firstname 2048]" and the [Hospital 228] medical record number. The specimen consists of a 4 mm punch biopsy of tan-white skin excised to a depth of 0.5 cm. The epidermal surface is grossly unremarkable after fixation. The margin is inked blue. The specimen is bisected and entirely submitted in cassette A. Brief Hospital Course: 33F h/o multiple sclerosis, recently diagnosed clinically with churgg-[Doctor Last Name ] syndrome and being treated with oral steroids, who presents with high fevers, diffuse muscle spasms, and R LE weakness, in the setting of discontinuation of oral steroids. . # fever / vasculitis / churgg [Doctor Last Name ] disease - initial ddx includes acute infection, but was felt more likely to represent flare of underlying vasculitis. pt was empirically covered with broad spectrum antibiotics (vanc, cefepime) and restarted on oral prednisone 80mg qdaily. CXR, blood, urine cultures were obtained and unremarkable. she continued to spike high fevers (>104) despite antibiotics, cooling blanket, acetaminophen, NSAIDs. . with high fever, despite IVF, her heart rate would increase up to 170bpm, prompting breif ICU transfer. She improved with tylenol, antibiotics, fluids, and continuation of steroids. . she was evaluated by the rheumatology service, who recommended initially continuing prednisone and azathioprine, while attempting to obtain pathologic confirmation of her diagnosis, then recommended discontinuing azathioprine. biopsy of the lungs and sural nerve were considered, but pt declined lung biopsy given her vocation as a singer, and EMG was unremarkable in the setting of R LE weakness, thus this was felt to be low yeild. dermatology was consulted to perform a right forearm skin biopsy in the bed of a former scar, which ultimately was felt to be supportive of, but not definitive for, churgg [Doctor Last Name ] disease. the patients hosiptal course was complicated by severe muscle spasms and neuropathic pain, attributed to her multiple sclerosis, and treated as below. . after review of the final pathology results, with rheumatology, pt's clinical symptoms and pathology were felt consistent with a diagnosis of vasculitis, specifically churgg [Doctor Last Name ]. she was treated with high dose steroids iv x5d as below for optic neuritis, then transitioned to oral prednisone 60mg on [2177-4-6] without difficulty. the patient was discharged home on a regimen of oral prednisone 60mg po qdaily without taper, with instructions to follow-up with her primary rheumatologist on [2177-4-15], to discuss initiation of methotrexate or cytoxan. she was otherwise discharged on calcium, vitamin d, bactrim, and fosamax. . . # multiple sclerosis / optic neuritis / muscle spasms - pt was evaluated by the neurology service given symptoms of right foot weakness, shoulder, lower extremity, and rib muscle spasms which were felt to be likely related to her history of multiple sclerosis. EMG testing was performed to see if the new RLE weakness could be attributed to a mononeuritis (which would suggest vasculitis), but the findings were felt more consistent with a peripheral neuropathy versus a central process likely MS versus pain/cooperation. . the patient then developed right eye pain consistent with prior episodes of optic neuritis, for which she was evalauted by opthalmology service, and felt consistent with optic neuritis. she was treated with methylprenisolone 1000 mg IV Q24H x5d starting [2177-4-1] with resolution of her symptoms. MRI of the head/orbit was obtained which revealed stable appearance of "U-shaped focus of FLAIR-hyperintensity in the right perirolandic subcortical white matter, without discrete abnormality of the overlying grey matter, when compared with previous examinations dating back to [2174-9-11]. No new foci of abnormal signal intensity or enhancement are identified to suggest progression of demyelinating disease." There was no evidence of abnormal signal intensity or enhancement involving the optic nerves, tracts or chiasm." . her hospital course was otherwise complicated by severe muscle spasms, and neuropathic pain, which were treated initially with iv ativan, dilaudid, and ultimately transitioned to oral dilaudid, valium, baclofen, tizanidine, and klonipin per neurology and pain service recommendation. she was also restarted on topamax 50mg po BID, and should increase to 100mg PO BID within the next week if she tolerates the present dose. she was instructed to follow-up with her outpatient chronic pain provider, [Name10 (NameIs) ] consider baclofen pump insertion in the future should her pain persist, at [Hospital1 112]. she was evaluated by physical therapy, and discharged home with plan for outpatient physical therapy. . Pt was otherwise discharged home on oral regimen of steroids as above, with instructions to follow-up with her neurologist, and to coordinate discussion between rheumatology and neurology regarding anti-inflammatory regimen. She was also encouraged to consolidate her medical care into a single institution to facilitate care. . . # hyperglycemia - pt with likely steroid induced diabetes, she was admitted on a regimen of lantus and metformin, which was continued at discharge. Medications on Admission: Provigil 100mg [Hospital1 ] PRN Aciphex 20mg [Hospital1 ] Baclofen 10mg TID OCP Metformin 1000mg [Hospital1 ] Zantac 300mg daily Lantus 20 units once daily Bactrim DS 800mg-160mg three times weekly Valium 5mg daily Topamax 25mg daily Azathioprine 200mg daily Prednisone 80mg daily (until [3-22]) Discharge Disposition: Home Discharge Diagnosis: primary: vasculitis - churgg [Doctor Last Name ] multiple sclerosis hyperglycemia muscle spasms neuropathic pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: you were admitted to the hospital with fevers. you were evaluated by the rheumatology service, underwent a skin biopsy which was consistent with, but not definitive of, churgg [Doctor Last Name ] disease, a vasculitis. . your infectious workup was negative, and your fevers improved with steroid therapy. you are being discharged home on prednisone 60mg po qdaily, with plans to follow-up with your outpatient rheumatologist, to discuss further anti-inflammatory treatment for your vasculitis. . your hospital course was complicated by a flare of your multiple sclerosis, including optic neuritis, and severe, diffuse muscle spasms, and neuropathic pain. you were started on the regimen below after discussion with the neurology service, chronic pain service. . the following changes were made to your medication regimen: 1. your baclofen dose was increased to 15mg three times daily. 2. your valium was increased to 5mg four times daily. 3. topamax was resumed, at 50mg twice daily, and will need to be increased to 50mg in the morning, and 100mg at night in 5 days, then to 100mg twice daily 5 days after that if you do not develop symptoms of excessive sleepiness. 4. azathioprine was discontinued. 5. you prednisone dose was changed to 60mg once daily, you should not reduce this dose until seen by you rheumatologist. 6. you were started on oral dilaudid. 7. you were continued on klonipin, which you were taking as a quick dissolve form previously. 8. you were started on tizanidine. 9. aciphex was switched to pantoprazole. 10. your lantus dose was reduced to 15, but can be titrated back up to 20 as needed, taken nightly. Followup Instructions: upon arriving home, please contact your primary care physician, [Name10 (NameIs) ] arrange to be seen within 2 weeks. [Last Name (LF) ],[First Name3 (LF) 18567] T. [Telephone/Fax (1) 644]. you will specifically need to discuss refills of your medications, and have removal of your sutures (should be done within 2 weeks of the procedure, which occured [2177-3-31]). . if you would like to be seen in the primary care clinic at [Hospital1 18], please call [Telephone/Fax (1) ] to schedule an appointment. . upon arriving home please contact your existing chronic pain provider, [Name10 (NameIs) ] arrange to be seen within 2 weeks of your discharge to ensure that your pain continues to be well controlled. . you will need to follow-up with your neurologist, within [1-29] weeks of your discharge, to discuss further MS therapy, in the context of your new vasculitis diagnosis. if you would like to be seen in the neurology clinic at [Hospital1 18], please call ([Telephone/Fax (1) 8951] to schedule an appointment. you were seen by dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1206] during this admission. . please contact your rheumatologist, dr. [First Name (STitle) ] and arrange to be seen within 1-2 weeks of your discharge, to discuss starting anti-inflammatory therapy for your new diagnosis of vasculitis. if you would like to be seen in the rheumatology clinic at [Hospital1 18], please call ([Telephone/Fax (1) 1668].	[ "377.30", "E932.0", "278.00", "288.3", "530.81", "256.4", "V58.65", "249.00", "446.4", "401.9", "780.60", "276.51", "340" ]	icd9cm	[ [ [] ] ]	[ "86.11" ]	icd9pcs	[ [ [] ] ]	18475, 18481	13175, 18113	321, 350	18642, 18642	3860, 9406	20455, 21970	3319, 3433				18502, 18621		18139, 18452			18793, 20432											3448, 3841				9640, 13152				9490, 9607																275, 283													378, 2375									9442, 9457	18657, 18769						2397, 2918	2934, 3303
67,512	178,225	10290	Discharge summary	report	Admission Date: [2185-6-15] Discharge Date: [2185-7-11] Date of Birth: [2125-8-3] Sex: M Service: MEDICINE Allergies: Byetta Attending:[First Name3 (LF) 603] Chief Complaint: Syncope at MRI Major Surgical or Invasive Procedure: Cervical spine surgery.... History of Present Illness: 59M w/ HIV (last CD4 count was in the 400s with a viral load of 41,000), DM, pulm art htn, R sided CHF who is s/p syncope at MRI, mild CP, resolved, in setting of CHF, pulm hypertension, persistent hypoxia, likely baseline. . Patient was scheduled for outpatient MRI of L spine for ongoing neurological workup. Feeling dizzy before MRI, has had this sensation before, then was in machine, then felt like body was hot, "burning", and was having back pain, so started to cry. Had them stop MRI and then sat up and then passed out. At some point, while in the MRI machine, reports feeling like he could not breath. Denies nausea, sweating prior to event. Has had panic attacks in the past. FSBG at the time was 73. . In the ED, initial VS 99.9, 89, 119/54, 15, 94% 3L (88% on RA). CXR showed mild fluid congestion. EKG: SR 83, NA/, Q 3, avF. Given 1L NS. Admitted to medicine for further workup of syncope, hypoxia. . On arrival to the floor, he is asymptomatic and resting comfortably in bed. . ROS: Denies fever, headache, vision changes, rhinorrhea, congestion, sore throat, cough, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. . Past Medical History: - HIV (last CD4 count 588 on [2184-1-17]) - Hepatitis C with stage IV cirrhosis, s/p antiviral tx - Chronic kidney disease requiring several hospitalizations and short-term dialysis - Hypercholesterolemia - Obstructive sleep apnea - Depression - CHF - last echo [10-17]: Moderate pulmonary hypertension. Dilated right ventricle with depressed systolic function. Moderate symmetric left ventricular hypertrophy with preserved systolic function. Normal valvular function. - GERD - Obesity - h/o C diff colitis ([3-14]) - Pancreatitis - s/p Cholecystectomy - s/p Appendectomy Social History: Patient lives with a female companion on [Location (un) ]. He lost most of his possessions, including property, when his bank when under and recalled his loans which he could not pay and foreclosed his home and other properties. This precipitated his psychiatric admission for depression in [Month (only) 116]. Denies tobacco, alcohol or current IV drug use. Has h/o IVDU Family History: Depression and anxiety. Father with DM, CAD; Mother with CAD. Brother was MI at age 46. Physical Exam: Admission PHYSICAL EXAM: VS: 99.2 138/P 86 22 96% 4l (75% RA sleeping) FSBG over 24h 159, 221, 174, 212 GENERAL: obese man in NAD, uncomfortable due to arm pain, appropriate. HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear. NECK: Supple, no thyromegaly, no JVD, no carotid bruits. HEART: RRR, no MRG, nl S1-S2. LUNGS: faint crackles at bases but otherwise clear, ?decreased inspiratory effort given pain ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding. EXTREMITIES: WWP, obese but does not appear fluid overloaded in LE, SKIN: No rashes or lesions. LYMPH: No cervical LAD. NEURO: Awake, A&Ox3, CNs II-XII grossly intact, pt has pain in arms from neuropathy, great difficult raising arms, also looks like some muscle wasting in arms [currently being worked up outpt] . Discharge: VS: 97.5 138/78 p84 r20 91% on RA GENERAL: obese man in NAD, appropriate. HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear. NECK: Supple, no thyromegaly, no JVD, no carotid bruits. HEART: RRR, no MRG, nl S1-S2. LUNGS: faint bibasilar crackles, otherwise clear, breathing comfortably on RA. ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding. EXTREMITIES: WWP, obese but does not appear fluid overloaded in LE, R wrist with mild edema compared to L wrist. SKIN: No rashes or lesions. LYMPH: No cervical LAD. NEURO: Awake, A&Ox3, CNs II-XII grossly intact, strength ?~1-2/5 in upper and extremities bilaterally, difficult to assess limitations [2-9] weakness versus discomfort Pertinent Results: Admission Labs: [2185-6-14] 10:00PM BLOOD WBC-5.9 RBC-3.87* Hgb-10.5* Hct-31.4* MCV-81* MCH-27.0 MCHC-33.3 RDW-16.3* Plt Ct-373# [2185-6-15] 07:10AM BLOOD WBC-5.2 RBC-3.79* Hgb-10.3* Hct-31.3* MCV-82 MCH-27.1 MCHC-32.9 RDW-16.2* Plt Ct-329 [2185-6-14] 10:00PM BLOOD Neuts-69.1 Lymphs-22.6 Monos-5.4 Eos-0.9 Baso-2.0 [2185-6-14] 10:00PM BLOOD Plt Ct-373# [2185-6-15] 07:10AM BLOOD Plt Ct-329 [2185-6-14] 07:40PM BLOOD Creat-1.9* [2185-6-14] 10:00PM BLOOD Glucose-74 UreaN-75* Creat-2.0* Na-137 K-3.8 Cl-90* HCO3-32 AnGap-19 [2185-6-15] 07:10AM BLOOD Glucose-232* UreaN-65* Creat-1.8* Na-137 K-3.7 Cl-94* HCO3-32 AnGap-15 [2185-6-15] 07:10AM BLOOD CK(CPK)-65 [2185-6-14] 10:00PM BLOOD proBNP-162 [2185-6-14] 10:00PM BLOOD cTropnT-0.01 [2185-6-15] 07:10AM BLOOD CK-MB-2 [2185-6-15] 07:10AM BLOOD Calcium-9.5 Phos-3.2 Mg-2.1 . Diabetes monitoring: [2185-6-20] 07:20AM BLOOD %HbA1c-8.3* eAG-192* . LFTs: [2185-7-2] 07:40AM BLOOD ALT-16 AST-22 LD(LDH)-201 AlkPhos-92 TotBili-0.6 Discharge labs: [2185-7-10] 08:58AM BLOOD WBC-4.7 RBC-3.65* Hgb-9.5* Hct-29.5* MCV-81* MCH-26.1* MCHC-32.3 RDW-15.7* Plt Ct-411 [2185-7-10] 08:58AM BLOOD Glucose-125* UreaN-42* Creat-0.8 Na-134 K-3.9 Cl-94* HCO3-32 AnGap-12 [2185-7-10] 08:58AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.0 . . Micro: [2185-7-7] 9:35 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): Reported to and read back by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ],7/02/11,9:52AM. STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Aerobic Bottle Gram Stain (Final [2185-7-9]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. . [2185-7-8] 8:00 am BLOOD CULTURE #2. Blood Culture, Routine (Pending): ., C. diff: negative x2 . Urine culture: negative . Blood cultures ([6-21]. [6-12], [6-23], [7-2], [7-3], [7-5]) negative . EKG admission: Sinus rhythm. Prolonged Q-T interval. Intraventricular conduction delay. Old inferior myocardial infarction. Poor R wave progression. Compared to the previous tracing of [2184-12-3] no significant change . Imaging: MR [Name13 (STitle) 6452] W & W/O CONTRAST Study Date of [2185-6-14] 6:54 IMPRESSION: 1. Disc herniations from C5-C6 through C7-T1. Severe spinal canal stenosis with spinal cord compression at C5-6, and moderate spinal canal stenosis with spinal cord deformation at C6-7. Evaluation for spinal cord edema or myelomalacia is limited by motion artifacts. 2. Globally narrow spinal canal from L3 through L5 due to short pedicles. This is further exacerbated by degenerative disease at L4-5 where there is moderate to severe spinal canal stenosis with crowding of the cauda equina. An osteophyte arising from the right L4-5 facet joint impinges the traversing right L5 nerve root in the subarticular recess. 3. Moderate bilateral L4-5 neural foraminal narrowing and severe bilateral L5-S1 neural foraminal narrowing, with impingement of the exiting L4 and L5 nerve roots, respectively. CHEST (PA & LAT) Study Date of [2185-6-14] 11:41 PM FINDINGS: There is mild cardiomegaly and mild vascular congestion. There is no pleural effusion and no pneumothorax. An external line/tube is projecting over the thoracic spine. IMPRESSION: Mild cardiomegaly and vascular congestion. No pneumonia. UNILAT LOWER EXT VEINS Study Date of [2185-6-15] 2:52 PM FINDINGS: [Doctor Last Name ]-scale and color son[Name (NI) 1417] of bilateral common femoral and left-sided superficial femoral, popliteal, and calf veins were evaluated. The calf veins demonstrated normal compressibility. Remaining vessels demonstrated normal flow, compressibility and augmentation. IMPRESSION: No DVT in the left lower extremity. CARDIAC PERFUSION PERSAN 2-DAY Study Date of [2185-6-18] INTERPRETATION: Resting and stress perfusion images reveal uniform tracer uptake throughout the left ventricular myocardium other than some mild attenuation at the apex. The LV cavity is enlarged. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 58%. The end-diastolic volume is 130 ml. No prior study is available for comparison. IMPRESSION: No evidence of pharmacologically induced ischemia. Moderate LV dilation. Cardiology Report Stress Study Date of [2185-6-19] INTERPRETATION: This 59 year old type 2 IDDM man with a Hx of obestiy, pulmonary HTN and shortness of breath was referred to the lab prior to non-cardiac surgery. The patient was infused with 0.142 mg/kg/min of dipyridamole over 4 minutes. No arm, neck, back or chest discomfort was reported by the patient throughout the study. There were no significant ST segement changes during the infusion or in recovery. The rhythm was sinus with rare isolated vpbs. Appropriate hemodynamic response to the infusion and recovery. The dipyridamole was reversed with 125 mg of aminophylline IV. IMPRESSION: No anginal type symptoms or ischemic EKG changes. Nuclear report sent separately. FOOT AP,LAT & OBL BILAT [2185-7-7] LEFT FOOT: There are no erosions identified. There are mild degenerative changes of the first MTP joint with minimal soft tissue prominence along the medial aspect of the first MTP joint. Mineralization is grossly preserved. RIGHT FOOT: There is a periarticular erosion involving the first metatarsal head with adjacent soft tissue calcifications. This finding is compatible with patient's known gouty arthritis. The joint spaces are preserved. Rest of bony structures are intact. Brief Hospital Course: Primary Reason for Hospitalization: 59M w/ HIV (last CD4 count was in the 400s with a viral load of 41,000), DM, pulm art htn, R sided CHF who initially presented due to syncopal episode in MRI scanner and was subsequently admitted for C5-T2 laminectomy fusion for severe cervical stenosis. He was transferred to the SICU immediately post-op for delayed extubation, and on POD#1 he was transferred to the medical service for management of his post-operative pain and multiple medical issues. . Active issues: . # Syncope: Likely panic attack in MRI scanner. Given flushing, could also be related vasovagal episode. Given h/o pHTN, appearance of mild fluid overload on CXR, hypoxia, there was concern for cardiogenic cause. However, pt didn't eat or drink for several hours before MRI, and is on high doses of diuretics, he could be hypovolemic. Pt was given fluids in ED and improved. Also got home dose of lorazepam w/good effect. No cardiac arrythmias detected on tele and pt was asymptomatic. . # Neuropathy, arm pain, DDD: Pt MRI shows severe degenerative changes in cervical region w/multiple disc herniations and stenosis. Pain is debilitating. Pt at one point voiced that he could not live this way and was thinking about suicide. Although he was a very high surgical risk he wished to persue surgery in the hopes of some improvement in symptoms. Surgery was consulted and eventually plan was for surgery on [2185-6-28]. . # S/p C5-T2 laminectomy/fusion: Pain was controlled with topical agents (lidoderm patch, bengay), tylenol, gabapentin (increased from his home dose of 800mg q8hr to 1200mg q8hr), and oxycodone PO liquid (10mL q4-6hrs prn). The spine service followed him and recommended outpatient follow-up 4-6 weeks after surgery. Physical therapy evaluated him and felt that he would benefit from a stay in a rehab facility for additional therapy due to his limited mobility. . # Chronic diastolic heart failure: Due to pulmonary hypertension and cor pulmonale. [Name (NI) ], pt initially required continuous O2 via NC due to hypervolemia. He was continued on his home dose of torsemide and metolazone, and his oxygenation improved as he became euvolemic. His torsemide and metolazone were later held due to evidence of pre-renal acute renal failure and a gout flare (see below). On discharge he was breathing comfortably and maintaining O2sats >94% on RA. It was recommended that he resume his home dose torsemide but refrain from using metolazone as it could increase risk of recurrent gout flares. . # Renal Insufficiency: Pt has h/o chronic renal insufficiency (baseline appears to be around 1.5), showed evidence of pre-renal acute renal failure during hospitalization based on urine lytes. Diuretics were held and creatinine improved to normal range. . # Gout: Pt had no known h/o gout prior to admission, but post-operatively developed pain/swelling of his R wrist, shoulder, and knee as well as low grade fevers (to 100.6F). DVT of the RUE was ruled out by RUE U/S. There was initial concern for possible infection, and an infectious work-up was pursued with blood/urine/stool cultures and CT C-spine to evaluate for possible post-operative abscess. After work-up was negative for infection, he was evaluated by rheumatology who performed a joint aspiration of the wrist and requested Xrays of the R shoulder, wrist, knee, and foot. His uric acid was notably elevated at 14.3. He was diagnosed with an acute gout flare based on clinical suspicion and radiographic evidence (erosion of the 1st R metatarsal on foot Xray). He started treated with prednisone 20mg PO daily and transitioned to colchicine 0.6mg daily prior to discharge. It was recommended that he discontinue his metolazone as it could increase risk of recurrent gout flare. OUTPATIENT ISSUES; -- Continue Colchine 0.6mg tablets. Take one tablet daily for 6mths -- Follow-up with Rheumatology (Dr. [Last Name (STitle) 34211] in 3-4weeks . # Diabetes type II: Continued lantus sc daily, SSI, diabetic diet. Reviewed [Last Name (un) 387] records and touched base w/PCP regarding [Name9 (PRE) ] dose, per pcp pt was on 180U qhs but pt working on diet control and decreasing lantus at home to 140-150U. Initially started on 40U lantus [Hospital1 ] due to poor PO intake and eventually uptitrated to home lantus 180U lantus qhs with insulin sliding scale prior to discharge. He will need to follow up with his PCP to evaluate his insulin regimen after leaving the hospital and resuming his normal diet. OUTPATIENT ISSUES; -- Continue close monitoring of fingers with adjustment of insulin and ISS as needed . # Diarrhea: Chronic, per patient. C diff antigen lab negative x3. Improved with immodium prn. . # Depression: Continued home citalopram. In setting of acute pain crisis and anxiety pt had voiced suicidal ideation but this resolved and mood improved post-operatively as pain better controlled. . # + Blood culture. Patient with 1 blood culture + Coag negative Staph Aureus on [7-7]. Thought likely a contaminant. Previous blood cultures ([6-21], [6-22], [6-23], [7-2], [7-3], [7-5]) negative; [7-8] blood culture pending. At time of discharge patient afebrile with normal WBC. OUTPATIENT ISSUES: -- Continue to follow-up pending culture date . # DISPO: rehab for continued PT to optimize strength and mobility . # CODE: DNI/DNR . Inactive issues: . # HIV: Continued home HAART medications. Discrepancy between med reconcilation on admission and standard HAART dosing. Discharged patient on Kaletra 200-50 [Hospital1 ] and Epzicom 600-300 QD. . # Pulmonary hypertension/CHF: Continued sildenafil, torsemide. Metolazone discontinued due to pre-renal failure and gout, as above. . # Hyperlipidemia: Continued home tricor, pravastain, ASA . # OSA: Continued CPAP . Transition: Mr. [Known lastname ] will need an appointment to follow up with his PCP, [Last Name (NamePattern4) ]. [First Name (STitle) 3535], within 1 week of leaving the hospital. He has appointments scheduled to follow up with his neurologist, Dr. [First Name (STitle) ], and his spine surgeon, Dr. [Last Name (STitle) ], after discharge. In addition, he will need appointments scheduled to follow up with the following providers within 2-4 weeks of hospital discharge: NAME: [Last Name (LF) 20863], [First Name3 (LF) 20862] DIVISION: Rheumatology OFFICE LOCATION: CLS-936 OFFICE PHONE: ([Telephone/Fax (1) 34212] Name: [Last Name (LF) ], [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] MD Location: [Hospital1 18] - DIVISION OF PULMONARY AND CRITICAL CARE Address: [Location (un) ], KSB-23, [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 612] Note: Dr. [Last Name (STitle) ] is currently booked through [Month (only) 216], but can call the clinic and receptionists will fit him into the schedule). He should follow up with his ID specialist, Dr. [Last Name (STitle) 724], within 3-4 weeks regarding his current CD4 count and viral load. Name: [Last Name (LF) 724], [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD Location: THE TRANSPLANT CENTER Address: [Doctor First Name ], [Apartment Address(1) 34213], [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 457] NAME: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], NP DEPARTMENT: Cardiology LOCATION: [Location (un) ]., W/[Hospital1 ] 319 PHONE: [Telephone/Fax (1) 13133] Medications on Admission: ABACAVIR-LAMIVUDINE [EPZICOM] - (Prescribed by Other Provider) - 600 mg-300 mg Tablet - 1 Tablet(s) by mouth daily ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - [1-9] puffs(s) by mouth every four (4) to six (6) hours as needed for cough/wheezing CITALOPRAM - 40 mg Tablet - 1 Tablet(s) by mouth twice a day FENOFIBRATE NANOCRYSTALLIZED [TRICOR] - 145 mg Tablet - 1 Tablet(s) by mouth 1 GABAPENTIN - 600 mg Tablet - 2 Tablet(s) by mouth three times a day INSULIN ASPART [NOVOLOG FLEXPEN] - 100 unit/mL Insulin Pen - for glucose control four times a day per sliding scale (4 packs per month; uses about 60 units QID) INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - 180 units at bedtime LOPINAVIR-RITONAVIR [KALETRA] - (Prescribed by Other Provider) - 100 mg-25 mg Tablet - 2 Tablet(s) by mouth 2 times per day LORAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth three times a day as needed for anxiety METOLAZONE - 5 mg Tablet - 1 Tablet(s) by mouth once a day take together with torsemide OMEPRAZOLE [PRILOSEC] - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth daily OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - 2 Tablet(s) by mouth three times a day as needed for pain PRAVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day SILDENAFIL [REVATIO] - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth three a day TORSEMIDE - 100 mg Tablet - one Tablet(s) by mouth once a day (take together with metolazone) TRAMADOL - 50 mg Tablet - 1-2 Tablets(s) by mouth every four (4) - six (6) hours as needed for pain . Medications - OTC ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth take one daily BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - Strip - use to test your blood sugar up to six times a day or as directed. Discharge Medications: 1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness of breath. 2. citalopram 40 mg Tablet Sig: One (1) Tablet PO twice a day. 3. fenofibrate micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). 4. gabapentin 400 mg Capsule Sig: Three (3) Capsule PO Q8H (every 8 hours). 5. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. sildenafil 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. insulin glargine 100 unit/mL Cartridge Sig: Forty (40) units Subcutaneous every twelve (12) hours. 8. insulin aspart 100 unit/mL Insulin Pen Sig: 0-65 units Subcutaneous four times a day as needed for elevated blood glucose: glucose control four times a day per sliding scale - see attached. 9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Acetaminophen Extra Strength 500 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain: Do not exceed 2g/24 hours. 11. methyl salicylate-menthol Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed for pain. 12. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply to affected area for 12 hours, remove for 12 hours before applying new patch. 13. lopinavir-ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO twice a day. 14. Epzicom 600-300 mg Tablet Sig: One (1) Tablet PO once a day. 15. Kaletra 200-50 mg Tablet Sig: Two (2) Tablet PO twice a day. 16. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 17. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for costipation. 18. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. 19. sodium chloride 0.65 % Aerosol, Spray Sig: [1-9] Sprays Nasal QID (4 times a day) as needed for dry nose, congestion. 20. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for indigestion. 21. torsemide 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 22. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for rash. 23. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID:prn as needed for anxiety. 24. insulin glargine 100 unit/mL Solution Sig: One Hundred Twenty (120) units Subcutaneous at bedtime. 25. Humalog 100 unit/mL Solution Sig: Per insulin sliding scale Subcutaneous four times a day: For glucose control, see attached sliding scale. 26. Insulin Pen Needle 29 x [1-9] Needle Sig: One (1) Miscellaneous As directed by insulin sliding scale. 27. One Touch Ultra Test Strip Sig: One (1) strip Miscellaneous Up to six times a day or per insulin sliding scale. 28. oxycodone 10 mg Tablet Sig: [1-9] to 1 Tablet PO every [4-13] hours as needed for pain. Disp:20 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital 745] Health Care Center Discharge Diagnosis: Primary: 1. syncope 2. cervical stenosis 3. cervical myelopathy 4. gout Secondary: pulmonary hypertension chronic diastolic heart failure HIV HCV HLD OSA Depression 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 came to the hospital because you experienced an episode of fainting while undergoing and MRI. Tests were performed to ensure that this was not heart related; these were negative. We believe that you episode of fainting was likely caused by a combination of factors including slightly low blood sugar for you, having to not eat or drink prior to the MRI, pain and emotional stress. You symptoms improved with IV fluids, food and receiving your home dose of lorazepam. . While in the hospital, the limited MRI that came back showed severe degenerative changes of the cervical spine (neck) with herniation of the discs and stenosis (narrowing). It was believed that this was causing your severe, debilitating arm pain and inability to move your arms. You were given steriods and medications to better manage your pain. The spine [Hospital 24379] evaluated you and felt that you would benefit from surgery given the severity of the pain and the significant impact that the pain and functional limitations it imposed. The risks and benefits were discussed with you. Given your cardiac history, a stress test was performed in preparation for surgery; this was negative. Pulmonary evaluation was performed as you are a high risk surgical candidate given your pulmonary hypertension and obstructive sleep apnea. They recommended working on breathing exercises (deep breathing) and incentive spirometer in preparation for your surgery. . On [6-28] you had surgery on your spine (laminectomy fusion) to try and improve your pain. You were transferred to the surgical intensive care unit because you still required a breathing tube. On [6-30] your breathing tube was removed and you were transferred to the medical service. Your diuretic medications were temporarily increased to remove fluid, and your pain medications were increased for pain control. You developed increased pain in your right hand, shoulder, and knee. You were evaluated by the Rheumatology service, who felt that this was due to gout (likely a result of taking diuretics). You were started on prednisone and colchicine for treatment of gout, and your metalazone was stopped. You were evaluated by Physical Therapy, who felt that you would benefit from additional therapy at a rehabilitation facility. . The following changes were made to your medications: - START colchicine 0.6mg daily - START lidoderm patch for 12 hours/day as needed for shoulder pain - START bengay ointment three times a day as needed for shoulder pain - START acetaminophen 500mg PO every 6 hours for pain (do not exceed 2g in 24 hours) - START oxycodone PO 5-10mg every 4-6 hours ONLY AS NEEDED FOR PAIN NOT CONTROLLED BY tylenol, bengay and/or lidoderm [Month/Year (2) 18539]. If your pain is well controlled with either tylenol, bengay and/or lidoderm [Last Name (LF) 18539], [First Name3 (LF) ] not take this medication. - INCREASE your gabapentin dose FROM 800mg TO 1200mg every 8 hours - DECREASE your insulin glargine (Lantus) dose FROM 180 units TO 120 units every day at bedtime - STOP oxycontin - STOP tramadol - STOP metolazone . We made no other changes to your medications. Please continue to take the rest of your home medications as prescribed by your physician. . Weigh yourself every morning, [Name8 (MD) 138] MD if your weight goes up more than 3 lbs in a single day. . Please be sure to keep all follow-up appointments with your primary care provider, [Name10 (NameIs) 24379] and other health care providers. . It was a pleasure taking care of you and we wish you a speedy recovery. Followup Instructions: Please have your rehab facility schedule an appointment with your primary care physician, [Last Name (NamePattern4) ]. [First Name (STitle) 3535], within 1-2 weeks of leaving the hospital. . You have the following appointments scheduled at [Hospital1 18]: . Department: NEUROLOGY When: FRIDAY [2185-7-15] at 12:00 PM With: [First Name8 (NamePattern2) ] [Name8 (MD) 162], MD [Telephone/Fax (1) 2574] Building: [Hospital6 29] [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Department: ORTHOPEDICS When: MONDAY [2185-7-18] at 8:20 AM With: ORTHO XRAY (SCC 2) [Telephone/Fax (1) 1228] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Department: SPINE CENTER When: MONDAY [2185-7-18] at 8:40 AM With: DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] [Telephone/Fax (1) 3736] Building: [Hospital6 29] [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . . In addition, you should ask your rehab facility to schedule appointments for you to follow up with the following specialists within 2-4 weeks of leaving the hospital: . NAME: [Last Name (LF) 20863], [First Name3 (LF) 20862] DIVISION: Rheumatology OFFICE LOCATION: CLS-936 OFFICE PHONE: ([Telephone/Fax (1) 34212] . Name: [Last Name (LF) ], [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] MD Location: [Hospital1 18] - DIVISION OF PULMONARY AND CRITICAL CARE Address: [Location (un) ], KSB-23, [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 612] The Pulmonary staff are working on an appointment for you to see Dr. [Last Name (STitle) ] within a few weeks. Please call the department directly after you leave the hospital to schedule an appointment time. . Name:[Last Name (LF) 724], [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD Location:THE TRANSPLANT CENTER Address:[Doctor First Name ], [Apartment Address(1) 34213], [Location (un) ],[Numeric Identifier 718] Phone:[Telephone/Fax (1) 457] . NAME: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], NP DEPARTMENT: Cardiology LOCATION: [Location (un) ]., W/[Hospital1 ] 319 PHONE: [Telephone/Fax (1) 13133*]	[ "780.2", "584.9", "357.2", "721.1", "272.0", "416.0", "311", "428.0", "585.3", "276.1", "070.70", "571.5", "278.01", "V08", "250.60", "780.60", "428.32", "274.01", "327.23" ]	icd9cm	[ [ [] ] ]	[ "81.03", "93.90", "81.62" ]	icd9pcs	[ [ [] ] ]	22265, 22329	9862, 10357	280, 308	22539, 22539	4191, 4191	26325, 28795	2564, 2654		19302, 22242		22350, 22518		17476, 19279			22722, 26302				5241, 5567							2694, 4172					5611, 6028							6062, 9839												226, 242		10372, 15257											336, 1541					15274, 17450	4207, 5225				22554, 22698						1563, 2150	2166, 2548
8,139	178,901	48618	Discharge summary	report	Admission Date: [2113-4-13] Discharge Date: [2113-4-14] Date of Birth: [2038-3-25] Sex: F Service: This is a 75-year-old patient with end-stage lung disease from sarcoid with pulmonary fibrosis on 3 liters of home oxygen and chronic prednisone and recent hospitalization here for worsening sarcoid versus CHF, for which she underwent diuresis, who was transferred from [Hospital6 33] ED to [Hospital3 ] on [4-13] with worsening shortness of breath and was evaluated by the Intensive Care Unit in the Emergency Room. At that time, she was comfortable, had stable O2 saturations and so she was admitted to Medicine Night Float to the Medicine wards. Over the early hours of her hospitalization, the patient had declining mental status and worsening hypoxia, and work of breathing. She was evaluated by her pulmonologist, Dr. [Last Name (STitle) 217], who felt that if aggressive care was indicated, she should get a trial of noninvasive ventilation, diuresis, and possible thoracentesis as she had a large left effusion and also by the CHF team, who felt she should have a Natrecor diuresis with the addition of Lasix and rate controlled with diltiazem. After discussion with the family between the [Hospital1 ] attending, Dr. [First Name8 (NamePattern2) ] [Name (STitle) 665] and the pulmonologist, the patient was admitted to the Medical Intensive Care Unit for further care. PAST MEDICAL HISTORY: 1. Sarcoid on home O2. 2. Mycobacterium gordonae lung colonization. 3. Type 2 diabetes. 4. Diastolic CHF. 5. Coronary artery disease status post four-vessel CABG in [2097] with pulmonary hypertension and tricuspid regurgitation. 6. Atrial fibrillation. 7. Multiple skin cancers. 8. Anemia felt to be from infiltrates from sarcoid. 9. Obesity. 10. Hypercholesterolemia. 11. Sleep disorder breathing. 12. Hypertension. 13. DVT complicated by pulmonary embolus. 14. Gallbladder stones complicated by cholecystectomy. 15. Pneumonia in [2112-12-1] and [1-4]. 16. Cellulitis in [1-4]. 17. Depression. SOCIAL HISTORY: The patient has a closely involved family and has never smoked or use alcohol to access. On her last admission she was changed to comfort care and had a goal of trying rehab one more time to see if she could go home, and was pleased with having accomplished this goal prior to her current admission. MEDICATIONS ON ADMISSION: 1. Lasix. 2. Levofloxacin. 3. Protonix. 4. Coumadin. 5. Folate. 6. Dapsone. 7. Calcium supplements. 8. Diltiazem. 9. Tylenol. 10. Albuterol and Atrovent. 11. Insulin. 12. Prednisone. 13. Colace. 14. Potassium. ALLERGIES: Ampicillin caused a rash. PHYSICAL EXAMINATION: On physical exam, she had a temperature of 99.8, sats dipping to the low 80s, and respiratory rate up to 35, blood pressure of 100, and heart rate of 104 in atrial fibrillation. Physical exam was notable for the inability to follow commands or communicate effectively and accessory muscle use. Facial surgical scars from skin cancer therapy and an irregularly, irregular cardiac exam obscured by rhonchorous respirations with rales and squeaks and poor air movement, grunting abdominal respirations, multiple skin tears, ecchymoses, and actinic keratoses, venous stasis changes, and substantial lower edema. Please see OMR for laboratory studies. HOSPITAL COURSE: The patient was admitted to the Intensive Care Unit and placed on noninvasive mask ventilation. She was continued on her antibiotics, nebulizers, and steroids, as well as nesiritide and Lasix. Diltiazem was given for rate control. Patient was minimally responsive throughout. Discussion was held to see whether she should have better access obtained through the central line and arterial line. Family decided to avoid any procedure, which could cause discomfort. Patient was maintained on noninvasive ventilation until the rest of the family and a minister could arrive. At that point, Morphine was titrated up. Her mask ventilation was discontinued and she died surrounded by her family at 21:20 on [2113-4-14]. An autopsy was declined. [Name6 (MD) ] [Name8 (MD) ], [MD Number(1) 17274] Dictated By:[Last Name (NamePattern1) 47584] MEDQUIST36 D: [2113-4-14] 22:54:37 T: [2113-4-17] 06:24:57 Job#: [Job Number ]	[ "517.8", "518.81", "515", "427.31", "496", "428.0", "428.30", "276.2", "135" ]	icd9cm	[ [ [] ] ]	[ "93.90", "00.13" ]	icd9pcs	[ [ [] ] ]													2467, 2743	3435, 4417																										2766, 3417																																								1463, 2122	2139, 2441
42,851	177,052	38427	Discharge summary	report	Admission Date: [2124-2-4] Discharge Date: [2124-2-7] Date of Birth: [2042-7-4] Sex: M Service: SURGERY Allergies: Keflex Attending:[First Name3 (LF) 371] Chief Complaint: Post operative bleeding Major Surgical or Invasive Procedure: None History of Present Illness: Patient is an 81M 10 days s/p resection of small bowel tumor who presents with BRBPR X 2 (one last night, one this morning). He denies any CP, SOB, nausea/vomiting, diziness, loss of consciousness. He was taken to an OSH, where his Hct was 17, coagulation parameters were normal. He had a tagged red cell scan that localized bleeding to proximal small bowel by the splenic flexure. He was given 2 units of PRBCs and transferred to [Hospital1 18]. Past Medical History: 2 vessel CAD - s/p PCI with DES in LCx and OM in [6-/2123] at [Hospital1 18] Bladder Cancer s/p resection [5-/2123] HTN HLD BPH s/p TURP Depression s/p appendectomy Social History: Wife just died of metastatic breast cancer during this admission - Tobacco: never - Alcohol: 6-8 beers a week - Illicits: None Family History: Cardiac disease. Brother died of melanoma Physical Exam: Vitals: Afebrile, BP: 115/88 mmHg supine, HR 83bpm, RR 16 bpm, O2: 99 % on 2L NC. Gen: NAD, AAOX3 HEENT: No icterus. MMM. . NECK: Supple, No LAD. CV:RRR. normal S1,S2. gallops LUNGS: CTAB anteriorly. ABD: Soft, NT, slightly distended. Laparotomy wound stapled and healing well. EXT: NO CCE. Pertinent Results: MB: 3 Trop-T: <0.01 [2124-2-7] 05:00AM 29.6* [2124-2-6] 05:40PM 30.8* [2124-2-6] 08:11AM 29.6* [2124-2-6] 01:49AM 29.1* [2124-2-5] 10:06PM 26.7# [2124-2-5] 02:15PM 20.3 Brief Hospital Course: Patient is an 81 yo male s/p exploratory laporotomy and small bowel resection for a small bowel tumor on [2124-1-25]. Upon discharge he was stable surgery and was holding his plavix. We have asked him to restart plavix on wednesday [2124-2-2]. He developed the bleed on Thursday ([2124-2-3]), in the context of re-initiating plavix. He was readmitted to [Hospital6 ] on [2-4] with BRBPR accompanied by chest pain, which he had his last admission with severe anemia. His Hct was 17. Tagged RBC scan showed bleeding in the proximal small bowel and he was transferred to [Hospital1 18]. Here he has been transfused 7 units of PRBC, 4u of FFP, and 2 bags of platelets. He continues to bleed as evidenced by a falling Hct and maroon stools. Patient's HCT was stable at 29 on [2124-2-6]. Patient had recieved 10 units of PRBC total and remains at a HCT of 19-30 for 24 hrs. Patient was sent to a regular nursing floor. Patient with non bloody stools, and no complaints of abdominal pain. Patient was seen by cardiology for his left sided chest pressure. His biomarkers were negative x3. Cardiology recommended that there was no need to restart plavix, however, patient should restart aspirin 81mg as soon as clinically able. His target Hct >29 as primary treatment of coronary ischemia. On [2124-2-7], patient was discharged to home with HCT >29, hemodynamically stable with no complaints. Patient to follow up with cardiology and surgery on an outpatient basis. He will start his Aspirin 81mg in 48 hors after discharge. Medications on Admission: aspirin 325mg daily plavix 75mg daily ramipiril 5mg QD Paxil 20mg QD Lipitor 10mg Daily Vitamin B 12 1000mcg monthly INJ atenolol 100mg QD Chlorthalidone 25mg PO daily Discharge Medications: 1. paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual ASDIR (AS DIRECTED). 3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 4. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 6. Aspirin Low-Strength 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day: Please start aspirin on Wednesday [2124-2-9]. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: LOWER GASTROINTESTINAL BLEEDING Discharge Condition: Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Discharge Instructions: * You were admitted to the hospital with weakness and dark colored stools due to bleeding at previous surgery site. * You required transfusion of blood products * Your symptoms have resolved with transfusion of blood products and holding of plavix. Please start aspirin in 48 hrs. * You should continue to eat a regular diet and stay well hydrated. * If you develop fevers, abdominal pain or have any new symptoms that concern you, please call the doctor or return to the Emergency Room. Followup Instructions: Call the Acute Care Clinic at [Telephone/Fax (1) 600] for a follow up appointment in 2 weeks.	[ "152.1", "V10.51", "600.00", "311", "E878.2", "414.01", "V45.82", "401.9", "412", "569.3", "285.1", "998.11", "272.4" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	4282, 4288	1758, 3317	286, 293	4364, 4454	1511, 1735	5029, 5130	1138, 1181		3536, 4259		4309, 4343		3343, 3513			4515, 5006											1196, 1492																								223, 248													321, 774										4469, 4491						796, 974	990, 1122
32,282	123,684	33035	Discharge summary	report	Admission Date: [2145-1-7] Discharge Date: [2145-1-14] Date of Birth: [2076-5-12] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4963] Chief Complaint: Upper GI bleed Major Surgical or Invasive Procedure: EGD [2145-1-8], [2145-1-12] History of Present Illness: 68 y/o F with PMHx as below, otherwise significant for recurrent sigmoid diverticulitis and severe COPD, admitted to OSH on [12-29] with SOB, malaise, and elevated WBC. A CXR showed an infiltrate in the RML c/w pneumonitis. A CT abd/pelvis showed RML infiltrate, no evid of diverticulitis. Her VS were sig for mild hypoxia to 91% on RA -> 96% 2L NC. She was admitted to their medical floor and treated with Zosyn for CAP due to her recent hospitalization. She was also placed on IV SoluMedrol & nebulizers to cover a possible COPD exacerbation. A Chest CT obtained on [1-4] showed a large hiatal hernia (old) with large amt of food impaction and ? chronic aspiration (patchy RML and LLL infiltrates). GI was consulted who performed an EGD on [1-6] which revealed esophagitis and fresh blood at the distal end of the esphoagus which was injected twice with epi. A large amt of clots were seen in the stomach without other etiology. A repeat hct showed a hct of 27 (36 on admission?) and 1u pRBC was given. 10mg SC Vit K was given for an INR of 1.7. Hct bumped to 34, then back down to 27. A repeat EGD on [1-7] again demonstrated showed active bleeding in the distal esophagus with large amt of clots in the stomach. Due to poor visibility, no further action was taken. An addt'l unit of pRBC was given, Protonix gtt was started, and pt was transferred to [Hospital1 18] for repeat EGD/intervention. Given her GIB her steroids were returned to her home dose of 5mg of prednisone. . On arrival, pt c/o epigastric abd pain, radiating to the LUQ. She denies any recent N/V, hematemesis, BRBPR, or hematochezia. Last BM today was reportedly guiaic (-). She otherwise denies any F/chills, productive cough, chest pain, dysuria, or any other symptom. Past Medical History: 1) recurrent sigmoid diverticulitis s/p sigmoid resection 12/[2143]. c/b mild wound infection. 2) Severe COPD on chronic steroids. FEV1 30% per report. Uses home oxygen intermittently. 3) Insulin dependent DM 4) HTN 5) GERD 6) Dysphagia 7) Esophageal stricture s/p resection in [2133]. 8) PUD/gastritis/esophagitis 9) hx of hiatal hernia 10) ? gastroparesis 11) chronic anemia 12) osteoporosis Social History: Heavy etoh use, "couple of pints on the weekend." Quit 1 yr ago. Former tob user, 25 pk-yr hx, quit 8 mo ago. No drug use. Recieved Pneumonvax, Flu vaccine this year. Lives at home alone - no family members. Family History: non-contributory Physical Exam: Physical Exam on MICU admission: VS: Temp:98.6 BP:121/65 HR:97 RR:16 O2sat: 92% on 1.5L NC GEN: Pleasant, in mild discomofort due to pain HEENT: PERRL, EOMI, anicteric, MM dry, op without lesions NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: Mild end-expiratory wheezing but otherwise good air movement throughout. No rales or crackles noted. CV: RR, S1 and S2 wnl, no m/r/g. + R subclavian in place ABD: TTP over epigastrium radiating into LUQ. No RUQ tenderness. No rebound or guarding. No masses or hepatosplenomegaly EXT: no c/c/e, warm, good pulses SKIN: no rashes/no jaundice NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. Pertinent Results: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2145-1-13] 09:31AM 26.5* [2145-1-13] 06:10AM 8.2 2.61* 8.1* 24.8* 95 30.9 32.6 15.5 399 . [2145-1-8] 05:26AM 16.7* 3.03* 9.1* 28.7* 95 30.2 31.8 16.4* 432 [2145-1-7] 07:24PM 17.8* 3.21* 10.1* 29.9* 93 31.4 33.7 15.4 391 . RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 [2145-1-12] 06:29AM 85 4* 0.5 145 3.6 110* 30 [2145-1-11] 05:23AM 79 4* 0.5 143 4.0 109* 30 . [2145-1-8] 05:26AM 64* 27* 0.5 142 4.5 111* 26 [2145-1-7] 07:24PM 87 30* 0.6 142 4.4 111* 27 . ENZYMES & BILIRUBIN ALT AST LD(LDH) AlkPhos TotBili [2145-1-7] 07:24PM 13 12 177 100 0.2 . Esophageal biopsy [2145-1-12] Squamous mucosa with focal mild active esophagitis. No glandular mucosa seen. . Portable CXR [2145-1-7] Left effusion and airspace disease, the latter slightly progressed versus prior. Again, pneumonia and atelectasis are possible. Brief Hospital Course: 68 y/o F with PMHx as below, otherwise significant for recurrent sigmoid diverticulitis and severe COPD, admitted to OSH on [12-29] with CAP, found to have UGIB . # UGIB: Has long-standing history of severe GERD and esophagitis however no h/o GIB; had prior esophageal resection for dysphagia, found to have stricture. s/p EGD x 2 during admission, no evidence of active bleeding seen however initial EGD showed blood in stomach; and biopsy showed esophagitis. Hematocrit remained stable during admission, she did not require any blood transfusions here although she received 2U at OSH. H.pylori serology negative. Continued pantoprazole daily, however also added carafate prior to discharge for abdominal pain. . # Abdominal pain: Localized to LUQ & epigastric area. Unclear etiology, improved during pt's stay. Etiology still unclear as EGD done unrevealing, however biopsy showed esophagitis. Pain control with dilaudid prn, pain improved during stay. Pt to f/u with PCP for further evaluation. . # COPD: Pt with significant COPD, on oxygen as needed at home. Had initially been treated at OSH hospital with high dose steroids, tapered down to home regimen prednisone 5mg po daily. Her O2sats were adequate here, did not require oxygen. We continued her on home regeimn advair, spiriva and nebs as needed. . # DM: Well controlled on admission, held lantus 7U at bedtime while on clear liquid diet. Resumed prior to discharge. . # HTN: Restarted pt on home regimen of furosemide 20mg po daily prior to discharge. Had been held on admission due to UGIB. . # Osteoporosis: Continued pt on home regimen Evista. . # Leukocytosis: Resolved prior to discharge, had been treated for CAP at OSH with 10day course of zosyn, also ?leukemoid reation from steroids. No evidence of active infection as afebrile without leukocytosis. No antibiotics. . Pt reached maximal hospital benefit and was discharged home to follow up with Gastroeneterology as well as PCP. Medications on Admission: Home Meds: Lantus 7u qhs ASA 81' Trazadone 100 qhs Evista 60' Protonix 40" Advair 250/50 [Hospital1 ] Spiriva Zocor 20' Lasix 20' Pred 5' . Meds on Transfer: Protonix gtt 8mg/hr Advair Spiriva Prednisone 5mg Dilaudid prn Zinc 220'/Vit C 500" Thiamine 100' Kdur 10' Zocor 20' Evista 60' Trazadone 100 qhs Zosyn 3.375 IV q6 Senna/Colace Benadryl Insulin SS Xopenex Zofran prn . Allergies: NKDA 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. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO QDAILY (). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. FoLIC Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. Insulin Glargine 100 unit/mL Solution Sig: Seven (7) units Subcutaneous at bedtime. 13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 15. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:120 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Upper GI bleed Severe COPD Insulin dependent diabetes Discharge Condition: Stable Discharge Instructions: You were transferred from [Hospital3 4107] for EGD and further management of upper GI bleed. EGD showed some inflammation of the lining of your stomach and no further bleeding. . We have not made any changes to your medications, we have added Carafate which coats your abdomen and may help with abdominal pain. We recommend that you do not drink alcohol or use aspirin as this may affect bleeding in your stomach & esophagus. . Call your PCP or come to the emergency room if you develop chestpain, shortness of breath, fatigue, blood in your stools or black stools. Followup Instructions: You have an appointment with your PCP [Last Name (NamePattern4) ].[First Name8 (NamePattern2) 553] [Last Name (NamePattern1) 6707] on [2145-1-27] @ 10am. Office# [Telephone/Fax (1) 14214]. You will need to have a repeat CXR by your PCP to evaluate resolution of your pneumonia, please discuss this with her. . Gastroenterology f/u with Dr [Last Name (STitle) 11510] on [2145-1-15] @ 430pm. Office # [Telephone/Fax (1) 4475]. You will need to have your hematocrit checked at that time.	[ "250.00", "E932.0", "V46.2", "733.00", "789.07", "288.60", "558.9", "530.10", "578.9", "V45.89", "285.1", "V58.67", "305.00", "530.81", "401.9", "496", "536.3" ]	icd9cm	[ [ [] ] ]	[ "45.13", "99.04", "45.16" ]	icd9pcs	[ [ [] ] ]	8400, 8455	4665, 6622	329, 367	8553, 8562	3668, 4642	9180, 9700	2848, 2866		7068, 8377		8476, 8532		6648, 6792			8586, 9157											2881, 3649																								275, 291													395, 2177																2199, 2604	2620, 2832		6810, 7045
49,023	171,020	40733	Discharge summary	report	Admission Date: [2179-9-2] Discharge Date: [2179-9-18] Date of Birth: [2137-6-30] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2641] Chief Complaint: Seizure with fall resulting in traumatic brain injury. Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. [Known lastname 1001] is a 42 year old man with a history of ETOH abuse, DTs, and withdrawal seizures who was found down and found to have SAH and intraparenchymal hemorrhage. Based on collateral history, the patient is a chronic alcoholic but had not been drinking much for the past 3 days prior to admission. He then may have had a withdrawal seizure, fell, and developed the SAH. No neurosurgical interventions were done and his bleeds stabilized, but his hospital course has been complicated by seizures over the weekend (thought to be withdrawal related vs [3-17] bleed) which resolved with keppra and benzos. Current active medical issues include: 1) group B strep bacteremia thought to be from CVL, for which he is on vanc and ID is following 2) moderate delirium (most likely secondary to sedatives, bacteremia neuro exam nonfocal) and he would benefit from room near nurses station 3) Resolving hepatitis and pancreatitis (likely ETOH related) 4) Resolving pancytopenia for which hem/onc has been following 5) Resolving refeeding syndrome c/b hypophosphatemia for which renal has been following. The constellation of his complex and active medical problems make internal medicine the best service of choice. Neurosurgery will follow as the consultant service with recommendations to continue keppra, f/u with neurosurg as outpatient in 1 month post discharge with plans for re-imaging at that time. . In addition to the above, his L IJ and a-line were discontinued once the bacteremia was diagnosed. The R subclavian were kept for access. He was extubated on [9-7] wo incident. ID has been consulted and recommend continuing vancomycin for now despite penicillin sensivity with concern for lowering the seizure threshold with pcn G. He has continued to exhibit delirium attributed to over medication with diazepam (currently on 25mg TID, dose increased after extubation). Insulin requirement has been minimal. Speech and swallow evaluated pt today and cleared for thin liquids and ground solids. Foley catheter discontinued prior to transfer to medicine. Regarding seizure activity: repeat imaging stable, no neuro deficits, no interventions were performed and no seizure activity since [9-3] (eeg subsequently dc'd). Vitals prior to transfer 97.6 88/53 109 17 98/RA (BP range 91/53-142/83). I/O: 2545/1828. Stooled today. . On the floor, patient was stable. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: Alcohol abuse History of skull fracture and intracranial bleed Social History: Social History: Heavy alcohol and tobacco use per mother and brother. Family History: unknown, patient and family not forthcoming with information Physical Exam: ON ADMISSION IN ED: Constitutional: Intubated sedated HEENT: Facial abrasions C. collar in place Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm Pelvic: No obvious signs of trauma Neuro: sedated, does not open eyes spontaneously, moves face, head, and neck sponaneously. No verbalization. Pupils 2->1 bilaterally. Corneal reflexes present bilaterally. Withdraws all four extremities to pain. . ON DISCHARGE: Vitals: 98.2, 97-110s/70-80s, 76-93, 16-18 98-100% General: Alert, oriented X 3, no acute distress HEENT: PERRL, Sclera anicteric, MMM, oropharynx clear, R subclav bandage dry and clean/ intact. Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation, no rales, ronchi, or wheezing CV: Regular rate and rhythm, nml S1 + S2, no murmurs, rubs, gallops Abdomen: soft, NT/ND, bowel sounds (+), no rebound/guarding, +HSM Ext: Extremities w/w/p, no c/c/e Neuro: motor function and sensation grossly normal Pertinent Results: LABS ON ADMISSION: . [2179-9-2] 12:05AM BLOOD WBC-5.1 RBC-3.22* Hgb-11.6* Hct-33.1* MCV-103* MCH-36.1* MCHC-35.1* RDW-14.7 Plt Ct-50* [2179-9-3] 06:12PM BLOOD Neuts-75* Bands-7* Lymphs-16* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2179-9-3] 06:12PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-OCCASIONAL Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL Envelop-1+ [2179-9-2] 12:05AM BLOOD PT-11.7 PTT-24.6 INR(PT)-1.0 [2179-9-2] 12:05AM BLOOD Fibrino-187 [2179-9-2] 12:05AM BLOOD Glucose-184* UreaN-8 Creat-1.2 Na-135 K-2.9* Cl-96 HCO3-11* AnGap-31* [2179-9-2] 04:14AM BLOOD ALT-343* AST-615* CK(CPK)-293 AlkPhos-292* TotBili-4.3* [2179-9-2] 12:05AM BLOOD Lipase-510* [2179-9-2] 04:14AM BLOOD CK-MB-7 cTropnT-<0.01 [2179-9-2] 04:14AM BLOOD Calcium-6.8* Phos-2.0* Mg-2.2 [2179-9-3] 12:02PM BLOOD VitB12-1870* Ferritn-7754* [2179-9-3] 08:29AM BLOOD Triglyc-311* HDL-25 CHOL/HD-8.4 LDLcalc-123 [2179-9-3] 11:03AM BLOOD Cortsol-26.1* [2179-9-2] 12:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2179-9-2] 12:05AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2179-9-2] 02:08AM BLOOD Type-ART pO2-207* pCO2-20* pH-7.29* calTCO2-10* Base XS--14 [2179-9-2] 12:11AM BLOOD Glucose-190* Lactate-1.5 Na-135 K-3.1* Cl-98* calHCO3-11* [2179-9-2] 12:11AM BLOOD freeCa-1.03* . LABS ON DISCHARGE: [2179-9-14] 06:40AM BLOOD WBC-6.7 RBC-2.87* Hgb-9.9* Hct-28.7* MCV-100* MCH-34.5* MCHC-34.5 RDW-14.5 Plt Ct-272 [2179-9-14] 06:40AM BLOOD Glucose-106* UreaN-19 Creat-0.8 Na-142 K-3.5 Cl-104 HCO3-26 AnGap-16 [2179-9-14] 06:40AM BLOOD Calcium-9.5 Phos-4.7* Mg-1.7 . . STUDIES: . CT C-spine - [2179-9-2] - No acute fractures. . CT Head - [2179-9-2] - Stable subarachnoid and intraparenchymal hemorrhage with no mass effect. Area of hypodensity in left frontal lobe stable from prior study, MRI can be considered to further evaluate. Slight prominence of ventricles and sulci. . MRI C-spine - [2179-9-3] - Mild degenerative disc disease. Otherwise normal examination with no evidence of fracture or ligamentous injury. . EEG - [2179-9-7] - This is an abnormal continuous ICU monitoring study because of severe diffuse background slowing with superimposed frontally maximal beta activity consistent with severe diffuse cerebral dysfunction. These findings are etiologically specific but likely in part due to pharmacologic sedation. There are no epileptiform discharges or electrographic seizures. Compared to the prior day's study, there is no significant change. . ECHO - [2179-9-9] - The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size is normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. Physiologic mitral regurgitation is seen (within normal limits). No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Limited study secondary to suboptimal image quality. No transthoracic echocardiographic evidence of endocarditis. Mildly dilated ascending aorta. . CXR - [2179-9-10] - No acute intrathoracic process. . TEE [2179-9-13] No mass/thrombus is seen in the left atrium, left atrial appendage, right atrium or right atrial appendage. 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 descending thoracic aorta 48 cm from the incisors. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion with no aortic regurgitation is seen. No vegetations or abscess cavities are seen. The mitral valve leaflets are structurally normal with trivial mitral regurgitation is seen. No vegetations or abscess cavities seen. The tricuspid valve leaflets are normal with trivial tricuspid regurgitation. IMPRESSION: Normal study. No valvular pathology or pathologic flow identified. CXR [2179-9-16] FINDINGS: As compared to the previous radiograph, the patient has removed the right subclavian line. There is no evidence of pneumothorax. No pneumomediastinum. Normal size of the cardiac silhouette. No pulmonary edema. No pleural effusions Brief Hospital Course: Mr. [Known lastname 1001] was seen and evaluated in the emergency department after a witnessed seizure and fall at home. His CT scan demonstrated subarachnoid and intraparenchymal hemorrhages. It was thought that his seizures were alcohol withdrawal seizures. He was loaded with Keppra and admitted to the Neuro ICU. . He was hyponatremic and pancytopenic with a metabolic acidosis on admission to the Neuro ICU. He continued to require critical care management of the above issues. A cervical MRI was obtained to rule out cervical spine injury, and this demonstrated no fracture or instability. His cervical spine collar was then removed. On [2179-9-4], EEG showed no seizure activity. He began showing evidence of alcohol withdrawal and soon after developed refeeding syndrome. On [2179-9-5] he was without seizure activity since [2179-9-3] and the EEG monitoring was discontinued. On [2179-9-6] he was started on Vancomycin for a Group B Strep infection. It was decided that his medical issues would be best managed in a medical inpatient unit. A bed was requested, and he was transferred once extubated on [2179-9-7] to a general medicine floor. He was stable on the medicine floor, receiving his final doses of ceftriaxone for 14 days total. . The following issues were dealt with on the general medicine floor once transferred: . - Group B Strep bacteremia: The patient came to the floor with a right subclavian line for administration of IV ceftriaxone. He continued to have no positive blood cultures from [2179-9-4] to discharge. He also received a transesophageal echocardiogram to rule out endocarditis which was negative for vegetations. He completed a total of 2 weeks intravenous antibiotics. . - Neurologic trauma: The patient continued to recover from subarachnoid and intraparenchymal hemorrhage complicated by alcohol withdrawal seizures. The patient's delirium began clearing and seizure activity remained stopped after high dose benzodiazapines were discontinued. He was continued on folate and thiamine as well as a Clonidine Patch and Keppra. . - Malnutrition: The refeeding syndrome the patient experienced in the ICU continued to improve. This was monitored by trending lipase and transaminase levels. He was cleared for a cardiac/heart healthy diet w/ boost supplementation by speech and swallow following a negative chest x-ray on [2179-9-10]. . - Cardiovascular: hemodynamically stable on floor, continued Carvedilol 6.25 [Hospital1 ]. . - Pulmonary: extubated with good oxygen saturation on room air. . - Renal: no active renal insufficiency; metabolic acidosis resolved. . - Hematology: Thrombocytopenia and pancytopenia resolved. . The patient was home as he was denied at [Hospital ] Hospital and did not want to go to [Hospital 89061] hospital. He did not qualify for a [Hospital1 1501] due to insurance issues. Follow up: With neurosurgery for repeat CT of head to determine if progression of intracranial processes. Medications on Admission: Lisinopril 2.5 Folic Acid 1 Carvedilol 6.25 [Hospital1 ] Discharge Medications: 1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:0 2. carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:0 4. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 5. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:60 Patch 24 hr(s) Refills:0 6. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSUN (every Sunday). Disp:3 Patch Weekly(s) Refills:0 7. levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home Facility: [Hospital6 2222] - [Location (un) 538] Discharge Diagnosis: TRAUMATIC BRAIN INJURY HYPONATREMIA THROMBOCYTOPENIA ALCOHOL ABUSE WITHDRAWAL SEIZURES SUBARACHNOID HEMORRHAGE INTRAPARENCHYMAL HEMORRHAGE INTRAVENTRIDULAR HEMORRHAGE METABOLIC ACIDOSIS Pancytopenic Hypophosphatemia Group B strep bacteremia refeeding syndrome. Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 1001], It was a pleasure taking care of you at [Hospital1 18]. You were admitted to the hospital for bleeding in your head and alcohol withdrawal after you were found down in your apartment. We found on imaging of your head that there was blood on the brain, but the decision was made to not operate on it. We will monitor the blood with a CT scan later this month. For follow up, please keep the following appointments below. Additionally, please call [0-0-] to find [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Last Name (NamePattern1) 1675] affiliated primary care providor in your neighborhood. The following changes were made to your medications this admission: -Continue folic acid 1 mg Daily -Continue carvedilol 6.25 mg, 2 times a day -Start LeVETiracetam 1000 mg daily -Start CeftriaXONE 2 gm IV every 24 hours through [2179-9-18] -Start thiamine 100 mg Tablet daily -Start famotidine 20 mg Tablet, 2 times a day -Start nicotine Patch one every 24 hours -Start clonidine 0.3 mg Patch one per week, change on Sundays -Stop Lisinopril It is important that you stop drinking alcohol and stop smoking cigarettes. Followup Instructions: Follow-Up Appointment Instructions ??????Please call [0-0-] to find [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Last Name (NamePattern1) 1675] affiliated primary care providor in your neighborhood. Department: RADIOLOGY When: WEDNESDAY [2179-10-13] at 1:15 PM With: CAT SCAN [Telephone/Fax (1) 327] Building: CC CLINICAL CENTER [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Notes: Please arrive at 1 PM for this appointment. Department: NEUROSURGERY When: WEDNESDAY [2179-10-13] at 2:00 PM With: [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 1669] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage	[ "349.82", "276.2", "E939.4", "571.1", "577.0", "999.31", "292.81", "276.8", "291.81", "303.90", "E888.9", "780.39", "041.02", "790.7", "276.1", "284.1", "263.9", "275.3", "853.00" ]	icd9cm	[ [ [] ] ]	[ "96.6", "88.72", "96.72" ]	icd9pcs	[ [ [] ] ]	13321, 13385	9405, 12304	358, 366	13690, 13690	4415, 4420	15057, 15833	3376, 3438		12522, 13298		13406, 13669		12437, 12499			13843, 15034											3453, 3868									12315, 12411								3882, 4396							264, 320				5845, 9382	2806, 3186								394, 2788								4434, 5826		13705, 13819						3208, 3272	3304, 3360
23,394	136,543	45417+58815	Discharge summary	report+addendum	Admission Date: [2179-3-16] Discharge Date: [2179-3-25] Date of Birth: [2109-9-13] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4232] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: None. History of Present Illness: 69 year old male with h/o COPD s/p recent admission for exacerabtion and respiratory acidosis, PAF, DM, CRI who was sent from [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] for confusion, lethargy, urinary incontinence and low grade temps. Patient has been at [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ] since [2179-2-25] after admission for COPD exacerbation. Over the past [2-9] days the patient reports he has been feeling more confused. He denies fevers, chills, dysuria, worsening cough, chest pain, N/V, diarrhea, abdominal pain. His breathing has been a bit more labored. Per report from [Last Name (un) 1188] house he had urinary incontinence, lethargy and confusion. His vitals this AM were BP 144/80 Temp 99.8 HR 90 and O2 sat 92% on 2L. He was sent to the [Hospital1 ] ER. Pt currently denying backpain or fecal incontinence. Says had some LE weakness and urinary incontinence in the past day. . Of note pt had recent admission from [Date range (1) 96935]/07 for hypercarbic respiratory failure and mental status changes. At that admission he was found down and had severe respiratory acidosis 7.10/112/146. He was treated with steroids, abx and bipap and subsequently improved. Also had acute on chronic renal failure and hyperkalemia. ARF was thought to be pre-renal. Patient improved and discharged to rehab on 7 days of levofloxacin and steroid taper that was scheduled to end [3-1]. However, appears he is still on a steroid taper. . In the ED, the patient was found to have severe wheezes and minimal air movement. He had an ABG of 7.33/86/47/47 on NRB. He was started on bipap and received ipratropium/albuterol nebs, lasix 40 mg IV, solumedrol 125 mg IV and zosyn. He also had right LENI which was negative. His repeat ABG was 7.31/88/103/47 on 40% FiO2. . In the MICU, patient was started on antibiotics for presumed pneumonia, treated for CHF with aggressive diuresis, started on IV steroids which were swicthed to PO upon transfer to floor, and placed on CPAP. ABGs were serially monitored with little improvement in oxygeneation and persistent co2 retention. . Seen and examined by medicine floor team. Patient not complaining of shortness of breath, chest pain. He has mild abdominal pain which he attributes to not having regular BMs while in hospital. Does not feel confused. Past Medical History: 1) Chronic obstructive pulmonary disease, no pulmonary function test on record, on 3L NC at home (only with exertion). 2) Obstructive sleep apnea on BIPAP (settings = 12&6 on 8 L oxygen.) 3) Type 2 diabetes (last A1C 6.4 on [2179-1-26]) c/b biopsy-proven diabetic nephrosclerosis. 4) Paroxysmal atrial fibrillation on aspirin 5) Chronic renal insufficiency from diabetic nephropathy, baseline Cr 2-2.5. Followed by Dr. [Last Name (STitle) ]. 6) Gout 7) Anemia 8) Hypertension 9) Anxiety Social History: Was living as [Hospital3 1186] since last d/c on [2179-2-25]. Prior to that lived with daughter. +tob (1 ppd), +occ EtOH (last admit was noted to be drinking 3 beers/day), no drugs. Family History: Non-contributory Physical Exam: VS: Tc 97.5 HR 84 BP 148/62 RR 24 O2 sat 93% on 3L Gen: elderly black male, awake, a&o x3 HEENT: PERRL, anicteric sclera, though some chemosis Neck: elevated JVP Pulm: no wheezes or rhonchi, faint bibasilar crackles, good inspiratory effort and air movement Cardio: RRR, nl S1 S2, no m/r/g Abd: soft, mildly distended, NT, + BS Ext: trace pitting edema up to sock lining, 1+ DP pulses b/l Neuro: moves all extremities and follows commands, PERRLA, EOMI Pertinent Results: [2179-3-16] 07:00PM BLOOD WBC-3.1# RBC-4.15 Hgb-10.2* Hct-30.8* MCV-74* MCH-24.6* MCHC-33.2 RDW-16.4* Plt Ct-184 [2179-3-19] 06:45AM BLOOD WBC-7.3 RBC-4.04* Hgb-9.4* Hct-29.4* MCV-73* MCH-23.3* MCHC-32.0 RDW-16.6* Plt Ct-245 [2179-3-16] 07:00PM BLOOD Neuts-71.3* Lymphs-18.9 Monos-9.2 Eos-0.4 Baso-0.2 [2179-3-16] 07:00PM BLOOD Hypochr-2+ Anisocy-1+ Microcy-3+ [2179-3-17] 03:12AM BLOOD PT-12.6 PTT-23.9 INR(PT)-1.1 [2179-3-16] 07:00PM BLOOD Glucose-195* UreaN-45* Creat-2.2* Na-139 K-6.2* Cl-95* HCO3-39* AnGap-11 [2179-3-19] 06:45AM BLOOD Glucose-210* UreaN-59* Creat-2.2* Na-140 K-4.4 Cl-93* HCO3-41* AnGap-10 [2179-3-17] 03:12AM BLOOD ALT-22 AST-17 CK(CPK)-60 AlkPhos-54 TotBili-0.2 [2179-3-17] 03:12AM BLOOD cTropnT-0.06* [2179-3-17] 11:53AM BLOOD CK-MB-NotDone cTropnT-0.06* [2179-3-17] 06:16PM BLOOD CK-MB-NotDone cTropnT-0.06* [2179-3-16] 07:00PM BLOOD Calcium-8.8 Phos-5.3# Mg-1.8 [2179-3-19] 06:45AM BLOOD Calcium-8.2 Phos-5.3* Mg-2.1 [2179-3-18] 03:24AM BLOOD Free T4-0.84* [2179-3-18] 03:24AM BLOOD TSH-0.30 [2179-3-17] 03:12AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2179-3-16] 08:39PM BLOOD Type-ART pO2-47* pCO2-86* pH-7.33* calTCO2-47* Base XS-14 [2179-3-17] 07:08PM BLOOD Type-[Last Name (un) ] Temp-37.4 pO2-24* pCO2-93* pH-7.32* calTCO2-50* Base XS-15 [2179-3-16] 08:30PM BLOOD Lactate-1.3 K-5.7* [2179-3-16] 08:39PM BLOOD Glucose-210* Lactate-1.4 Na-141 K-5.8* Cl-92* [2179-3-16] 08:39PM BLOOD freeCa-1.14 . IMAGING: UNILAT LOWER EXT VEINS RIGHT [2179-3-16] 9:49 PM IMPRESSION: No evidence of right lower extremity DVT. . CHEST (PORTABLE AP) [2179-3-16] 7:40 PM Mild-to-moderate pulmonary edema. More confluent opacity in the right lower lung zone may represent asymmetric edema, however, followup radiograph following diuresis is recommended to exclude an underlying pneumonia. . ECG Study Date of [2179-3-16] 9:03:32 PM Technically difficult study * CONSIDER ACUTE ST ELEVATION MI * Probable sinus rhythm upper normal rate Since previous tracing, heart rate faster, QRS same, ST-T wave abnormalities can not be compared Suggest repeat tracing Clinical correlation is suggested . CHEST (PA & LAT) [2179-3-17] 6:02 PM IMPRESSION: Small right-sided pleural effusion. No pneumonia. Emphysema. . ECG Study Date of [2179-3-17] 3:43:50 AM Technically difficult study Sinus rhythm [Month (only) 116] be normal ECG Since previous tracing, heart rate slower Brief Hospital Course: 69 yo male with h/o COPD, PAF, DM who presents with lethargy, confusion, urinary incontinence and hypercabic and hypoxic respiratory failure. . Hypercarbic respiratory failure: When patient arrived had significant wheezes and ABG showed hypoxemia as well as hypercapnea. Hypoxia improved on bipap. ABG revealed chronic respiratory acidosis, with component of metabolic alkalosis. This is different from his previous presentation of an acute respiratory acidosis. Likely d/t component of CHF, PNA and COPD with acute bronchoconstriction. Echo with EF of >70% and mild LV diastolic dysfunction. PE is also on the differential, negative LENIs. Last ABG from previous admission was 7.32/59/58/32. Breath sounds improved w/ nebs, and improved O2 sat. One episode of SOB during day [2179-3-17], improved w/ nebs. No events, overnight, now comfortable. CKs flat, trop stable at 0.06 (likely [3-12] to renal failure). DC'd vanc/zosyn given no leukocytosis, afebrile, and no pneumonia on CXR. Pt continues to desat on ambulation, which likely is his baseline and he will require supplemental oxygen at all times with activity. Continue lasix 20mg IV qd for goal negative 500cc - 1 liter per 24hr. Continue nebs (advair, combivent nebs). Continue azithromycin, now day 3, for total of 5 days. Continue prednisone daily, slow taper over 2 months. Setup for outpt PFTs and pulmonary f/u with Dr. [Last Name (STitle) ] in [Month (only) 958]. . Mental status changes: Recent MS changes in setting of hypercarbia and low grade temps. Afebrile here and patient currently mentating well, though currently not fully oriented. Could be [3-12] some component of hypercapnea, though this does not appear to be an acute insult. [Month (only) 116] have underlying infection, though BPs are stable and he does not have fevers. Also considered toxic ingestion or ETOH withdrawal. Now improved with correction of hypoxia and with BiPAP. Urine/serum tox negative. Now back to baseline mental status per daughter, conversational, [Name2 (NI) 3584], fully oriented. Culture data negative. . Tremors: Patient developed tremors a short while after arriving on the floor. These could be [3-12] to hypercapnea, electrolyte disturbances, SE of albuterol or possibly ETOH withdrawal. Pt denies recent ETOH use and does not have tachycardia, diaphoresis, agitation or significant hypertension. He also states he has had tremors in the past. Thyroid panel with TSH low end of normal and low free T4, expected in stress situations. Serial neuro exams stable. No valium for now in setting of hypercapnea and MS changes. PCP will followup outpatient. . CRI: Baseline 2.2-2.5 per last notes. Currently remains at baseline. PTH level elevated secondary to low calcium level. Started on procrit as anemia likely secondary to renal insufficiency. Administered phosphate binders. As outpatient, start vit D supplementation once phos level decreases. . DM: Diet controlled. -insulin SS while on steroids . PAF: Cont on ASA and diltiazem. No events on telemetry while inpatient. . Anemia: Hct baseline 34-40, though at last admit was more in the low 30s. Hct stable from last admit at 30.8 and iron and ferritin levels were nl. TIBC was low suggesting ACD, likely [3-12] to renal failure. Started on procrit as above. . HTN: Continued terazosin and dilatiazem. Monitor BP in setting of diuresis. . PPx: Bowel regimen, PPI, SC heparin . FEN: Cardiac, regular diet, monitor K . Access: PIVs . Communication: Daughter ([Doctor First Name ]; HCP): [Telephone/Fax (1) 96936](c); [Telephone/Fax (1) 96937](h) Daughter ([Location (un) ]): [Telephone/Fax (1) 96938](c) Daughter ([Doctor First Name ]; MD): [Telephone/Fax (1) 96939] . Code status: Full d/w patient . Dispo: DC to rehab. Followup with PCP. Medications on Admission: Hexavitamin one tab qd Aspirin 325 mg qd Celexa 20 mg qd Tiotropium Bromide 18 mcg one inhalation qd Terazosin 2 mg qhs lasix 40 mg qd Diltiazem HCl 360 mg qd Omeprazole 20 mg qd Advair 250/50 one puff [Hospital1 ] Albuterol-Ipratropium 2 puffs q6 hrs Docusate Sodium 100 mg [Hospital1 ] Levofloxacin 250 mg x 7 days last d/c Trazodone 50 mg qhs Ativan 0.5 mg, one tab q8 hours prn anxiety Regular insulin sliding scale while taking prednisone Prednisone ( 7.5 mg qd x 7 days to end [3-19] and was then supposed to do 5 mg and then 2.5 mg for 7 days at a time) Discharge Medications: 1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 4. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 9. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 10. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours) for 3 days. 11. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 13. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 14. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 15. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 16. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 17. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q2H (every 2 hours) as needed for shortness of breath or wheezing. 18. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: SLIDING SCALE Subcutaneous with meals and at bedtime. 19. Prednisone 10 mg Tablet Sig: TAPERED DOSE Tablet PO once a day for 2 months: 60mg (6 tabs) for 2 weeks, then 40mg (4 tabs) for 2 weeks, then 20mg (2 tabs) for 2 weeks, then 10mg (1 tab) for 2 weeks. 20. Combivent 103-18 mcg/Actuation Aerosol Sig: One (1) Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: PRIMARY DIAGNOSES: COPD exacerbation Hand tremor from ? anxiety CHF exacerbation Community acquired-pneumonia . SECONDARY DIAGNOSES: 1) Chronic obstructive pulmonary disease, no pulmonary function test on record, on 3L NC at home (only with exertion). 2) Obstructive sleep apnea on BIPAP (settings = 12&6 on 8 L oxygen.) 3) Type 2 diabetes (last A1C 6.4 on [2179-1-26]) c/b biopsy-proven diabetic nephrosclerosis. 4) Paroxysmal atrial fibrillation on aspirin 5) Chronic renal insufficiency from diabetic nephropathy, baseline Cr 2-2.5. Followed by Dr. [Last Name (STitle) ]. 6) Gout 7) Anemia 8) Hypertension 9) Anxiety. Discharge Condition: Stable. Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1L Please take all medications as prescribed. Call your PCP or return to the ED if you experience shortness of breath, chest pain, fevers, chills. You should use your supplemental oxygen at all times, at rest and with activity. Followup Instructions: Provider: [First Name11 (Name Pattern1) 3210] [Initial (NamePattern1) ] [Last Name (NamePattern4) ], DPM Phone:[Telephone/Fax (1) 543] Date/Time:[2179-4-5] 2:50 Please followup with your PCP [Last Name (NamePattern4) ] 1 week for further medical management, call number below to make an appointment: PCP: [Name10 (NameIs) ],[Name11 (NameIs) ] [Telephone/Fax (1) 608] Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2179-4-12] 2:30 Dr. [Last Name (STitle) ] at [Hospital1 18] Pulmonary on [4-12] at 3:40pm on [Hospital Ward Name 516], [Location (un) 436]. Call 617-667-LUNG for questions. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(1) 4236] Name: [Known lastname 6421],[Known firstname 15421] JR Unit [Name2 (NI) ]: [Numeric Identifier 15422] Admission Date: [2179-3-16] Discharge Date: [2179-3-25] Date of Birth: [2109-9-13] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 161] Addendum: Please note addition to brief hospital course and updated discharge medication list. Patient remained in the hospital three additional days due to desaturations with exertion, which had subsided prior to discharge. Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname ] is a 69 year old male with h/o COPD s/p recent admission for exacerabtion and respiratory acidosis, PAF, DM, CRI who was sent from [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 15423] for confusion, lethargy, urinary incontinence and low grade temps. Patient has been at [First Name4 (NamePattern1) 3008] [Last Name (NamePattern1) ] since [2179-2-25] after admission for COPD exacerbation. Over the past 1-2 days the patient reports he has been feeling more confused. He denies fevers, chills, dysuria, worsening cough, chest pain, N/V, diarrhea, abdominal pain. His breathing has been a bit more labored. Per report from [Last Name (un) 3008] house he had urinary incontinence, lethargy and confusion. His vitals this AM were BP 144/80 Temp 99.8 HR 90 and O2 sat 92% on 2L. He was sent to the [Hospital1 ] ER. Pt currently denying backpain or fecal incontinence. Says had some LE weakness and urinary incontinence in the past day. . Of note pt had recent admission from [Date range (1) 15424]/07 for hypercarbic respiratory failure and mental status changes. At that admission he was found down and had severe respiratory acidosis 7.10/112/146. He was treated with steroids, abx and bipap and subsequently improved. Also had acute on chronic renal failure and hyperkalemia. ARF was thought to be pre-renal. Patient improved and discharged to rehab on 7 days of levofloxacin and steroid taper that was scheduled to end [3-1]. However, appears he is still on a steroid taper. . In the ED here today the patient was found to have severe wheezes and minimal air movement. He had an ABG of 7.33/86/47/47 on NRB. He was started on bipap and received ipratropium/albuterol nebs, lasix 40 mg IV, solumedrol 125 mg IV and zosyn. He also had right LENI which was negative. His repeat ABG was 7.31/88/103/47 on 40% FiO2. . Currently thinks breathing has improved since admit and he feels less confused. . Past Medical History: 1) Chronic obstructive pulmonary disease, no pulmonary function test on record, on 3L NC at home (only with exertion). 2) Obstructive sleep apnea on BIPAP (settings = 12&6 on 8 L oxygen.) 3) Type 2 diabetes (last A1C 6.4 on [2179-1-26]) c/b biopsy-proven diabetic nephrosclerosis. 4) Paroxysmal atrial fibrillation on aspirin 5) Chronic renal insufficiency from diabetic nephropathy, baseline Cr 2-2.5. Followed by Dr. [Last Name (STitle) 2955]. 6) Gout 7) Anemia 8) Hypertension 9) Anxiety Social History: Was living as [Hospital3 163] since last d/c on [2179-2-25]. Prior to that lived with daughter. +tob (1 ppd), +occ EtOH (last admit was noted to be drinking 3 beers/day), no drugs. Family History: Non-contributory Physical Exam: VS: Tc 97.4 HR 89 BP 149/66 RR 12 O2 sat 89% on BIPAP 12/5 Fi02 0.3 Gen: well appearing, elderly male, bipap in place, opening eyes and conversing HEENT: PERRL, anicteric sclera, though some chemosis, bipap in place Neck: elevated JVP, but bipap strap compressing vein Pulm: crackles at left lung base, good air movement, no wheezes or rhonchi Cardio: RRR, nl S1 S2, no m/r/g Abd: soft, mildly distended, NT, + BS Ext: 2+ pitting edema, 1+ DP pulses b/l Neuro: A&O x 1 (to person,states year [2172] and he is at [First Name4 (NamePattern1) 3008] [Last Name (NamePattern1) ]), moves all extremities and follows commands PERRL, EOMI Pertinent Results: [2179-3-16] 07:00PM WBC-3.1# RBC-4.15 HGB-10.2* HCT-30.8* MCV-74* MCH-24.6* MCHC-33.2 RDW-16.4* [2179-3-16] 07:00PM NEUTS-71.3* LYMPHS-18.9 MONOS-9.2 EOS-0.4 BASOS-0.2 [2179-3-16] 07:00PM GLUCOSE-195* UREA N-45* CREAT-2.2* SODIUM-139 POTASSIUM-6.2* CHLORIDE-95* TOTAL CO2-39* ANION GAP-11 [2179-3-16] 08:30PM LACTATE-1.3 K+-5.7* [2179-3-16] 08:39PM TYPE-ART PO2-47* PCO2-86* PH-7.33* TOTAL CO2-47* BASE XS-14 [2179-3-16] 10:07PM TYPE-ART PO2-103 PCO2-88* PH-7.31* TOTAL CO2-46* BASE XS-13 . [3-17] CXR: IMPRESSION: Small right-sided pleural effusion. No pneumonia. Emphysema. . [3-23] CXR: CONCLUSION: New right basal atelectasis or infiltrate. . [3-25] CXR: 1. Improving right basilar atelectasis. 2. Prominence of the right upper mediastinum again seen, possibly representing prominent vessels versus possible enlarged thyroid. Clinical correlation recommended, and if indicated, ultrasound could be helpful for further evaluation (Of note, pt with normal TSH, T4) . Brief Hospital Course: # Hypercarbic respiratory failure: Patient required extra 3 days in the hospital because his oxygen saturations dropped to 60% on ambulation with physical therapy on Friday [2179-3-19]. He was diuresed further with improvement in his saturations and advair was increased to [Hospital1 ]. Respiratory compromise appears to be from progression of COPD, complicated by PNA and moderate CHF with BNP of 1300s. Patient continued to desat down to mid-80s on ambulation with 3L supplement oxygen, which likely is his baseline and he will require supplemental oxygen at all times with activity. He started a 2 week course of azithromycin and will continue slow prednisone taper over 2 months as instructed. V/Q to evaluate for PE was considered but not done given his clinical improvement. He was ordered for a outpatient sleep study to make sure his BiPAP settings are appropriate. Goal is to maintain resting sats ~92% and titrate exertional O2 supplement for SaO2 >88%. Encourage smoking cessation, continue nebs and pulmonary rehab. He is set up for outpt PFTs and pulmonary f/u with Dr. [Last Name (STitle) ] in [Month (only) 880]. . # Paroxysmal afib: Pt with hx of PAF dating back to [2174] when he had his first documented episode of a fib while admitted for COPD exacerbation. Started on anticoagulation with coumadin which was continued by Dr. [Last Name (STitle) 86] on followup in [2174], when he was noted to be in NSR. In [2175], Dr. [First Name (STitle) ] discontinued coumadin as he only had one episode of a fib, which was thought to be from combination of COPD and EtOH use. Pt had afib/a flutter during recent admission in [2-/2179] during MICU course and was started on diltiazem with good response on serial EKGs. Echo last month showed EF>70%, mild LVOT obtruction increased with valsalva, During current hospital course, pt has had intermittent episodes of tachycardia to 150s noted to be afib on telemetry. EP consulted, increased diltiazem from 90mg to 120mg qid. Pt should start long acting Diltiazem on [2179-3-26] (120mg qid regular dilt=480mg daily of long-acting dilt). No amiodarone given poor lung function and risk of toxicity. Added on heparin and coumadin after discussion with pt and daughter. Should keep pt on coumadin 7.5mg daily, and stop heparin drip (currently at 700 units/hr, target PTT 50-60) once INR therapeutic ([3-13]). . # Mental status changes: Since [2179-3-20], the patient has been oriented x3, cooperative with the exam. Ativan only prn, avoiding if possible because of respiratory effects. Blood cx with no growth to date since [3-16]. . # Tremors: significantly improved since admission with possible contributions of albuterol nebs and smoking cessation. Inform PCP to [Name Initial (PRE) ]/u issue as outpt. Consider nicotine patch if pt has cravings. . # CRI: Baseline 2.2-2.5 per last notes. Discharged better than baseline at 1.8. PTH level elevated secondary to low calcium level. Cont procrit. Cont phosphate binders. . # DM: Normally diet controlled, but insulin SS while on steroids. . # Anemia: Hct baseline 34-40, though at last admit was more in the low 30s. Hct stable from last admit at 30.8 and iron and ferritin levels were nl. TIBC was low suggesting ACD, likely [3-12] to renal failure. Continued Procrit. . # HTN: cont terazosin and dilatiazem. . # Communication: Daughter ([Doctor First Name ]; HCP): [Telephone/Fax (1) 15425] (c); [Telephone/Fax (1) 15426](h) Daughter ([Location (un) ]): [Telephone/Fax (1) 15427](c) Daughter ([Doctor First Name 1679]; MD): [Telephone/Fax (1) 15428] . Medications on Admission: Hexavitamin one tab qd Aspirin 325 mg qd Celexa 20 mg qd Tiotropium Bromide 18 mcg one inhalation qd Terazosin 2 mg qhs lasix 40 mg qd Diltiazem HCl 360 mg qd Omeprazole 20 mg qd Advair 250/50 one puff [Hospital1 ] Albuterol-Ipratropium 2 puffs q6 hrs Docusate Sodium 100 mg [Hospital1 ] Levofloxacin 250 mg x 7 days last d/c Trazodone 50 mg qhs Ativan 0.5 mg, one tab q8 hours prn anxiety Regular insulin sliding scale while taking prednisone Prednisone ( 7.5 mg qd x 7 days to end [3-19] and was then supposed to do 5 mg and then 2.5 mg for 7 days at a time) Discharge Medications: 1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 7. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 8. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 10. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 11. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 12. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 13. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q2H (every 2 hours) as needed for shortness of breath or wheezing. 14. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: SLIDING SCALE Subcutaneous with meals and at bedtime. 15. Prednisone 10 mg Tablet Sig: TAPERED DOSE Tablet PO once a day for 2 months: 50mg (5 tabs) for 5 days, then 40mg (4 tabs) for 1 week, then 30mg (3 tabs) for 1 week, then 20mg (2 tabs) for 1 week, then 10mg (1 tab) for 1 week. 16. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 17. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 18. Diltiazem HCl 120 mg Tablet Sig: One (1) Tablet PO four times a day for 1 days: Please continue until AM on [3-26]; then start Long-acting diltiazem. 19. Diltiazem HCl 240 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO once a day: Please start [3-26] AM. 20. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO bid:prn as needed for anxiety. 21. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 22. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: Seven Hundred (700) units/hr Intravenous ASDIR (AS DIRECTED) for 3 days: Titrate drip to keep PTT between 50-60 until INR [3-13] for 24 hours. 23. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours) for 7 days. 24. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation every eight (8) hours. Discharge Disposition: Extended Care Facility: [Hospital3 2215] - [Location (un) 42] Discharge Diagnosis: PRIMARY DIAGNOSES: COPD exacerbation Paroxysmal Atrial fibrillation . SECONDARY DIAGNOSES: 1) Chronic obstructive pulmonary disease 2) Obstructive sleep apnea on BIPAP (settings = 12&6 on 8 L oxygen.) 3) Type 2 diabetes 4) Chronic renal insufficiency from diabetic nephropathy 5) Gout 6) Anemia 7) Hypertension 8) Anxiety. Discharge Condition: Stable Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 233] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1L . Please take all medications as prescribed. Call your PCP or return to the ED if you experience shortness of breath, chest pain, fevers, chills. . You should use your supplemental oxygen at all times, at rest and with activity. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 15429], DPM Phone:[Telephone/Fax (1) 456] Date/Time:[2179-4-5] 2:50 Please followup with your PCP [Last Name (NamePattern4) ] 1 week for further medical management, call number below to make an appointment: PCP: [Name10 (NameIs) 635],[Name11 (NameIs) 634] [Telephone/Fax (1) 6696] Provider: [Name10 (NameIs) 1421] FUNCTION LAB Phone:[Telephone/Fax (1) 9570] Date/Time:[2179-4-12] 2:30 Dr. [Last Name (STitle) ] at [Hospital1 8] Pulmonary on [4-12] at 3:40pm on [Hospital Ward Name 600], [Location (un) 336]. Call 617-667-LUNG for questions. You have a outpatient sleep study ordered and will be contact[Name (NI) ] by the [Hospital1 ] Sleep Center for scheduling. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 165] MD [MD Number(1) 166] Completed by:[2179-3-25]	[ "250.40", "427.31", "274.9", "585.9", "486", "428.0", "518.81", "491.21", "403.90", "327.23", "285.21" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	27007, 27079	20134, 23790	15645, 15652	27446, 27455	19091, 20111	27854, 28849	18394, 18412		24414, 26984		27100, 27170		23816, 24391			27479, 27831											18427, 19072		27191, 27425																						15586, 15607													15680, 17649																17671, 18171	18187, 18378
30,195	177,686	7885	Discharge summary	report	Admission Date: [2168-6-12] Discharge Date: [2168-6-12] Date of Birth: Sex: M Service: MICU HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 6884] is a 27 -year-old man with a history of substance abuse, attention deficit disorder with hyperactivity, and depression, who was transported to the Emergency [Hospital1 ] after being found slumped against a car outside of a nightclub. Bystanders mentioned that he may have been using drugs and/or alcohol in the course of that evening. The patient was brought to the Emergency [Hospital1 ] and intubated for airway protection. He was given 15 mg of Versed for sedation for agitation. Electrocardiogram in the Emergency [Hospital1 ] showed tall T-waves and possible J-point elevations in the anterior precordial leads. Toxicology screen in the Emergency [Hospital1 ] was positive for alcohol at a level of 148, as well as for amphetamines. PAST MEDICAL HISTORY: 1. Substance abuse with cocaine and GHB. 2. Gonococcal urethritis. ALLERGIES: No known drug allergies. ADMITTING MEDICATIONS: Effexor and Adderall. Social history: Cocaine use and GBH use, documented in the past. The patient also came in with a prison identification card and a temporary alcohol license. Cigarettes were found in his pockets. FAMILY HISTORY: Unknown. PHYSICAL EXAMINATION: The patient's temperature was 96.2 F, pulse of 80, blood pressure was 134/70. The patient was mechanically ventilated with oxygen saturation of 96%. In general, he was a sedated, non-responsive male, intubated and on a ventilator. Head, eyes, ears, nose and throat examination was normocephalic with a cut on the lower lip. Pupils were equal, round, and reactive to light, size was 4.0 mm baseline and 3.0 mm and reactive to light. oral mucosa were moist and an endotracheal tube was in place. Chest examination significant for a few inspiratory wheezes; otherwise clear to auscultation bilaterally. Cardiovascular examination: the patient had a regular rhythm, normal S1, S2, no murmurs, rubs, or gallops. Abdominal examination was soft, nontender, nondistended, there were normoactive bowel sounds and no hepatosplenomegaly. The patient's extremities were warm, peripheral pulses were 2+. There was no cyanosis, clubbing or edema. Neurologic examination: the patient was sedated, cranial nerves examination demonstrated a positive oculocephalic and gag reflexes. Strength: the patient was moving all four extremities in the Emergency [Hospital1 ]. Reflexes are 1+ throughout. NOTABLE LABORATORY DATA: Arterial blood gas with pH of 7.33, PaCO2 is 48, PO2 is 206. The patient had a white blood cell count of 12.1, hematocrit of 45.6, and platelets of 278,000. The differential was 83 neutrophils, 14 lymphocytes, 2 monocytes, and 1 eosinophils. His Chem 7 included a sodium of 143, potassium of 3.5, chloride 103, bicarbonate of 20, BUN of 8.0, creatinine of 1.0, glucose of 99, and an anion gap of 20. The patient also had osmotic gap of 4.0. The patient's urinalysis indicated a few amorphic crystals, otherwise within normal limits. Serum toxicology screen: alcohol was 148, A.S.A., Tylenol, barbiturates, benzodiazepine, and Tri-Cyclen antidepressants were negative. Urine toxicology screen: amphetamine was positive and benzodiazepine, opiates, cocaine, and methadone were negative. Chest x-ray indicated an endotracheal tube and orogastric tube were in place. There was no pneumothorax or infiltrate. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit and given charcoal. Serial electrocardiograms were concerning for the possible J-point elevations in the anterior precordial leads, versus repolarization abnormalities. The Cardiology Fellow was called and a nitroglycerin was started. Cardiac enzymes were drawn which were negative. The patient became increasingly agitated in the Intensive Care Unit and it was decided to wean the patient's sedation and extubate the patient, which was done without any difficulty. As the patient became more alert, he provided additional history, stating that he had taken Ecstasy and GHB prior to losing consciousness. He described his reaction as an accident and denied suicidal ideation. After further consultation with Cardiology, it was decided that the electrocardiogram changes were probably benign in nature and reflected repolarization abnormality. A Substance Abuse consult was ordered. Psychiatry came to evaluate the patient and found that he did not have active suicidal ideation. Further, the patient has been enrolled in intensive rehabilitation and day hospital program for his drug abuse and psychiatric issues. According to Psychiatry, the patient has excellent follow-up in these areas. After the patient was cleared to go home, both by Psychiatry and by the Intensive Care Unit team, his mental status having cleared and cardiac issues resolved, he was discharged to home. DISCHARGE DIAGNOSIS: Ecstasy and GHB intoxication. FOLLOW-UP: The patient is to follow-up with his primary care provider, [Last Name (NamePattern4) ]. [Last Name (STitle) 8310], within one to two weeks. He will also report back to his psychiatric day hospital program the day following discharge. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3090], M.D. [MD Number(1) 3091] Dictated By:[Last Name (NamePattern1) 194] MEDQUIST36 D: [2168-6-13] 14:18 T: [2168-6-13] 22:02 JOB#: [Job Number 28371]	[ "311", "518.81", "314.01", "305.52" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.04" ]	icd9pcs	[ [ [] ] ]							1340, 1350				4999, 5562			3527, 4978																										1373, 2318																								157, 947														2342, 3509		969, 1124	1141, 1323
79,224	131,806	42810	Discharge summary	report	Admission Date: [2162-2-11] Discharge Date: [2162-2-16] Date of Birth: [2129-5-11] Sex: F Service: MEDICINE Allergies: Amoxicillin / Metoclopramide / Compazine Attending:[First Name3 (LF) 2291] Chief Complaint: respiratory distress Major Surgical or Invasive Procedure: none History of Present Illness: 32F h/o asthma and intubations, pulmonary emboli, and DVT p/w wheezing, tachycardia, pleuritic chest pain and dyspnea. Her symptoms started 4 days prior to admission with wheezing and dyspnea. Her best peak flow is 450cc and yesterday at home it was 250cc. She went to [Hospital 2436] Hosp ED 2 days prior to admission and was hospitalized overnight. She then signed herself out AMA because she didn't think they were doing anything for her she could not do at home. She reports one episode of hemoptysis occuring yesterday (2 tablespoons full). She also developed a cough productive of green sputum and reports a temperature to 100.8 two days ago. She has no night sweats but reports chills. Her chest pain is sternal, dull with sharp exacerbations and constant for >9 hours. . In the ED, initial VS were: 97.8, 132/76, 130, 18, 100% RA Triggered in ED for tachypnea and HR 130. Wheezing on presentation. Aggressive duonebs times three, 2mg MgSO4, solumedrol 125mg iv, Ativan 1mg iv, morphine 5mg iv, toradol 30mg iv. Left femoral triple lumen was placed. EJ was also placed for CTA. She was treated with NIV now with stacked nebs. CTA prior to transfer showed no pulmonary embolism. She reports occassional bloody diarrhea due to colitis; the last episode day prior ato admission . On arrival to the MICU, she was speaking in full sentences and complaining of constant chest discomfort. . Review of systems: (+) Per HPI (-) Denies night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies palpitations, or weakness. Denies nausea, vomiting,constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: asthma with 3 intubations at [Hospital1 2436], last [7-26] DVT [12-25] pulmonary embolism [12-25] s/p 3m coumadin ?COPD: dxed at [Hospital1 2025] GERD Pneumonia in [2156] Syncope and bradycardia s/p PM in [2156] Headaches: migraines Anxiety Colitis: Inflammatory Bowel Dz, unknown type, not sure how it was diagnosed Social History: Tobacco: none - Alcohol: none - Illicits: none - works as a PA at a rehab Family History: paternal grandfather MI at 40 Asthma on father's side Physical Exam: Admission Physical General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact . Physical Exam on day prior to Discharge: vs temp 96.9 BP 110/80 HR 90 RR16 96RA Gen: sleeping female, just awoken, appears stated age. HEENT: MMM CV: RRR, no m/r/g Lungs: When patient still groggy asleep, clear but slightly reduced breath sounds. When patient asked to take a deep breath, Absent breath sounds. Abd: soft, ND, NT Ext: wwp. no edema. Neuro: A&OX3, responds appropriately to questions. Exam on Day of discharge: vss Gen: young female, appears stated age, NAD HEENT: MMM CV: RRR, no m/r/g Lungs: clear breath sounds, patient cooperative with exam Abd: soft, ND, NT Ext: wwp. no edema. Neuro: A&OX3, responds appropriately to questions. Pertinent Results: Admission Labs [2162-2-11] 11:55PM PT-12.0 PTT-28.8 INR(PT)-1.1 [2162-2-11] 10:25PM URINE HOURS-RANDOM [2162-2-11] 10:25PM URINE UCG-NEGATIVE [2162-2-11] 10:25PM URINE bnzodzpn-POS barbitrt-POS opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG [2162-2-11] 10:25PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.017 [2162-2-11] 10:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [2162-2-11] 10:08PM TYPE-ART RATES-/17 TIDAL VOL-500 PEEP-8 PO2-536* PCO2-33* PH-7.41 TOTAL CO2-22 BASE XS--2 INTUBATED-NOT INTUBA VENT-SPONTANEOU [2162-2-11] 10:00PM GLUCOSE-103* UREA N-9 CREAT-0.8 SODIUM-144 POTASSIUM-3.7 CHLORIDE-112* TOTAL CO2-24 ANION GAP-12 [2162-2-11] 10:00PM estGFR-Using this [2162-2-11] 09:17PM VoidSpec-QNS FOR AB . Labs Prior to Discharge: [2162-2-15] WBC-9.6 RBC-3.87* Hgb-10.3* Hct-32.1* Plt Ct-298 Glucose-85 UreaN-17 Creat-0.7 Na-142 K-3.4 Cl-106 HCO3-26 AnGap-13 VBG pO2-151* pCO2-44 pH-7.37 calTCO2-26 Base XS-0 . [2162-2-11] FRONTAL CHEST RADIOGRAPH: The heart size is normal. A left-sided pacemaker generator projects leads into the right atrium and ventricle. Hilar and mediastinal contours are within normal limits. There is no pneumothorax, focal consolidation, or pleural effusion. . [2162-2-11] CTA Chest: IMPRESSION: 1. No pulmonary embolus detected to the subsegmental levels. No dissection. 2. No consolidations or pleural effusions. Brief Hospital Course: 32F h/o asthma and intubations consistent with severe asthma exacerbation. ASTHMA [Known firstname 5877] was initially admitted to the MICU where she was started on solumedrol 80mg IV q8hrs and transitioned to oral prednisone 50mg daily for 5 days total. Albuterol/Ipratropium nebs q6hr prn were continued. Advair substituted for symbicort while in house. Was also treated with Azithromycin for 5 days for presumed bacterial Bronchitis based on purulent sputum. She was noted have atypical respiratory exam with nearly absent breath sounds, but appeared in no respiratory distress. Wheezes were not audible. On multiple occassions patient reported concern that she was not being treated appropriately (due to transition from IV steroids to oral) and tried to leave AMA. She also stated on numerous occassions that she "wished she was inutabed" thinking she would feel better if that had been the case. She maintained that she asked the team not to intubate her. Patient was suspected of breath holding and this was confirmed by placing stethoscope on chest for prolonged periods, patient would cough and in the process large volume air movement could be appreciated X 1 then no breath sounds again for 30 seconds to one minute. This process would repeat. Patient was continued on oral steroids/azithromycin 5 day course which was completed while patient was hospitalized. She was continued on prn nebulizers which were prescribed for patient comfort. On day of discharge patient was cooperative with exam, she had good airmovement with clear breath sounds, no wheezes. She reported her breathing was much improved. Patient described pleuritic chest pain which was found not to be cardiac in origin or related to PE as negative CTA. She was treated symptomatically. She continued to report intermittent chest tightness which resolved by day of discharge. . UNRESPONSIVENESS Her hospitalization was notable for three episodes of sudden unresponsiveness with chest discomfort/tightness prior to all. Pt denies any history of episodes like these previously, says they are different from prior syncopal drop attacks she has had previously. First episode was noted in the ED on arrival, no breath sounds were noted, HR 160, Hemodynamically stable, O2 sats in the 90s to 100%. Symptoms improved suddenly with NIV. Subsequent episode in ICU was observed, possibly thought to be secondary to low cardiac output in vagal state, and initiation of CLS feature as described below. She was tachycardic and hemodynamically stable, no air movement noted on exam, no drop in O2 sats throughout the episodes. Episodes resolve suddenly with no postdrome. During third episode which occured several hours after transfer to the floor. Began suddenly after episode of "chest tightness", patient was unresponsive to sternal rub and multiple ABG attempts. Patient had slight resistance to eye opening, eyes were roaming, at one point eyes made contact but patient did not respond to voice or commands. Eyes remained roaming as head was turned side to side. Arms had reduced tone, but patient protected her face when arm was dropped over her head. Vitals remained normal. ABG was notable for 7.38/92/42/26 on room air. Episode resolved suddenly in [11-29] minutes with no postictal state, no self urination or tongue biting. Patient was at baseline mental status, alert and oriented immediately after the event reporting nausea and dry heaving. There was no emesis. Neurology was consulted who found her episode to be highly unsuggestive of a seizure episode or related to patient reported history of reversible cerebral vasoconstriction syndrome. Possibility of vasovagal syncope related to migraine headaches was raised, though this would require no further intervention. There is also concern for non-organic causes of her symptoms. Patient, herself, demonstrated less concern for her unresponsive episodes than her asthma symptoms. Patient is to follow up with a new neurology attending at [Hospital1 3278], Dr. [First Name (STitle) ]. She was previously seen at [Hospital1 2025], but decided to change neurologists when somatisization was raised as a cause of her symtpoms. TACHYCARDIA Also during her hospitalization, patient had intermittent tachycardia as high as 140-160s. Tachycardia was more significant when patient was describing respiratory distress, and came down to 70's to 80s when calm. Patient had one unusual episode thought to be vagal episode during which patient was noted to be unresponsive and tachycardiac. HR was in 140s, EKG showed that she was apaced. Electrophysiology was consulted realized pacer was triggered by low cardiac output states like vasovagal episodes. This CLS feature of the pace maker was turned off and this was communicated to her electrophysiologist. Despite this she continued to have intermittent tachycardia which continued through subsequent episodes of unresponiveness as well as when she was in her baseline state. Tachycardia was not noted when patient was calm or sleeping. . The summary of the EP report is as follows "Summary (normal / abnormal device function): Stable lead parameters, without evidence of over/undersensing or inappropriately tracking. Her CLS function appears to be activating during rest in the absence of vagal episodes, prompting atrial pacing to 130 bpm while in bed. To avoid confusion and inappropriate pacing during this hospitalization, this feature was turned off (programmed to DDD). She should follow-up with her cardiologist soon after discharge so that this feature can be addressed and optimized. She notes that she has also had an episode since implantation where she was not adequately treated by the device and lost consciousness, indicating that the device needed to be optimized prior to this encounter." Outpatient cardiologist, Dr. [Last Name (STitle) ] of [Hospital1 2025] was notified and felt her symptoms seemed unlikely to be cardiogenic, no intervention needs to be made to CLS function. Routine follow up is appropriate. Physicans: Prior medical care received at [Hospital1 2025]. Primary Care Physician: [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] ([Hospital1 2025]), Pulmonary Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 92475] ([Hospital1 2025]--now at Brighmam), GI Dr. [Last Name (STitle) 92476] ([Hospital1 2025]). Dr. [Last Name (STitle) ] ( cardiology, [Hospital1 2025]) also follows with neurology and hematology at [Hospital1 2025] Transition of care to [Hospital1 3278]: Dr. [First Name (STitle) ] (Neuro, [Hospital1 ], new doctor) PCP [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 84152] [State ]. Mailbox 401 [Location (un) 86], [Numeric Identifier 4809] Appt. Phone: [Telephone/Fax (1) 12807] Fax: [Telephone/Fax (1) 92477] Medications on Admission: protonix 40mg [Hospital1 ] ranitidine 300mg qhs fludrocortisone .1mg [Hospital1 ] topamax 100mg [Hospital1 ] naproxen 375mg [Hospital1 ] klonopin 1mg qhs, .5mg qAM symbicort 80mcg 2 puff [Hospital1 ] Alb inh and nebs prn singulair 10mg qhs fioricet prn nortriptyline 50mg qhs asacol 2400mg daily nimodipine 60mg [Hospital1 ] Discharge Medications: 1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 2. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 3. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. topiramate 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. naproxen 375 mg Tablet Sig: One (1) Tablet PO twice a day as needed for headache. 6. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 7. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Symbicort 80-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs puffs Inhalation twice a day. 9. 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. 10. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for headache. 11. nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 12. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 13. nimodipine 30 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 14. propranolol 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 15. Singulair 10 mg Tablet Sig: One (1) Tablet PO once a day. 16. nimodipine 30 mg Capsule Sig: Two (2) Capsule PO once a day. 17. Progestin only OCP Discharge Disposition: Home Discharge Diagnosis: asthma exacerbation unresponsiveness Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure to take care of you during your hospitalization. You were admitted for an asthma exacerbation which was managed with high dose steroids and antibiotics and you completd a five day course. You did require intubation and your symptoms improved during your hospitalization. During your hospitalization you also had several episodes of unresponsiveness of unclear etiology. But it was felt that you were not having a seizure or stroke. Neurology team evaluated you and recommended getting records of prior EEGs and if symptoms continue outpatient EEG may be warranted. No changes were made to your medications. Followup Instructions: please follow up with your primary care doctor, neurlogist, and cardiologst as already scheduled. we will communicate the events of your hospitalization with them. Completed by:[2162-2-17]	[ "276.2", "V45.01", "780.09", "493.92", "V12.55", "V12.51", "786.30", "785.0" ]	icd9cm	[ [ [] ] ]	[ "38.91" ]	icd9pcs	[ [ [] ] ]	14300, 14306	5486, 12438	323, 329	14387, 14387	3959, 5463	15193, 15389	2601, 2657		12838, 14277		14327, 14366		12464, 12815			14538, 15170											2672, 3940																					1774, 2120			262, 285													357, 1755										14402, 14514						2142, 2489	2506, 2585
60,139	149,643	35001	Discharge summary	report	Admission Date: [2170-8-28] Discharge Date: [2170-9-1] Date of Birth: [2151-1-7] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3043] Chief Complaint: respiratory distress Major Surgical or Invasive Procedure: intubation History of Present Illness: This is a 19 year old female with minimal past medical history who presented to the ED with back and chest pain and shortness of breath of one days duration. She had been standing on a chair using a drill two days prior to presentation when she fell backwards onto her back. She had immediate pain and then this improved. The following day, however, which was the day prior to presentation she was bothered by intermittent shortness of breath and pleuritic chest pain (worst in her left shoulder and substernal). She also was having subjective fevers and chills. This pain was fairly moderate so she managed to go about most of her normal behaviors. Unfortunately,the following morning she was awoken very early with quite severe chest and left shoulder pain that continued to be worse with deep breaths. Thus, she went into the emergency department at approximately 3 am on [2170-8-28] for further evaluation. In the ED initial vital signs were T 100.8, P 124, BP 153/96, RR 26, O2 Sat 97% on RA. A work up was begun for musculoskeletal causes of chest and back pain including CXR, CT scan of L and C spines, CT Head, and radiograph of the left shoulder. These were all benign on prelim reads and the plan was to discharge the patient after obtaining adequate pain control. This proved difficult and per ED sign-out the patient threatened to leave AMA multiple times over frustrations with their efforts to control her pain. At approximately 9:00 am a final read on the chest radiograph suggested a retrocardiac opacity. The patient received a dose of levofloxacin for presumed CAP then suddenly desaturated to 70% on room air requiring transition to 6L of O2 by nasal cannula (leading PO2 to increase to 85%) and then 100% NRB mask, which brought sats to mid 90's. At this point repeat imaging revealed an impressive left lower lobe infiltrate so the patient received vancomycin and ceftriaxone before being admitted to the MICU. Last set of vitals prior to transfer were HR 99, BP 108/59, RR 28, O2 Sat 94 % on 100% NRB. At presentation to the ICU the patient was dyspneic and very uncomfortable with any sort of inhalation. CTA was obtained to rule out PE given tachycardia and pleuritic pain. This showed dense symmetric posterior consolidations as well as other areas of involvement suggestive of multifocal pneumonia. Given the patient also complained of having developed rather severe headache while in the ED and had diffuse myalgias there was concern for H1N1 influenza so she received oseltamavir and rimantidine for empiric coverage. The patient was intubated shortly thereafter as she appeared to be tiring and also to accomodate multiple needed procedures as she was extremely uncomfortable with simple breathing even at rest. Past Medical History: -ADHD -obesity/gastric bypass surgery -Depression? Social History: lives with roommates. attends BU Family History: One grandmother with hypertension. No family history of pulmonary emboli, DVT, or vasculitic/rheumatologic processes. Physical Exam: HEENT: Normocephalic, anicteric, PERRL, OP benign, MMM Neck: Supple, Slightly tender to palpation along left neck, No masses appreciated, no thyroid nodules appreciated CV: Tachycardic, no M/R/G; there was no jugular venous distension appreciated Pulm: Expansion equal bilaterally, reduced breath sounds at the bases bilaterally Abd:Soft, NT, ND, BS+, no organomegaly or masses appreciated Extrem: Warm and well perfused, no C/C/E, tender to calf squeeze bilaterally, +/- [Last Name (un) 5813] sign on right Neuro: (prior to intubation) A and O3 anxious appearing, CNII-XII grossly intact Pertinent Results: ****need to include micro data, still pending currently********** LABS ON ADMISSION: [2170-8-28*] 03:53AM BLOOD WBC-16.6# RBC-4.51 Hgb-13.6 Hct-39.7 MCV-88 MCH-30.2 MCHC-34.3 RDW-13.6 Plt Ct-321# [2170-8-28] 03:53AM BLOOD Neuts-93.1* Lymphs-5.6* Monos-1.0* Eos-0.1 Baso-0.1 [2170-8-28] 03:53AM BLOOD Plt Ct-321# [2170-8-28] 03:53AM BLOOD Glucose-96 UreaN-10 Creat-0.8 Na-138 K-3.3 Cl-99 HCO3-27 AnGap-15 [2170-8-28] 07:20PM BLOOD ALT-14 AST-10 LD(LDH)-136 AlkPhos-33* TotBili-0.6 [2170-8-28] 07:33PM BLOOD Calcium-6.5* Phos-3.3 Mg-1.0* [2170-8-28] 07:33PM BLOOD HIV Ab-NEGATIVE [2170-8-28] 03:53AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2170-8-28] 08:59AM BLOOD Lactate-1.5 [2170-8-29] 12:51AM BLOOD freeCa-1.14 [2170-8-28] 05:30AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.025 [2170-8-28] 05:30AM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-1 pH-6.5 Leuks-TR [2170-8-28] 05:30AM URINE RBC-[2-8]* WBC-[2-8] Bacteri-NONE Yeast-NONE Epi-0 [2170-8-28] 05:57AM URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-NEG amphetm-POS mthdone-NEG Brief Hospital Course: 19 year old female presenting with hypoxic respiratory failure in the context of fever, myalgias, and headache found to have strep pne 1. Hypoxic Respiratory Failure: Patient presented with hypoxic respiratory failure and fevers. On presnetation had O2 sats in the low to mid 90's on 100% nonrebreather and appeared to be tiring. PE was ruled out by CTA of the chest but the patient had dense bilateral consolidations of the lower lobes. Initially she received broad spectrum coverage with vancomycin, ceftriaxone, and levofloxacin. Given myalgias and headache she also received oseltamavir and rimantidine given concern for influenza. Given high O2 requirements, rapid progression of infiltrates and respiratory failure, and appearance she was tiring she was electively intubated on the day of presentation. The following day she managed to maintain an adequate O2 sat on minimal ventilator settings so she was extubated. Blood cultures were positive for streptococcus pneumoniae and influenza antigen testing was negative so oseltamavir was stopped on [8-30] and she was kept on vancomycin/ceftriaxone because of concerns of meningitis. Sensitivities from blood cultures returned with pansensitive strep pneumoniae, patient had no signs of meningismus and so vancomycin was discontinued. Patient improved to saturating well on room air on IV ceftriaxone. She was discharged with oral levofloxacine to complete a 2 week course of antibiotics and will follow up in [Hospital ] clinic. 2. Myalgias/Headache: Initially there was concern given the patients myalgias and headache that despite obvious respiratory process she could have meningitis. Thus, she initially received CNS doses of ceftriaxone and vancomycin. There was minimal suspicion of HSV encephalitis so no empiric IV acyclovir was started. LP was attempted on the night of admission but was unable to be successfully obtained. As blood cultures returned positive for a common pulmonary pathogen and the index of suspicion had always been quite low we decided not to reattempt LP. 3. Iron Deficiency Anemia: Patient with indices consistent with iron deficiency and anemia. Therefore, she was started on PO iron and colace. This should be closely monitored for recovery as her previous gastric bypass makes her at high risk for iron malabsorption. 4. PPX: She received SC heparin. While intubated she received H2 blocker for GI prophylaxis. Medications on Admission: - Adderall when taking classes - Sertraline 100 mg (just titrated up several days ago from 50 mg) - Sublingual Vitamin B-12 - Super B Complex - Calcium 1200 mg daily - Multivitamin Discharge Medications: 1. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 3. Super B Complex 27-300 mg Tablet Sig: One (1) Tablet PO once a day. 4. Calcium 600 600 mg (1,500 mg) Tablet Sig: Two (2) Tablet PO once a day. 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 11 days. Disp:11 Tablet(s) Refills:0 7. Adderall 20 mg Tablet Sig: One (1) Tablet PO three times a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Pneumonia Discharge Condition: Good, afebrile, saturating well on room air Discharge Instructions: You were admitted to [Hospital1 69] for pneumonia. You had respiratory distress requiring intubation and ICU stay. During your admission, your pneumonia was treated with IV antibiotics. On discharge you will need to continue oral antibiotics to finish a two week course. Please make note of the following changes to your medications: - new medication: levofloxacin 750 mg daily, for 11 days The rest of your medications have not changed, please continue to take them as originally prescribed. If you experience chest pain, worsening shortness of breath, or any other worrisomen symptoms, please return to the emergency room. Followup Instructions: Please follow up with your own PCP (Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 34709] [Telephone/Fax (1) 80036]) within 1-2 weeks after discharge. Please follow up with: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 288], MD (Infectious Disease) LM [Hospital Ward Name ] BLDG ([Doctor First Name ]), BASEMENT Phone: [Telephone/Fax (1) 457] Date/Time: [2170-9-28] at 10:00	[ "311", "041.2", "780.52", "280.9", "518.81", "481", "790.7", "458.9", "V45.86", "314.01" ]	icd9cm	[ [ [] ] ]	[ "38.93", "96.04", "96.71", "33.22" ]	icd9pcs	[ [ [] ] ]	8440, 8446	5230, 7657	334, 346	8519, 8565	4009, 4088	9248, 9689	3261, 3380		7889, 8417		8467, 8467		7683, 7866			8589, 8902											3395, 3990																				8931, 9225				274, 296													374, 3121							8486, 8498	4102, 5207								3143, 3195	3211, 3245

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